标题：Analysis of Hospital Community Benefit Expenditures’ Alignment With Community Health Needs: Evidence From a National Investigation of Tax-Exempt Hospitals
摘要：Objectives. We investigated whether federally tax-exempt hospitals consider community health needs when deciding how much and what types of community benefits to provide. Methods. Using 2009 data from hospital tax filings to the Internal Revenue Service and the 2010 County Health Rankings, we employed both univariate and multivariate analyses to examine the relationship between community health needs and the types and levels of hospitals’ community benefit expenditures. The study sample included 1522 private, tax-exempt hospitals throughout the United States. Results. We found some patterns between community health needs and hospitals’ expenditures on community benefits. Hospitals located in communities with greater health needs spent more as a percentage of their operating budgets on benefits directly related to patient care. By contrast, spending on community health improvement initiatives was unrelated to community health needs. Conclusions. Important opportunities exist for tax-exempt hospitals to improve the alignment between their community benefit activities and the health needs of the community they serve. The Affordable Care Act requirement that hospitals conduct periodic community health needs assessments may be a first step in this direction. Considerable effort has been devoted to investigating how much tax-exempt hospitals spend on community benefits, that is, services and other activities that hospitals undertake at their own expense for the good of the community. 1–9 These benefits include charity care, community health improvement initiatives, and unprofitable, but essential, clinical services. Because most nonprofit hospitals in the United States are exempt from federal, state, and local taxes, the interest in documenting these expenditures derives from a general expectation that nonprofit hospitals will provide community benefits in exchange for their tax exemption. 10 Recently, Young et al. reported the results of a large national investigation of hospital expenditures on community benefits on the basis of the Internal Revenue Service (IRS) definition of community benefits and tax filings. 11 The study showed that in 2009, tax-exempt hospitals spent, on average, 7.5% of their operating budgets on community benefits. More than 85.0% of this total community benefit spending went to clinical services, such as charity care and the provision of unprofitable clinical services, and the remainder went to services benefiting the community more broadly. Young et al. also documented considerable variation among hospitals in total community benefit spending, with a more than 20-fold difference between hospitals in the top and bottom deciles. Perhaps more important than the amount hospitals spend on community benefits is the distribution of such benefits among communities. Little is known about the pattern of expenditures among communities on the basis of health needs, not just medical needs but also the social, physical, and behavioral needs of a community that can affect people’s health. Specifically, do hospitals respond to greater community health needs by spending more on community benefits? Is there a general correspondence between types of community needs and types of community benefit expenditures? The national investigation of community benefits did examine whether hospitals spent more on community benefits in communities with greater health needs, measured in terms of county per capita income and the proportion of uninsured residents. 11 Although no relationship was observed between these 2 community health indicators and hospital community benefit expenditures, these indicators represent just 1 dimension of community health needs. A more comprehensive view of community health needs—including indicators of socioeconomic factors, clinical care, health behaviors, and the physical environment—may provide additional insight into the relationship between community health needs and hospital expenditures on community benefits. We investigated the pattern of hospital community benefit expenditures in relation to community health needs on the basis of a broad set of indicators of health needs from the County Health Rankings. 12 An understanding of the relationship between hospital expenditures on community benefits and community need is critically important in light of the mandate from the Patient Protection and Affordable Care Act (ACA) that federally tax-exempt hospitals conduct community health needs assessments every 3 years and develop plans for addressing identified health needs. 13,14 By conducting regular community health needs assessments, hospitals will presumably be in a better position to determine how much and what types of benefits are most appropriate for the communities they serve. Because the IRS has yet to fully implement this mandate, we sought to assess the relationship between hospital community benefit expenditures and community health needs before the ACA. This information can help gauge the success of the community health needs assessment mandate in the future. Therefore, we focused our analysis on hospital community benefit expenditures in 2009, 1 year before the ACA was passed.
