Community Benefit& Baltimore, Maryland Daniel Waits & Melinda GarciaCOMHE 405: Health Systems & Health Policy13 May 2015

The Affordable Care Act• The Affordable Care Act (ACA) requires nonprofit hospitals to

provide transparency of their efforts to benefit the community they serve, from the perspective of someone who represents that community▫ Enacted in 2010, established new standards that nonprofit hospitals

must meet for federal tax exemption including… Conducting a community health needs assessment and developing an

implementation strategy every three years Adopting and publicizing a financial assistance policy; Limiting charges, billing, and collections with respect to individuals

eligible for financial assistance under the hospital’s financial assistance policy

What is Community Benefit?• Community Benefit generally includes community health

improvement services, financial assistance, subsidized health services and health training, research and education

• At the federal level, community benefit is broadly defined to include anything that promotes the health of the community▫ Some states, counties and municipalities have additional requirements

but must respond to a demonstrated health-related community need Seek to achieve at least one of the following community benefit

objectives: improve access to health services, enhance population health, advance

knowledge and/or demonstrate a charitable purpose

Federal vs. State Policies • Although the ACA has set federal requirements

for hospitals concerning their community benefits, the states have the power to set regulations▫ In Maryland, to be recognized as a

community benefit, an activity must be intended to address community needs and priorities primarily through disease prevention and improvement of health status Maryland provides health services to

vulnerable or underserved populations, financial support of public health programs, and health education screening and prevention services.

Schedule• Prior to the 2008 tax year, hospitals reported community benefit

primarily as charity care and unreimbursed Medicaid costs▫ In 2007, the IRS released a new form, the Schedule H, to attempt to standardize

community benefit reporting for charity care Requires hospitals to report financial assistance and other community benefits at cost,

community building activities and report bad debt, Medicare and collection practices

• Tax exempt hospitals must report their community benefits annually to IRS on form 990, Schedule H▫ New federal community benefit reporting requirements found in Schedule H

provide the general public with more detailed information about the charitable practices of tax-exempt hospitals

Barriers to Community Benefit• The Affordable Care Act revises the conditions that

nonprofit hospitals must satisfy in order to qualify for federal tax-exempt status▫ A new condition establishes a formal “community health needs

assessment” (CHNA) process, whose purpose is to increase the relationship between the health needs experienced by communities and the “community benefit investments” made by nonprofit hospitals as a condition of tax exemption. The major issue with the ACA requirements is the difficulty of

maintaining a consistent policy to work collaboratively within the community and developing a way to measure these efforts appropriately.

Baltimore, Maryland• As of 2010, the census recorded a population of

616,802 in Baltimore, Maryland▫ 21.6% of the population is under the age of 18 years▫ 66.5% of that population is between the ages of 18 and 64

years old▫ 11.8% is 65 years and above▫ 63.7% are African-Americans▫ 29.7% are non-Hispanic whites▫ 4.2% are Hispanic▫ 2.4% are Asian

Baltimore, Maryland• The median household income was reported as $37,385 –

nearly half of the median household income reported for the state of Maryland ($71,419)

• Baltimore’s infant mortality rate is 12.3 per 1000 live births, nearly doubled compared to the state of Maryland’s 6.7 per 1000 live births

• Heart disease, cancer, stroke, HIV/AIDS, and chronic lower respiratory disease are the top five causes of death in Baltimore, reducing life expectancy down to 71.8 compared to the state’s 78.7

City of Baltimore CommunityHealth Assessment (2010-2015)

City of Baltimore CommunityHealth Assessment (2010-2015)

Healthy Baltimore 2015• In May 2011, the Baltimore City Health Department

issued the Healthy Baltimore 2015 to promote access to quality health care for residents in Baltimore▫ Reduce tobacco use, promote heart health, stop the spread of

HIV and STIs, advocate mental health needs, reduce substance abuse, and redesign obesity prevention with a focus on community-wide health promotion and adolescent health

Interim Report (2013)• Baltimore City Health Department released an

interim status report highlighting some of the barriers and accomplishments in 2013▫ Tactics included policy development, prevention, access and

quality of care, and community engagement▫ Racial disparities was identified as the biggest determinate of

health ▫ Diabetes, hypertension, and asthma were the top three

preventable and manageable diseases and African Americans showed higher rates for all three

Interim Report Cont.• 20.9% decrease in hospitalization for hypertension• Decrease in disparity between black and white residents for

hypertension (27.6%), Type 1 Diabetes (24.4%), and Type 2 Diabetes (29.5%)

• 5% decrease in disparity between black and whites hospitalized for asthma

• 20% decrease in hospitalization rates for asthma as a whole with the exception of children ages 5 to 17 years old

Bon Secours Baltimore Health Systems

• Bon Secours Baltimore Health Systems (BSBHS) is a non-profit hospital serving four zip codes in West Baltimore▫ 17.1% of residents are uninsured and 31% are on

Medicaid ▫ 125 beds with 6,579 admissions▫ Serves 17,885 people in southwest Baltimore

West Baltimore• Median income of $28,514• Unemployment rate of 24.3% • 76% are African-American• 18% are Caucasian• 3.6% are Hispanic• 1.2% are Asian• 1.21% Other

BSBHS Community Benefit • Provide clinical and community based behavioral health

services, free health screenings, and free transportation to and from medical appointments for the elderly▫ Served more than 120,000 people▫ 1,200 sought substance abuse treatment ▫ 240 were intensive outpatient▫ 124 were specialized cases

98% received mental health treatment and 95% received housing – 35% were able to re-establish themselves and reconnect with their community

BSBHS Community Benefit Cont.• Provide chronic disease

management, focusing on congestive heart failure and hypertension and partnering with local churches▫ Provided 1,887 blood pressure

screenings Discovered 75% of patients screened

had elevated blood pressure

BSBHS Community Benefit Cont.• Provided safe and affordable

housing▫ Used community blight and

abandoned houses to revitalize the community 119 families and 529 seniors and

disabled adults were provided housing by transforming 644 vacant lots and planting 1,003 trees

BSBHS Community Benefit Cont.• Provide comprehensive services for establishing economic

dependence through childhood development programs for children under 4 years old▫ Provided parenting classes targeted toward teen parents, adult

basic education, GED preparation, tutoring, job skill training, financial literacy classes, and workforce development

▫ Visited 45 young mothers - providing prenatal care, provided early childhood education Served 449 children, helped 51 mothers earn their GED, and

enrolled 100% of participants in Public Benefit Assistance and WIC

BSBHS Community Benefit Cont.• Assist residents establish economic independence through

programs such as Our Money Place Career Development ▫ Offers Job placement and financial building program assisting

adults job readiness training finance management skills and financial counseling 1,425 applicants in their job readiness program, 715 graduating,

and 650 employed 1,700 participants in their financial counseling program and they

prepared 5,000 free tax returns

BSBHS Community Benefit Cont.• Provide women with the health

care services, free meals, and a place to bathe and wash clothes▫ Served 300-600 women and

prevented 60 evictions▫ Provided 1,100 meals, computer

training, recreation, over 500 counseling session, and 300 referrals to other programs and services available

BSBHS Community Benefit Cont.• Youth Employment and

Entrepreneurship Program (YEEP) launched in 1999 for ages 13-17 years▫ Promote knowledge, skills, and

expectations in academia , financial literacy, career development and leadership skills Served over 1,000 Baltimore youth with

a graduation rate of 93%, 76% attending college, 34 graduated college, and 520 placed in employment

Transparency• The community benefit rule

allows community members access to detailed reports regarding hospital programs and success rates▫ State regulation in Maryland

requires hospitals to focus on disease prevention and improvement of health status

Community Benefit in Baltimore, MD• Baltimore City Department of Health and local hospitals

such as Bon Secours Baltimore Health System (BSBHS) address racial disparities in health by targeting socioeconomic status and putting forth initiatives to lift adults and families out of poverty

• The initiatives detailed in BSBHS’s 2012 Community Benefit Report address issues such as…▫ poverty, job readiness, financial counseling, and education that

have all been proven as determinates of health outcomes

Works Cited1. Congressional Budget Office. Non-profit hospitals and the provision of community benefits. (Online) December

2006. Available: www.cbo.gov/ ftpdocs/76xx/doc7695/12-06-non-profit.pdf.2. International Revenue Service. IRS Revenue Ruling 69-545, 1969-2 C.B. 117 Available: http://

www.irs.gov/pub/irs-tege/rr69-545.pdf3. Patient Protection and Affordable Care Act, Pub. L. No. 111-148, § 9007, 124 Stat. 855-858 (2010) (codified in

scattered sections of 26 U.S.C.) 4. General Accounting Office. Nonprofit hospitals: variation in standards and guidance limits comparison of how

hospitals meet community benefit requirements. (Online) September 2008. Available: http://www.gao.gov/new.items/d08880.pdf

5. American Hospital Association. AHA Hospital Statistics, 2013 Edition. (Online) 2012. Available: http://www.aha.org/research/rc/stat-studies/index.shtml

6. Government Accountability Office. Nonprofit, ForProfit, and Government Hospitals: Uncompensated Care and Other Community Benefits. (Online) May 2005. Available: www.gao.gov/new.items/d05743t.pdf.

7. Catholic Health Association. Criteria for What Counts. (Online) Available: http://www.chausa.org/communitybenefit/what-counts

8. Internal Revenue Service. (n.d.b). Form 990, Schedule H Instructions. (Online) 2010 Available: http://www.irs.gov/pub/irs-pdf/i990sh.pdf

9. Patient Protection and Affordable Care Act, Pub. L. No. 111-148, § 9007, 124 Stat. 855-858 (2010) (codified in scattered sections of 26 U.S.C.).

Works Cited10. International Revenue Code. Notice and Request for Comments Regarding the Community Health Needs

Assessment Requirements for Tax-Exempt Hospitals. (I.R.C. §501(r)(3)(B). Available: http://www.irs.gov/irb/2011-30_IRB/ar08.html

11. University of Maryland Medical Center. Community Benefit. (Online) April 2015. Available: http://umm.edu/about/community/benefit

12. The Hilltop Institute. Community Benefit State Law Profile: New York. (Online) January 2015. Available: http://www.hilltopinstitute.org/hcbpDocs/HCBP_CBL_ny.pdf

13. Patient Protection And Affordable Care Act. 26 US.C. §501(r)(3) Community Health Needs Assessment. Available: https://web.law.columbia.edu/sites/default/files/microsites/attorneys-general/501(r)%20Article-2.pdf

14. Alper, J; Baciu, A. Financing population health improvement: workshop summary. Institute of Medicine. 201515. Chandran A, Fuller C, Morris-Compton S, Rodgers V, Barbot O. Healthy Baltimore 2015: An Interim Report.

Baltimore City Health Department, October 2013. 16. Baltimore City Health Department. Community health assessment (2010-2015).

http://www.naccho.org/topics/infrastructure/accreditation/upload/BCHD-CHA-overview.pdf. Published 2015. Updated 2015.

17. Bon Secours Baltimore Health System. 2012 community benefit report. http://bonsecoursbaltimore.com/assets/pdfs/FY12-CBR_Report.pdf. Published 2012.