1. Leveraging Health Reform’s New Hospital Community Benefit Requirements to Address Unmet Needs
Jessica L. Curtis, JD
Director, Hospital Accountability Project
Community Catalyst
November 2010

2. Overview
Welcome
Community Benefit: What It Is, Why It Matters, and What the ACA Requires
Jessica Curtis, Community Catalyst
Best Practices and New Tools: How Hospitals Are Gearing Up for the New Law
Indu Spugnardi, Catholic Health Association
Integrating Public Health into Community Health Needs Assessment and Planning
Julia Joh, National Association of County & City Health Officials
Discussion
Community engagement and integration of public health priorities are hallmarks of strong hospital community benefit programs. The Affordable Care Act requires non-profit hospitals to conduct regular “community health needs assessments” and to address unmet health needs identified, with input from public health experts and community members.
© Community Catalyst 2010

3. Goals for Today
Clear understanding of new ACA requirements for hospitals and the opportunities they present for the communities they serve
What is “community benefit”?
Why is this an important issue for early implementation of the ACA?
What questions remain unanswered that require advocates’ attention?
Which communities and populations are of particular concern?
Learn about existing best practices and tools from hospitals and public health practitioners
How are hospitals and public health experts integrating community perspectives and members into their needs assessments and planning processes?
How can advocates and community members become more involved?
Begin a dialogue between advocates, hospitals, and public health experts
What are areas ripe for better collaboration? Areas of concern?
Advocates: are you currently involved in community/hospital work? What are some challenges and successes you have witnessed? Do you see opportunities stemming from these new requirements to improve access to care and address community health needs? If not, why not?
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4. Community Benefit Key Concepts New Standards for Hospitals
Policy Considerations
Who’s Still Vulnerable Now and After Implementation?
How Does This Connect to Other Policy Concerns?
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5. Our Nation’s Hospitals: Rooted in Charitable Care
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6. IRS standard for tax-exempt hospitals:
Provision of health = charitable purpose
Add at least one factor:
ER open to all, regardless of ability to pay
Community members on governance board
Extra $ goes to facility improvement, patient care, and medical training/education/research
Inpatient care for all, including Medicare/Medicaid
Open medical staff with privileges available to all qualifying physicians
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7. What is “community benefit”?
Unreimbursed goods, services, and resources provided by health care institutions offered in response to needs and concerns identified by the community, particularly those of people who are traditionally underserved (Community Catalyst/The Access Project, Community Benefits Workbook for Grassroots Leaders)
Flexible - local solutions to local problems
Inclusive - wide range of services and programs, so long as tied to community need; also includes all health care institutions serving a community
Empowering - community is engaged and involved in planning; particular focus placed on vulnerable, traditionally disenfranchised populations
Collaborative – involves leveraging existing resources in planning and implementation (e.g., public health, insurers)
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8. Community Benefit Can Include…
Charity care (or, financial assistance)
Includes reduced-cost care and care to the “medically indigent”
For all medically necessary services
Health and disease-screening programs that focus on increasing access to primary care and preventive health
Medicaid shortfall
Health research, training and education programs (provided they are related to identified community health needs)
Other services, resources and programs tied to identified community needs
- examples from Community Catalyst’s Model Act
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9. A Model Community Benefit Process
Clearly defined mission statement and board-level commitment
Community health needs assessment
Solicits comment from community groups, government officials, other providers
Incorporates and gathers available public health data
Gives community opportunity to review
Updated regularly (every 3 years)
Community benefits plan
Designed to: Increase access for targeted communities, address critical health care needs for targeted communities, OR foster measurable improvements for health
Includes other institutions and public health
Describes targeted community
Clear reporting on process, groups involved, priorities chosen, evaluation mechanisms
Public reporting, with opportunities for review and comment
- Community Catalyst’s Model Act and Commentary
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10. Consumer Values for Community Benefit
Collaborative process
Between health care institutions and communities they serve
Includes other institutions and public health
Broadly defined, but tied to community needs
Allows for flexibility
Requires active, ongoing engagement, discussion, and evaluation
Prioritizes unmet needs of vulnerable populations
Involved and engaged in decision-making and priority-setting
- Community Catalyst’s Model Act and Commentary
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11. New Standards for Hospitals
Summary of ACA’s requirements for tax-exempt hospitals
IRS oversight (Schedule H reporting)
Changes in funding for safety-net hospitals
An important point: each hospital in a system that qualifies for federal tax-exempt status has to individually meet these requirements. The first three requirements go into effect immediately; the fourth, to conduct a community health needs assessment, is in full effect by March 2012.
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12. New Standards for Non-Profit Hospitals
Have - and communicate - a written financial assistance and debt collection policy.
Say whether you offer free or discounted care
List eligibility criteria
Describe how to apply
Say how you decide charges
Explain steps you’d take to collect on a bill
Explain how you’ll publicize the policy widely in your community
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13. New Standards for Non-Profit Hospitals
Limit what you charge for care.
No more “gross charges”
Added protection for patients who qualify for financial assistance
Emergency or medically necessary services only
Amounts generally billed to insured patients
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14. New Standards for Non-Profit Hospitals
3. Stop unfair billing and collection activity.
No “extraordinary collection activity” unless you’ve made a “reasonable effort” to qualify the patient for financial assistance
Joint Committee on Taxation:
Lawsuits,liens on residences, arrests, body attachments, or similar acts
Notification upon admission and in written and oral communications with the patient regarding the patient’s bill, including invoices and telephone calls, before collection action
Joint Committee - Congressional committee showing congressional intent. Terms in quotes have yet to be defined.
© Community Catalyst 2010

15. New Standards for Non-Profit Hospitals
4. Conduct a community needs assessment.
Must seek input from people who “represent the broad interests” of the hospital’s community, including public health experts
Must make assessments available to the public
Every three years
$50,000 civil fine for failure to comply
Effective March 2012
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16. IRS Oversight Mechanisms
Annual reporting requirement for tax-exempt hospitals in Schedule H
Detailed questions on charity care and community benefit
Charity care based on ability to pay, in keeping with the hospital’s policy; no fixed eligibility guidelines
Broad range of community benefit or community-building activities
Community need must be established (request from community group can be used to demonstrate need)
Mix of hard numbers and descriptions, especially in defining a hospital’s community and their needs
ACA requires regular review of community benefits
Audited financial statements
Descriptions of how they are addressing identified community needs
Regular IRS review of community benefit
Treasury/HHS reports to Congress on bad debt, charity care, community benefit, and means-tested government program costs
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17. Schedule H currently includes questions about hospital efforts to enroll in public programs.
It’s very likely that Schedule H will be the tool the IRS uses to audit and measure compliance with the new requirements. There are key points in the Schedule that already ask questions that will let us know, to the extent that hospitals self-report it, what they’re doing. Here are examples about the charity care policy and a snippet showing questions about patient education. Note, too, the question circled here: this is an example of how form might go further than the law’s requirements and how this could be used in enrollment efforts down the line. It asks whether hospitals have helped patients enroll in public programs or the Exchange. So as we work to implement reform generally, this is just one example of how we could use community benefits to encourage hospitals to help implement reform in a way that makes sense for communities (e.g., by actively screening patients for eligibility in new programs).
© Community Catalyst 2010

18. Schedule H, Continued Charity care includes:
Free, reduced cost, and “medically indigent”
Notification of all programs, not just financial assistance
Community benefit = document a community need (reduce government burden, direct response to public agency or community group’s request)
Reduce government burden (e.g. address health disparities)
Public health initiatives, such as violence prevention, removing lead from homes, addressing air quality
Build up workforce
Medical interpreters
Community health advocacy (includes coalition-building)
© Community Catalyst 2010

19. Changes in Safety-Net Funding
Medicaid Disproportionate Share Hospital (DSH) funds
Federal allocation to be reduced and redistributed starting FY 2014
Biggest cuts to states that don’t target DSH to charity care/Medicaid, have higher numbers of insured, and aren’t low DSH
Consideration given to states that have used DSH funds in the past to expand coverage
© Community Catalyst 2010

20. Policy Considerations
Who’s Still Vulnerable Now and After Implementation?
How Can Community Benefit Address these Unmet Needs?
How Does Community Benefit Connect Up to Other Policy Concerns?
© Community Catalyst 2010

21. Vulnerable Populations
Uninsured and underinsured
People are struggling now with medical debt and finding affordable care
Affordability protections after 2014 inadequate for some, particularly low-to-moderate income families
Employers shifting more costs to insured employees
Enrollment efforts will need to be robust
Immigrants
Individuals with chronic illness
Communities of color
These populations are likely to be prime “targets” for community benefits programs and financial assistance in many communities.
© Community Catalyst 2010

22. The Impact on Coverage Nationally
The ACA dramatically reduces—but does not eradicate—the number of uninsured. 8%
19% 8%
13%
18%
10% 9%
58%
57%
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23. Average Annual Worker and Employer Contributions to Premiums and Total Premiums for Family Coverage,
$5,791
$6,438*
$7,061*
$8,003*
$9,068*
$9,950*
$10,880*
$11,480*
$12,106*
Growth in worker contributions
$12,680*
$13,375*
$13,770*
* Estimate is statistically different from estimate for the previous year shown (p<.05).
Source: Kaiser/HRET Survey of Employer-Sponsored Health Benefits,

24. Among Firms Offering Health Benefits, Percentage of Firms That Report They Made the Following Changes as a Result of the Economic Downturn, by Firm Size, 2010
Reduced benefits and/or increased cost sharing in employer-sponsored coverage is becoming more prevalent.
*Estimate is statistically different between All Small Firms and All Large Firms within category (p<.05).
Source: Kaiser/HRET Survey of Employer-Sponsored Health Benefits, 2010.

25. What Does It Mean to Be Underinsured?
Commonwealth Fund’s definition
Under 200% FPL = out-of-pocket (OOP) spending exceeds 5% of income
Over 200% FPL = OOP spending exceeds 10% of income
Insurance deductible is 5% or more of income
One-third of families run into trouble before these limits are reached
Under 200% FPL = 2.5% or less of family income
Between % FPL = 2.5 – 5% of income
Over 400% FPL = 5-7.5% of family income
Commonwealth Fund definition – NOTE THAT THIS DOES NOT INCLUDE SHARE OF PREMIUMS. The second data set comes from Center for Studying Health System Change (2008, Peter Cunningham). It is sobering to realize that, although the ACA will significantly reduce the number of uninsured, significant numbers of underinsured people may remain.
© Community Catalyst 2010

26. Immigrants Will Need Access to Care
Undocumented immigrants
Barred from buying Exchange plans at full cost and from getting subsidies
Can get exemption from individual mandate (proof)
Legal immigrants
Eligible for Exchange plans and subsidies
Still subject to five-year Medicaid bar
Education on the law is crucial
Changes to Medicaid DSH funding may have particular impact on immigrant access to services.
© Community Catalyst 2010

27. How Does Community Benefit “Link Up”?
CHNA - could look for and report access problems
Target vulnerable, underserved populations
Collaboration with CHC’s, others
Eligibility screening for public programs, Exchange
Data collection demonstrating successes and/or continued need for safety net services, better affordability standards
Hospital roles in new models of care
Public Education
Early win for consumers
Tested well in 2008 polls
© Community Catalyst 2010

28. Challenges and Opportunities
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29. Opportunities for Advocacy and Collaboration
Opportunities exist at the federal, state and local level
Federal – grants; regulatory actions around DSH and hospital requirements
State – pursue options to support primary care and preventive access; state grant funds to help secure monies for CHC expansion; consider strengthening community benefit laws at the state level
Local – community outreach and public education on financial assistance; community needs health assessments
Begin thinking now about:
Public education and outreach
Establishing priorities
Working with broad set of partners
Involving community, hospital and public health partners in strategic planning
© Community Catalyst 2010

30. Local Options
Research issues of medical debt in your community. Are charity care and billing practices impeding access to care?
Educate community members about hospitals’ new obligations, and train leaders to be involved in monitoring and planning efforts.
Build partnerships with new allies whose constituencies may stand to gain from these provisions (providers, vulnerable communities).
Approach hospitals and health officials now about working collaboratively on community needs assessments.
Begin thinking about strategic approaches and priorities within the community (see Community Catalyst Resources Lists).
© Community Catalyst 2010

31. Challenges Competing priorities
Lack of community engagement, or community capacity
Compliance vs. mission-driven approach
Silos within public health, advocacy, and/or hospital sector
Real differences of opinion
Tough fiscal climate
Regulatory guidance from IRS
© Community Catalyst 2010

32. We Can’t Do It Alone
Committed and knowledgeable state and federal policymakers
Providers and public health experts who engage the community
Informed and empowered consumer advocates
Dr. McCoy from the Star Trek Enterprise said it best: “Damn it, Jim, I’m a doctor, not a magician.” Similarly, the law requires collaboration between hospitals, public health experts, and consumer advocates for a reason: each plays a unique role in ensuring that financial assistance and other community benefit programs really fit the community’s needs. We have to work together to get the job done right, and the ACA gives us new tools to do that.
© Community Catalyst 2010

33. Resources http://www.communitycatalyst.org/projects/hap/
Fact sheets for consumer organizations and others
Community benefits workbook for grassroots leaders
Community benefits/financial assistance model acts
Summaries of state laws
Case studies
Questions? Contact Jessica Curtis at
© Community Catalyst 2010