Simone R. Singh

Public Health Spending and Population Health: A Systematic Review

CONTEXT This systematic review synthesizes what is known about the relationship between public health spending and population health outcomes, as well as the pathways that may explain how outcomes vary with spending. It also discusses the limitations of the existing literature and identifies areas in need of future research. EVIDENCE ACQUISITION Studies included in this review were retrieved through an iterative process, primarily through key word searches in two literature databases (PubMed and JSTOR) conducted in 2013. All retrieved studies underwent initial and secondary screening. Articles were included if they (1) examined the link between spending and outcomes or (2) explored pathways that mediate the relationship between spending and outcomes. EVIDENCE SYNTHESIS Seventeen empirical studies and five literature reviews published between 1985 and 2012 were included in this review. Existing evidence suggests that increases in public health spending are associated with improved population health, at least for some outcomes. However, there is little evidence to suggest that increased spending contributes to meaningful reductions in health disparities. Moreover, the pathways through which greater spending translates into better outcomes are not well understood. CONCLUSIONS Although the complexity of the public health delivery system makes it difficult to demonstrate definitive associations between spending and outcomes, financial investments in public health have the potential to improve community health. Additional research is needed to explore the pathways that mediate this relationship. This research would benefit public health practitioners who need evidence on how to best spend financial resources to achieve better health outcomes.

Tax-Exempt Hospitals and Community Benefit: New Directions in Policy and Practice

The current community benefit standard for nonprofit hospital tax exemption has been the subject of mounting criticism. Many different constituencies have advanced the view that in its present form it fails to ensure that nonprofit hospitals provide adequate benefits to their communities in exchange for their tax exemption. In contrast, hospitals have often expressed the concern that the community benefit standard in its current form is vague and therefore difficult to comply with. Various suggestions have been made regarding how the existing community benefit standard could be improved or even replaced. In this article, we first discuss the historical and legal development of the community benefit standard. We then present the key controversies that have emerged in recent years and the policy responses attempted thus far. Finally, we evaluate possible future policy directions, which reform efforts could follow.

Accreditation intent, community health assessments, and local health department-hospital collaboration

Background: Community health assessments (CHAs) are among the most core of activities conducted by local health departments (LHDs), and many LHDs have been conducting CHAs on a regular basis for years. More recently, completing a CHA has also become a prerequisite for LHDs seeking accreditation by the Public Health Accreditation Board (PHAB). Similarly, under the Affordable Care Act, tax-exempt hospitals are required to conduct periodic community health needs assessments. Opportunities thus exist for LHDs and tax-exempt hospitals to engage in collaborations related to CHAs. Yet, it remains unclear whether interest in PHAB accreditation provides incentive to LHDs to engage in collaborations with hospitals around community health assessment and improvement planning. Methods: Using data from the 2013 National Association of County and City Health Officials (NACCHO) Profile study, LHD-hospital collaborations related to CHAs were examined, including characteristics of LHDs involved in such collaborations and the relationships between LHDs’ level of engagement with accreditation activities and their involvement in collaborations with hospitals. Results: LHDs that collaborate with hospitals on CHAs are larger, have higher total and per capita expenditures, and are more likely to be locally governed and to have a local board of health. Three PHAB prerequisites—completion of a CHA, completion of a community health improvement plan, and completion of an agency-wide strategic plan within the previous 5 years—were all significantly correlated (p<0.01) with LHD-hospital collaborations, suggesting that accreditation efforts may be a positive influence on collaborations. Implications: Policymakers could provide incentive for voluntary accreditation to encourage greater collaboration between LHDs and hospitals around CHAs.

Evaluating Hospitals’ Provision of Community Benefit: An Argument for an Outcome-Based Approach to Nonprofit Hospital Tax Exemption

Nonprofit hospitals are exempt from federal income taxation if they pass organizational and operational tests, including satisfying the community-benefit standard. Policymakers, however, have questioned the adequacy of the community benefits that nonprofit hospitals provide in exchange for these exemptions. The Internal Revenue Service recently responded to these concerns by redesigning its tax forms for nonprofit hospitals. The new Form 990 Schedule H requires nonprofit hospitals to provide additional information about their community-benefit activities. This new reporting requirement, however, places an undue focus on input-based community-benefit indicators, in particular expenditures. We argue that expanding the current input-based reporting requirement to include not only monetary inputs but also population health outcomes would achieve greater benefit for society.

Intimate Partner Violence Victimization : Identification and Response in Primary Care

In the United States more than 1 out of 3 women experiences lifetime intimate partner violence (IPV) victimization. Short screening instruments such as HITS or the AAS can identify IPV victimization. Nonjudgmental statements that validate an IPV victims experience should be followed by safety assessment and planning. Intervention includes referral to services, treatment of associated health conditions, mandatory reporting if required, and documentation. Counseling has been shown to reduce IPV victimization. Clinical guidelines recommend IPV screening for all or most women, and providing or referring victims to intervention. The Affordable Care Act will increase coverage of screening and counseling for IPV victims.

Economies of Scale in the Production of Public Health Services: An Analysis of Local Health Districts in Florida

OBJECTIVES We examined the existence and the extent of scale and scope economies in the delivery of public health services. We also tested the strength of agency, population, and community characteristics that moderate scale and scope economies. METHODS We collected service count and cost data for all Florida local health districts for 2008 and 2010, complemented with data on agency, population, and community characteristics. Using translog cost functions, we built models of operating efficiencies for 5 core public health activities: communicable disease surveillance, chronic disease prevention, food hygiene, on-site sewage treatment, and vital records. RESULTS Economies of scale were found in most activities, with cost per unit decreasing as volume increased. The models did not, however, identify meaningful economies of scope. CONCLUSIONS Consolidation or regionalization might lower cost per unit for select public health activities. This could free up resources for use in other areas, further improving the publics health.

Efficiency in Public Health Service Delivery: An Analysis of Clinical Health Services Provided by Local Health Departments in Florida

The ability of local health departments (LHDs) to provide public health services to improve the health of their communities depends to a large extent on their financial resources. More money by itself, however, does not necessarily translate into better population health. LHDs also have to use their resources in an efficient manner to achieve the best possible outcomes. This article first describes two techniques that LHDs can use to assess their efficiency at providing public health services: process costing, a technique used by management accountants, and stochastic frontier analysis, a technique used by economists. Using data for LHDs in Florida, both techniques are then applied to estimate the efficiency at which LHDs provide three types of clinical health services: adult, child, and dental health services. The results show that LHDs’ efficiency varies both within and across agencies. Few LHDs have consistently low costs for all three services examined. Being relatively efficient at providing one type of service therefore does not necessarily translate into being able to provide other, even closely related, services at a low cost.

The Progress of US Hospitals in Addressing Community Health Needs

OBJECTIVES To identify how US tax-exempt hospitals are progressing in regard to community health needs assessment (CHNA) implementation following the Patient Protection and Affordable Care Act. METHODS We analyzed data on more than 1500 tax-exempt hospitals in 2013 to assess patterns in CHNA implementation and to determine whether a hospitals institutional and community characteristics are associated with greater progress. RESULTS Our findings show wide variation among hospitals in CHNA implementation. Hospitals operating as part of a health system as well as hospitals participating in a Medicare accountable care organization showed greater progress in CHNA implementation whereas hospitals serving a greater proportion of uninsured showed less progress. We also found that hospitals reporting the highest level of CHNA implementation progress spent more on community health improvement. CONCLUSIONS Hospitals widely embraced the regulations to perform a CHNA. Less is known about how hospitals are moving forward to improve population health through the implementation of programs to meet identified community needs.

Local Health Departments’ Involvement in Hospitals’ Implementation Plans

Background: More than half of all local health departments (LHDs) in the U.S. are involved in collaborations with nonprofit hospitals on a community health needs assessment (CHNA), yet little is known about the role that LHDs play in hospitals’ implementation plans. Purpose: This study aims to explore the current state of hospital–LHD collaborations around the implementation plan using data from a survey of LHDs across the country. Methods: The study sample included 457 LHDs that completed both the 2015 Forces of Change survey and the 2013 Profile survey conducted by the National Association of County and City Health Officials. Univariate and bivariate analyses were used to compare LHDs involved in hospitals’ implementation plans to LHDs not involved in such activities. All analyses were conducted in 2016. Results: Of the 457 sample LHDs, 62% were involved in at least one activity associated with hospitals’ implementation plans. These LHDs were larger, had greater budgets, and were more likely to be locally governed. In addition, almost all of these LHDs reported that they also collaborated with hospitals around the CHNA. Implications: There is evidence of substantial involvement of LHDs in hospitals’ implementation plans. Importantly, joint CHNAs appear to pave the path for hospital–LHD collaboration in this area. Since LHDs that collaborate with hospitals on their implementation plans tended to be better resourced, policymakers may want to find ways to ensure that smaller LHDs have the necessary human and fiscal resources to be engaged in joint community health needs assessment and improvement planning activities.

Community Benefit Spending By Tax-Exempt Hospitals Changed Little After ACA

Provisions of the Affordable Care Act (ACA) encouraged tax-exempt hospitals to invest broadly in community health benefits. Four years after the ACAs enactment, hospitals had increased their average spending for all community benefits by 0.5 percentage point, from 7.6 percent of their operating expenses in 2010 to 8.1 percent in 2014.