Creating the next Community Health Needs Assessments in the aftermath of COVID

Local hospitals are just now preparing their fourth community health needs assessment (CHNA) and implementation strategy, a federally mandated procedure designed to force nonprofit hospitals to make health investments in their service areas or risk a $50,000 per year fine, or worse, loss of their tax-exempt status.

That’s the stick behind this every-three-years process when health care systems are not only required to work with public health professionals and grassroots activists to identify and prioritize community health care needs, but also to develop implementation plans. The resulting CHNAs will be on healthcare facilities’ websites come next July.

Unlike the first rounds of CHNAs published by individual hospitals in 2013 and 2016, there is a growing trend towards hospitals collaboratively working to produce their CHNAs.

“This will be the fourth time doing the needs assessment,” said Health Care Improvement Foundation (HCIF) Senior Director Susan Choi. “The first two cycles, a lot of hospitals did it on their own. The last cycle [2019] is the first time [local hospitals] took a collaborative approach.”

The HCIF will be facilitating the development of the 2022 Philadelphia regional CHNA, a role they played in the development of the 2019 Regional Community Health Needs Assessment. “The Philadelphia healthcare market has a lot of healthcare systems and they serve different communities but there is still overlap and [the communities] have similar needs,” Choi said.

In the 2019 report, the top three of 16 identified priorities were opioid use and substance abuse, behavioral health, and access to affordable preventative and primary healthcare.

Revisiting this needs assessment a year after the pandemic ravaged the city’s health, brought on an economic crisis and a racial reckoning, showed that the most pressing issues uncovered by COVID, were also the issues furthest down on the Regional CHNA’s priorities list.

• COVID unveiled the depth of housing insecurity in the region, but affordable housing came in 8th place and homelessness was dead last at number 16.
• Community violence, despite a 37 percent increase in homicides in the city as compared to this time last year, came in 13th.
• Racism in health care settings, which was implicated as one of the causes for health disparities in COVID care, was 14th.
• Neighborhood conditions, safe outdoor spaces for recreation, for example, came in 15th, although the need for greenspace to counteract the isolation of social distancing became essential during the pandemic.

Researchers contend that the CHNA is an opportunity to finally link medicine and public health but “The COVID-19 pandemic made the failure to invest in programs combatting these public health challenges — exacerbated by health disparities — glaringly clear.”

That’s a conclusion from the Hospital & Health System Association of Pennsylvania (HAP) which is now calling for more significant investment in the state’s public health infrastructure.

HAP, which represents 240 healthcare systems and hospitals across the state, noted that the Commonwealth ranks near the bottom in terms of federal money for building public health infrastructure: “Pennsylvania received $15.6 million from the Centers for Disease Control and Prevention (CDC) during FY 2020, ranking 46 in total state funding per capita. Of the CDC COVID-19 pandemic response funding to states, Pennsylvania received 1.5 billion, ranking 46 per capita.”

Even before the first CHNA was released to the public there were concerns about its ability to impact health disparities.

“The bleak health conditions that will emerge in many CHNAs comprise a picture sufficient for an Occupy Healthcare movement, particularly due to the bare revelation of racial, ethnic, and income inequities,” predicted a 2013 Nonprofit Quarterly article, the year the first CHNA plans started appearing.

Jefferson,  for example, in its 2013 maiden effort conducted a survey which showed its community found chronic disease management, access to care and smoking cessation some of their most important issues. Doylestown Hospital in Bucks County selected cancer and heart disease, while Cooper University Health Care in Camden County focused on increasing access to healthcare and Temple University Hospital targeted the percentage of uninsured adult and adults without prescription coverage.

These results were replicated across the country where the most common top five priorities included obesity, access to care, diabetes, cancer, and mental health.

These early efforts left researchers underwhelmed.

One group calculated that by 2014, hospital spending on community health benefit had only increased by one-half of one percent going from 7.6% of operating expenses in 2010 to 8.1% in 2014.

However, the CHNA does keep a public focus on whether hospitals provide enough community benefit to justify their tax-exempt status, or whether they are corporate entities in nonprofit clothing.

Since 2004, Iowa’s Republican Senator Charles Grassley has been investigating this question after disclosures showed some nonprofit hospitals provided little charitable care, failed to publicize the availability of financial support for poor patients, and used aggressive bill collection practices.

It was through Grassley’s influence that the CHNA requirement was inserted in the the Patient Protection and Affordable Care Act (ACA) which passed in 2010. However,  a 2018 study from the Johns Hopkins School of Public Health found that nonprofit hospitals still weren’t delivering community benefits that outweighed the value of their tax exemptions worth billions of dollars.

“Hospitals have an important and big role to play in supporting public health infrastructure,”  Choi said. “One of the highest priorities (for 2022) is to expand the qualitative data collection process to enable more community members and organizations to share their perspectives on what they see as pressing community needs, as well as community strengths and assets.”