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JAMA Forum Archive, 2012-2019: Health policy commentary from leaders in the field
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Using Community Health Trusts to Address Social Determinants of Health

As an increasing body of research demonstrates, there’s a link between “social determinants”—such as poverty, low educational attainment, unemployment, and housing instability—and the propensity for poor health. Many chronic diseases, such as diabetes, cancer, and heart disease, may be preventable or more readily manageable with community-based interventions addressing social determinants and fundamental risk factors such as diet and tobacco use.

But although health care systems deliver care for patients with chronic diseases, most medical centers are ill-equipped to tackle the social determinants of health themselves. This is a significant blind spot for the vision of a patient-centered, population health–driven system, and one that community health trusts could help address.

The idea of a financial trust to support community-based prevention isn’t novel. David Kindig, MD, PhD, and others have argued for “health outcomes trusts” to organize local public-private partnerships around common investment in better health. In Massachusetts, for example, the Prevention and Wellness Trust Fund makes grants to community organizations, municipal collaborations, and employers supporting workplace wellness. The fund was started with a $60 million allocation through the state’s health care cost-containment legislation, fueled by the notion that financing evidence-based programs that address costly preventable health conditions could save money.

Whatever the name, the concept of community health trusts is buoyed by the current policy milieu. For instance, nonprofit hospitals are required to provide benefits to the communities they serve, and the Affordable Care Act (ACA) established new standards relating to community health needs assessment, financial assistance policies, and hospital charges and billing. The ACA requirement, as enforced by the Internal Revenue Service (IRS), is expected to bring about greater accountability and transparency for US nonprofit hospitals’ tax exemption (estimated in 2002 to total $13 billion annually), although much depends on how the regulation is enforced.

Defining Community Benefit

Traditionally, community benefit has been interpreted expansively: it includes certain types of patient care, research, and education, as well as community health activities. In recent years, the IRS has designated categories of “community health improvement” (such as support to school-based health centers) and “community-building” (such as housing and local workforce development). One study based on 2009 IRS filings showed that 85% of community benefit expenditures went to charity care and other patient care services, and about 8% was allocated for community health improvement and community building. Some argue that the coverage expansion wrought by the ACA will shift community benefit expenditures away from patient care to community health, although the magnitude of that change is unclear.

The most salient health issues in any community—such as obesity and tobacco use—are likely to require collective action across health systems. However, at the local level, individual hospital systems attempting to address community benefit requirements may result in somewhat arbitrary and uncoordinated health improvement efforts. Instead of siloed efforts, a modest proportion of total funds dedicated by each hospital to community benefit could be put toward a common investment in proven, evidence-based public health priorities, such as those recommended by the Community Preventive Services Task Force.

Beyond Hospitals and Health Care

Some proponents of community health trusts suggest that hospital contributions could form the nucleus of a trust, providing a stable funding base that could be used to attract financing from health insurance plans, philanthropic monies, additional federal resources, or other community investment strategies being pioneered by the Federal Reserve. To invest funds with the goal of maximizing population health, there should be a mix of short-, medium-, and long-term securities that represent the spectrum from disease management to local development. For example, short-term investments, perhaps by health insurance plans, might focus on care coordination for patients who use a disproportionately high amount of health care services across multiple health care systems. Medium-term job creation programs for community health workers, meanwhile, could help a broader population achieve longer-term lifestyle changes in diet and physical activity.

Performance measures for trusts should be relevant to community organizations, local businesses, and potential investors. The assessment process should include analysis of both health improvement and effects on social determinants, such as job creation potential, improvement in education programs, and impact upon physical environment.

Creating a Framework

Creating a community health trust requires leadership from local and state elected officials. Mandatory contributions of some proportion of nonprofit hospitals’ community benefit dollars might be required to seed a trust. A more voluntary version, as described by Sara Rosenbaum, JD, and colleagues, could designate community health trusts as regulatory “safe harbors” for hospitals’ contributions. In either case, IRS rulemaking—for example, specifying that a minimum percentage of community benefit dollars must be dedicated to community health improvement or community building—would help facilitate greater public health investment by hospitals. Care should be taken to avoid unintended consequences for safety-net providers and health systems with robust and effective community programs already in place.

The concept of community health trusts is not without critics. Hospitals may be reluctant to cede authority over community benefit resources or subject themselves to what may be perceived as more burdensome regulation. Skeptics may question whether community health trusts will be able to attract broader investment, particularly from nonhealth and private sectors. And some argue that there’s insufficient evidence to warrant collective financing of community prevention strategies, characterizing these efforts as well intentioned but inconsequential.

These concerns are worth consideration, but as individual communities experiment with diverse ways to organize community health funding, they may prove soluble. Local, state, and federal policy change could help accelerate and expand incipient efforts. For example, New York has indicated an interest in shoring up state-level regulatory oversight of community benefit—including tying hospital community service plans to the State Prevention Agenda, its blueprint for reducing health disparities and improving population health.

There’s an emerging realization that our most intractable health problems, including obesity, mental illness, and tobacco use, require multifaceted solutions that cross health systems’ boundaries and require addressing the social determinants of health. Just as payment reform encoded in the ACA is beginning to transform health care delivery, community health trusts could help spur a transformation in population health.

About the authors:
Dave A. Chokshi, MD, MSc, (@davechokshi) is Director of Population Health Improvement and Assistant Professor of Medicine and Population Health at NYU Langone Medical Center.  He practices primary care at NYU Internal Medicine Associates.  During 2012-2013, he served as a White House Fellow at the US Department of Veterans Affairs.
Prabhjot Singh, MD, PhD, (@prabhjotsinghNY) is an Assistant Professor of International and Public Affairs at Columbia University, Director of Systems Design at the Earth Institute, and a part-time resident in Internal Medicine at Mount Sinai Health System. Prabhjot is a Robert Wood Johnson Foundation Young Leader, lead advisor to City Health Works and a member of Mayor Bill DeBlasio’s Child Well-Being advisory group.
Nicholas W. Stine, MD, is Chief Medical Officer of the HHC Accountable Care Organization at the New York City Health & Hospitals Corporation, the country’s largest municipal health system. He is also an Attending Physician at Bellevue Hospital and an Assistant Professor at the NYU School of Medicine in the Departments of Population Health and Medicine.
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