June 5, 2017

Nonprofit hospitals in the Nation’s largest cities are increasingly identifying the importance of equity in addressing the health needs of their communities, according to a new report published today in a health equity-themed issue of the journal Health Affairs. Researchers from the Dornsife School of Public Health at Drexel University found that urban nonprofit hospitals are starting to shift beyond charity medical care provisions and are looking to increase their impact on improving health outcomes by addressing social inequities in the communities they serve.

“It is encouraging that the vast majority of the nonprofit hospitals we studied recognize the social factors that cause health inequities,” said study author Amy Carroll-Scott, PhD, MPH, assistant professor in the Department of Community Health and Prevention and Urban Health Collaborative member. “Public health experts have known for a long time that we will not be able to reduce the inequities we see in health between different communities unless we first reduce the social inequities that are driving them.” 

Health care is only about 10 percent responsible for health, whereas social factors – such as race, socioeconomic status, neighborhood environment – are considered 80 percent responsible for health. These social factors, as well as structural economic and political forces, shape individuals’ ability to access care, practice healthy behaviors, and lead productive and stress-free lives as members of a safe and socially cohesive neighborhood environment.

A provision within the Affordable Care Act requires that nonprofit hospitals file community health needs assessments (CHNAs) at least once every three years, in which each hospital evaluates the health needs of the community it serves and proposes an implementation strategy that shows how it will use its community benefit dollars to address this need. This requirement was intended to prompt a culture shift among nonprofit hospitals to go beyond traditional community benefit activities (such as providing charity care) and address these underlying causes of health inequities through community building activities (such as housing or job training programs).

The Dornsife School of Public Health team conducted a quantitative content analysis of the publicly available CHNAs of 179 nonprofit, non-specialty hospitals in 28 of the United States’ largest cities between August and December 2016.

They found that 100 percent of the hospitals highlighted the need to address health equity in their CHNAs. However, only a small handful – 10 of 179 hospitals – proposed community-building activities in their implementation strategies that invested in upstream solutions.

“While we see early signs that some hospitals are already taking action to address inequities in their communities, we hope to see more hospitals propose strategies tied directly to achieving health equity in the future,” says co-author Jennifer Kolker, MPH, associate clinical professor in the Department of Health Management and Policy. “Although increasing health care access is important, we hope that hospitals will play a greater role in changing the systems that continue to create both social disadvantage and subsequent health disparities. ”

The analysis also found that CHNAs conducted by multiple hospitals or health systems demonstrated a deeper level of understanding health inequities and their causes than those conducted by a single hospital or health system, suggesting that collaborations may provide enhanced capacity to understand population health inequities.

While upstream solutions such as affordable housing programs or job training could have a major impact on improving health outcomes, researchers noted, hospitals are unlikely to pursue these complex strategies unless incentives encourage them to move beyond clinically-focused activities.

Study authors suggested that, whatever happens with the Affordable Care Act, the requirement for the completion of a community health needs assessment should stay in place. Hospitals have shown both compliance and commitment to the CHNA process and their implementation and continuation is important for improving population health. Further, they suggest changes should be made to community benefits reporting requirements that encourage community-building rather than clinically-focused strategies. With such alignment of policy, tax incentives, and partnership and capacity-building, nonprofit hospitals can be supported to complete CHNAs that both contribute new information to understand community health needs, and propose solutions that maximize community benefit dollars to address these needs.

View the Health Affairs study, The Role Of Nonprofit Hospitals In Identifying And Addressing Health Inequities In Cities, by Amy Carroll-Scott, Rosie Mae Henson, Jennifer Kolker, and Jonathan Purtle.