Abstract

Research Objective: The Affordable Care Act created enhanced IRS requirements for not-for-profit hospitals regarding the provision of community benefits, potentially stimulating new approaches to community health needs assessment, priority setting, and engagement with public health agencies and other community stakeholders. Yet the economic downturn has constrained hospital earnings and increased demand for uncompensated care, potentially crowding out hospital contributions to public health activities. This study uses data from 1998-2012 on a national cohort of communities to examine: (1) the extent and nature of change in hospital contributions to public health activities; and (2) the economic, institutional, and policy-related factors that influence these changes.

Study Design: Our retrospective cohort design follows 360 U.S. communities over time using survey data collected initially in 1998 and again in 2006 and 2012. The surveys, completed by the local public health official in each community, ask about the availability of 20 recommended public health activities in the community, which organizations contribute to each activity, and how well each activity is performed. We construct measures of the scope of hospital participation in public health activities each year, along with network analytic measures of hospital influence (density and centrality) within the local public health delivery network. Data on hospital market characteristics, ownership, and uncompensated care characteristics were obtained from the Area Resource File and Medicare Cost Report data. Generalized estimating equations models are used to estimate the effects of economic, market, and institutional characteristics on hospital contributions.

Population Studied: A total of 360 communities containing 100,000 or more residents in 1998, representing more than 70% of the total U.S. population. A sample of 50 smaller communities was added in 2006.

Principal Findings: The proportion of recommended public health activities contributed by hospitals in the average community increased from 37% in 1998 to 41% in 2006, but fell back to 39% in 2012. Almost two-thirds of communities experienced reductions in the scope of public health activities contributed by hospitals between 2006 and 2012. Hospital contributions to community health assessment activities remained level or increased in more than 80% of communities, but involvement in epidemiological investigation activities declined in 47% of communities, and hospital implementation of community-wide health improvement initiatives declined in 44% of communities. Multivariate estimates reveal that hospital contributions declined significantly in communities with larger growth in uninsured residents (p<0.05) and in communities with greater hospital competition (p<0.01). Communities that experienced increases in hospital community assessment activities were more likely than their counterparts to see reduced hospital contributions to other public health activities.

Conclusions: Increased demand for uncompensated care and the early policy focus on community health assessment activities appear to crowd out hospital contributions to other types of public health activities. The reduced scope of hospital contributions appear to leave hospitals in less influential positions within local public health networks, as indicated by organizational centrality measures.

Implications: The existing incentives and economic conditions shaping hospital provision of community benefits may fail to produce an optimal mix of activities needed for community health improvement.

Document Type

Presentation

Publication Date

6-24-2013

Notes/Citation Information

A presentation at the AcademyHealth Annual Research Meeting in Baltimore, MD.

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