"A Threat to All Texas Physicians:" TMA Backs Surgeon in Defamation Suit.

Miguel Gomez, MD's well-publicized legal fight isn't over yet. In its latest turn, the Texas Medical Association is still standing behind the surgeon as he fights to uphold a verdict against one of the state's largest nonprofit hospital systems for defaming him.

State-Level Community Benefit Regulation and Nonprofit Hospitals' Provision of Community Benefits.

Do nonprofit hospitals provide enough community benefits to justify their tax exemptions? States have sought to enhance nonprofit hospitals' accountability and oversight through regulation, including requirements to report community benefits, conduct community health needs assessments, provide minimum levels of community benefits, and adhere to minimum income eligibility standards for charity care. However, little research has assessed these regulations' impact on community benefits. Using 2009-11 Internal Revenue Service data on community benefit spending for more than eighteen hundred hospitals and the Hilltop Institute's data on community benefit regulation, we investigated the relationship between these four types of regulation and the level and types of hospital-provided community benefits. Our multivariate regression analyses showed that only community health needs assessments were consistently associated with greater community benefit spending. The results for reporting and minimum spending requirements were mixed, while minimum income eligibility standards for charity care were unrelated to community benefit spending. State adoption of multiple types of regulation was consistently associated with higher levels of hospital-provided community benefits, possibly because regulatory intensity conveys a strong signal to the hospital community that more spending is expected. This study can inform efforts to design regulations that will encourage hospitals to provide community benefits consistent with policy makers' goals.

The Progress of US Hospitals in Addressing Community Health Needs.

OBJECTIVES: To identify how US tax-exempt hospitals are progressing in regard to community health needs assessment (CHNA) implementation following the Patient Protection and Affordable Care Act. METHODS: We analyzed data on more than 1500 tax-exempt hospitals in 2013 to assess patterns in CHNA implementation and to determine whether a hospital's institutional and community characteristics are associated with greater progress. RESULTS: Our findings show wide variation among hospitals in CHNA implementation. Hospitals operating as part of a health system as well as hospitals participating in a Medicare accountable care organization showed greater progress in CHNA implementation whereas hospitals serving a greater proportion of uninsured showed less progress. We also found that hospitals reporting the highest level of CHNA implementation progress spent more on community health improvement. CONCLUSIONS: Hospitals widely embraced the regulations to perform a CHNA. Less is known about how hospitals are moving forward to improve population health through the implementation of programs to meet identified community needs.

Health and Taxes: Hospitals, Community Health and the IRS.

The Affordable Care Act created new conditions of federal tax exemption for nonprofit hospitals, including a requirement that hospitals conduct a community health needs assessment (CHNA) every three years to identify significant health needs in their communities and then develop and implement a strategy responding to those needs. As a result, hospitals must now do more than provide charity care to their patients in exchange for the benefits of tax exemption. The CHNA requirement has the potential both to prompt a radical change in hospitals' relationship to their communities and to enlist hospitals as meaningful contributors to community health improvement initiatives. Final regulations issued in December 2014 clarify hospitals' obligations under the CHNA requirement, but could do more to facilitate hospitals' engagement in collaborative community health projects. The Internal Revenue Service (IRS) has a rich opportunity, while hospitals are still learning to conduct CHNAs, to develop guidance establishing clear but flexible expectations for how providers should assess and address community needs. This Article urges the IRS to seize that opportunity by refining its regulatory framework for the CHNA requirement. Specifically, the IRS should more robustly promote transparency, accountability, community engagement, and collaboration while simultaneously leaving hospitals a good degree of flexibility. By promoting alignment between hospitals' regulatory compliance activities and broader community health improvement initiatives, the IRS could play a meaningful role in efforts to reorient our system towards promoting health and not simply treating illness.

Medicine as a Public Calling.

The debate over how to tame private medical spending tends to pit advocates of government-provided insurance--a single-payer scheme--against those who would prefer to harness market forces to hold down costs. When it is mentioned at all, the possibility of regulating the medical industry as a public utility is brusquely dismissed as anathema to the American regulatory tradition. This dismissiveness, however, rests on a failure to appreciate just how deeply the public utility model shaped health law in the twentieth century-- and how it continues to shape health law today. Closer economic regulation of the medical industry may or may not be prudent, but it is by no means incompatible with our governing institutions and political culture. Indeed, the durability of such regulation suggests that the modern embrace of market-based approaches in the medical industry may be more ephemeral than it seems.

Building community while complying with the Affordable Care Act in the Lehigh Valley of Pennsylvania.

PROBLEM: The Affordable Care Act (ACA) requires nonprofit hospitals to conduct community health needs assessments (CHNA) every 3 years. Best practices for CHNAs are still emerging and, along with growing economic pressures, contribute to uncertainty about the short- and long-term costs hospitals will face as a result of the ACA. PURPOSE: This article describes a community-based partnership coordinated by a nonprofit hospital and a consortium of academic institutions as a model for conducting a CHNA. KEY POINTS: Similar partnerships offer key advantages in complying with the ACA: local academic institutions are existing stakeholders in the community--they possess research expertise and have a vested interested in shaping implementation strategies to improve health; the process of collaborating itself helps to generate community resources, conceive of community health as a shared and iterative enterprise, and mobilize community partners in supporting long-term health priorities. CONCLUSIONS: No CHNA is ever perfect, but there are compelling reasons for nonprofit hospitals to seek community-based partnerships, not only because such partnerships comply with the law but, more importantly, because they hold great promise for linking the CHNA process and results to the health realities of local communities, ultimately bolstering community engagement while creating shared health priorities.

Policy commercializing nonprofits in health: the history of a paradox from the 19th century to the ACA.

UNLABELLED: POLICY POINTS: Health policy in the United States has, for more than a century, simultaneously and paradoxically incentivized the growth as well as the commercialization of nonprofit organizations in the health sector. This policy paradox persists during the implementation of the Affordable Care Act of 2010. CONTEXT: For more than a century, policy in the United States has incentivized both expansion in the number and size of tax-exempt nonprofit organizations in the health sector and their commercialization. The implementation of the Affordable Care Act of 2010 (ACA) began yet another chapter in the history of this policy paradox. METHODS: This article explores the origin and persistence of the paradox using what many scholars call "interpretive social science." This methodology prioritizes history and contingency over formal theory and methods in order to present coherent and plausible narratives of events and explanations for them. These narratives are grounded in documents generated by participants in particular events, as well as conversations with them, observing them in action, and analysis of pertinent secondary sources. The methodology achieves validity and reliability by gathering information from multiple sources and making disciplined judgments about its coherence and correspondence with reality. FINDINGS: A paradox with deep historical roots persists as a result of consensus about its value for both population health and the revenue of individuals and organizations in the health sector. Participants in this consensus include leaders of governance who have disagreed about many other issues. The paradox persists because of assumptions about the burden of disease and how to address it, as well as about the effects of biomedical science that is translated into professional education, practice, and the organization of services for the prevention, diagnosis, treatment, and management of illness. CONCLUSIONS: The policy paradox that has incentivized the growth and commercialization of nonprofits in the health sector since the late 19th century remains influential in health policy, especially for the allocation of resources. However, aspects of the implementation of the ACA may constrain some of the effects of the paradox.

Nonprofit hospitals' approach to community health needs assessment.

OBJECTIVES: We sought a better understanding of how nonprofit hospitals are fulfilling the community health needs assessment (CHNA) provision of the 2010 Patient Protection and Affordable Care Act to conduct CHNAs and develop CHNA and implementation strategies reports. METHODS: Through an Internet search of an estimated 179 nonprofit hospitals in Texas conducted between December 1, 2013, and January 5, 2014, we identified and reviewed 95 CHNA and implementation strategies reports. We evaluated and scored reports with specific criteria. We analyzed hospital-related and other report characteristics to understand relationships with report quality. RESULTS: There was wide-ranging diversity in CHNA approaches and report quality. Consultant-led CHNA processes and collaboration with local health departments were associated with higher-quality reports. CONCLUSIONS: At the time of this study, the Internal Revenue Service had not yet issued the final regulations for the CHNA requirement. This provides an opportunity to strengthen the CHNA guidance for the final regulations, clarify the purpose of the assessment and planning process and reports, and better align assessment and planning activities through a public health framework.

Preparing for section 501(r).

Steps hospitals should take to prepare for Section 501(r) requirements include the following: Prepare the board for its role in approving updated financial assistance, billing and collections, and emergency medical care policies. Revisit financial assistance policy eligibility requirements. Conduct a policy gap analysis. Review how the current financial assistance policy is publicized and make adjustments where necessary.

What can be learned from the types of community benefit programs that hospitals already have in place?

After implementation of the Patient Protection and Affordable Care Act (ACA) how will tax-exempt hospitals adjust their community benefit programs to maintain their non-profit status? This literature review categorized existing hospital-based community benefit programs by reviewing published articles that met the following inclusion criteria: affiliated or funded by a hospital; described the program design; focused on community benefit or outreach; evaluated program outcomes; located within the United States. Of 4,917 original citations, we reviewed 265 full-text articles. One hundred and six (106) programs met all inclusion criteria and were used to develop a hospital-based community benefit program taxonomy. Results indicate that programs to enhance patient care, clinic-based programs and programs with a community partner make up the majority of community benefit programs (25%, 28% and 31%, respectively). Few programs were rigorously evaluated or provide evidence of program impact. Hospitals should work with public health professionals to design, implement, and evaluate their community benefit programs.

The Affordable Care Act and community benefit: a mandate Catholic health care can (partly) embrace.

The 2010 Patient Protection and Affordable Care Act (ACA) requires not-for-profit hospitals, including Catholic hospitals, to engage in meaningful community assessment and collaboration efforts in order to maintain their tax-exempt status. Now that the ACA has been upheld by the U.S. Supreme Court, this paper argues that the requirements related to a more robust community engagement process should be embraced by Catholic not-for-profit hospitals and health systems. Apart from the legal requirements under ACA, an equally persuasive moral mandate to engage in community-level assessment and action exists in the ethical tradition of Catholic health care, particularly in the notions of the common good, preferential option for the poor, and subsidiarity. This paper examines the compelling nature of these moral norms in light of the dual goals of improving overall community health and reducing health disparities among vulnerable populations. It concludes with the examination of one model of community collaboration: Mobilizing for Action through Planning and Partnerships (MAPP).

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.