Last week before celebrating another fireworks-filled Fourth of July here in Boston, we pressed “send” on comments addressing proposed rules on how non-profit hospitals engage community and public health partners in their community benefit planning. The proposed rules also address what the penalties will be for hospitals that fall short of the new Affordable Care Act (ACA) requirements to establish financial assistance, billing and collections, and community benefit policies that reflect and respond to community needs.

The proposed rules will implement a section of the ACA that requires non-profit hospitals to conduct regular assessments of community health needs and develop strategies to address unmet needs. (This quick summary explains more.) As part of this process, the ACA requires these hospitals to “take input” from people who “represent the broad interests of the community” as they develop these plans. And while that’s a fairly abstract, amorphous definition, the proposed rules go farther than the agencies’ previous publications to encourage hospitals to focus on the needs—and heed the voice and experiences—of vulnerable populations.

A Place for Tension

For many health care advocates, community benefit has historically been about ensuring patients have access to hospital care through financial assistance programs and billing and collections policies that protect low- and moderate-income families against medical debt. That’s still a vital piece of community benefit, but it’s not the only piece. Community benefit can help hospitals proactively address issues that impact health outside the four walls of their facilities, from transportation to housing to economic opportunity to environmental health. To strike the right balance between immediate and long-term fixes, hospitals, public health departments, and communities (including advocates!) need to collaborate from the get-go on what should be addressed, when, how, and by whom.

Targeting Community Benefit Dollars to Address Health Equity: It Starts by Having the Right Folks in the Room

As part of the hospital’s required community health needs assessment, the proposed rules state they must take input from community members or their representatives who are low-income, from minority populations, and who are “medically underserved.” They may take input from consumer advocates, community-based organizations and other non-profits, organized labor, and other groups. While we have concerns the proposed rules still allow hospitals to get away with minimal outreach, we fully support the intention expressed here: that hospitals routinely engage those who have been marginalized and excluded from experiencing the best that our health care system has to offer.

Breaking Down Silos between Financial Barriers to Care and Population Health

In many hospitals, decisions about financial assistance, billing and collections policies are often made by the CFO. Hospital staff tasked with carrying out community benefit sit in many different departments: community relations, government affairs, even marketing. These staff may never think to ask about financial barriers to care, and they may not report to the CFO. While it’s common for advocates to think of financial assistance as a community benefit issue, anecdotal evidence suggests that financial assistance and community benefit policies “meet” for the first time when they are reported on hospitals’ federal tax filings. We think this contributes to the “Jekyll and Hyde” syndrome many advocates have pointed out to us, where the same hospitals that are touted for strong prevention or community health programs use aggressive billing and collections tactics against very low-income patients. The proposed rules encourage hospitals to use the assessment process to ask about financial barriers to care—something we think could go a long way to breaking down these silos.

But, We Still Have More to Do…

The proposed rules adopted a number of recommendations that we, together with many advocacy groups, submitted to the IRS and Treasury back in 2011. But they fall short in two areas:

  • While community input is required during the assessment process, we think it should be required throughout the process
  • Hospitals should have to make their implementation strategies widely available on their website. The proposed rules say they can file them on their annual tax returns, but that won’t allow communities to see in real time how their suggestions have been incorporated into the hospital’s action plan.

While the IRS and Treasury move forward, it’s important to note that most non-profit hospitals have already completed their first community health needs assessment. Many are knee-deep in attempting to implement community benefit plans. In the coming months, the Hospital Accountability Project will keep you posted on ways to get involved in these processes at a hospital near you. Stay tuned!

— Jessica Curtis Hospital Accountability Project Director