leveraging health reforms new hospital community benefit requirements to address unmet needs jessica...

Leveraging Health Reform’s New Hospital Community Benefit Requirements to Address Unmet Needs

Jessica L. Curtis, JDDirector, Hospital Accountability ProjectCommunity CatalystNovember 2010

• 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 LawIndu Spugnardi, Catholic Health Association

• Integrating Public Health into Community Health Needs Assessment and PlanningJulia Joh, National Association of County & City Health Officials

• Discussion

© Community Catalyst 2010

Overview


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?


Community Benefit

1. Key Concepts

2. New Standards for Hospitals

3. Policy Considerations

a. Who’s Still Vulnerable Now and After Implementation?

b. How Does This Connect to Other Policy Concerns?


Our Nation’s Hospitals: Rooted in Charitable Care


• 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

IRS standard for tax-exempt hospitals:


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)

What is “community benefit”?


• 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

Community Benefit Can Include…


• 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

A Model Community Benefit Process


• 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

Consumer Values for Community Benefit


New Standards for Hospitals

1. Summary of ACA’s requirements for tax-exempt hospitals

2. IRS oversight (Schedule H reporting)

3. Changes in funding for safety-net hospitals


New Standards for Non-Profit Hospitals

1. 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



2. 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



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



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


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


Schedule H currently includes questions about hospital efforts to enroll in public programs.


Schedule H, ContinuedCharity 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)

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


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?


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.


Employer Employer

Nongroup Nongroup

Medicaid/CHIP Medicaid/CHIP

ExchangesUninsuredUninsured

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

Without Reform With ReformEmployer Employer

Nongroup Nongroup

Medicaid/CHIP Medicaid/CHIP

ExchangesUninsuredUninsured

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

Without Reform With Reform

The ACA dramatically reduces—but does not eradicate—the number of uninsured.

13%

58%

10%

19%8%

8%

57%

9%

18%

The Impact on Coverage Nationally

Average Annual Worker and Employer Contributions to Premiums and Total Premiums for Family Coverage,

1999-2010

* Estimate is statistically different from estimate for the previous year shown (p<.05).

Source: Kaiser/HRET Survey of Employer-Sponsored Health Benefits, 1999-2010.

$5,791

$6,438*

$7,061*

$8,003*

$9,068*

$9,950*

$10,880*

$11,480*

$12,106*

$12,680*

$13,375*

$13,770*

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

*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.


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 200-400% FPL = 2.5 – 5% of income

• Over 400% FPL = 5-7.5% of family income


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.

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


Challengesand

Opportunities

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


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).


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

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


Questions? Contact Jessica Curtis at 617-275-2859 [email protected]

Resources

• 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

http://www.communitycatalyst.org/projects/hap/

mailto:[email protected]

http://www.communitycatalyst.org/projects/hap/

leveraging health reforms new hospital community benefit requirements to address unmet needs jessica...

Documents

community members

community perspectives

address community health

welcome community benefit

community benefits workbook

health care institutions

provision of health

public health experts