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Community Health: From Assessment to Action. June 5, 2013. The Affordable Care Act. New IRS Requirements for Tax-Exempt Hospitals. Hospitals Required to Comply. All hospitals recognized as a 501(c)(3), including governmental hospitals.
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Community Health: From Assessment to Action June 5, 2013
The Affordable Care Act New IRS Requirements for Tax-Exempt Hospitals
Hospitals Required to Comply • All hospitals recognized as a 501(c)(3), including governmental hospitals. • Must complete a CHNA and adopt an implementation strategy, but are not required to file a form 990. Hospitals with this status should make their assessments and implementation strategies widely available. • If more than one hospital is operated by an organization, each hospital is required to complete a CHNA and adopt an implementation strategy.
Timing and Frequency of CHNAs • The CHNA must be conducted once every three years, beginning in the hospital’s first taxable year after March 23, 2012. • To be considered conducted, the written report must also be made widely available to the public. Posted “conspicuously.”*
Collaboration – New Hospitals may collaborate to conduct a CHNA if: • the collaborating hospitals define their community to be the same • the report clearly identifies that it applies to the hospital • the governing body of each hospital adopts the joint report
Defining Community – New • Hospitals have flexibility in defining the community they serve. The proposed facts and circumstances approach recognizes variance in defining community (e.g. geographic area, target populations, principal function) • Community may be defined by a particular area of specialty or disease. • Medically underserved, low-income or minority populations may not be excluded.
Identifying Health Needs – New • Hospitals must identify the “significant” health needs of the community rather than “all” needs. • Prioritize needs and identify potential measures, resources and facilities to address them. Hospitals have flexibility for determining what is significant and setting priorities.
Broad Community Input • Two categories of persons must have input taken into account in conducting the assessment. • one nonfederal governmental public health department • members of medically underserved, low-income and minority populations (or organizations representing their interests)
Broad Community Input – New • When subsequent CHNAs are conducted, written input received on a hospital’s existing CHNA or implementation strategy must be taken into account. • This requires a hospital’s most recent CHNA remain widely available until its two subsequent CHNAs are adopted and made widely available.
Collaboration • Hospitals that collaborate on a CHNA may collaborate on an implementation strategy but must clearly identify that it: • applies to each hospital • outlines and identifies each hospital’s particular role and responsibilities, including programs and resources it will commit • provides a summary or tool to help the reader locate the strategies that relate to each hospital
Addressing Significant Needs • Every significant need identified must include a description of how the hospital will address the need or why it will not be addressed. For needs to be addressed, include: • the actions the hospital will take • the anticipated impact • a plan to evaluate the impact • identification of the programs and resources the hospital will commit
Transition Relief – New • The implementation strategy must be adopted by the hospital’s governing body in the same tax year as the hospital finishes the CHNA. • Recognizing that many hospitals will not be able to meet this initial requirement, the proposed rule adds four and a half months to the original three-year period for adoption of the first implementation strategy.
Noncompliance – New Proposed penalties for non-compliance. • Excused noncompliance. Forgives immaterial failures to comply as well as those that were corrected under two circumstances: • if the infraction is minor, inadvertent and due to reasonable cause and the hospital promptly takes remedial steps • if the infraction is more serious, but is neither willful nor egregious and is corrected by the hospital and disclosed to the IRS • Willful and Egregious Noncompliance that may result in revocation of a hospital’s tax-exempt status. • determined after a review of all facts and circumstances including prior infractions, magnitude and reasons for noncompliance, size and functions of the noncompliant facilities, policies and procedures implemented and followed to comply
Noncompliance • Facility-level tax • If one organization in a multi-hospital system egregiously or willfully fails to comply, but does not warrant loss of exemption for the entire organization, a “facility-level tax” would be imposed. The tax would calculated as if the hospital was a taxable corporation and the amount of the income tax it would have owed would be the amount owed.
Final Rule • Comments on the proposed rule due July 5 • No firm date on final rule (estimate October 2013) • Rely on proposed rule for guidance until October 5, 2013.
Steps To Conducting A CHNA • Define the community • Identify internal and external partners • Collect secondary data • Develop and conduct primary data collection • Analyze and prioritize primary and secondary data • Identify and prioritize community health issues • Develop and widely disseminate the CHNA report • Develop and implement a strategy to address the priority health issues
CAUTION: Conserve Energy Keep in Mind: The hard work begins with implementation. Commit to Three • Stakeholders/partners • Secondary data sources • Formats for primary survey • At-risk population groups • Routes to disseminate findings • Priorities to address • Strategies for each priority • Three indicators per priority • Three year plan
Population-based model for improving health outcomes CHNA questions and data Outcome measures Strategies and process measures Categories for analysis and priorities Implementation Plan
Step One: Define the Community The community definition must include • Geographical service area • Population served • Specialty services provided • At-risk populations • Unique community characteristics • Federal designation for medically underserved • Other hospitals in same “community”
Step Two: Identify Partners Rationale for Partnerships • Many health care and community organizations benefit from assessments • Many health care organizations are required or encouraged to conduct assessments Benefits • Collective wisdom • Collective impact • Efficiency
Step Three: Collect Secondary Data • Definition: existing data collected for another purpose • Data are available from local, state and national resources • Data provide the foundation for the quantitative information • Establish a baseline • Reveal health issues
Secondary Data Categories • Demographics • Health outcomes • Mortality • Morbidity • Health factors • Health behaviors • Clinical care, including access • Social and economic factors • Physical environment
Step Four: Primary Data Collection • Primary data: data collected specifically for the purpose of answering project-specific questions. • After review of secondary data, development of a survey tool should be used to • Validate secondary information • Fill gaps in data not provided by secondary sources • Provide more depth and information about a specific health issue identified through secondary data review • Provide qualitative information
Primary Data Collection (cont’d) • Planning considerations: • More resource intensive; requires development, testing and implementation prior to review of results • Collect exactly what you want and need, keep your questions focused (e.g. chronic disease) • Process can be simplified by using existing questions • Individual versus group response
Data Collection: Group Responses Community Forums • Varied size – can be large • Diverse composition • Open invitation • Broad-based, open-ended questions • Less formal Focus Groups • Small • Homogeneity • Invitation-only • Specific topic and focus • Requires strong facilitation
Step Five: Analyze and Prioritize Begin with dialogue….
The Community’s Focus • Primary research • Significant community issues • Non-health related • Health related • Current programs • Failed programs
Prioritization Score – Available Data • Is measurable and historical data available? • No data “0” • Perception/anecdotal “1” • Perceptions and counts “2” • Perceptions and baseline “3” • Perceptions and trend “4” Source: Adapted from Thruston County Public Health and Social Services. Retrieved from http://www.countyhealthrankings.org/take-action/pick-priorities
Prioritization Score – Size of Issue • What percentage of the population does this health issue affect? • Less than 1% “1-2” • 1.0 – 9.9% “3-4” • 10 – 24.9% “5-7” • 25% or greater “8-10” Note: because the size of the problem is considered more critical that data, this score is multiplied x 2. Source: Adapted from Thruston County Public Health and Social Services. Retrieved from http://www.countyhealthrankings.org/take-action/pick-priorities
Prioritization Score - Importance • What is the seriousness of this issue? Urgency – high death rate– hospitalization – premature death rate – economic burden – impact on others? • Not serious/little impact “1-2” • Moderate – illness “3-5” • Serious – some death, impact “6-8” • Very serious – high death “9-10” Note: because the size of the problem is considered more critical that data or population affected, this score is multiplied x 3. Source: Adapted from Thruston County Public Health and Social Services. Retrieved from http://www.countyhealthrankings.org/take-action/pick-priorities
Step Seven: Disseminate Results Final Report Format - sample • Community description • Demographics • Socioeconomic • Health resources • Community health strengths and risks • Quality of life • Behavioral risk factors • environment • Health status • Social and mental health • maternal and child health • Death, illness, injury • Infectious disease • Sentinel events Collecting Data • Demographics • Health outcomes • Mortality • Morbidity • Health factors • Health behaviors • Clinical care, including access • Social and economic factors • Physical environment
Keep in Mind: The hard work begins with implementation. Develop and Implement a Strategy Step Eight
Collaboration: Art and Science • Every organization may have different reasons for collaboration – that is okay – but you need a common goal • Ensure those with authority for resource allocation support the goals and objectives • Find an inspired champion • Time is required to build trust and innovate • Measure, evaluate
Sample Ground Rules • Innovation and creativity are encouraged • Challenge assumptions • Be respectful • Be engaged • Are you being quiet? Speak • Are you talking a lot? Pause • Avoid side conversations • Keep technology use to a minimum
Collective Impact • Common agenda • Shared measurement system • Mutually reinforcing activities • Continuous communication • Backbone support organization Source: Kramer, M. & Kania, J. (2011). Social innovation. Stanford Review. Retrieved from http://www.fsg.org/tabid/191/ArticleId/211
Staff Contact Leslie Porth, MPH, R.N. Vice President of Health Planning 573-893-3700 x 1305 lporth@mail.mhanet.com Mary Becker Senior Vice President of Strategic Communications 573-893-3700 x 1303 mbecker@mail.mhanet.com