The Attorney General’s Community Benefits Guidelines For .
The Attorney General’sCommunity BenefitsGuidelinesfor Non-Profit HospitalsNEAHOUMSET TSCOMWLT HSSOF MAACCommonwealth of MassachusettsOffice of Attorney GeneralMaura HealeyFebruary 2018
Office of the Massachusetts Attorney GeneralTable of ContentsIntroduction. 1Charitable Role of Hospitals and Health Maintenance Organizations. 1Updates to Guidelines . 1Advisory Task Force. 3Statewide Priorities. 4Medical Debt/Hospital Collection Practices. 6Scope of this Document. 6Community Benefits Principles.7Community Benefits Mission Statement. 8Leadership. 9Community Engagement.10Individuals and Organizations with Whom to Engage.10Community Engagement Spectrum.11Community Health Needs Assessment.12Elements of a Community Health Needs Assessment.12Defining the Community Served.13Joint Community Health Needs Assessments.13Identifying Health Disparities.13Implementation Strategy.14Identification of Significant Needs/Target Populations.14Hospital Plan to Address Significant Health Needs.15Joint Implementation Strategies .19Amending the Implementation Strategy.19Shared Learning and Dynamic Improvement of Community Benefits Programs.19Report .21Report Content.21Community Feedback.24Appendix I - Recommended Hospital Debt Collection Practices.25Appendix II - Timeline for Reporting. 27Appendix III - Timeline for Development of Community Benefits Programs.28Appendix IV - History of the Guidelines.30Appendix V - Community Benefits Advisory Task Force Members.31Glossary. 32Non-Profit Hospitalsi
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Office of the Massachusetts Attorney GeneralIntroductionCharitable Role of Hospitals and Health Maintenance OrganizationsHospitals and health maintenance organizations (“HMOs”) have critical roles in thedelivery of health care in communities across the Commonwealth. As non-profit institutions,hospitals and HMOs also have important fiduciary obligations to provide benefits to theircommunities commensurate with their tax-exempt status. The provision of CommunityBenefits is an important component of a hospital’s and HMO’s charitable activity. TheAttorney General’s Community Benefits Guidelines for Non-Profit Acute Care Hospitalsand The Attorney General’s Community Benefits Guidelines for Health MaintenanceOrganizations outline principles for developing, implementing, and reporting on theseactivities.The Attorney General’s Community Benefits Guidelines set forth voluntary principlesencouraging Massachusetts hospitals and HMOs to build upon their commitment toaddress health and social needs in the communities they serve. The Guidelines encouragecharitable activities on the part of hospitals and HMOs as well as the spirit of cooperation andpartnership between hospitals and HMOs and their communities that promote meaningfuland effective Community Benefit programs. The Guidelines represent a unique, nonregulatory approach that calls upon hospitals and HMOs to identify and respond to unmetcommunity health needs by formalizing their approach to Community Benefits planning,collaborating with community representatives to develop and implement programs thataddress those needs, and issuing annual reports on their efforts. The Guidelines do notdictate the specific programs that hospitals and HMOs must provide; rather, they encouragehospitals and HMOs to use their expertise and resources, as well as the expertise oftheir communities, to target the particular needs of underserved and at-risk populations.In addition, by providing a mechanism to report on Community Benefit initiatives andexpenditures, the Guidelines allow for public recognition of hospitals’ and HMOs’ activities insupport of their charitable missions.Updates to GuidelinesThe Attorney General’s Office (“AGO”) originally issued the Community Benefits Guidelinesfor Non-Profit Acute Care Hospitals in June 1994. They were followed by the AttorneyGeneral’s Community Benefits Guidelines for Health Maintenance Organizations in February1996, in recognition of the increased role played by HMOs in the health care system.11The Guidelines were developed consistent with the AGO’s oversight of numerous aspects of the health caresystem. For example, through the Non-Profit Organizations/Public Charities Division, the AGO overseeshospitals and health plans as non-profit charitable organizations. The Division is responsible for carrying outthe AGO’s responsibilities to ensure the “due application of funds given or appropriated to public charities”(M.G.L. C.12 s.8). The AGO’s authority with respect to non-profit organizations and charities includes ensuringthat a charity’s trustees meet their fiduciary duties to the organization, and that they operate the organizationin accordance with its mission. Concurrently, the AGO’s Health Care Division (1) investigates and litigatesconsumer protection cases involving health insurers, health providers, and pharmaceutical companies; (2)addresses consumer complaints relating to health insurance and health care; and (3) leads the office’s healthpolicy and health reform responsibilities, including improving quality, restraining costs, promoting public health,improving the economy, and protecting consumersNon-Profit Hospitals1
Office of the Massachusetts Attorney GeneralThe evolution of these Guidelines is summarized in Appendix IV. In the 24 years since thefirst Guidelines were published, hospitals and HMOs have demonstrated their commitment tothe principles underlying the Community Benefits Program and have invested substantially inthe unmet health and social needs of their communities.Since the Guidelines were last updated in 2009, there have been important federal andstate developments affecting the Community Benefits Program. The Patient Protection andAffordable Care Act (the “ACA”)2 passed in 2010 included federal requirements for how nonprofit hospitals approach Community Benefits, including standards for Community HealthNeeds Assessments (“CHNAs”) and Implementation Strategies, and public reporting onCommunity Benefits programs.3 In Massachusetts, the Department of Public Health (“DPH”)updated its Determination of Need (“DoN”) regulations in 20174 and included new guidelineson statewide health priorities and community engagement for the DoN Community HealthInitiative program.5Significant changes in health care also underscore the continued value of the CommunityBenefits Program and the need to update the Guidelines. In the last decade, evidencehas become even more clear that the utilization of medical services is not the primarydeterminant of community health. Rather, the social conditions in which people are born,grow, live, work, and age play a key role in determining health outcomes and healthdisparities.6 As the health care system shifts to a “population health” framework for paymentand delivery system reform, hospitals and HMOs are working hard to engage in newopportunities to keep patients healthy by addressing social and environmental factors. Therole of effective Community Benefits programs in addressing such unmet public health needsand promoting health equity has never been more critical.With the passage of a groundbreaking health care reform law in Massachusetts in 20067and the ACA in 2010, health insurance coverage rates in Massachusetts remain high relativeto other states. Affordability, however, remains an issue for many in Massachusetts, wheremeasures of income inequality are among the highest in the nation.8 In addition, state datashow troubling health disparities across categories of race, ethnicity, gender, gender identity,sexual orientation, disability, and other groups, as well as increased incidence of chronicdiseases, particularly among vulnerable populations.9 Updates to the Guidelines reflect thecontinued importance of Community Benefits programs in addressing health disparities and242 U.S.C. § 18001 et seq. (2010).326 C.F.R. § 1.501(r) (2017).4105 Mass. Code Regs. 100.000 (2017).5DoN Guidelines and Policy Advisories, available at: s-andpolicy-advisories.6See, e.g., Frieden T. American Journal of Public Health, April 2010, Volume 100 No. 4 (identifying efforts toaddress socioeconomic determinants of health as having the greatest potential impact among public healthinterventions).7Chapter 58 of the Acts of 2006.8See Posey K.G. “American Community Survey Briefs, Household Income: 2015,” Issued September 2016; U.S.Department of Commerce Economics and Statistics Administration.9Determination of Need Health Priorities Guideline, available at: delines-health-priority.pdf.2Community Benefits Guidelines
Office of the Massachusetts Attorney Generalthe needs of those without meaningful access to health care.Advisory Task ForceIn April 2017, Attorney General Maura Healey convened an Advisory Task Force to assisther in reviewing the Guidelines in the context of updated statewide health priorities, newIRS requirements associated with the ACA, and accelerating delivery system transformation.The Advisory Task Force, which included representatives of hospitals, health maintenanceorganizations, and community groups, and public health experts, participated in a thoughtful,focused, and productive review process that concluded in December 2017.10 AttorneyGeneral Healey asked the Advisory Task Force to consider how the Guidelines could beimproved to help hospitals and HMOs most effectively assess the needs of their communities,design programs to meet these needs, and measure the success of their programs. TheseGuidelines were directly shaped by the recommendations of the Advisory Task Force but donot represent the views of all Advisory Task Force members on every topic.In particular, the Advisory Task Force considered:1)Improved Reporting: How to reduce unnecessary administrative burden by harmonizingthe Guidelines with overlapping federal and state requirements and increasetransparency into key aspects of the Community Benefits process and expenditures;2)Statewide Priorities: How to encourage hospitals and HMOs to leverage their CommunityBenefits programs to address statewide health challenges;3)Community Engagement: How to improve engagement with community partners in theplanning, implementation, and evaluation of Community Benefits programs;4)Regional Collaboration: How to encourage regional collaboration on needs assessments,Implementation Strategies, and sharing of best practices; and5)Evaluation: How to offer focused guidance on setting, reporting, and learning from goalsand benchmarks.Concurrent with the Advisory Task Force, the AGO conducted a series of listeningsessions to engage directly with the public on the Guidelines and to gather feedback on howthey could be improved.10 Members of the Advisory Task Force are listed in Appendix V.Non-Profit Hospitals3
Office of the Massachusetts Attorney GeneralStatewide PrioritiesThe Community Benefits Program should be viewed in the context of coordinatedinitiatives across state government to build long-term capacity to improve outcomesand reduce disparities around common health priorities.11 Accordingly, these Guidelinesrecognize as statewide priorities the same four focus issues identified by the ExecutiveOffice of Health and Human Services and DPH in 2017 as significant statewide needs thatdrive mortality, morbidity, and health care costs. We ask that all hospitals and HMOs closelyconsider these four focus issues, along with identified local needs, as they conduct theirCommunity Health Needs Assessments and prepare their Implementation Strategies:Chronic Disease with a Focus on Cancer, Heart Disease and DiabetesHousing Stability/HomelessnessMental Illness and Mental HealthSubstance Use DisordersIn addition to these four focus issues, in 2017 DPH adopted six health priorities to guidethe Community Health Initiative investments funded by the Determination of Need process.These health priorities underscore the relevance of investing in the social determinants ofhealth, and the AGO encourages hospitals and HMOs to consider these six priorities in theirCommunity Benefits planning:Built EnvironmentThe built environment encompasses the physical parts of where we live, work, traveland play, including transportation, buildings, streets, and open spaces.Social EnvironmentThe social environment consists of a community’s social conditions and culturaldynamics.HousingHousing includes the development and maintenance of safe, quality, affordable livingaccommodations for all people.ViolenceViolence is the intentional use of physical force or power, threatened or actual, againstoneself, another person, or against a group or community, with the behavior likely tocause physical or psychological harm.11The AGO works closely with sister agencies and plays a central role across a number of coordinated initiativesto improve health care in the Commonwealth. For example, the Attorney General appoints three members tothe Health Policy Commission, which is charged with developing policy to reduce health care cost growth andimprove the quality of patient care. Mass. Gen. Laws ch. 6D, § 2. She appoints three members of the Boardof the Health Insurance Connector Authority, which is charged with promoting access to affordable healthinsurance for the Commonwealth’s residents and small businesses. Mass. Gen. Laws ch. 176Q, § 2. She alsoappoints two members to the Oversight Council of the Center for Health Information and Analysis, the agencyof record for Massachusetts health care information. Mass. Gen. Laws ch. 12C, § 2A. The Attorney Generalalso serves on the board of the Betsy Lehman Center for Patient Safety and Medical Error Reduction, which ischarged with catalyzing efforts of stakeholders working toward safer health care in Massachusetts. Mass. Gen.Laws ch. 12C, § 15. The thrust of all of these efforts is to support health care reform, reduce barriers to access,improve quality and reduce cost in health care for all citizens of the Commonwealth.4Community Benefits Guidelines
Office of the Massachusetts Attorney GeneralEducationEducation refers to a person’s educational attainment – the years or level of overallschooling a person has.EmploymentEmployment refers to the availability of safe, stable, quality, well-compensated work forall people.A lengthier description of the six health priorities is available on the DPH website at idelines-health-priority.pdf.The theme of health equity is strongly reflected throughout these health priorities. Itis well understood that racism – in all of its forms12 – and institutional bias impact healthoutcomes, both through their influence on the social determinants of health and also as anindependent factor affecting health. The health equity framework below illustrates howracism has an independent influence on all the social determinants of health and that racismin and of itself has a harmful impact on health. The AGO recommends that hospitals andHMOs consider this framework and continue to recognize and address the role that racismand institutional bias play in impacting health outcomes in their communities.From the Boston Public Health Commission’s Racial Justice and Health Equity Initiative; availableat: cuments/RJHEI%202015%20Overview%20FINAL.pdf.These Guidelines identify the four focus issues and six health priorities to encouragehospitals and HMOs to work in concert on issues of particular concern and to achievecollective improvements in these areas. However, hospitals and HMOs must also assessthe needs of their particular service areas and get direct input from their communities about12 See YW Boston Stand Against Racism Resources, available at: sm/resources/ (describing the “4I’s” of racism, including interpersonal racism, institutional racism,ideological racism, and internalized racism); see also Glossary page 36.Non-Profit Hospitals5
Office of the Massachusetts Attorney Generalwhich programs to include in their Implementation Strategies, including programs that maynot address these issues. In reviewing the Community Benefits Reports, the AGO will payspecial attention to programs that address the focus issues and priorities described abovefor purposes of public recognition and dissemination of best practices. The AGO may updatethese issues and priorities over time to continue to
updated its Determination of Need (“DoN”) regulations in 20174 and included new guidelines on statewide health priorities and community engagement for the DoN Community Health Initiative program.5 Significant changes in health care also underscore the continued value of the Community Benefits Program and the need to update the Guidelines .
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