Hospital Collaboration with Local Health Departments on Community Health Improvement Activities: Is the Whole More Effective Than the Sum of Its Parts?

Abstract

We examined the effect of nonprofit hospital (NFP) and local health department (LHD) collaboration in local health planning on drug‐induced mortality. NFPs must provide certain types of community benefit (CB) in order to keep their tax‐exempt status. The IRS reported that NFPs spent over $60 billion on CB activities in 2011. Despite the magnitude of spending, there is little evidence as to whether this spending leads to tangible improvements in population health. Traditionally, NFPs dedicated most of their CB dollars to charity care, health professions education, and research. While these areas of spending are beneficial to the community, they represent a partial fulfillment of the CB requirement per the IRS. NFPs are also expected to improve the overall health of the communities they serve by providing health care and prevention activities outside its four walls. Section 9007 of the PPACA, part of the IRS CB requirement, is a regulatory approach that steers NFPs toward providing community health activities that fall outside its acute care focus. It required NFPs to submit a triennial community health needs assessment (CHNA) and an implementation strategy. A few states have leveraged Section 9007 to encourage collaboration between NFPs and LHDs. New York (NY) is the only state that has required NFPs and LHD to collaborate on all three of the following key local health planning activities: CHNA, joint selection of health priorities, and joint implementation of initiatives to address health priorities.We estimated a difference‐in‐differences model using hospital and county data collected before and after hospitals targeted drug use in their community health improvement implementation strategy in 2013. We used robust standard errors clustered on county to calculate the p‐value. As a robustness check, we also used permutation tests to calculate the p‐value. We implemented several sensitivity and falsification tests. The study’s outcome is county‐level drug‐induced mortality per 100,000 residents.Our sample included 220 counties of which 22 were in NY and 198 were control counties.We found that NY’s requirement to collaborate on all three local health planning activities led to a decrease in drug‐induced mortality of approximately 7 deaths per 100,000 population compared with hospitals that did not collaborate with local health departments. This represents a 35% decrease in drug‐induced mortality rate based on the 2016 US national rate.Our findings support the hypothesis that the NY policy, with its requirement for NFP and LHD collaboration, is associated with a decrease in drug‐induced mortality when drug use is jointly prioritized. The requirement for NFP and LHD collaboration is the cornerstone of the NY policy.This finding may be of particular relevance to states that are moving in a similar direction as NY; for instance, Maryland’s Local Health Improvement Coalitions and Maine’s Shared Community Health Needs Assessment. Ohio recently enacted regulation that is virtually identical to NY which mandated all hospitals to collaborate with their LHDs on community health assessment and improvement plans by 2020. Moving forward, it will be key to monitor whether these states experience a similar effect as observed in NY.Agency for Healthcare Research and Quality.