Threatening Nonprofit Hospital Tax Exemption: A Better Path Forward.

This Viewpoint discusses regulation of nonprofit hospitals in a way that will advance their charitable purposes without eliminating their tax exemption status.

The Policy Alliance Between Hospitals and Debt Collection Agencies: Content Analysis of Public Comments on Regulations on Billing and Collections.

Significant debate persists about the obligations of nonprofit hospitals toward low-income patients. Many issues pertaining to this subject were discussed during the rulemaking process following the passage of the Affordable Care Act of 2010, which set forth rules for hospital billing and collection. In public comments, hospitals, debt collectors, and patient advocates debated what constituted "reasonable efforts" to determine whether a patient qualified for hospital financial assistance before resorting to extraordinary collection actions including lawsuits, wage garnishments, and adverse credit reporting. This study analyzes public comments to the proposed Internal Revenue Service rule on section 501(r)(6). After an initial review of the data, 5 commonly mentioned issues were identified. Respondents were organized into commenter types, and the opinion of each respondent to each issue was coded by 2 separate reviewers. Discrepancies between reviewer determinations were resolved by consensus during follow-up discussions. This analysis revealed a set of common concerns: whether reporting delinquent medical debt to credit bureaus and selling debt to third party buyers should be considered extraordinary collection actions; whether hospitals should be able to use presumptive eligibility to rule patients either eligible or ineligible for financial assistance; and whether hospitals should be held legally liable for the actions of third-party debt collectors. Hospitals and debt collection agencies were allied on most issues, particularly in their shared belief that reporting debt to credit bureaus and selling debt to third parties should not be tightly regulated. Patient advocacy organizations and hospitals had divergent opinions on most issues. The alliance of hospitals and debt collectors in advocating for fewer regulations around collections is part of a history of hospital lobbying to maintain tax-exemption with fewer charity care mandates. This alignment helps explain why third-party debt collection agencies, and aggressive collection tactics, have become commonplace in hospital billing.

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

OBJECTIVE: 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. DESIGN: 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. SETTING: The United States. PARTICIPANTS: 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. MAIN OUTCOME MEASURES: 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. RESULTS: 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. CONCLUSIONS: 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.

Provision of Social Care Services by US Hospitals.

Policy Points Hospitals address population health needs and patients' social determinants of health by offering social care services. Tax-exempt hospitals are required to invest in community benefits, including social care services programs, though most community benefits spending is toward unreimbursed health care services. Tax-exempt hospitals offer about 36% more social care services than for-profit hospitals. Among tax-exempt hospitals, those that allocate more resources to community benefits spending offer more types of social care services, but those in states with minimum community benefits spending requirements offer fewer social care services. Policymakers may consider specifically incentivizing community benefits expenditures toward particular social care services, including linking tax exemptions to implementation, utilization, and outcome targets, to more directly help patients. CONTEXT: Despite growing interest in identifying patients' social needs, little is known about hospitals' provision of services to address them. We identify social care services offered by US hospitals and determine whether hospital spending or state policies toward community benefits are associated with the provision of these services by tax-exempt hospitals. METHODS: National secondary data about hospitals were collected from the American Hospital Association Annual Survey, with additional Internal Revenue Service (IRS) Form 990 data on community benefits spending from CommunityBenefitInsight.org and state-level community benefits policies from HilltopInstitute.org. Descriptive statistics for types of social care services and hospital characteristics were calculated, with bivariate chi-square and t-tests comparing for-profit and tax-exempt hospitals. Multivariable Poisson regression was used to estimate associations between hospital characteristics and types of services offered and among tax-exempt hospitals to estimate associations between social care services and community benefits spending and policies. Multivariable logistic regressions modeled associations between community benefits spending/policies and each type of social care services. FINDINGS: Private US hospitals offered an average of 5.7 types of social care services in 2018. Tax-exempt hospitals offered about 36% more social care services than for-profit hospitals. Larger number of beds, health system affiliation, and having community partnerships are associated with more social care services, whereas rural hospitals and those managed under contract offered fewer social care services. Among tax-exempt hospitals, greater community benefits spending is associated with offering more total (incidence rate ratio [IRR] = 1.10, p < 0.01) and patient-focused social care services (IRR = 1.16, p < 0.01). Hospitals in states with minimum community benefits spending requirements offered significantly fewer social care services. CONCLUSIONS: Although tax-exempt status and increased community benefits spending were associated with increased social care services provision, the observation that certain hospital characteristics and state minimum community benefits spending requirements were associated with fewer social care services suggests opportunities for policy reform to increase social care services implementation.

Trends in the Provision of Community-Building Activities by Nonprofit Hospitals, 2010-2019.

As part of their annual tax report, nonprofit hospitals are asked to report their community-building activities (CBAs); yet, little is known to date about hospitals' spending on such activities. CBAs are activities that improve community health by addressing the upstream factors and social determinants that impact health. Using data from Internal Revenue Service Form 990 Schedule H, this study used descriptive statistics to examine trends in the provision of CBAs by nonprofit hospitals between 2010 and 2019. While the number of hospitals reporting any CBA spending remained relatively stable at around 60%, the share of total operating expenditures that hospitals contributed to CBAs decreased from 0.04% in 2010 to 0.02% in 2019. Despite the increasing attention paid by policy makers and the public to the contributions that hospitals make to the health of their communities, nonprofit hospitals have not made corresponding efforts to increase their spending on CBAs.

When States Mandate Hospital Community Benefit Reports, Provision Increases.

GOAL: We examined the variation in community benefit and charity care reporting standards mandated by states to determine whether state-mandated community benefit and charity care reporting is associated with greater provision of these services. METHODS: We used 2011-2019 data from IRS Form 990 Schedule H for 1,423 nonprofit hospitals to create a sample of 12,807 total observations. Random effects regression models were used to examine the association between state reporting requirements and community benefit spending by nonprofit hospitals. Specific reporting requirements were analyzed to determine whether certain requirements were associated with increased spending on these services. PRINCIPAL FINDINGS: Nonprofit hospitals in states that required reports spent a higher percentage of total hospital expenditures on community benefits (9.1%, SD = 6.2%) compared to states without these requirements (7.2%, SD = 5.7%). A similar association between the percentage of charity care and total hospital expenditures (2.3% and 1.5%) was found. The greater number of reporting requirements was associated with lower levels of charity care provision, as hospitals allocated more resources to other community benefits. PRACTICAL APPLICATIONS: Mandating the reporting of specific services is associated with greater provision of certain specific services, but not all. A concern is that when many services must be reported, the provision of charity care might be reduced as hospitals choose to allocate their community benefit dollars to other categories. As a result, policymakers may want to focus their attention on the services they most want to prioritize.

Influence of Not-for-Profit Hospital Ownership Type on Community Benefit and Charity Care.

Non-profit hospitals are expected to provide charity care and other community benefits to adjust their tax exemption status. Using the Medicare Hospital Cost Report, American Hospital Association Annual Survey, and the American Community Survey datasets, we examined if church-affiliated hospitals spent more on charity care and community benefit. For this analysis, we defined five main categories of community benefits were measured: total community benefit; charity care; Medicaid shortfall; unreimbursed other means-tested services; and the total of unreimbursed education and unfunded research. Multiple regression was used to examine the effect of church ownership, controlling for other factors, on the level of community benefit in 2644 general acute care non-profit hospitals. Descriptive analyses and multiple regression were used to show the relationship between the provision of community benefits and church affiliation including Catholic (CH), other church-affiliated hospitals (OCAH), and non-church affiliated hospitals (NCAH). The non-profit hospital on average spent 6.5% of its total expenses on community benefits. NCAH spent 6.09%, CH spent 7.5%, and OCAH spent 9.4%. Non-profits spent 2.8% of their total expenses on charity care, with the highest charity care spending for OCAH (5.2%), followed by CH (3.9%), and NCAH (2.4%). Regression results showed that CH and OCAH, on average, spent 1.08% and 2.16% more on community benefits than NCAHs. In addition, CH and OCAH spent more on other categories of community benefits except for education and research. Church-affiliated hospitals spend more on community benefits and charity care than non-church affiliated nonprofit hospitals.

Association between non-profit hospital community benefit spending and health outcomes.

OBJECTIVE: To determine if greater non-profit hospital spending for community benefits is associated with better health outcomes in the county where they are located. DATA SOURCES AND STUDY SETTING: Community benefit data from IRS Form 990/Schedule H was linked to health outcome data from Area Health Resource Files, Map the Meal Gap, and Medicare claims from the Center for Medicare and Medicaid Services at the county level. Counties with at least one non-profit hospital in the United States from 2015 to 2019 (N = 5469 across the 5 years) were included. STUDY DESIGN: We ran multiple regressions on community benefit expenditures linked with the number of health professionals, food insecurity, and adherence to diabetes and hypertension medication for each county. DATA COLLECTION: The three outcomes were chosen based on prior studies of community benefit and a recent survey sent to 12 health care executives across four regions of the U.S. Data on community benefit expenditures and health outcomes were aggregated at the county level. PRINCIPAL FINDINGS: Average hospital community benefit spending in 2019 was $63.6 million per county ($255 per capita). Multivariable regression results did not demonstrate significant associations of total community benefit spending with food insecurity or medication adherence for diabetes. Statistically significant associations with the number of health professionals per 1000 (coefficient, 12.10; SE, 0.32; p < 0.001) and medication adherence for hypertension (marginal effect, 0.27; SE, 0.09; p = 0.003) were identified, but both would require very large increases in community benefit spending to meaningfully improve outcomes. CONCLUSIONS: Despite varying levels of non-profit hospital community benefit investment across counties, higher community benefit expenditures are not associated with an improvement in the selected health outcomes at the county level. Hospitals can use this information to reassess community benefit strategies, while federal, state, and local governments can use these findings to redefine the measures of community benefit they use to monitor and grant tax exemption.

One Decade Later: The Generalizability, Diversity, and Inclusion of Community Health Needs Assessments.

CONTEXT: The 2010 Patient Protection and Affordable Care Act aimed to reduce health disparities and change medicine to be more community-driven. To maintain tax-exempt status, hospitals must complete a Community Health Needs Assessment (CHNA) every 3 years. This assessment must ( a ) integrate input from individuals the community serves, ( b ) make the report publicly assessable, and ( c ) adopt an implementation strategy based on community health needs identified in the assessment. However, there is little information on how representative CHNAs are of the community. DESIGN: A content analysis was performed on a random sample of CHNA reports. SETTING: This investigation examined nonprofit hospitals across the United States. OBJECTIVES: This investigation analyzed the quality of CHNAs and described existing CHNA practices through 4 means: (1) identified the type of data included; (2) examined the frequency in the methods of data collection; (3) understood how representative those data are of the hospital's service region; and (4) explored to what extent the hospital addressed diversity and inclusion such as through recruitment. METHODS: A stratified random sample was drawn of CHNAs published in the past 3 years (n = 450 reports). The sample was stratified by the US Department of Agriculture's Rural-Urban Continuum codes to balance hospital representation from metro and nonmetro areas. RESULTS: A series of dependent t tests revealed that these hospitals' reports represented a significantly more female, White, college-educated, and older population than the service area. In addition, only 3.12% of hospitals collected primary youth data. Finally, results also found that survey recruitment was not inclusive of individuals who did not have Internet access, could not read, or did not speak English fluently.

Proadi-SUS: analysis of financial resources in the three-year periods 2009-2011, 2012-2014 and 2015-2017 / Proadi-SUS: análise dos recursos financeiros nos triênios 2009-2011, 2012-2014 e 2015-2017

ABSTRACT OBJECTIVE To characterize the tax exemption resources used in the Support Program for Institutional Development of the Unified Health System (Proadi-SUS) in the 3-year periods 2009-2011, 2012-2014, 2015-2017, considering the total volume of resources linked to the debate on tax expenditures on health and the constitution of a "new form of philanthropy" in the sector. METHODS To understand the philanthropic sector, tax expenditures between 2001 and 2017 were analyzed. To evaluate the resources used in the program, the values of projects and areas of activity were examined. RESULTS A real increase in the values of general tax expenses and tax expenses referring to the philanthropic sector was found. There was also a real increase in the program's resources. A total of 407 projects were carried out, amounting to R$ 3.4 billion for the period. An analysis of the average value of the projects shows an increase in values for all hospitals included in the program, with the exception of one of the institutions. In the 2009-2011 and 2012-2014 periods, the area with the highest number of projects and the most resources was "Management techniques and operation in health services". In the 3-year period 2015-2017, however, the sector that received the most investments and the largest number of projects developed was "Human Resources Training". CONCLUSION The program characterizes a different expression of the public-private partnership in the health sector linked to the principles of the new public management. As a development for future investigations, a qualitative characterization of the projects developed and the actions' impact on the public sector demands is necessary.

RESUMO OBJETIVO Caracterizar os recursos de isenção fiscal usufruídos no Programa de Apoio ao Desenvolvimento Institucional do Sistema Único de Saúde (Proadi-SUS) nos triênios 2009-2011, 2012-2014, 2015-2017, considerando o volume total dos recursos atrelado ao debate dos gastos tributários em saúde e a constituição de uma "nova modalidade de filantropia" no setor. MÉTODOS Para compreender o setor filantrópico, analisaram-se os gastos tributários no período de 2001 e 2017. Para avaliar os recursos utilizados no programa, foram examinados os valores dos projetos e das áreas de atuação. RESULTADOS Foi constatado um crescimento real dos valores dos gastos tributários gerais e dos gastos tributários referentes ao setor filantrópico. Constatou-se, também, um aumento real dos recursos do programa. Foram realizados 407 projetos, totalizando um valor de R$ 3,4 bilhões para o período. Ao se analisar o valor médio dos projetos, explicita-se ampliação dos valores para todos os hospitais inseridos no programa, com exceção de uma das instituições. Nos triênios 2009-2011 e 2012-2014, a área de atuação com maior número de projetos e mais recursos foi a "Área de técnicas e operação de gestão em serviços de saúde". Já no triênio 2015-2017, o setor que contou com mais investimentos e maior número de projetos desenvolvidos foi o de "Capacitação de recursos humanos". CONCLUSÃO O programa caracteriza outro patamar na relação do setor público com o setor privado/empresariado da saúde, atrelado aos princípios da nova gestão pública. Faz-se necessária, como desdobramento para futuras investigações, uma caracterização qualitativa dos projetos desenvolvidos e do impacto das ações diante das demandas do setor público.

Understanding the relationship between nonprofit hospital community benefit spending and system membership: An analysis of independent hospital acquisitions.

The Internal Revenue Service (IRS) requires nonprofit hospitals to report community benefit spending to justify their nonprofit tax exemption. We examined whether nonprofit hospital acquisitions influence the amount and type community benefit spending. We analyzed 2011-2018 data on urban, nonprofit hospitals. The analysis dataset included 57 hospitals that were acquired and a matched control group. We estimated difference-in-differences specifications to measure the effect of acquisitions on total community benefit spending, and three subcategories - clinical, population health, and other spending types. We found that acquisitions led to decreased population health spending (-$0.32 million, p < 0.01) and other spending categories (-$1.5 million, p < 0.05), but no significant change in total or clinical spending. If the acquirer was located out-of-state, total community benefit spending declined by $2.4 million (p < 0.10). Our findings support the need for community benefit spending to be considered, along with quality, efficiency, and prices, when evaluating the welfare impact of acquisitions.

Characteristics of US hospitals using extraordinary collections actions against patients for unpaid medical bills: a cross-sectional study.

OBJECTIVE: This study aims to characterise and evaluate the largest 100 hospitals in the USA that have adopted aggressive collection tactics to pursue patients with unpaid medical bills, such as lawsuits, wage garnishments and liens. DESIGN: Cross-sectional study. SETTING: We examined state and county court record systems to measure the magnitude and prevalence of these practices at the largest 100 hospitals in the UA between 1 January 2018 and 31 July 2020. MAIN OUTCOMES MEASURES: The main outcome of this study was the number of lawsuits, wage garnishments and liens. A secondary outcome was the characterisation of a hospital's safety, charitability, size and financial practices. RESULTS: Between 1 January 2018 and 31 July 2020, 26 hospitals filed 38 965 court actions (lawsuits, wage garnishments and liens) against patients for unpaid medical debt. For 16 of 26 hospitals, the dollar amount pursued in the court claim was available for 100% of cases, totalling US$71.8 million. The average aggregate amount sought by hospital lawsuits during the study period was US$4.5 million. Three hospitals filed US$56.2 million in amounts pursued in court, or 78.3% of the total amount pursued by all hospitals in the sample. In the remaining 74 hospitals, the study team did not identify extraordinary collection actions through the court system. CONCLUSIONS: Standardised medical debt collections best practices and metrics of medical debt collections quality are needed to increase public accountability for hospitals, particularly non-profit hospitals. There is a need to re-evaluate Internal Revenue Service rules pertaining to non-profit hospitals' tax-exempt status to ensure tax-exempt hospitals provide community benefits commensurate with the value of tax exemption.

Shifts in Community Benefits Spending Among Nonprofit Hospitals in Nebraska and 10 Proximate States, 2012 and 2015.

CONTEXT: Federal and state policy makers have debated the evolving concept of community benefit and the extent to which nonprofit hospitals are providing benefits to the community in exchange for the tax benefits they receive. OBJECTIVE: This study compares community benefits spending by nonprofit hospitals in Nebraska and other selected states in both 2012 and 2015. Expenditures are also examined by rural, regional, and urban hospitals within Nebraska. METHODS: Community benefit expenditure data were taken from Community Benefit Insight and consolidated into the categories of direct patient care, community health improvement initiatives, and health professions education and research. RESULTS: When community benefit expenditures were compared across 11 states, Nebraska had the highest percentage of expenditures for community health improvement initiatives in both 2012 and 2015. Although community benefit expenditures for the 44 nonprofit hospitals within Nebraska increased from 2012 to 2015, they remained flat as a share of total hospital expenditures. In 2015, 63% of community benefit expenditures were allocated to direct patient care, which represented a 7.3% decrease from 2012. This decline led to greater spending on community health improvement initiatives (3.1%) and health professions education and research (4.2%). Rural, regional, and urban hospitals spent more proportionately on community health improvement initiatives in 2015 than in 2012. CONCLUSIONS: The shift in community benefit expenditures from direct patient care to community health improvement initiatives and health professions education and research suggests that hospitals are investing in programs with broader community-wide benefits. Nebraska allocates a significantly larger share of its community benefits spending to community health improvement activities than other Great Plains and Midwestern states. Nebraska is in the process of implementing Medicaid expansion, which may shift future community benefits spending decisions.

Comparing the value of community benefit and Tax-Exemption in non-profit hospitals.

OBJECTIVE: We examined the characteristics of non-profit hospitals providing more community benefits and charity care than value of their tax exemptions and how this relationship changed between 2011 and 2018. DATA SOURCES: Primary dataset was schedule H Form IRS 990 data. This data was merged with the American Hospital Association, Medicare Hospital Cost Report, and the America Community Survey. STUDY DESIGN: We measured six categories of tax benefits and 17 types of community benefits. Subtracting the average value of community benefits provided by for-profit hospitals, we computed incremental community benefit and charity care provided by each non-profit hospital. EXTRACTION METHODS: A nationally representative sample was created of 11 776 non-profit hospital-year observations from 1472 unique hospitals over the 2011 to 2018 period was created. Descriptive analyses and random effect logistic regression were used to show associations between hospital characteristics and difference between incremental net community benefits and the value of tax-exemption. PRINCIPAL FINDINGS: After adjusting for community benefits provided by for-profits hospitals, on average, non-profit hospitals spent 5.9% (CI: 5.8%-6.0%) of their total expenses on community benefits; 1.3% (CI: 1.2%-1.3%) on charity care; and received 4.3% (CI: 4.2%-4.4%) of total expenses in tax exemptions. A total of 38.5% of non-profit hospitals did not provide more community benefit and 86% did not provide more charity care than the value of their tax exemption. Hospitals with fewer beds, providing residency education and located in high poverty communities were more likely to provide more incremental community benefits and charity care than the value of their tax exemption, while system affiliation had a negative association. CONCLUSION: The amount of community benefits and charity care provided by non-profits varied substantially across non-profit hospitals. Establishing minimum requirements for non-profit hospitals or publicly ranking hospitals based on their community benefit or charity care contributions, could encourage greater community benefits and charity care.

Effects of the Out-of-pocket Payment Exemption in the Public Health Center on Medical Utilization of the Korean Elderly.

OBJECTIVES: The distribution of hospitals in Korea is unbalanced in terms of accessibility. Many local public health centers (PHCs) exempt out-of-pocket payments (OOPs) based on local government laws to increase coverage. However, this varies across administrative regions, as many make this exemption for the elderly, while others do not. This study aimed to evaluate the effects of the OOP exemption at local PHCs among elderly individuals. METHODS: This study used online data on Korean national law to gather information on individual local governments' regulations regarding OOP exemptions. Individual-level data were gathered from the 2018 Community Health Survey and regional-level data from public online sources. RESULTS: The study analyzed 132 regions and 44 918 elderly people. A statistical analysis of rate differences and 2-level multiple logistic regression were carried out. The rate difference according to whether elderly individuals resided in areas with the OOP exemption was 1.97%p (95% confidence interval [CI], 1.07 to 2.88) for PHC utilization, 1.37%p (95% CI, 0.67 to 2.08) for hypertension treatment, and 2.19%p (95% CI, 0.63 to 3.74) for diabetes treatment. The regression analysis showed that OOP exemption had an effect on hypertension treatment, with a fixed-effect odds ratio of 1.25 (95% CI, 1.05 to 1.48). CONCLUSIONS: The OOP exemption at PHCs can affect medical utilization in Korea, especially for hypertension treatment. The OOP exemption should be expanded to improve healthcare utilization in Korea.

Community Benefit: Policies, Practices, and Opportunities at the Half-Century Mark.

In the 50 years since the expansion of the legal definition of charity for tax-exempt hospitals, there have been periodic regulatory actions at the municipal, state, and federal level to quantify charitable contributions and justify the deferral of tax revenues. The movement toward risk-based reimbursement in the last decade creates an incentive for a shift in hospital leadership understanding and approach to community benefit programs and services. The historical interpretation of community benefit as an issue of compliance with legal obligations is being questioned by forward-thinking hospital leaders, in recognition that more strategic resource allocation offers the potential to reduce financial risk associated with preventable emergency department and inpatient utilization. Recent actions in the policy arena to strengthen community benefit practices, as well as policies in related areas such as homelessness and behavioral health, challenge hospitals to strengthen their focus on prevention. At the same time, increased availability of data on health care costs, mapping of health care utilization patterns, and parallel overlays of hospital location, jurisdictional boundaries, and the social determinants of health offer significant potential for informed public dialogue at the regional level that builds an ethic of shared ownership for health across sectors. Local public health agencies can play an important role by establishing baselines, goals, and objectives in communities where health inequities are concentrated within county and municipal jurisdictional boundaries to align and focus the assets of health, community development, and business sector stakeholders.