Strengthening Connections between Nonprofit Hospitals and Their Communities: an Interview with Jessica Curtis, Community Catalyst
Hilltop recently spoke with Jessica Curtis, Project Director of the Hospital Accountability Project and Staff Attorney of the Integrated Care Advocacy Project at Community Catalyst, about opportunities that the ACA affords for building and strengthening connections between nonprofit hospitals and their communities.
Hilltop: In a recent blog post, you said the ACA draws a “new line in the sand for non-profit hospitals.” Can you explain that concept more fully? What new connections and outcomes should communities expect from hospitals due to the ACA?
Curtis: Sure. The ACA, on the issue of tax-exempt hospitals, is not radical. Each of its requirements has legal precedence in one or more states’ laws, is a well-accepted standard of basic good practice, or both. The law simply codifies a very basic set of expectations that communities have come to expect of hospitals: be transparent and fair, especially in financial dealings with patients who can’t afford to pay; and be responsive, engaged partners in addressing broader community needs.
So, what does the ACA add to the mix? Our hope—and, I believe, the intent of Congress—is that it will set some parameters for hospital behavior that will apply across the board. The existing federal community benefit standard is vague at best. Some states have set tougher standards, and a number of the national and state hospital associations have done exemplary work to outline what hospitals should do to have a quality community benefit program. And, many nonprofit hospitals see community benefit as a cornerstone part of their organizational missions. But our experience—and that of the state-based and local organizations with whom we work—has been that aspiration alone does not yield good practice.
What does this mean to communities? Right now, the ability of an uninsured or underinsured hospital patient in, say, South Dakota to access information about financial assistance will depend largely on the policies, staff education and follow-through, and leadership of the hospital where he or she happens to receive treatment. The patient might not even know to ask about financial assistance. We’ve heard of multiple cases in which patients who ultimately qualified for Medicaid or hospital financial assistance took on credit card debt or got behind in other bills because they did not know to ask—and the hospital did not inform them—about other options. Put that same patient in California or Maine—two states with strong requirements about how and when hospitals have to notify patients about financial assistance—and the outcome could be different. The ACA sets a minimum federal standard that all nonprofit hospitals must meet. In that way, it also implicitly provides some basic safeguards that patients can rely on, regardless of where they live.
What’s interesting about that “line,” though, is that in many ways it’s dotted. Some of this may change, of course, depending on what regulations come from the IRS, but the statute as written appears to leave hospitals with a fair amount of discretion. There are some firm prohibitions on overcharging. The requirements surrounding the community health needs assessment are fairly clear on the “community engagement” piece. But, hospitals still have ultimate discretion about the partners they choose and the issues they pursue as part of their implementation strategy. And almost all of the financial protections for patients—whether they qualify for financial assistance, when the hospital can pursue certain collection actions—will hang on how the hospital defines its financial assistance policy. That’s a really critical point for community advocates and state policymakers to understand: the ACA starts the conversation by requiring greater transparency and fostering communication. This alone may not be enough.
The real proving ground will be what happens in local communities. Can community groups and members get access to financial assistance policies? Is there a dialogue happening—and change occurring, if it is needed—about how hospitals charge and collect? Do community members see a connection between their suggestions and the strategies hospitals choose to pursue? Are they part of the evaluation of community benefit programs? I believe it is going to require vigilance and active engagement on the part of community members, state and local policymakers, public health experts, and hospitals themselves to ensure that the spirit of the law is fully realized.
Hilltop: When conducting a community health needs assessment, a hospital must take into account input from persons representing broad community interests. What advice are you giving community groups as they develop connections with hospitals?
Curtis: Our first task is to let groups know about the new requirements; from there, it’s up to them to decide whether this as an opportunity worth pursuing with their local hospitals. One of the challenges we face is simply the complexity of the times. Implementation of the whole Affordable Care Act and the crises occurring in many local and state budgets are just two of the major issues taking up a lot of space for (predominantly state-based) advocates. In addition, participating in a community health needs assessment and implementation strategy can be a heavy lift for groups who may not have existing knowledge of the issues or established relationships with hospital leadership.
But even so, groups are trying to establish, improve, or build upon existing relationships with their local nonprofit hospitals.
Our advice to community groups really depends upon the situation. Some key points include:
- Develop your understanding of community benefit, its potential, and its limitations. What is at stake? Gather data: does the hospital have community-friendly financial assistance policies in place? What does it do already in community benefit? Does it target its resources to vulnerable populations? What is appropriate for your community?
- Recognize the value community groups and members bring to the conversation.
- Ask questions. How will the hospital involve the community? What types of data will it collect? Who will collect, analyze, and report the data/conduct the assessment? Model good behavior by setting an inclusive table. Who else should be involved in this process? Understand the dynamics involved in these situations, but have an open mind. What is the previous history of the organizations involved? What strategies could you use if your efforts to become involved are ignored or rebuffed?
We give remarkably similar advice to hospitals, by the way. There’s more in our workbook, Community Benefits: The Need for Action, an Opportunity for Healthcare Change, which we wrote for The Access Project. We intend to update this to reflect the changes in the ACA and incorporate some new case studies.
Hilltop: The ACA refers to broad community interests in the context of planning, but that same community focus is not carried over to the parts of the law related to hospital financial assistance policies and reporting processes. Do you have thoughts about strategies community groups can use to ensure that hospitals are also responsive to broad community interests when developing their financial policies, and also in the breadth and depth of their reporting about their community benefit activities?
Curtis: We firmly believe that a hospital’s financial policies should be on the table during the community health needs assessment and implementation strategy, and that hospitals themselves should be actively seeking community input on how to improve them. There is a false divide in some circles, I think, to separate this area from other forms of community benefit. In truth, they are inextricably connected. It is shortsighted to acknowledge the linkages between poverty, race and ethnicity, and the social determinants of health but ignore the impact that inadequate financial assistance policies and aggressive debt collection tactics have on poor and middle-income communities, especially for those with chronic illness and the uninsured or underinsured.
We have seen hospitals lose credibility with community partners due to inadequate financial assistance policies even when the hospital is making good-faith efforts to engage them on other issues. Particularly for groups working with and from low-income communities, hospital financial assistance and debt collection policies speak the truth about the hospital’s commitment to them and their clients. Unwillingness to discuss, reveal, or consider changes to the policy can sour relationships quickly.
We think there could be significant crossover between the populations who are receiving uncompensated care—whether that’s classified as charity care (financial assistance) or bad debt—and those who are targeted for other community benefit interventions, like community health service improvements. We like to hear that more hospitals are using their community benefit programs to “head upstream” to solve health problems before patients walk in the doors of their ER. That’s good care. That’s smart care. That’s also cost-effective care. We want to see more of that. But we’d also like them to think “downstream” about the impact of their financial assistance policies. What’s the financial impact on a patient of carrying a hospital debt they cannot pay? Does asking that patient to put a bill on a credit card, demanding an upfront payment to be seen, putting a lien on the patient’s sole automobile, or charging interest that makes the bill untenable strengthen the community? It does not. These things are linked.
Finally, it's not common practice yet, but as state and federal funding for uncompensated care shrinks, it behooves hospitals to think about their community benefit and financial assistance programs as a cohesive whole and plan accordingly.
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