Strategies and Innovations for Health-Related Community Investing

1. Strategies and Innovations for Health-Related Community Investing Presentation Financial Innovations Roundtable March 24-25, 2014 Federal Reserve Board, Washington DC Kevin Barnett, DrPH, MCP Senior Investigator Public Health Institute

2. Overview • Emerging Opportunities in the Community Benefit Arena • CB Defined • New realm of transparency • Snapshot of current practices • ACA and the Imperative for Intersectoral Alignment • Moving from Compliance to Transformation • Challenges to be Addressed • Climate of Crisis Management • Filling the Knowledge Gaps • Managing Competitive Dynamics • Priorities Moving Forward • Building Critical Mass: Focus in Places with Health Inequities • Role of Institutional Leadership in Policy Advocacy

3. Community Benefit Defined • IRS definition - The promotion of health for class of beneficiaries sufficiently large enough to constitute benefit for the community as a whole. • Reference to a defined community suggests a population health orientation • Determining the minimum size for the “class of beneficiaries” needed suggests accountability for a measurable impact. • IRS Rulings 69-545 (1969) and 83-157 (1983)

4. Historical Tendencies in Practice

5. Transparency • Pricing • Billing for procedures, equipment, pharmaceuticals • Comparative analysis of reimbursements, reported shortfalls, other CBs • Outcomes • Public “ROI” for care • Location • Payer mix • Jurisdiction • SDH • Public expectations • IRS reporting requirements opens the door to a broad set of questions

6. Schedule H and Transparency • There will be comparative analyses conducted at national, state, MSA, county, municipality, and congressional districts. Examples: • Language in charity care policies, and budget levels established • Billing and collection practices (e.g., eligibility criteria, thresholds) • How community is defined in geographic terms and includes proximal areas where there are health disparities. • How solicit and use input from diverse community stakeholders. • Connection between priorities and program areas of focus. • Explanation of why a hospital isn’t addressing selected health needs. • Volume of charitable contributions in each category.

7. Focus of CHIDSS Development • How • Community is defined • Community stakeholders are engaged • Priorities are set • Implementation strategies are designed • Select specific geographic regions to allow for comparative analysis • Sources of data are public reports from • Hospitals • Public health agencies • United Ways • Community Action Agencies

8. Service Area Exclusion of Geo Areas with Concentrated Poverty

9. Selected Findings • Only 10 of 44 hospitals, or 23% ID geo concentrations of disparities in CHNA • Significant decline in community member engagement after initial data collection • Limited content scope of investments • Lack of geo focus where disparities are concentrated in implementation strategies • Lack of alignment with other stakeholders and sectors

10. Challenges to be Addressed • Crisis Management • IS development, consolidation, acquisitions • Preparing for constraints on reimbursement • CB viewed as compliance issue, rather than an engine for transformation • Knowledge Gaps • Local leaders don’t know what they don’t know • Power used to date by system leaders limited in population health capacity development • Competitive Dynamics • Limited focus on clinical care coordination is impeding potential for collaboration on broader issues

11. Selected Recommendations • Harmonize disparate, but similar CHI practices among community stakeholders. • LHDs, CAAs, UWs, CHCs, and other institutions post assessment findings. • Stakeholders develop proactive strategies to align schedules for assessment and planning processes • Increase focus of CHI resource allocations in communities where health disparities are concentrated. • Hospitals use tools to implement a QI approach consistent with a commitment to transformation. • Clarify roles of stakeholders in setting priorities, planning, implementation, evaluation, and oversight of CHI practices.

12. Compliance and Transformation Compliance Transformation Shared Ownership Co-finance consultant to conduct CHNA Hold meetings to discuss design Return to hospital to set priorities Ongoing stakeholder engagement to build common vision and shared commitments Set shared priorities & take coordinated action Diverse Community Engagement Engage diverse community stakeholders as ongoing partners with shared accountability Identify shared priorities to improve community health Solicit input through surveys, focus groups, town halls on health care needs – no action required Meet with local or state PH officials Broad Definition of Community Define community as hospital service area Identify underserved pops w/in service area Design programs at service area level ID concentrations of health inequities w/in larger region that includes hospital service area Select geo focus where needs are greatest Maximum Transparency Post CHNA report on hospital website Attach Implementation Strategy (IS) to Schedule H submittal or post on website Post CHNA & shared priorities in multiple settings Develop and post IS in multiple settings with defined roles for diverse community stakeholders

13. Compliance and Transformation, cont’d. Compliance Transformation Innovative & Evidence-InformedInvestments Survey best practices to ID strategies with evidence of effectiveness or that offer considerable promise Establish shared metrics that will document ROI at multiple levels Describe how hospital will address priority unmet needs Incorporate Continuous Improvement Establish indicators of progress (e.g., systems reforms)that validate progress towards outcomes Establish monitoring strategy that integrates adjustments based upon emerging findings Pooling and Sharing of Data Sharing of utilization data across hospitals, PH, CHCs to assess total cost of care Proactive determination of ROI at institutional and community level

14. Health Reform and the Imperative for Alignment • Expanded coverage for populations in low income communities • Movement to global budgeting; shift in financial incentives • Drivers of poor health are beyond clinical care management • Business and financial community with shared obligations & interests

15. Coming to Terms with Health Inequities • Unhealthy housing • Exposure to array of environmental hazards • Limited access to healthy food sources & basic services • Unsafe neighborhoods • Lack of public space, sites for exercise • Limited public transportation options • Inflexible and/or poor working conditions • Health impacts (e.g., allostatic load) of chronic stress

16. Interaction Intervention possibility slim Adapted from McGuinnis et al.

17. Stressed Increased cardiac output Increased available glucose Enhanced immune functions Growth of neurons in hippocampus & prefrontal cortex Stressed Out Hypertension & cardiovascular diseases Glucose intolerance & insulin resistance Infection & inflammation Atrophy & death of neurons in hippocampus & prefrontal cortex Stressed vs. Stressed Out Source: Anthony Iton, MD, JD SVP, The California Endowment

18. When the external becomes internal: How we internalize our environment Allostatic Load High Demand-Low Control Jobs Stress Inadequate TransportationLong Commutes Stress Lack of access to stores, jobs, services Stress Housing Stress Stress Lack of social capital Stress Crime Source: Anthony Iton, MD, JD, SVP, The California Endowment

19. Building a Seamless Continuum of Care:Ambulatory Care Sensitive Conditions • CMS move on re-admissions only the 1st “shot across the bow” • Near term challenge for hospitals to ID, engage, and strengthen community support systems after discharge of patients. • Opportunity to “bend the cost curve” by reducing preventable ED and inpatient utilization. • Research by John Billings established framework of ambulatory care sensitive conditions (ACS) in the 1990s • GIS coding of utilization data, with overlay of demographic and health status metrics provides a clear path

20. Strong Correlation with Avoidable Admissions Note:Ambulatory Sensitive Conditions if treated properly in an OP setting, do not generally require an acute care admission

21. Defining the BoundariesBreaking Down Complex Issues with Problem Analysis Root Causes NT Causes NT Impacts LT Impacts En vivo smoking 2nd hand Smoke Immune Distress High Morbidity School/Work Absence Indoor triggers Asthma Poor housing Lack of Knowledge Poor Aca. Performance Reduced Career options External Air Reduced Productivity Poverty Poor medical Mgmt High Svs Utilization Low self Esteem Poor HC Access Helplessness Stress Genetic Predet. Medical care dependence

22. Opportunities for Alignment

26. New Area of Investment for Hospitals/HSOpportunities for Alignment • Dignity Health • Pre-development loans for affordable housing • Capital campaign bridge loan for low income dental care center • Revolving loan fund for small business development NP • Lending capital for post disaster reconstruction • CHE – Trinity Health • Scholarship Loan Programs • Loans for child care businesses and other small business development • Pre-development loans for affordable housing • Financing for neighborhood revitalization • Low income housing linked with support services

27. Opportunities for CDFIs • Work more closely with local hospitals to identify convergence investment opportunities. • Engage UW, CACs, CHCs, LPHAs and local foundations on opportunities for convergence • Engage hospital/health system leaders on opportunities to leverage influence with financial institutions for targeted investments • Scale up and diversify investment strategies (e.g., food, retail, housing, support services, education, job development)

28. Place-Based, “Collective Impact” Approach Community CDFI Engagement Backbone Org. - Integrator Actions Hospital 1 Youth Serving CBO Hospital 2 Expanded Care Management Faith Community Health Education LPHA, UW, CHC, CAA Resident Coalition Community Mobilization K – 12 Schools Policy Development Elected Officials CDFI Facilitation Local Business 1 Community Development Parks &Rec Dept. Local Business 2 Shared Metrics ↓ Diabetes PQIs ↑ Food Access ↑ + Options in schools ↑ Awareness/knowledge ↑ Physical activity Philanthropy Community Development Corps. Higher Ed Financial Institutions

29. Contact Information • Kevin Barnett, Dr.P.H., M.C.P. Public Health Institute 555 12th Street, 10th Floor Oakland, CA 94607 Tel: 10-285-5569 Mobile: 510-917-0820 Email: kevinpb@pacbell.net