2020 was a year like no other. COVID-19 laid bare many inequities in our Commonwealth and nation. Black and Latinx residents, many of whom are low-wage essential workers, immigrants, and non-English speakers were most impacted by both the virus leading to higher rates of hospitalization and death, as well as by the accompanying chronic economic challenges such as affordable housing and food insecurity.
The past year also saw a growing movement for social justice and calls to address structural racism, including calls by Attorney General Maura Healey and other elected officials to address key social determinants of health in order to advance statewide health equity. In late fall, Healey focused specific attention on the responsibility of the health care sector—and especially hospital systems – to take action against structural racism in a report that her office authored.
Last month, Healey’s office released its annual summary of hospital community benefit submissions for fiscal year 2019, the first year that revised community benefit guidelines issued in 2018 went into effect. We described the main points of change and our hopes a few years ago when the guidelines were first promulgated. A review of this past year’s hospital submissions leads us to these recommendations:
All non-governmental hospitals should be reporting, with greater categorical consistency, and there should be specific designation when determination of need obligations drive the expenditure.
Though technically voluntary, practically all non-governmental hospitals, including not-for-profit and even for-profit ones, report annually to the attorney general’s office. One persistent exception is Boston Medical Center, which to our knowledge and continuing surprise, neglects to file a report.
The decline in reported community benefit investment by the for-profits, especially the Steward system, is notable compared to past years, although the system’s hospitals do pay property and other taxes. Also, hospitals are no longer asked to report determination of need spending separately, so some large boosts in hospital community benefit spending as compared to prior years are not evidence of new and heightened commitments, but rather an outgrowth of a capital project driving required expenditures for a defined period under Department of Public Health regulations. This appears to be the case in the latest reporting period with Boston Children’s Hospital.
Hospital spending should be focused more “upstream” on social and environmental determinants of health.
We found that the new requirement for community benefit reporting two different ways – by program type (i.e., community linkages, clinical services, or population health) and by health needs addressed (i.e., heart disease, substance abuse, homelessness, etc.), overall provides a better understanding of how hospitals view their community benefits investment strategy. It also offers the public an opportunity to better view the extent to which hospital investments are targeted to address key social determinants of health. We also found the new requirement that individual hospitals break out spending for external organizations and grants, versus internal, a useful change in reporting.
However, a review of the FY 2019 reporting for all hospitals combined still demonstrates a lack of upstream investment in Department of Public Health identified health needs. By program type, only 25 percent of statewide community benefit program spending went to total population or community wide interventions. Massachusetts hospitals spent 26 percent of community benefit program spending on chronic disease interventions, but only 16 percent on mental health programs, 6.5 percent on substance abuse, and less than 2 percent on housing programs. Half of the spending was on other identified needs that did not fall into these state prioritized categories.
A deeper dive into program spending reveals that while 68-78 percent of all hospitals reported some investment in housing and substance abuse programs, often these were small investments. In housing, three hospitals gave about half of the $6.7 million reported statewide. For substance abuse, three hospitals contributed about 65 percent of the $23.7 million hospitals spent statewide. The overwhelming number of hospitals that reported any spending in either of these two categories spent only a small proportion of their reported total community benefit expenditures. To us, this clearly indicates our state’s nonprofit hospitals still have a good way to go to show that their yearly spending aligns with addressing key state public health priorities.
In addition, a continuing concern of ours is that hospitals simply aggregate total spending on a specific health need area, without attribution to named activities. This reality, combined with the fact that hospitals do not have to show when an activity is grant or contract supported, leaves the report reader ignorant of a hospital’s true spending priorities as evidenced by the level of its own resource commitment to specific types of programs.
Even if we view as progress the fact that total reported direct program spending increased for the field overall—with 41 percent of nonprofit hospitals spending more than 1 percent of their revenues on direct programs this past year, up from 27 percent in 2016 – the inability to see specific project spending amounts makes it difficult for the reader to better assess a hospital’s commitment to specific efforts.
Community engagement needs to be taken more seriously at all steps of the process.
The attorney general’s revised guidelines clearly call on hospitals for more intense emphasis on the need for greater community engagement. They require hospitals to more demonstrably show community member involvement in performing needs assessment, developing community benefit plans, and evaluating efforts. Both hospital self-assessment and community member assessment of the hospital’s engagement efforts in these processes became required elements for reporting for the first time this past year.
The public can view an individual hospital’s self-assessment form on the attorney general’s website. Included in the form is the hospital’s plan to address health equity in its community. In recent weeks, the attorney general’s office also published a summary report of community members’ experience with hospital’s engagement efforts. This year, 209 respondents from across 45 hospitals completed an assessment of community engagement efforts by their hospital; 87 percent of the respondents were members of a hospital community benefit committee.
While there was a generally positive overall response to hospitals’ efforts, there was a mixed response when it came to engagement for defining the community to be served, establishing priorities for implementation and program design, and engaging in program implementation and evaluation. Community members offered some good strategies for expanded and deeper collaboration, including giving community members’ perspectives more weight in helping to guide issue prioritization, and in establishing the levels of investment in social determinants of health. Community member evaluations also noted a need for greater regional collaboration, as well as the need for greater involvement and presence of hospital senior leadership in the entire community benefits process. We hope hospital administrators will review community comments and take to heart some of the suggestions offered by community members.
Key lessons from the COVID pandemic.
We all know that in both treating those sick and infected with COVID, as well as preventing the spread of further infection, good care and infection control practices are not required for hospitals alone. The COVID pandemic underscores that at nursing homes, other congregate living facilities for seniors and disabled, and in-home care environments—these are all settings where good infection control practices and abilities, and the health of workers in those settings, will ultimately impact both the numbers of hospitalized COVID patients as well as overall community public health.
If there were any doubts that community benefits of a hospital in such an era should include providing support to institutional or individual home care providers for such things as personal protection equipment, infection control, testing, and vaccination access, COVID erases all of them. It will be of interest to see how many such hospital efforts are identified in next year’s hospital submissions.
The COVID pandemic has also catalyzed something that the attorney general encouraged in its revised 2018 guidelines – joint planning and implementation of efforts to address community needs. There is even a specific expense category for such collaborations. The range of reporting spending in this category was interesting. Some like Boston Children’s and Dana Farber, reported over $2 million and $1 million of expense, respectively. Lawrence General at over $300,000, reported more expense here than any other direct spending category. This compares with our largest hospital system, Massachusetts General Brigham, which reported no expense at all in this category even though we have personally participated with Mass General Brigham on such initiatives. Something seems amiss here.
We witnessed the benefits of hospital cooperation during COVID, with hospitals offering mutual help with PPE shortages or to prevent any one hospital from being overwhelmed with too many patients. This reminds us what our hospitals can do when they truly feel a need to work together—remember what happened during the Marathon bombing.
We need to capture this collaborative spirit and employ it daily, well beyond the duration of these (hopefully) worst phases of the pandemic, and use it to address a range of social and public health issues. There have been some small steps in this direction around affordable housing in Boston (even pre-pandemic) by a few institutions, but even there, the efforts to date have been limited and really are only an outgrowth of mandated determination of need expenditures.
All in all, though these revised guidelines have helped move the field ahead in efforts to better align their community benefit programs and spending with key community health and equity needs, there is still a ways to go. More than ever, we need to make sure that the next steps forward are much bigger leaps.
Enid Eckstein is active in community engagement, development, and healthcare transformation and Paul Hattis is a retired associate professor at Tufts Medical School.