The U.S. population continues to face significant health disparities and inequalities. Troubling racial, ethnic, socioeconomic and geographic variations in access to care, service utilization, quality and health outcomes persist. The economic burden is substantial and growing, with costs of health inequalities and premature mortality already estimated at $1.24 trillion from 2003 to 2006. Major savings in direct medical care expenditures and indirect costs in the billions of dollars could be realized by eliminating inequalities in minority populations.
The Patient Protection and Affordable Care Act contains a variety of legislative provisions designed to advance health equity for racially and ethnically diverse populations. Numerous collaborative efforts under way include: the Office of Minority Health's National Partnership for Action to End Health Disparities, the American Hospital Association's Equity of Care — National Call to Action to Eliminate Health Care Disparities and the American Medical Association's Commission to End Healthcare Disparities.
The Association of American Medical Colleges recently has called for aligning the ACA disparities provision and value-based health care through (1) payment reform, (2) health information technology, (3) community health needs assessments and (4) expanding health equity research ( "Making equity a value in value-based health care," by P.M. Alberti, A.C. Bonham and D.G. Kirch in Academic Medicine  88:1619–1623). In the present article, we focus on the third of these levers of change.
Community Health Needs Assessments
Tax-exempt hospitals and other health care providers can meet their Internal Revenue Service community benefit obligation by supporting initiatives designed to eliminate disparities. Providers also can meet their obligation by fostering equity in the triennial Community Health Needs Assessments and resulting Community Health Implementation Plans required by Section 9007 of the ACA. All of these approaches are described by C.J. Evashwick in Hospitals and Community Benefit: New Demands, New Approaches (Chicago: Health Administration Press, 2013).
An important national study identified significant variations in the community benefits provided by tax-exempt hospitals, ranging from 20 percent to 1 percent of operating expenses, with 85 percent of expenditures going to charity care and other patient care services; 5 percent to community health improvement; and the remainder to education of health professionals, research and contributions to community groups. (Details of this study are available in "Provision of community benefits by tax-exempt U.S. hospitals," by G.J. Young, C.H. Chou, J. Alexander, S.Y. Lee and E. Raver in New England Journal of Medicine  368:1519–1527.)
Questions have been raised as to the adequacy of investments in "community health improvement" activities. Nonprofit hospitals are experiencing increased scrutiny to justify their tax-exempt status by addressing the aforementioned variations in meeting federal, state and local community benefit requirements.
Enhanced National CLAS Standards
We recommend that hospitals and other health care providers use the Health & Human Services Office of Minority Health's National Culturally and Linguistically Appropriate Services (CLAS) Standards in Health and Health Care to guide their work with diverse populations and communities. The enhanced CLAS standards build on those previously released in 2000 and are "intended to advance health equity, improve quality, and help eliminate health care disparities by providing a blueprint to implement culturally and linguistically appropriate services."
There are 15 standards, including a principal standard and three groups of standards that focus on governance, leadership and the workforce; communication and language assistance; and engagement, continuous improvement and accountability. An annotated blueprint also provides examples of best and promising practices for implementing CLAS, as well as numerous print and Web-based resources.
CLAS standards particularly relevant for the IRS community benefit requirements include the following:
Standards 5–8 focus on ensuring access to linguistically appropriate services to meet compliance obligations relating to Title VI of the 1964 Civil Rights Act and the Office for Civil Rights Limited English Proficiency guidance.
Standards 11–13 focus on the need for health care organizations to become more actively involved in engaging and partnering with communities to identify local health needs and assets, developing culturally and linguistically appropriate interventions, and working collaboratively to improve community and population health outcomes.
Standard 15 emphasizes the need to communicate progress in implementing and sustaining CLAS to key stakeholders, constituencies and the general public.
A number of important reports and tools for conducting CHNAs can assist hospitals and health care providers in carrying out "community health improvement" and "community building activities," as well as in completing IRS Form 990, Schedule H. See figure below for links to several useful materials.
Effective Leadership and Governance
Critical to implementing and sustaining health equity strategies are executive leadership teams and governance bodies that are representative of, and responsive to, diverse communities — facts highlighted in the enhanced CLAS standards. Pursuing better health for diverse communities needs to be part of hospitals' organizational environments, reflected in their policies and practices, supported with effective operational and administrative infrastructures, and incorporated as a key element in determining their organizational effectiveness.
Closely linked to effective leadership is viewing communities not just as recipients of health care, but as equal partners in improving health status and providing quality care for all. Hospitals and health care providers need to develop and maintain open discussions with the communities they serve. They can work with trusted members and leaders to identify effective strategies for improving the public's health and access to quality care. Effective community engagement, however, goes beyond mere dialogue; it ensures that the community has influence in developing policies and practices that affect the health of both individuals and communities.
The ACA and the accompanying IRS regulatory changes bring greater transparency in community benefit investments and a stronger community voice in these efforts to improve community health. In addition to prospective discounts for uninsured patients and participation in Medicaid and other means-tested programs, there are community health improvement investments in research, training and education; community health improvement activities; and non-billable, community-based services. The needs assessment and public input requirements of the ACA will, we hope, lead to a shift in community benefit investments toward improving community health.
Meaningful Community Engagement
Meeting the ACA, IRS and state community benefit requirements by addressing the Office of Minority Health's CLAS standards can support ongoing efforts to improve population health, eliminate disparities and foster health equity. Hospitals, health care providers and the associations that represent them must ensure that the community benefit requirements are being met from the perspectives of the individuals, families and communities being served. Developing trusting and respectful relationships is an essential part of this process.
Disclaimer: The ideas and opinions expressed in this article are those of the authors and do not necessarily reflect the policies or positions of the organizations with which they are employed or affiliated.
Robert C. Like, M.D., M.S., is a family physician with a background in medical anthropology; he is a professor and the director of the Center for Healthy Families and Cultural Diversity at the Department of Family Medicine and Community Health, part of Rutgers Robert Wood Johnson Medical School in New Brunswick, N.J. Edward L. Martinez, M.S., is a health care consultant and the 2013 chair of the board of directors of the Institute for Diversity in Health Management of the American Hospital Association. Frederick D. Hobby, C.D.M., M.A., is the president and chief executive officer of the Institute for Diversity in Health Management at AHA.
Figure. Selected Community Health Needs Assessment Resources
- Hilltop Institute. Hospital Community Benefit Program, University of Maryland, Baltimore County
- Catholic Health Association. Assessing and Addressing Community Health Needs
- American Hospital Association. Schedule H/Community Benefit Project and Report
- Public Health Institute. Advancing the State of the Art in Community Benefit
- Community Commons CHNA Toolkit
- ACHI Community Health Assessment Toolkit
- Maximizing the Community Health Impact of Community Health Needs Assessments Conducted by Tax-exempt Hospitals
- National Association of County and City Health Officials (NACCHO). MAPP: Mobilizing for Action Through Planning and Partnership
- A Healthcare Advocate's Guide to Community Health Needs Assessments
- Texas Health Institute. The Affordable Care Act & Racial and Ethnic Health Equity Series Report No. 2. Supporting and Transitioning the Health Care Safety Net
- George Washington University School of Public Health and Health Services Department of Health Policy. Principles to Consider for the Implementation of a Community Health Needs Assessment Process.