Hospitals' Community Influence, Responsibility Growing

Hospitals will need to invest in efforts to improve the community's social determinants of health if they want to reduce preventable illness.

When we talk about healthcare quality at hospitals, it is usually in terms of accurate diagnoses, appropriate testing, and evidence-based treatments. But, hospitals are now being asked to pull the lens back and look at quality more broadly.

The change comes with shifting Internal Revenue Service rules, the Affordable Care Act, and evidence linking life struggles such as poor housing with the risk of illness. Now, many healthcare organizations are being held responsible for the health status of their communities, not just their patients.  

And we're not talking about community blood drives.

The Centers for Medicare & Medicaid Services' 2016 Quality Strategy calls for the creation of programs to address the so-called "social determinants of health," which the agency describes as "the conditions in which people are born, grow, work, live, and age, and the wider set of forces and systems shaping the conditions of daily life and improving health outcomes."

Isn't that the job of social workers or community activists? It is, but hospitals are now being asked to play a role as well—and it's not one that comes easily.

Gary Young, director of the Northeastern University Center for Health Policy and Healthcare Research in Boston, says the ACA's Community Health Needs Assessment requirement is intended to integrate hospitals more tightly into the public health Infrastructure.

As it is, Young's research team recently reported wide variation in community benefit spending by hospitals. 

"Hospitals have always been focused on treatment and not prevention and promotion," Young says. "That's what they've been paid to do. From a cultural standpoint, that's the orientation of hospitals. "

They do not have the infrastructure—intellectual or material—to deal with community health, he says. However, they are facing a paradigm shift.  

One place where they may find allies in the effort is at state and city health departments. New findings out of Yale University suggest a positive association between social services spending and better health outcomes.

With new payment models linked to population health, the study makes these partnerships more inviting and offers a metric the C-suite needs to consider.

The researchers found that residents of states with a higher ratio of social to health spending (calculated as social service and public health spending divided by Medicare and Medicaid spending) had better health outcomes on a number of measures, including adult obesity, asthma, mortality rates for lung cancer, heart attacks, and type 2 diabetes.

Lead author Elizabeth Bradley, a professor at the Yale School of Public Health, says the study, which focuses on spending rather than services, is one more piece of evidence to support the idea that social services lead to better health.

Rather than count programs or list anecdotes, the study offers "qualitative, very empirically based, heavily statistical evidence," she said.  

As hospitals move toward accountable care organization models, they face the same problem that state policy makers have: How much should I be spending on social services?  

"Our research would suggest a balanced portfolio of investments if you want to improve people's health," she said. "You have to take care of their nutrition and their housing or you will end up paying more for their medical care."  

The changes are being driven not just by CMS, but also from the IRS, which grants tax-exempt status to the nation's nonprofit hospitals.

Hospitals are under pressure to justify their tax breaks, and a debate is underway over what qualifies as community services under the IRS rules. The discussion involves a dizzying effort to sort out IRS rules for "community benefits" versus "community building."

So, it's no wonder there's a lot of confusion. On the American Hospital Association's website, a page devoted to "tax-exempt status" lists widely varying community benefits contributions—and definition—reported by state hospital associations.

Calculations include financial assistance to needy patients, Medicaid losses, and subsidized health services, defined in Virginia as "billed clinical services hospitals provide to patients where reimbursements fail to cover hospitals' cost." They also include money for traditional community services like mobile clinics, support groups, and asthma education.  

What About Social Services?

"Many hospital administrators, if they are being candid, would say: That is not our job," Young of Northeastern says. "We're are not a public health department. We treat people who we are sick. Now you're asking us to get involved in social services… We can't be all things to all people." 

However, he says, there is a push to allow hospitals to include social services in their accounting of community benefits reported to the IRS.

In December, the IRS complied in part and decided that some "housing improvements and other spending on social determinants of health that meet a documented community need may qualify as community benefit."

For some communities—like West Baltimore—the link between social needs and health is so glaring that the Bon Secours Health System did its community needs assessment more than 20 years ago, says Curtis Clark, the health system's vice president of mission.

He says he thinks that approach—known as Community Works—offers lessons for more affluent communities where the issues may be underemployment and prescription drug abuse.

His advice to hospitals that are now setting out on the same journey: Don't assume you know what the community wants. In a neighborhood where street corner drug dealers were the inspiration for the gritty television series "The Wire," his team thought crime and drugs would be major issues.

Instead, residents wanted help dealing with trash and rats. Clark says "the most salient point to understand is the importance of genuine community engagement—genuine partnering, genuine co-creation of the healthy communities predicated on the dignity of the person. "