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Here in Boston, cooperation between health care providers is a fraught issue.
Competition is fierce among local, not-for-profit teaching hospitals, and the idea of collaboration brings to mind collusion, mergers and monopolies.
Unfortunately, these concerns may be keeping Boston hospitals from pursuing cost-effective strategies to meet federal tax-exemption requirements and improve community health. Over the next year, each of Boston’s 12 hospitals will have to conduct a community health needs assessment (CHNA) to retain their tax-free status. New requirements in the Affordable Care Act specifically encourage collaboration between hospitals and with other health care agencies, such as public health departments.
We argue that doing one, citywide CHNA presents a rare opportunity for high-value, low-commitment coordination among Boston hospitals.
In return for tax-exempt status, all nonprofit hospitals are required to invest in charitable activities that benefit the communities they serve. In 2015, eleven Boston hospitals invested a total of $139,428,644 on direct community benefit programs, including direct services like health screenings and grants to community organizations to conduct job readiness training.
In 2012, the Affordable Care Act began requiring all nonprofit hospitals to complete a CHNA every three years to identify priority areas for charitable spending and to ensure that hospitals are systematically identifying and responding to their communities’ health needs. Conducting a CHNA includes focus groups with community members and a deep dive into statistics describing the health of local populations. Completed reports are available to the public on hospitals’ websites as well as that of the Massachusetts attorney general. The AG, in its Community Benefit Guidelines, also suggests cooperation:
As nonprofit institutions, hospitals and HMOs also have important fiduciary obligations to provide benefits to their communities commensurate with their tax-exempt status …Hospitals may choose to collaborate with each other and with health plans in order to determine each hospital’s Community Benefits Target Populations and to develop a coordinated Community Benefits plan for the region...
To date, Boston hospitals have chosen to complete CHNAs separately, leading to substantial duplication of effort and output. As a result, community groups in neighborhoods with poor health outcomes have been called upon repeatedly to serve in focus groups for multiple hospitals. The majority of local hospitals’ current CHNAs were done by the same consultancy and drew on many of the same data sources to measure community health, a process that could surely be streamlined to save redundant effort and spending.
Unsurprisingly, Boston hospitals’ individual CHNAs arrived at the largely the same priorities: Poverty and health disparities, obesity and nutrition, mental health and substance abuse, and crime and violence were consistently identified as focal health challenges. Since these assessments were first completed in 2012 and 2013, Boston hospitals have been independently spending community benefit dollars to address these broadly similar priorities.
To be sure, these are important health goals and it's encouraging that hospitals are committed to addressing Boston’s pressing community health needs, but the complex challenges they’ve identified cannot be solved by working independently.
Boston residents would be well-served if hospitals collaborated to pursue one, citywide CHNA rather than 12 individual efforts. First, the creation of a jointly funded, jointly conducted CHNA for all of Boston would set the stage for a citywide strategic plan for health, around which a range of collaborators could focus resources and attention. The Boston Public Health Commission, our many philanthropies, local universities and community-based organizations could bring their unique abilities to bear on the shared goals identified in the CHNA. It is worth noting that the types of projects CHNAs are intended to catalyze -- such as safe neighborhoods -- are often public goods that require large-scale investments and benefit all Boston residents. It’s only right to think about these investments holistically.
Other American cities offer a precedent for this kind of collaborative effort among hospitals.
• Four hospitals in Baton Rouge came together to conduct a joint CHNA led by the mayor’s office and quickly saw the benefits of collaboration; upon identifying HIV as a priority, the city was able to drive screening rates up 28 percent.
• In Greater Cincinnati, 20 hospitals formed a nonprofit collaborative that rallied over 600 community organizations and patients around a unified set of priorities, which the hospitals noted would have otherwise been impossible.
• In Seattle, all 12 local health systems formed Hospitals for a Healthier Community to conduct a joint CHNA, viewing this collective effort as the most effective way to tackle shared social and contextual factors affecting health. After identifying obesity and diabetes as key issues, the Seattle hospitals responded with a pledge to change procurement practices to improve access to healthy food and beverages within their own facilities.
Locally, a similarly collaborative effort has proven successful in the MetroWest area of Massachusetts. There, six organizations -- including two hospitals, a local foundation, a federally qualified health center and a physician group -- created a single CHNA in 2013. Although only Marlborough Hospital was legally required to conduct a CHNA, all organizations paid part of the cost and together were able to afford tools to translate community surveys into Spanish and Portuguese.
Rebecca Donham, a senior program officer at the MetroWest Health Foundation, noted that this would have been impossible for any one participant acting alone. The resulting needs assessment report was publicly released at a MetroWest health summit, which brought together local health and social service organizations that have since adopted the priorities reflected in the assessment.
MetroWest Health Foundation President and CEO Martin Cohen sees his community’s experience as a model for others, including Boston: “Joint community health needs assessments and plans are essential to moving away from current silos of care to a true focus on population health,” Cohen said.
To be sure, there would be real coordination costs to developing a coalition-based needs assessment in Boston. The process of creating a joint CHNA would inevitably require more time to build consensus among collaborating facilities. Scheduling, traveling and communicating across organizational boundaries is no picnic. Even so, we believe a joint CHNA would cost less than each organization conducting their own CHNA and the transformative potential of a single plan is too large to ignore.
Michael Anne Kyle and Lauren Taylor are both doctoral students in health policy at Harvard University.