Hospital Community Benefit Research Articles

Opportunities for Prevention: Assessing Where Low-Income Patients Seek Care for Preventable Coronary Artery Disease.

The Affordable Care Act has many aspects that are aimed at improving health care for all Americans, including mandated insurance coverage for individuals, as well as required community health needs assessments (CHNAs), and reporting of investments in community benefit by nonprofit hospitals in order to maintain tax exemptions. Although millions of Americans have gained access to health insurance, many--often the most vulnerable--remain uninsured, and will continue to depend on hospital community benefits for care. Understanding where patients go for care can assist hospitals and communities to develop their CHNA and implementation plans in order to focus resources where the need for prevention is greatest. This study evaluated patient care-seeking behavior among patients with coronary artery disease (CAD) in Florida in 2008--analyzed in 2013--to assess whether low-income patients accessed specific safety net hospitals for treatment or received care from hospitals that were geographically closer to their residence. This study found evidence that low-income patients went to hospitals that treated more low-income patients, regardless of where they lived. The findings demonstrate that hospitals-especially public safety net hospitals with a tradition of treating low-income patients suffering from CAD-should focus prevention activities where low-income patients reside.

Hospital community benefit programs: increasing benefits to communities.

Hospital community benefit programs: increasing benefits to 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.

Analysis of Hospital Community Benefit Expenditures’ Alignment With Community Health Needs: Evidence From a National Investigation of Tax-Exempt Hospitals

Analysis of Hospital Community Benefit Expenditures’ Alignment With Community Health Needs: Evidence From a National Investigation of Tax-Exempt Hospitals

Does Nonprofit Hospital Community Benefit Vary by State?

The initial analysis of the revised Internal Revenue Service Schedule H community benefit report revealed that only about 5% of these dollars are allocated for community health improvement activities. These results have prompted suggestions for improved community health via community benefit reform, given the poor performance of the US population health system. However, if such a reform were enacted, it would have differential impacts across states due to variation in nonprofit hospitals, expenditures, and community benefit allocations. We model this variation, indicating that the range in per capita benefit across states would approximately range from $30 to $335. This variation should be taken into account as community benefit reform is considered.

Hospital Ownership and Community Benefit: Looking Beyond Uncompensated Care

Not-for-profit (NFP) hospitals have come under increased public scrutiny for management practices that are inconsistent with their charitable focus. Of particular concern is the amount of community benefit provided by NFP hospitals compared to for-profit (FP) hospitals given the substantial tax benefits afforded to NFP hospitals. This study examines hospital ownership and community benefit provision beyond the traditional uncompensated care comparison by using broader measures of community benefit that capture charitable services, community assessment and partnership, and community-oriented health services. The study sample includes 3,317 nongovernment, general, acute care, community hospitals that were in operation in 2006. Data for this study came from the 2006 American Hospital Association Hospital Survey and the 2006 Area Resource File. We used multivariate regression analyses to examine the relationship between hospital ownership and five indicators of community benefit, controlling for hospital characteristics, market demand, hospital competition, and state regulations for community benefit. We found that NFP hospitals report more community benefit activities than do FP hospitals that extend beyond uncompensated care. Our findings underscore the importance of defining and including activities beyond uncompensated care when evaluating community benefit provided by NFP hospitals.

PRACTITIONER APPLICATION: Hospital Ownership and Community Benefit: Looking Beyond Uncompensated Care

PRACTITIONER APPLICATION: Hospital Ownership and Community Benefit: Looking Beyond Uncompensated Care

Commentary: A Public Health and Hospital System Collaboration for Conducting Community Health Assessments and Community Health Improvement Plans: Seven Hospital Systems in Oregon and Washington and Four County Public Health Departments in Oregon and One in Washington

Commentary: A Public Health and Hospital System Collaboration for Conducting Community Health Assessments and Community Health Improvement Plans: Seven Hospital Systems in Oregon and Washington and Four County Public Health Departments in Oregon and One in Washington

Hospital Tax-Exempt Policy: A Comparison of Schedule H and State Community Benefit Reporting Systems

The Patient Protection and Affordable Care Act (ACA) revises federal tax exemption standards for nonprofit hospitals by clarifying and augmenting their community benefit obligations. The ACA amendments followed the 2009 launch of Schedule H – the form on which hospital community benefit, financial, and institutional activities are reported and which must be appended to each facility’s annual Form 990 nonprofit institution information return. Schedule H effectively creates a nationwide, standardized, facility-specific, transparent, and fully publicly accessible reporting system covering the nation’s more than 2,900 nonprofit hospitals. Schedule H delineates financial assistance and bad debt, and requires identification of community health improvement and community building. Many states have attempted to capture similar information regarding nonprofit hospitals’ community benefit activities through their own reporting systems. We analyzed state statutes and reporting systems for a sample of 24 states. We found that, in general, state laws lack the clarity of the IRS approach in terms of how community benefit is defined, categorized and reported. In contrast to Schedule H, state laws tend to be broadly drawn, with considerable variability in terms, less delineation among bad debt and financial assistance, and variability in treatment of community health improvement and community building. This article is available in Frontiers in Public Health Services and Systems Research: http://uknowledge.uky.edu/frontiersinphssr/ vol2/iss1/3

Hospital community benefits and the effect of Schedule H: A difference-in-difference approach

Since 1969 private, nonprofit hospitals have qualified for tax exemption as charitable institutions and in exchange for the preferential tax treatment were required to provide community benefits. However, in the absence of mandatory reporting of community benefits at the federal level and in the absence of a clear definition of community benefits, the previous literature provides but ambiguous evidence regarding hospitals’ supply of community benefits. Responding to policymakers’ concerns, the Internal Revenue Service (IRS) mandates all private, non-profit hospitals to report charity care at cost as well as unreimbursed Medicaid costs starting with the tax year 2008. Using data from hospitals in California before and after tax year 2008 (2009 filing), this study examines whether changes in the IRS 990 Schedule H had a significant effect on the supply of community benefits by non-profit hospitals relative to for-profit hospitals. Empirical results suggest that nonprofit hospitals do not supply more community benefits relative to for-profit hospitals for both definitions of community benefits reported in Schedule H. Although the supply of community benefits increased for all hospitals after 2008, the increase was not higher for nonprofits. Moreover, nonprofits supplied significantly less community benefits according to some definitions. Thus, minimum charity care standard is justified.

Hospital Tax Exemption: How Did We Get Here?

Nonprofit organizations, (1) including nonprofit hospitals, have been exempt from federal income taxation since their inception in the early 20th century, when these organizations accounted for a small portion of the U.S. economy. Nearly all hospitals were organized as nonprofit at that time, affiliated with either religious groups or foundations, and they served families who could not afford to pay a doctor to visit their home. Providing public benefits without question, these hospitals depended heavily on charitable gifts to finance their operations and earned little, if any, net income. Over the ensuing 100 years, drastic changes in medical technology have transformed hospitals from places where the poor seek primary care and comfort to places where everyone goes to get various types of care when needed. growth in the last century of private insurance and government financing of care for the elderly and poor has played a major role in stimulating the development and adoption of that medical technology, and has made it feasible for nonprofit hospitals to finance most, if not all, of their operations through patient revenues (Gentry and Penrod 1994). At the same time, however, it fueled the emergence and growth over the past 50 years of for-profit, investor-owned hospitals. Today, some nonprofit hospitals have expanded their roles further by undertaking programs to promote healthy lifestyles or otherwise prevent illness. Beginning in the mid-1950s, and extending until 1969, the Internal Revenue Service (IRS) required a hospital seeking exemption under Section 501(c) (3) to be operated to the extent of its financial ability for those unable to pay for the services rendered. In 1969, however, the IRS issued Revenue Ruling 69-545, which eliminated this charity care standard in favor of a broad standard, where promotion of health for the general benefit of the community would now be considered a charitable purpose. As part of that ruling, the IRS set forth several factors for demonstrating a community benefit: an emergency room (ER) open to all; a board of directors drawn from the community; an open medical staff policy; treatment of Medicare, Medicaid and other government program patients; use of surplus funds to improve facilities, equipment and patient care; and provision of medical training, education and research. Revenue Ruling 69 545 was requested by the hospital field itself, believing that the Medicare and Medicaid programs, in combination with employer-based private insurance coverage, would by and large eliminate the need for charity care. This ruling has now been intact for more than 40 years, with one modification made 14 years after inception. That change, Revenue Ruling 83-157, states that although the operation of an ER open to all patients is a strong indicator of community benefit, the presence of other significant factors would warrant tax exemption if a state or local planning agency determined that an ER was unnecessary and duplicative (Crossley 2007). breadth of the standard, promotion of health, continues to this day to generate considerable confusion and debate both within and outside the nonprofit hospital sector. From 1988 through the early 1990s, a national demonstration project, The Hospital Community Benefit Standards Program. was created with lending by the W.K. Kellogg Foundation. Based at the Robert F. Wagner School of Public Service at New York University and spearheaded by Robert Sigmond, National Steering Committee chairman, Anthony Kovner, project director, and Paul Haddis, project deputy director, the program developed and field-tested such standards, with the ultimate intent of having them adopted and applied by the Joint Commission on the Accreditation of Hospitals (now called the Joint Commission). These standards, process-oriented in nature, focused on community benefit governance, planning, management and reporting and emphasized hospital collaboration with other community stakeholders. …

Hospital Ownership and Community Benefit

Objective: Not-for-profit (NFP) hospitals have come under increased public scrutiny for management practices that are inconsistent with their charitable focus. Of particular concern is the amount o...

Distinguishing Community Benefits: Tax Exemption Versus Organizational Legitimacy

US policymakers continue to call into question the tax-exempt status of hospitals. As nonprofit tax-exempt entities, hospitals are required by the Internal Revenue Service (IRS) to report the type and cost of community benefits they provide. Institutional theory indicates that organizations derive organizational legitimacy from conforming to the expectations of their environment. Expectations from the state and federal regulators (the IRS, state and local taxing authorities in particular) and the community require hospitals to provide community benefits to achieve legitimacy. This article examines community benefit through an institutional theory framework, which includes regulative (laws and regulation), normative (certification and accreditation), and cultural-cognitive (relationship with the community including the provision of community benefits) pillars. Considering a review of the results of a 2006 IRS study of tax-exempt hospitals, the authors propose a model of hospital community benefit behaviors that distinguishes community benefits between cost-quantifiable activities appropriate for justifying tax exemption and unquantifiable activities that only contribute to hospitals' legitimacy.

Community Benefit Activities of Private, Nonprofit Hospitals

The definition of hospital community benefits has been intensely debated for many years. Recently, consensus has developed about one group of activities being central to community benefits because of its focus on care for the poor and on needed community services for which any payments received are low relative to costs. Disagreements continue, however, about the treatment of bad debt expense and Medicare shortfalls. A recent revision of the Internal Revenue Service's Form 990 Schedule H, which is required of all nonprofit hospitals, highlights the agreed-on set of activities but does not dismiss the disputed items. Our study is the first to apply definitions used in the new IRS form to assess how conclusions about the adequacy of nonprofit hospital community benefits could be affected if bad debt expenses and Medicare shortfalls are included or excluded. Specifically, we examine 2005 financial data for California and Florida hospitals. Overall, we find that conclusions about community benefit adequacy are very different depending on which definition of community benefits is used. We provide thoughts on new directions for the current policy debate about the treatment of bad debts and Medicare shortfalls in light of these findings.

Table of Contents

AbstractTax Law Extenders Legislation Signed Into LawHouse Passes Charity Enhancement Act of 2008College and University Compliance‐Check Project is Under WayGAO Responds to Sen. Grassley on Hospital Community Benefit RequirementsIRS Issues Inflation Adjustments for 2009Other Developments

Increasing Access to Health Care: Examination of Hospital Community Benefits and Free Care Programs

The present study explored hospital community benefits and free care programs at seven hospitals in Nassau and Suffolk counties in Long Island, NewYork. There were two components to this project: (1) assessment of information regarding the availability of free care and (2) an analysis of the community benefits information filed with state regulatory offices. Results show that not one of the seven hospitals consistently informed surveyors that free care was available to low-income, uninsured people. Surveyors had difficulty obtaining written free care policies. The article concludes with suggestions for government agencies, hospital administrators, social workers, and other advocates on how to get involved in efforts to increase access to health care for the uninsured population.

Nonprofit hospital conversions and community benefits: new evidence from three states.

Health Tracking Health AffairsVol. 18, No. 5 Nonprofit Hospital Conversions And Community Benefits: New Evidence From Three StatesGary J. Young and Kamal R. Desai AffiliationsGary Young is an associate professor of health services and codirector of the Program on Health Policy and Management at the Boston University (BU) School of Public Health. He is also a senior researcher for the Management Decision and Research Center, a research and consulting component of the Health Services Research and Development Service, U.S. Department of Veterans Affairs (VA). Kamal Desai is a research analyst with the BU School of Public Health and the VA Management Decision and Research Center.PUBLISHED:September/October 1999No Accesshttps://doi.org/10.1377/hlthaff.18.5.146AboutSectionsView articleView Full TextView PDFPermissions ShareShare onFacebookTwitterLinked InRedditEmail ToolsAdd to favoritesDownload CitationsTrack CitationsPermissions View articleTOPICSNonprofit statusFor-profit statusHospital costsHospitalsUncompensated careAcute careHospital careMarketsTeaching hospitalsPatient care Loading Comments... Please enable JavaScript to view the comments powered by Disqus. DetailsExhibitsReferencesRelated Article MetricsCitations: Crossref 22 History Published online 1 September 1999 InformationCopyright © by Project HOPE: The People-to-People Health Foundation, Inc.ACKNOWLEDGMENTSThis study was funded by the Robert Wood Johnson Foundation's Changes in Health Care Financing and Organization (HCFO) Initiative.PDF downloadCited byOtolaryngology–Head and Neck SurgeryQuality Competition, Location Choice and Ownership Conversion in Health Care MarketSSRN Electronic JournalPrivate capital investments in health care provision through mergers and acquisitions: from long-term to acute care27 January 2016 | The International Journal of Health Planning and Management, Vol. 31, No. 4A Quantitative Analysis of the Effects of Postsecondary Institution Conversions from Not-For-Profit to For-Profit5 May 2015 | Public Organization Review, Vol. 16, No. 3Mergers and acquisitions in Western European health care: Exploring the role of financial services organizationsHealth Policy, Vol. 105, No. 2-3Does state budget pressure matter for uncompensated care spending in hospitals? Findings from Texas and California19 April 2012 | The International Journal of Health Planning and Management, Vol. 27, No. 2Hospital ownership type and treatment choicesJournal of Health Economics, Vol. 31, No. 2Distinguishing Community Benefits: Tax Exemption Versus Organizational LegitimacyJournal of Healthcare Management, Vol. 57, No. 1The convergence between for-profit and nonprofit hospitals in the United States20 May 2009 | International Journal of Health Care Finance and Economics, Vol. 9, No. 4The impact of hospital ownership conversions: Review of the literature and results from a comparative field study9 March 2015Regulatory and Judicial Oversight of Nonprofit HospitalsNew England Journal of Medicine, Vol. 356, No. 6Uncompensated Care Provided by Emergency Physicians in Florida Emergency DepartmentsHealth Care Management Review, Vol. 30, No. 4Association of Market, Mission, Operational, and Financial Factors on Hospital Acquisition PricesHealth Care Management Review, Vol. 30, No. 1The Paradox of the Not-for-profit HospitalThe Health Care Manager, Vol. 23, No. 3The Effect of Hospital Ownership Conversions on Nonacute Care Providers16 December 2003 | The Milbank Quarterly, Vol. 81, No. 4Two Decades of Research Comparing For-Profit and Nonprofit Health Provider Performance in the United States *19 May 2003 | Social Science Quarterly, Vol. 84, No. 2Effect of Hospital Conversion on Organizational Decision Making and Service CoordinationHealth Care Management Review, Vol. 28, No. 2Performance evaluations of for-profit and nonprofit U.S. hospitals since 198015 July 2003 | Nonprofit Management and Leadership, Vol. 13, No. 4Databases for Research on Nonprofit Health Care Organizations16 November 2016 | American Behavioral Scientist, Vol. 45, No. 10Health Care Organizations: For-profit and NonprofitHospital Conversions, Margins, And The Provision Of Uncompensated CareA new nationwide study finds that uncompensated care levels decline when nonprofit hospitals convert to for-profit status.Kenneth E. Thorpe, Curtis S. Florence, and Eric E. Seiber13 December 2018 | Health Affairs, Vol. 19, No. 6Public Hospitals: Privatization And Uncompensated CareIn California, Florida, and Texas, former public hospitals provided less uncompensated care after they became for-profit entities.Kamal R. Desai, Carol VanDeusen Lukas, and Gary J. Young13 December 2018 | Health Affairs, Vol. 19, No. 2