In the following Q&A, Mary Crossley, Professor of Law and former Dean at the University of Pittsburgh, School of Law helps us understand the Affordable Care Act’s community health needs assessment (CHNA) requirement and how it might foster collaboration between local health departments and hospitals. Professor Crossley was a scholar in residence at the San Francisco Department of Health (SFDPH), and worked closely with the department on this issue.
Network: Why are CHNAs required for some hospitals?
Mary Crossley: The ACA creates several new requirements for nonprofit hospitals to maintain tax-exempt status. One requirement is that each hospital conduct a community health needs assessment, report on the needs identified, and develop a strategy for responding to them. Hospitals must complete this process every three years, and in completing their assessment, they must take into account input from persons with special knowledge of or expertise in public health. The CHNA requirement effectively re-orients hospitals away from a primary focus on providing charity care and toward greater attention to community and population health issues.
Network: What regulations did you examine?
Mary Crossley: I examined Proposed Regulations issued by the IRS in April 2013 to see whether those regulations seem likely to stimulate or dampen hospitals’ interest in collaborating with local health departments on initiatives addressing community health issues. Though only proposed so far, these regulations signal the IRS’s thinking on how to implement the CHNA requirement.
Notably, the proposed regulations specifically require a hospital conducting a CHNA to take health department input into account. This requirement could create a platform for continuing engagement between hospitals and health departments and highlight opportunities for collaboration as a hospital develops strategies to respond to the identified community needs.
Network: What conclusions did you draw and did you have recommendations for the SFDPH? Would your recommendations be applicable to any city health department?
Mary Crossley: Although parts of the Proposed Regulations encourage collaboration between hospitals and health departments, I found other aspects that may make collaboration less likely. The Proposed Regulations go pretty easy on hospitals in terms of transparency and accountability. For example, a hospital must have a plan for evaluating the impact of its implementation strategy, but does not have to report to anyone what that evaluation shows. The Proposed Regulations leave open the possibility that some hospitals may “go through the motions” to comply with the CHNA requirement, but not embrace any broader sense of commitment to addressing community health needs.
Of course, for most hospitals the CHNA requirement and the thought of having any responsibility for community health (as opposed to the health of individual patients) are brand new, and there may be some wisdom in initially adopting modest regulatory requirements. As hospitals become accustomed to the CHNA requirement and engage with health departments, the public health legal community can play a valuable role in consulting with the IRS on how to make its CHNA regulations more effective.
I realized as I was working on my project that the SFDPH’s relationship with the hospitals in San Francisco in many ways provides a model for meaningful collaboration among hospitals and the health department. California law has required nonprofit hospitals to conduct “community needs assessments” for nearly two decades. As a consequence hospitals in San Francisco are accustomed to the process and have increasingly partnered with the SFDPH in recent years. Having models like San Francisco should be of real value to big-city health departments in other states, as they think about how they might support and engage hospitals for which the CHNA process is new and challenging.
Network: What steps can local health departments (LHDs) take in initiating CHNA collaboration with hospitals?
Mary Crossley: First, LHDs should be aware that, because the IRS has proposed that hospitals conducting CHNAs must to take into account input from local, state, or tribal health departments, hospitals may soon be asking for their help – if they haven’t already. LHDs should recognize that conducting a CHNA is a daunting prospect for a hospital that has never done one, and that the LHD’s responsiveness in providing input and guidance regarding community health needs can lay the foundation for future collaborations.
Second, I’d recommend that LHDs take a long-term view of hospitals as potential partners and look first for ways to work together on discrete projects of mutual concern. For example, an early collaboration between hospitals and the health department in San Francisco was to create a psychiatric urgent care center in a community setting. Collaborating on a limited-scale project lets hospitals and LHDs learn how to communicate and begin to develop trust, which are both key to more ambitious collaborations.
Finally, LHDs should remember that many nonprofit hospitals are feeling stressed and threatened by a changing health care environment and may not be eager to take on new community health responsibilities. That means a hospital is most likely to partner with the LHD if it can see how a project will serve some interest of the hospital. As one hospital administrator in San Francisco described it, potential collaborations exist at the place on a Venn diagram where community care and acute care intersect. A health department that can work with a hospital (or hospitals) to identify those points of intersection may find a willing partner.
Network: Are there aspects of the project that you will bring back to the classroom? Do you think your approach to teaching public health law will be a little different now that you’d had this experience?
Mary Crossley: Although I have not had a chance to teach this specific topic, being in residence in the SFDPH this summer was incredibly valuable for my teaching. When teaching public health law topics, I have been better able to contextualize the importance of political and resource constraints, as well as persuasion and leadership for attorneys advising clients. I also have a much greater appreciation of how public health law issues could arise in other courses I teach, such as Bioethics and Health Care Civil Rights, and so I have been able to expose a broad range of students to public health law as a result of my experience.
Professor Crossley will discuss the CHNA requirement in detail in a March 26 webinar presented by the Network and the CDC Public Health Law Program. Get more information and register for the webinar.
Scholars in Residence, a fellowship program funded by the Robert Wood Johnson Foundation and administered by the Network for Public Health Law, placed six law professors at local and state public health agencies around the U.S. The aim of the program was to provide legal expertise to aid health agencies in dealing with critical public health issues, and provide the professors with real-world experiences to bring back to their classrooms.
The Network for Public Health Law provides information and technical assistance on issues related to public health. The legal information and assistance provided in this document does not constitute legal advice or legal representation. For legal advice, readers should consult a lawyer in their state. The views expressed in this post do not represent those of the Robert Wood Johnson Foundation