In past coverage, NPQ noted how health advocates might be able to use community health needs assessments (CHNAs) to better the quality of healthcare in their communities. CHNAs are part of the Patient Protection and Affordable Care Act (ACA), often referred to as the “health care reform law” by some and as “Obamacare” by others. In June of 2012, the U.S. Supreme Court upheld the constitutionality of the ACA, which means that nonprofit healthcare providers need to become more familiar with these mandatory reports. This article outlines four misconceptions that nonprofit healthcare providers should be careful to avoid.
How Community Health Needs Assessments Came into Being
CHNAs were included in the ACA because there is concern that nonprofit hospitals may not be paying sufficient attention to the “public benefit purpose” which lies at the heart of the justification for their tax-exempt treatment by the Internal Revenue Service (IRS). Congress wanted a way to assess whether tax-exempt hospitals are fulfilling their responsibilities as nonprofit organizations as well as being health care facilities. The U.S. Department of Health and Human Services (HHS) oversees hospitals and, in that role, implements a variety of assessment and compliance requirements for hospitals and health care facilities, including nonprofit hospitals. On the other hand, the IRS is responsible for oversight of nonprofit organizations. Therefore, it makes sense that the CHNA requirement is tied to the IRS and the Form 990 filed by nonprofit organizations.
CHNAs are designed to document public benefit purpose, which, in this case, entails an examination of how well nonprofit hospitals function as charities. More specifically, they are an attempt to document the responsiveness of nonprofit hospitals to community needs. However, we are concerned that the legislative intent of the CHNA assessment process is being ignored by some and misinterpreted by others, which could yield negative results for hospitals and their communities. The IRS, responsible for monitoring compliance, has signaled their strong interest in evaluating assessments based on Congress’s legislative intent. So, ignoring or misconstruing the intended purpose and uses of the assessments may have enforcement implications as well as implications for the management, delivery, and governance of health care in communities across the country.
Four Misconceptions about Community Health Needs Assessments
This author has been following the development practices surrounding community health needs assessments since 2009, when my firm performed an assessment for a Sioux Falls, S.D. hospital. Since then, we have developed a process for assisting nonprofit hospitals with their CHNAs. We are currently pilot-testing this CHNA process with two rural hospitals, and we anticipate working with several more hospitals on their assessments this year. This experience leads to our understanding that there are at least four distinct mistaken beliefs that hospital leaders, and those who seek to help them comply with the CNHA require, may be making.
Misconception #1: Statistical data is sufficient.
There is a belief that CHNAs are a data-driven reporting exercise and that access to the right statistical data compiled from third-party sources is the key to success.
Misconception #2: A CHNA is a marketing exercise.
CHNAs are sometimes portrayed as a hospital’s marketing exercise—similar to a community benefit survey—where the hospital’s job is to “educate” the community using the CHNA process.
Misconception #3: CHNAs are a structure for public health sector alignment.
Some are portraying the CHNA process as a way for public health officials and organizations to change the focus of nonprofit hospital service delivery to more closely reflect established public health priorities. While CNHAs might be used for this purpose by healthcare advocates, that is not the primary intention of the CHNA.
Misconception #4: CHNAs aren’t really that different or that important.
Some are misrepresenting the CHNA process and, incidentally, minimizing the need for outside assistance by hospitals in formulating assessments and developing action plans.
The mistakes have one common thread; they discourage or discount the soliciting of opinions, attitudes, and perceptions from community members being served by the hospital doing the CHNA. Let’s address these four mistakes one by one.
Misconception #1: Statistical Data Is Sufficient
It’s not surprising that hospitals are focusing on the data aspects of the CHNA requirement. After all, relatively few hospitals track external health care data on a regular basis; they tend to rely on internal utilization data and anecdotal reporting on external trends in their planning. They are unlikely to employ statistical analysts in their administrative offices, and they are unlikely to even know where to start when asked to consult external data. There are several groups and organizations that are developing, or have developed, web-based or workstation-based access to various statistical databases. U.S. Census data, CDC data, state health department data, and other data are now available online either free or for a fee. These data sets may be downloaded and analyzed. Some providers even make sophisticated geographic information systems (GIS) mapping software available over the Internet.
Providing access to statistical data definitely makes the CHNA research process easier. However, it’s not a substitute for the process itself. I spoke with a hospital CEO recently who assured me that he “had the CHNA covered” because his state was developing an Internet-based tool for statistical data reporting. He didn’t realize that the statistical data collection is part of the preparation, not the assessment itself. Statistical data doesn’t involve asking real people what they think about and what they want, and it doesn’t do a lot when formulating an action plan to address community health needs. Both of these non-statistical activities are essential to CHNA success.
Misconception #2: A CHNA Is a Marketing Exercise
Some have presented CHNAs as an opportunity to “sell” a hospital or its services. There’s nothing wrong with a hospital using the data from its CHNA to improve its marketing efforts. In fact, we believe that one of the key findings in many communities will be that many community members are unaware of the breadth and depth of services provided by their nonprofit hospital. Understanding this finding will provide hospitals (and the communities they serve) with opportunities to increase utilization, and perhaps even revenue. However, in order to learn what someone thinks and why they act the way they do, it’s usually necessary to ask them. Observation from a distance gets one only so far in assessing community perceptions. Hospitals need to have the courage to ask the right questions about their services, even if the answers are uncomfortable. Those answers may not necessarily help with a hospital’s marketing strategy.
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Misconception #3: CHNAs Are Primarily a Tool for Advocacy
There is a passage in the Affordable Care Act that states that CHNAs “take[s] into account input from persons who represent the broad interests of the community served by the hospital facility, including those with special knowledge of or expertise in public health…” This has opened a door that public health professionals and advocates are using to attempt to influence the CHNA process toward promoting established public health goals and initiatives.
Some see the CHNA requirement as the method by which nonprofit hospitals become instruments of public health advocates’ agenda. The CDC is advocating that hospitals use a service area description that explicitly includes medically underserved areas that would not necessarily be evident when looking at a hospital’s utilization data. CDC officials have been quoted as expressing strong interest in partnering with the IRS, as it writes the regulations for evaluating the CHNA reports that must accompany Schedule H of the IRS Form 990 filing for each nonprofit hospital.
CDC officials also have well-defined ideas of what should be included in a nonprofit hospital’s CHNA action plan. For example, one CDC staffer on a webinar conference call indicated that all CHNAs should include a priority on smoking and tobacco use cessation activities. Smoking and tobacco use cessation activities are a laudable goal in the abstract, but is it realistic to expect all communities to identify it at or near the top of their list of priorities? Is it appropriate for all nonprofit hospitals to devote resources to this activity, regardless of other community-based initiatives and regardless of other pressing health concerns in the community? When pressed, CDC officials recognize that communities, and the hospitals that serve those communities, may identify issues not on the CDC’s list. They also realize that there may be valid reasons why initiatives or issues that appear valid at first may be impractical owing to geographic, regulatory, or other reasons outside of the control of the hospital or even its potential partners.
While the ACA clearly acknowledges that CHNAs should take into account the opinions of public health experts, and while, as NPQ has previously noted, health advocates may wish to use CHNAs to push for hospital policy changes, the core purpose of the CHNA is to gauge a community’s needs and how the nonprofit hospital serving that community chooses to respond to those needs. This does not mean that a hospital shouldn’t care for the poor, the medically underserved, or other vulnerable populations in their communities. The hospital has the responsibility to be responsive to the whole community.
Misconception #4: CHNAs Aren’t Really That Different or That Important
The Community Health Assessment Toolkit assembled by the Association for Community Health Improvement (ACHI), Community Connections, and the American Hospital Association (AHA) is a framework for conducting a CHNA to comply with the requirements of the ACA and the likely regulations yet to be issued by the IRS.
In 2011, ACHI estimated that conducting a CHNA would cost a nonprofit hospital between $60,000 and $140,000. On the other hand, there are those who believe – and are telling nonprofit hospital administrators, public health officials, and others – that a CHNA can be performed for $10,000 or less. Why do the estimates vary so widely?
We believe that the ACHI/Community Connections/AHA process is comprehensive and envisions extensive assistance from outside consultants. Most hospitals, and especially smaller, more rural, independent hospitals, do not have the staff time or expertise to engage in a comprehensive CHNA process once every three years while conducting routine business. However, if a hospital buys into the statistics-driven process without substantive community input, then it’s possible to deliver a product of some sort that might be called a CHNA for a lower price. However, there are four problems with a hospital short-changing itself in this way.
The hospital may or may not find itself in substantial compliance with the IRS regulations governing CHNAs via this shortcut route, but the hospital shortchanges itself of the opportunity to discover, in Peter Drucker’s phrase, “what the customer considers value,” which is the central issue of the CHNA. In addition, a CHNA performed to the ACHI/Community Connections/AHA standard is a powerful document that can inform not only marketing and program services, but also organizational strategic planning. A minimalist approach to the CHNA process invites the hospital to miss a lot of potentially valuable information that can be used in several productive ways. Lastly, a comprehensive process that engages the community at large as well as potential partners and other community experts increases the visibility and leadership profile of the hospital.
We anticipate that many hospitals will rush to complete something – anything – resembling a CHNA to meet the first deadline. Hospitals rushing to meet a looming deadline are at risk of falling into many or all of the traps identified here, particularly a reliance on statistical reports with little or no substantive community input. Such reports provide little or no value beyond bare tax compliance (if that), and may move the hospital away from its core competencies and stated mission. We’d rather see the CHNA provisions of the ACA implemented in such a way as to provide benefit to the community and the hospital that serves the community.