Community Benefit Activities Research Articles

Evaluation of Community Benefit Activities Among Nonprofit Hospitals, 2018-2021.

This study examined approaches that nonprofit hospitals use to evaluate community benefit activities in the Community Health Needs Assessment/Implementation Plan (CHNA/IP) process. Content analysis of CHNAs/IPs completed between 2018 and 2021 from a 20% stratified random sample (n = 503) of US nonprofit hospitals. A coding sheet was used to record details about the evaluation content reported by hospitals in their CHNAs/IPs. Evaluation was coded into 4 categories: (1) no mention of evaluation; (2) description of evaluation without reporting any measures; (3) reporting reach (number of people served) only; and (4) reporting social/health outcomes. For logistic regression analyses, categories 1 and 2 were grouped together into "no evaluation measures" and categories 3 and 4 were grouped into "evaluation measures" for binary comparison. Multinomial logistic regression was also used to individually examine categories 3 and 4 compared with no evaluation measures. While a majority of nonprofit hospitals (71.4%, n = 359) mentioned evaluation in their CHNAs, almost half (49.7%, n = 250) did not report any evaluation measures. Among the 50.3% (n = 253) of hospitals that reported evaluation measures, 67.2% (n = 170) only reported reach. Fewer than 1 in 5 hospitals (16.5%, n = 83) reported social/health outcomes. Hospitals that hired a consultant (adjusted odds ratio [AOR] = 1.61; 95% confidence interval [CI], 1.08-2.43) and system members (AOR = 1.76; 95% CI, 1.12-2.75) had higher odds of reporting evaluation measures. Using hospitals that reported no measures as the base category, system members (AOR = 7.71; 95% CI, 2.97-20.00) also had significantly higher odds of reporting social/health outcomes, while rural locations had lower odds (AOR = 0.43; 95% CI, 0.20-0.94). Although hospitals are required to evaluate the impact of actions taken to address the health needs identified in their CHNAs, few hospitals are reporting social/health outcomes of such activities. This represents a missed opportunity, as health/social outcomes could be used to inform the allocation of resources to maximize community benefits and the expansion of successful community initiatives.

Hospital Community Benefit Reporting: How Group Reporting Practices Limit Accountability.

To identify the prevalence of group reporting of hospital community benefit efforts to the Internal Revenue Service (IRS) and understand hospital and community characteristics associated with this practice. The study was based on data collected from publicly available community benefit reports from 2010 to 2019, as well as secondary data from the 2020 American Hospital Association (AHA) Annual Survey. The sample was drawn from the entire nonprofit US hospital population reporting community benefit activities. The analytic plan employed descriptive statistics and bivariate analysis. The United States. All data are self-reported by US hospitals, either through the publication of community benefit reports (IRS Form 990 Schedule H) or a response to the AHA Annual Survey. Analyzed variables include whether a hospital reported its community benefit expenditures individually or as a group member; community benefit spending as a percentage of hospital operating expenses; and whether the hospital was part of a multihospital system, with consideration of hospital and community characteristics. Between 2010 and 2019, more than 40% of hospitals participated in group reporting, with most doing so consistently. System membership and hospital size were significantly and positively tied to group reporting, with state community benefit policy tied to the lower prevalence of group reporting. The high prevalence of group reporting limits accountability to communities and restricts an accurate assessment of community benefit expenditures, counter to policy intentions. Stakeholders should consider what modifications to reporting rules could be made to promote transparency and to ensure that the effects of community benefit policies align with intentions.

Do Nonprofit Hospitals Evaluate Their Community Benefit Activities?

Nonprofit hospitals in the United States are required to conduct a community health needs assessment (CHNA) every 3 years to identify the most pressing health issues in their community and then develop an implementation strategy for addressing these health issues. CHNA reports must include "evaluation of the impact of any actions that were taken to address the significant health needs identified in the immediately preceding CHNA." To determine whether and how nonprofit hospitals are responding to the requirement to evaluate their implementation strategies addressing their community's priority health needs. Using content analysis, we reviewed CHNA reports of all Minnesota nonprofit hospitals (n = 96) since regulations were finalized in December 2014. Nonprofit hospitals in Minnesota. Reports were coded to determine whether hospitals are responding to the evaluation requirement and the types of evaluation measures (process vs outcome indicators) used to assess hospitals' activities. Most of the reports (116 of 136 reports, or 85.3%) include narrative evaluating community benefit programs, showing widespread conformity with the IRS (Internal Revenue Service) mandate. All of the evaluations use process indicators, such as the number of individuals reached. More than half of the evaluations (64 of 116 reports, or 55.2%) also use outcome indicators, with many reporting short- and medium-term changes in health-related knowledge and behaviors. Use of outcome indicators increased substantially in CHNAs in the 2017-2020 period compared with 2015-2016. In general, Minnesota hospitals are using program evaluation to assess their community benefit implementation strategies, although the extent to which they evaluate their strategies varies considerably between hospitals. While the use of outcome indicators of impact has increased over time, levels of use suggest the importance of incorporating public health expertise in CHNA work.

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

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.

How Do Payment Reforms Affect Hospitals’ Community Benefit Decisions?

In 2014, Maryland established a global budget policy, setting limits on hospitals’ spending and regulating reimbursement amounts. This study assesses whether the implementation of the policy changed the nature of hospitals’ community benefit activities. Using data from the Internal Revenue Service Form 990 Schedule H, we compared the community benefit trends of Maryland hospitals with those of a state control group and found some key differences. Maryland hospitals increased their spending on clinical services but not on broader community health improvement. Payment reform does have the potential to affect hospital investments to improve health, but more focused policies may be required for greater hospital involvement in nonmedical drivers of health.

Association of State Medicaid Expansion With Hospital Community Benefit Spending

Medicaid expansion was widely expected to alleviate the financial stresses faced by hospitals by providing additional revenue in the form of Medicaid reimbursements from patients previously receiving uncompensated care. Among nonprofit hospitals, which receive tax-exempt status in part because of their provision of uncompensated care, Medicaid expansion could have released hospital funds toward other community benefit activities. To examine changes in nonprofit hospital spending on community benefit activities after Medicaid expansion. This cohort study used difference-in-differences analysis of 1666 US nonprofit hospitals that filed Internal Revenue Service Form 990 Schedule H detailing their community benefit expenditures between 2011 and 2017. The analysis was conducted from February to September 2019. State Medicaid expansion between 2011 and 2017. Percentage of hospital operating expenditures attributable to charity care and subsidized care, bad debt (ie, unreimbursed spending for care of patients who did not apply for charity care), unreimbursed Medicaid spending, noncare direct community spending, and total community benefit spending. Of 1478 hospitals in the sample in 2011, nearly half (653 [44.2%]) were small hospitals with fewer than 100 beds, and nearly 70% of hospitals (1023 [69.2%]) were in urban areas. Among the 1666 nonprofit hospitals, Medicaid expansion was associated with a decrease in spending on charity care and subsidized care (-0.68 [95% CI, -0.99 to -0.37] percentage points from a baseline mean [SD] of 3.6% [4.0%] of total hospital expenditures; P < .001) and in bad debt (-0.17 [95% CI, -0.32 to -0.01] percentage points). There was an increase in unreimbursed spending attributable to caring for Medicaid patients (0.85 [95% CI, 0.60 to 1.10] percentage points; P = .04), which canceled out uncompensated care savings from the expansion. Noncare direct community expenditures decreased overall (-0.24 [95% CI, -0.48 to 0.00] percentage points; P = .049). Direct community expenditures remained more stable in small hospitals (-0.07 [95% CI, -0.20 to 0.05] percentage points; P =.26) compared with large hospitals (-0.37 [95% CI, -0.86 to 0.12] percentage points; P = .14) and in nonurban hospitals (0.02 [95% CI, -0.09 to 0.14] percentage points; P = .70) compared with urban hospitals (-0.36 [95% CI, -0.73 to 0.01] percentage points; P = .06). In this study, Medicaid expansion was associated with a decrease in nonprofit hospitals' burden of providing uncompensated care, but this financial relief was not redirected toward spending on other community benefits.

Nonprofit Hospital Community Benefit in the U.S.: A Scoping Review From 2010 to 2019

Background: U.S. nonprofit hospital community benefit recently underwent significant regulatory revisions. Starting in 2009, the Internal Revenue Service (IRS) required hospitals to submit a new Schedule H that provided greater detail on community benefit activities. In addition, the Affordable Care Act (ACA), which became law in 2010, requires hospitals to conduct community health needs assessments (CHNA) and develop community health implementation plans (CHIP) as a response to priority needs every 3 years. These new requirements have led to greater transparency and accountability and this scoping review considers what has been learned about community benefit from 2010 to 2019.Methods: This review identified peer-reviewed literature published from 2010 to 2019 using three methods. First, an OvidSP MEDLINE search using terms suggested previously by community benefit researchers. Second, a PubMed search using keywords frequently found in community benefit literature. Third, a SCOPUS search of the most frequently cited articles in this topic area. Articles were then selected based on their relevance to the research question. Articles were organized into topic areas using a qualitative strategy similar to axial coding.Results: Literature appeared around several topic areas: governance; CHNA and CHIP process, content, and impact; community programs and their evaluation; spending patterns and spending influences; population health; and policy recommendations. The plurality of literature centered on spending and needs assessments, likely because they can draw upon publicly available data. The vast majority of articles in these areas use spending data from 2009 to 2012 and the first cycle of CHNAs in 2013. Policy recommendations focus on accountability for impact, enhancing collaboration, and incentivizing action in areas other than clinical care.Discussion: There are several areas of community benefit in need of further study. Longitudinal studies on needs assessments and spending patterns would help inform whether organizations have changed and improved operations over time. Governance, program evaluation, and collaboration are some of the consequential areas about which relatively little is known. Gaps in knowledge also exist related to the operational realities that drive community benefit activities. Shaping organizational action and public policy would benefit from additional research in these and other areas.

The Evolution of Community Benefit: Perspective on Progress Toward Purpose.

To maintain exemption from federal taxes, non-profit hospitals in the USA are required to contribute to their communities an amount comparable to the taxes they otherwise would have paid. Since 2008, non-profit hospitals have had to file Form 990 Schedule H with the Internal Revenue Service (IRS) to document their “Community Benefit” (CB) activities. The purpose of this article is to present an overview of the evolution of hospitals' engagement with their communities and to examine how the policy enforced by the IRS has evolved. The IRS has not made explicit the assumptions underlying the CB policy. As a result, the evidence about the impact of CB policy and CB activities on the health of a community is sparse. Non-profit hospitals are spending millions of dollars in CB activities and reporting requirements annually, but if and how these expenses contribute to a community's health and well-being are unclear. Conceptual frameworks, such as logic models or Collective Impact models, could be used to explicate the assumed relationships. As the field has evolved and grown more complex, identifying and measuring the contributions of a single hospital or single program to the health status of a community have become more challenging. Collaboration—promoted by the IRS and CDC—has increased these challenges. Until assumptions about relationships are made explicit and tied to measurable goals, non-profit hospitals must continue to comply with IRS requirements but should use their own targets, metrics, and evaluations to ensure that the resources devoted to CB programs are being used cost-effectively.

Association of Nonprofit Hospitals’ Charitable Activities With Unreimbursed Medicaid Care After Medicaid Expansion

In the United States, nonprofit hospitals receive tax-exempt status with the expectation that they provide a high level of benefit to local communities. Prior work has shown that Medicaid expansion reduced hospital spending on uncompensated care. To measure the association of tax-exempt hospital spending with community benefit and changes in uncompensated care after Medicaid expansion. This cohort study was performed using a difference-in-differences analysis (ie, a pre-post treatment-control design) to estimate changes in reported charitable categories associated with Medicaid expansion. Data from Internal Revenue Service form 990, Schedule H, tax filings for 2253 tax-exempt hospitals in the United States from 2012 to 2016 were used. Data were analyzed from June to November 2019. The proportion of the hospital's tax filing that spanned the period after Medicaid expansion. Hospital-reported spending on uncompensated care, unreimbursed Medicaid expenses, and other community benefit spending categories. Across 2253 hospitals, mean (SD) uncompensated care costs between 2012 and 2016 were $4.20 million ($8.80 million) and unreimbursed Medicaid expenses were $7.60 million ($18.62 million). Compared with tax-exempt hospitals in states that did not expand Medicaid, those in states that did expand Medicaid reported mean reductions in their provision of uncompensated care of $1.11 million (95% CI, $0.35 million to $1.87 million; P < .001), representing a mean change of -2% (95% CI, -6% to 2%; P < .001). These reductions have been offset by mean reported increases in the provision of unreimbursed Medicaid expenses of $1.63 million (95% CI, $0.31 million to $2.94 million; P = .02), representing a mean increase of 2% (95% CI, 1% to 4%; P = .01). Tax-exempt hospitals in states that expanded Medicaid reported no statistically significant mean increase in spending on other community benefit activities. In this study, large decreases in uncompensated care among tax-exempt hospitals associated with Medicaid expansion were not accompanied by increases in other reportable categories of community health benefit spending. Instead, they were accompanied by increased spending on unreimbursed Medicaid expenses.

State Laws and Nonprofit Hospital Community Benefit Spending.

To determine the association of state laws on nonprofit hospital community benefit spending. We used multivariate models to estimate the association between different types of state-level community benefit laws and nonprofit hospital community benefit spending from tax filings. All 50 US states. A total of 2421 nonprofit short-term acute care hospital organizations that filled an internal revenue service Form 990 and Schedule H for calendar during years 2009-2015. Between 2009 and 2015, short-term acute care hospitals spent an average of $46 billion per year in total, or $20 million per hospital on community benefit activities. Exposure to a state-level community benefit law of any type was associated with an $8.42 (95% confidence interval: 1.20-15.64) per $1000 of total operating expense greater community benefit spending. Spending amounts and patterns varied on the basis of the type of community benefit law and hospital urbanicity. State laws are associated with nonprofit hospital community benefit spending. Policy makers can use community benefit laws to increase nonprofit hospital engagement with public health.

Health impact assessments in hospital community benefit: A multiple case study of the use of HIAs at Children’s Hospital Colorado

&lt;p&gt;&lt;strong&gt;Objective:&lt;/strong&gt; To explore the use of Health Impact Assessments (HIAs) within non-profit hospital community benefit activities.&lt;/p&gt;&lt;p&gt;&lt;strong&gt;Methods:&lt;/strong&gt; We constructed case studies of three HIAs that were conducted in collaboration with Children’s Hospital Colorado as part of the hospital’s community benefit portfolio. These HIAs were part of a pilot that was funded by the Health Impact Project, a collaboration of the Robert Wood Johnson Foundation and The Pew Charitable Trusts.&lt;/p&gt;&lt;p&gt;&lt;strong&gt;Results:&lt;/strong&gt; HIAs provided Children’s Hospital Colorado with a transparent and systematic process for generating evidence-based recommendations with community and stakeholder feedback within the hospital’s community benefit activities. HIAs were used to generate recommendations to inform community benefit planning activities and to generate public policy recommendations to enhance child health. The case studies highlighted several issues that need to be addressed in order to further advance the use of HIA within hospital community benefit activities including: use of HIA on explicit health issues, hospital capacity for HIA, potentially broadening the scope of HIA recommendations, and the use of HIA to generate recommendations from broad priority areas.&lt;/p&gt;&lt;p&gt;&lt;strong&gt;Conclusion: &lt;/strong&gt;HIAs can help meet the need for established, evidence-based, and stakeholder responsive tools and processes to be used within non-profit hospital community benefit activities. In meeting this need, the non-profit hospital community benefit area can potentially serve as a major institutional home for the practice of HIA. There is a need for additional research and practice innovation to further explore and refine the use of HIA within non-profit hospital community benefit activities. &lt;/p&gt;

The Potential Role for Health Impact Assessments in Nonprofit Hospital Community Benefit Activities.

The Potential Role for Health Impact Assessments in Nonprofit Hospital Community Benefit Activities.

What Challenges Do Nonprofit Hospitals Face in Taking on Community Health Needs Assessments? A Qualitative Study From Appalachian Ohio.

The purpose of this study is to understand the experiences of Appalachian hospitals in undertaking Community Health Needs Assessments (CHNAs). Of particular interest is whether new requirements to undertake regular evaluation and public health programming pose challenges for rural, Appalachian hospitals. Using a sample of nonprofit hospitals in Appalachian Ohio, we conducted in-depth qualitative interviews with hospital administrators overseeing community benefit activities and external consultants hired to complete assessments. Following a grounded theory approach, we coded interviews to ascertain major themes. Our findings suggest that there are several challenges faced by nonprofit hospitals that may relate to their status as rural hospitals. In particular, we found that these hospitals struggle to hire staff to oversee CHNAs, often lack the material resources to address needs identified in reports, and seek more concrete guidelines from the IRS on carrying out these new activities in their communities. The results from these interviews suggest that there is significant support for new CHNA activities in Appalachian Ohio, but challenges remain to translate these efforts into improved health outcomes in this region. Because rural Appalachia, in particular, faces significant health disparities and a relative lack of health care providers, there is a potential for hospitals to take on an important role in public and preventive health if initial challenges are addressed.

The Impact of IRS Tax Policy on Hospital Community Benefit Activities.

The Internal Revenue Service (IRS) recently introduced tax code revisions requiring stricter oversight of community benefit activities (CBAs) conducted by tax-exempt, not-for-profit hospitals. We examine the impact of this tax requirement on CBAs among these hospitals relative to for-profit and government hospitals that were not subject to the new policy. We employed a quasi-experimental, difference-in-difference study design using a longitudinal observational approach and used secondary data collected by the American Hospital Association (years 2006-2010 including 20,538 hospital year observations). Findings show a significant increase in the reporting of 7 of the 13 CBAs among tax-exempt, not-for-profit hospitals compared with other hospitals after the policy change. Examples include partnering to conduct community health assessments ( b = 0.035, p = .002) and using capacity assessments to identify unmet community health needs ( b = 0.041, p = .001). Recent tax revisions are associated with increases in reported CBAs among tax-exempt, not-for-profit hospitals. As the debate continues regarding tax exemption status for not-for-profit hospitals, policy makers should expand efforts for enhanced accountability.

Hospital Community Benefit in the Context of the Larger Public Health System: A State-Level Analysis of Hospital and Governmental Public Health Spending Across the United States.

Achieving meaningful population health improvements has become a priority for communities across the United States, yet funding to sustain multisector initiatives is frequently not available. One potential source of funding for population health initiatives is the community benefit expenditures that are required of nonprofit hospitals to maintain their tax-exempt status. In this article, we explore the importance of nonprofit hospitals' community benefit dollars as a funding source for population health. Hospitals' community benefit expenditures were obtained from their 2009 IRS (Internal Revenue Service) Form 990 Schedule H and complemented with data on state and local public health spending from the Association of State and Territorial Health Officials and the National Association of County & City Health Officials. Key measures included indicators of hospitals' community health spending and governmental public health spending, all aggregated to the state level. Univariate and bivariate statistics were used to describe how much hospitals spent on programs and activities for the community at large and to understand the relationship between hospitals' spending and the expenditures of state and local health departments. Tax-exempt hospitals spent a median of $130 per capita on community benefit activities, of which almost $11 went toward community health improvement and community-building activities. In comparison, median state and local health department spending amounted to $82 and $48 per capita, respectively. Hospitals' spending thus contributed an additional 9% to the resources available for population health to state and local health departments. Spending, however, varied widely by state and was unrelated to governmental public health spending. Moreover, adding hospitals' spending to the financial resources available to governmental public health agencies did not reduce existing inequalities in population health funding across states. Hospitals' community health investments represent an important source for public health activities, yet inequalities in the availability of funding across communities remain.

In California, not-for-profit hospitals spent more operating expenses on charity care than for-profit hospitals spent.

In exchange for sizable tax exemptions, not-for-profit hospitals must engage in activities that meet the Internal Revenue Service's community benefit standard. The provision of charity care-free care to those unable to pay-can help meet that standard. Bad debt, the other form of uncompensated care, cannot be used to meet the standard, although Medicaid shortfalls can. However, the ACA lacks guidelines for providing charity care, and federal law sets no minimum requirements for community benefit activities. Using data from California, we examined whether the levels of charity and uncompensated care provided differed across general acute care hospitals by profit status and other characteristics during 2011-13. The mean proportion of total operating expenses spent on charity care differed significantly between not-for-profit (1.9percent) and for-profit hospitals (1.4percent), in contrast to the mean proportion spent on uncompensated care. Both types of spending varied widely across hospitals. Policy makers should consider measures that remove disincentives to meeting the persistent considerable need for charity care-for example, increasing supports to offset rising Medicaid shortfalls resulting from program expansion-and facilitate the tracking of ACA impacts on the distribution of charity care and uncompensated care delivery.

The Value Of The Nonprofit Hospital Tax Exemption Was $24.6 Billion In 2011.

The federal government encourages public support for charitable activities by allowing people to deduct donations to tax-exempt organizations on their income tax returns. Tax-exempt hospitals are major beneficiaries of this policy because it encourages donations to the hospitals while shielding them from federal and state tax liability. In exchange, these hospitals must engage in community benefit activities, such as providing care to indigent patients and participating in Medicaid. The congressional Joint Committee on Taxation estimated the value of the nonprofit hospital tax exemption at $12.6 billion in 2002--a number that included forgone taxes, public contributions, and the value of tax-exempt bond financing. In this article we estimate that the size of the exemption reached $24.6 billion in 2011. The Affordable Care Act (ACA) brings a new focus on community benefit activities by requiring tax-exempt hospitals to engage in communitywide planning efforts to improve community health. The magnitude of the tax exemption, coupled with ACA reforms, underscores the public's interest not only in community benefit spending generally but also in the extent to which nonprofit hospitals allocate funds for community benefit expenditures that improve the overall health of their communities.

Analysis of hospital community benefit expenditures' alignment with community health needs: evidence from a national investigation of tax-exempt hospitals.

We investigated whether federally tax-exempt hospitals consider community health needs when deciding how much and what types of community benefits to provide. Using 2009 data from hospital tax filings to the Internal Revenue Service and the 2010 County Health Rankings, we employed both univariate and multivariate analyses to examine the relationship between community health needs and the types and levels of hospitals' community benefit expenditures. The study sample included 1522 private, tax-exempt hospitals throughout the United States. We found some patterns between community health needs and hospitals' expenditures on community benefits. Hospitals located in communities with greater health needs spent more as a percentage of their operating budgets on benefits directly related to patient care. By contrast, spending on community health improvement initiatives was unrelated to community health needs. Important opportunities exist for tax-exempt hospitals to improve the alignment between their community benefit activities and the health needs of the community they serve. The Affordable Care Act requirement that hospitals conduct periodic community health needs assessments may be a first step in this direction.

Assessing Community-Based Injury Prevention Services in U.S. Children's Hospitals.

ObjectiveNot-for-profit hospitals are required to meet federal reporting requirements detailing their community benefit activities, which support their tax-exempt status. Children's hospitals have long provided community injury prevention (IP) programming and thus can inform public health outreach work in other areas. This work describes IP programming as a community service offered by children's hospitals in the U.S.MethodsThe IP specialist at 232 US-based member institutions of the Children's Hospital Association were invited to complete an assessment of their hospital's IP outreach programming.Results47.7 percent of hospitals request financial data from IP programming for tax reporting purposes. Almost all offer injury prevention (IP) services; the majority are in the community (60.3%) and 34.5% are hospital-based. Most IP units are independent (60.3%) and 71.8% are responsible for their own budgets.ConclusionsBy integrating dissemination and implementation sciences and community health needs assessments, these findings can help advance community services provided by hospitals to impact public health.

Tax-Exempt Hospitals and Their Communities

Hospitals in the U.S. have long been able to obtain exemption from federal income tax because they meet the requirement known as the standard of “community benefit.” Yet lawmakers and scholars know virtually nothing about the actual workings of tax-exempt hospitals, or about whether, how, and to what extent they deliver benefits to their communities. Within the last five years, however, IRS tax return forms have started asking hospitals to quantify these benefits, as well as to give detailed information about their financial practices with respect to their patients. These new questions coincide with new requirements for tax-exempt hospitals put in place as part of the 2010 Affordable Care Act. The new tax return data offer a first-time opportunity to evaluate the workings of tax-exempt hospitals from the perspective of both the traditional requirements for tax-exempt hospitals and the 2010 healthcare reforms of the Affordable Care Act. This Article analyzes data from all tax-exempt hospitals in the U.S. in 2012 to show that tax-exempt hospitals differ widely in their provision of community benefits (and financial practices). In particular, these activities vary systematically in relation to their different notions of “community” and the characteristics of the communities where the hospitals are located. This evidence demonstrates that tax-exempt hospitals seem to be responding to the specific needs of their own communities when allocating their resources among different community-benefit activities. The data show, in addition, that while tax-exempt hospitals are generally adopting the financial policies that Congress and the IRS are requesting, hospital financial aid policies also vary by community. These findings raise several fundamental questions for lawmakers and tax policy scholars in the era of the Affordable Care Act. In particular, the findings suggest that lawmakers need to grapple seriously with how they allow tax-exempt hospitals to define their communities. For example, is it appropriate for tax-exempt hospitals merely to benefit a narrowly defined community or should they operate in terms of a broader understanding of community? In light of the new data presented, this Article considers these questions and outlines several alternatives to the “community benefit” standard to address them.