Leider Jonathon P, Tung Greg J, Lindrooth Richard C, Johnson Emily K, Hardy Rose, Castrucci Brian C
de Beaumont Foundation, Bethesda, Maryland (Dr Leider and Mr Castrucci); and Colorado School of Public Health, University of Colorado Anschutz Medical Campus-Denver, Denver, Colorado (Drs Tung and Lindrooth and Mss Johnson and Hardy).
J Public Health Manag Pract. 2017 Nov/Dec;23(6):e1-e9. doi: 10.1097/PHH.0000000000000493.
Community Benefit spending by not-for-profit hospitals has served as a critical, formalized part of the nation's safety net for almost 50 years. This has occurred mostly through charity care. This article examines how not-for-profit hospitals spent Community Benefit dollars prior to full implementation of the Affordable Care Act (ACA).
Using data from 2009 to 2012 hospital tax and other governmental filings, we constructed national, hospital-referral-region, and facility-level estimates of Community Benefit spending. Data were collected in 2015 and analyzed in 2015 and 2016. Data were matched at the facility level for a non-profit hospital's IRS tax filings (Form 990, Schedule H) and CMS Hospital Cost Report Information System and Provider of Service data sets.
During 2009, hospitals spent about 8% of total operating expenses on Community Benefit. This increased to between 8.3% and 8.5% in 2012. The majority of spending (>80%) went toward charity care, unreimbursed Medicaid, and subsidized health services, with approximately 6% going toward both community health improvement and health professionals' education. By 2012, national spending on Community Benefit likely exceeded $60 billion. The largest hospital systems spent the vast majority of the nation's Community Benefit; the top 25% of systems spent more than 80 cents of every Community Benefit dollar.
Community Benefit spending has remained relatively steady as a proportion of total operating expenses and so has increased over time-although charity care remains the major focus of Community Benefit spending overall.
More than $60 billion was spent on Community Benefit prior to implementation of the ACA. New reporting and spending requirements from the IRS, alongside changes by the ACA, are changing incentives for hospitals in how they spend Community Benefit dollars. In the short term, and especially the long term, hospital systems would do well to partner with public health, other social services, and even competing hospitals to invest in population-based activities. The mandated community health needs assessment process is a logical home for these sorts of collaborations. Relatively modest investments can improve the baseline level of health in their communities and make it easier to improve population health. Aside from a population health justification for a partnership model, a business case is necessary for widespread adoption of this approach. Because of their authorities, responsibilities, and centuries of expertise in community health, public health agencies are in a position to help hospitals form concrete, sustainable collaborations for the improvement of population health.
The ACA will likely change the delivery of uncompensated and charity care in the United States in the years to come. How hospitals choose to spend those dollars may be influenced greatly by the financial and political environments, as well as the strength of community partnerships.
近50年来，非营利性医院的社区福利支出一直是美国安全网的关键组成部分且已正式确立。这主要通过慈善医疗来实现。本文研究了在《平价医疗法案》（ACA）全面实施之前，非营利性医院是如何使用社区福利资金的。
利用2009年至2012年医院税收及其他政府备案文件中的数据，我们构建了全国、医院转诊区域和机构层面的社区福利支出估算。数据于2015年收集，并在2015年和2016年进行分析。数据在机构层面进行匹配，涉及非营利性医院的美国国税局税务申报文件（990表格，H附表）以及医疗保险和医疗补助服务中心（CMS）医院成本报告信息系统和服务提供商数据集。
2009年，医院将约8%的总运营费用用于社区福利。这一比例在2012年增至8.3%至8.5%之间。大部分支出（>80%）用于慈善医疗、未报销的医疗补助以及补贴性医疗服务，约6%用于社区健康改善和卫生专业人员教育。到2012年，全国社区福利支出可能超过600亿美元。最大的医院系统支出了全国大部分的社区福利资金；排名前25%的系统支出了每1美元社区福利资金中的80多美分。
社区福利支出占总运营费用的比例一直相对稳定，因此随着时间推移有所增加——尽管慈善医疗仍是社区福利支出的主要总体重点。
在《平价医疗法案》实施之前，用于社区福利的支出超过600亿美元。美国国税局新的报告和支出要求，以及《平价医疗法案》带来的变化，正在改变医院在使用社区福利资金方面的激励机制。从短期来看，尤其是从长期来看，医院系统与公共卫生部门、其他社会服务机构甚至竞争医院合作开展基于人群的活动会有好处。法定的社区健康需求评估过程是这类合作的合理归宿。相对适度的投资可以提高其社区的健康基线水平，并使改善人群健康变得更容易。除了基于人群健康的合作模式理由外，广泛采用这种方法还需要一个商业案例。由于其在社区健康方面的权力、责任和数百年的专业知识，公共卫生机构有能力帮助医院形成具体、可持续的合作关系以改善人群健康。
在未来几年，《平价医疗法案》可能会改变美国无偿和慈善医疗的提供方式。医院如何选择使用这些资金可能会受到财务和政治环境以及社区伙伴关系强度的极大影响。
