Public Health and Community Benefit: A Q&A with RWJF's Abbey Cofsky
Non-profit hospitals are required to provide a “community benefit” to qualify for tax-exempt status with the Internal Revenue Service. To date, many hospitals have generally fulfilled this requirement by providing charity care to uninsured and underinsured individuals. The Patient Protection and Affordable Care Act (ACA) includes provisions for expanded community benefit opportunities with the assumption that the law will decrease the need for charity care in the future.
To help public health officials and policy-makers better understand the opportunity around the community benefit requirements in ACA, The Robert Wood Johnson Foundation funded the The Hilltop Institute at UMBC – a research center that focuses on the needs of vulnerable populations – to publish a series of issue briefs on best practices, new laws and regulations, and study findings related to community benefit activities and reporting. This week, The Hilltop Institute held a symposium on Responding to Community Health Needs within the Framework of the Affordable Care Act. NewPublicHealth spoke with Abbey Cofsky, program officer at the Robert Wood Johnson Foundation, about community benefit in 2011 and beyond, and about the Foundation’s interest in the opportunities around community benefit created through ACA.
NewPublicHealth: We haven’t talked about community benefit on NewPublicHealth before. Is this a new concept?
Abbey Cofsky: No, the concept of community benefit has a long history – the Hilltop Institute’s first issue brief, Hospital Community Benefits After ACA: The Emerging Federal Framework, does a great job of providing a chronology of how community benefit has evolved over the years. However, the provisions in ACA that require non-profit hospitals to do a community health assessment and improvement plans – and the opportunity to redirect towards community prevention the funds that have largely supported charity care – have put it on the radar screen of the public health community. The law requires that hospitals, starting in 2012, perform a community health needs assessments at least every three years that takes into account input from those that represent the needs of the community and those with public health expertise. The assessments must be made public and serve as the foundation of an implementation plan to address the identified needs.
NPH: What do you mean by community health needs assessment?
Community health needs assessment is a process that brings together key stakeholders within a community to collect and analyze qualitative and quantitative health-related data from a variety of sources within a specific community. So it might pull data from a source like the County Health Rankings. The intent of the assessment is to identify key needs of the community and inform community decision-making, the prioritization of health problems, and the development and implementation of community health improvement plans.
In this case, according to the new law, hospitals are required to follow up on health needs addressed by the assessment and explain, annually, what needs were identified and whether they have been addressed.
NPH: Why is the Robert Wood Johnson Foundation interested in this area?
Abbey Cofsky: The County Health Rankings have made clear to all of us the need to engage multiple stakeholders in the efforts to improve the health of a community. This is a perfect example of where and how key stakeholders such as the community hospital and the public health department can work with the community to answer the questions of how healthy their community is, and what they can do to ensure the community members they serve and represent are as healthy and safe as they can be.
The ACA requirement around community benefit also comes at a time when many health departments are preparing for national public health accreditation. Community health needs assessment and improvement planning, which have long been recognized as a core function of local public health departments, are both prerequisites for public health department accreditation. In fact, as part of an effort to help health departments prepare for accreditation, RWJF just recently launched a new project with NACCHO to generate exemplary community health assessments and community health improvement plans that engage the community in a meaningful way, address the social determinants of health and use quality improvement and quality planning techniques.
So clearly there is an opportunity here to connect these efforts around community benefit with many of the Foundation’s efforts to transform public health, but a lot of questions remain about the value of that opportunity and what the ACA provisions will look like when implemented. These are questions our public health law and research programs are paying attention to, and coupled with the work Hilltop is doing, we hope to help shed light on what this means for public health agencies and community efforts to transform population health.
NPH: Why is it so important to bring everyone to the table?
Abbey Cofsky: Maybe I’m being over-simplistic, but there is seemingly an opportunity here for public health and non-profit hospital leaders to say, “Listen, we’re all really working towards the same thing at the end of the day. How do we keep the people in our community healthy? How do we keep them safe? And how do we leverage the limited assets and resources in our community to do so?” By bringing everybody together, there’s a real opportunity to be holistic and to leverage all of the resources that exist in a community. The reason we were looking towards collaboration is to make sure that the various stakeholders aren’t working at cross-purposes, so we can really have a broader sense of everyone’s activities working towards this notion of community health and being part of the health improvement process. That includes folks at the hospital and within the public health department, but also this broader scope of potential players, like folks who are working in parks and recreation or transportation or education and really getting at the social determinants of health as part of the community health assessment. So it’s not just how many folks have heart disease or how many folks have diabetes, but really looking at these other factors that are contributing to health issues in the community.
NPH: What are you hearing about the collaborations? Do you have examples yet of health departments and non-profit hospitals working together?
Abbey Cofsky: We know of several health departments and non-profit hospitals that have actually begun to connect around community health assessment. It is really encouraging because it means they’re going into that assessment process with that broader frame, and not just what are the traditional mortality, morbidity rates. So that’s exciting. In terms of real partnerships on full development and implementation of the plan, there is a sense that that innovation is out there and bubbling up. According to the National Association of City and County Health Officers, in Snohomish County, Washington, a hospital engaged in strategic planning contracted with the health department for statistical and epidemiological expertise, using data sets that already existed at the health department. This arrangement serves the hospital and the health department not only with respect to the immediate objective, but also by establishing a basis for a longer term partnership in ongoing community health improvement activities. Again, this is one example and we’re anxious to gather more examples of these types of partnerships.
NPH: Finally, how do hospitals and health departments work together to maximize the benefit of the community benefit provision?
Abbey Cofsky: Engaging thecommunity in a meaningful way is critical. If you don’t really engage the community, you run the risk of losing sight of what the need is. If you just look at the numbers without the people and the stories behind those numbers, you’re not going to have a full picture of not only what the challenges are, but what the barriers are to improving those challenges in the community. So, I think that’s a critical piece.
If we don’t maximize the opportunity for collaboration between health departments, hospitals and the community, it’s a lost opportunity to make a difference, to really improve health at the community level, especially in a time of scarce resources.
And, lastly, to go back to the County Health Rankings, there is an important opportunity here for these assessments and the improvement strategies to move upstream. These efforts need to consider the broad range of social, economic, environmental and behavioral factors that influence our health and focus on the places where health happens – the places where we live, learn, work and play.
Read previous NewPublicHealth.org Q&As with newsmakers and difference makers in public health.