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Lopez L, Dhodapkar M, Gross CP. US Nonprofit Hospitals’ Community Health Needs Assessments and Implementation Strategies in the Era of the Patient Protection and Affordable Care Act. JAMA Netw Open. 2021;4(8):e2122237. doi:10.1001/jamanetworkopen.2021.22237
In response to congressional concerns that US nonprofit hospitals were providing insufficient community benefit to justify their tax-exempt status (estimated at $24.6 billion in 2011),1 the Patient Protection and Affordable Care Act (ACA) added new requirements. These rules mandated that all nonprofit hospitals (1) conduct a triennial community health needs assessment (CHNA) and adopt an implementation strategy, (2) abide by specific documentation requirements, and (3) make these documents publicly available. This cross-sectional study examines US nonprofit hospitals’ adherence to these requirements during the ACA era.
The Yale University Human Research Protection Program determined that this study is not considered human participants research; thus, neither institutional review board approval nor informed consent was needed, in accordance with 45 CFR §46. This study follows the Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) reporting guidelines for cross-sectional studies.
We used a standardized search on the ProPublica Nonprofit Explorer in January 2019 and identified 1662 nonprofit hospitals in the US and the District of Columbia.2 We randomly selected 500 of these hospitals, proportionally by the number of active nonprofit hospitals in each state in 2017. We then accessed their respective Internal Revenue Service form 990 Schedule H directly from ProPublica. From these forms, we assessed whether each hospital reported that it had conducted a CHNA, adopted an implementation strategy, and made these reports available online.
We downloaded the CHNAs and implementation strategies directly from hospitals’ websites. We used 7 specific Internal Revenue Service documentation elements to evaluate the available CHNAs and used 3 reporting requirements to evaluate the implementation strategies3 (Table 1). Similar to prior studies, we used a Likert scale to rate the level of detail of each CHNA and implementation strategy (range, 0-5, with higher scores indicating more detail and higher quality).4 A co-rater (L.L.) conducted a review of 10% of the sample using the same instrument, and the κ value was greater than 0.8. The analyses were conducted in Stata statistical software version 15.1 (StataCorp) in June 2020.
Among the 500 hospitals in our sample, 495 (99.0%) reported on their Internal Revenue Service 990 form that they had conducted a CHNA, and 412 (84.0%) of these CHNAs were identified online. A total of 491 hospitals (99.0%) reported that they adopted an implementation strategy, and 331 of these (75.0%) were identified on their website. In aggregate, 229 (60.0%) of the hospitals in our sample had both a CHNA and corresponding implementation strategy that could be found online.
The 412 CHNAs had a mean quality score of 3.2 of 5, consistent with partial detail. Many were missing the required documentation elements: 174 CHNAs (42.2%) did not include an evaluation of impact description, and 101 (25.0%) did not describe the resources available to address the health needs they identified (Table 2). The 331 implementation strategies had a mean quality score of 3.2 of 5; 136 (41.0%) were rated as solid-high quality (score 4 or 5 of 5).
This cross-sectional study found that since the passage of the ACA’s CHNA and implementation strategy regulations, most hospitals reported that they are conducting CHNAs and adopting related implementation strategies. However, only 60.0% of the hospitals in our sample had both a CHNA report and an implementation strategy on their website, and many of the documents were missing the required documentation elements.
This study had some limitations. Our sampling methods were determined according to the ProPublica database. However, we are confident in the comprehensiveness of this source because it includes more than 3 million tax filings under 27 different nonprofit designations.2
The ACA sought to ensure that hospitals fulfill their obligations to their communities. However, many CHNAs and implementation strategies are not available at all, and those that are accessible do not provide the required information regarding how hospitals are assessing and addressing community health needs. There is much work to be done, and federal policy makers have an opportunity to improve hospitals’ accountability and transparency.
Accepted for Publication: June 19, 2021.
Published: August 24, 2021. doi:10.1001/jamanetworkopen.2021.22237
Open Access: This is an open access article distributed under the terms of the CC-BY License. © 2021 Lopez L III et al. JAMA Network Open.
Corresponding Author: Leo Lopez III, MD, MHS, National Clinician Scholars Program, Department of Internal Medicine, Yale School of Medicine, 333 Cedar St, Courier SHM IE-66, PO Box 208088, New Haven, CT 06510 (email@example.com).
Author Contributions: Dr Lopez had full access to all of the data in the study and takes responsibility for the integrity of the data and the accuracy of the data analysis.
Concept and design: Lopez, Gross.
Acquisition, analysis, or interpretation of data: Lopez, Dhodapkar.
Drafting of the manuscript: Lopez, Dhodapkar.
Critical revision of the manuscript for important intellectual content: Lopez, Gross.
Statistical analysis: Lopez, Dhodapkar.
Conflict of Interest Disclosures: Dr Lopez reported receiving grants from the National Institutes of Health during the conduct of the study. Ms Dhodapkar reported receiving grants from the Food and Drug Administration Centers of Excellence in Regulatory Science Scholars and grants from Yale School of Medicine Medical Student Summer Fellowship outside the submitted work. Dr Gross reported receiving grants from the National Comprehensive Cancer Network (Pfizer/Astra-Zeneca), Johnson & Johnson for new models of clinical trial data sharing, and Genentech and travel and speaking fees from Flatiron outside the submitted work.
Funding/Support: Dr Lopez completed this work at Yale University School of Medicine while part of the National Clinician Scholars Program, and was supported through grant TL1 TR001864 from the National Center for Advancing Translational Science, a component of the National Institute of Health.
Role of the Funder/Sponsor: The funder had no role in the design and conduct of the study; collection, management, analysis, and interpretation of the data; preparation, review, or approval of the manuscript; and decision to submit the manuscript for publication.
Disclaimer: The contents of this work are solely the responsibility of the authors and do not necessarily reflect the official views of Yale University, NYC Health and Hospitals, New York University, or the National Institutes of Health.