Nonprofit hospitals regulatory and social requirements for improving population health

• Online Access: http://hdl.handle.net/2047/D20361355

The Patient Protection and Affordable Care Act (ACA) of 2010 significantly broadened the requirements for hospitals to think beyond community benefits as only charity care and toward playing a larger role in community health by requiring hospitals to conduct both community health needs assessments (CHNAs) and develop plans to meet identified needs. Beyond the ACA, there is an awareness that greater collaboration is needed between the health care delivery and public health sectors. Study 1 used a national sample of nonprofit hospitals to assess CHNA implementation activities and to determine whether hospitals reporting more activity spent more on community benefits. Study 2 sought to understand whether collaborative action between local health departments (LHDs) and nonprofit hospitals was associated with healthier self-reported behaviors. Social capital was tested as a possible effect modifier. Study 3 entailed a qualitative investigation of nonprofit hospitals' efforts to comply with community benefit regulations. In Study 1, hospitals that were part of a health system, located in an urban area, and had an accountable care organization (ACO) were more likely to report more progress. A significant and positive association existed between hospitals reporting the highest level of progress and spending on community health improvement activities. In Study 2, significant and positive associations were found between LHD-hospital collaborative action and risk behaviors, healthy nutrition/lifestyle behaviors, not smoking, eating vegetables daily, and vigorous exercise. Social capital was found to modify some of these relationships. In Study 3, community benefit departments did not have a consistent reporting structure. Eight of ten hospitals (80%) had a full-time community benefit administrator (CBA). CBAs reported three overarching barriers: data availability, evaluation challenges, and resource constraints. In understanding their role within community benefits at a broad level, CBAs often felt caught in a state of uncertainty. This dissertation offers three separate yet related papers on nonprofit hospital community benefit policies. While progress is being made, there remains a long way to go. Clarifying expectations for nonprofit hospitals seeking to impact social determinants of health is essential. Stronger oversight and enforcement are also needed.