Toward a New Community Benefit Strategy for Healthcare Delivery Organizations

Community benefit strategy for healthcare delivery organizations is evolving — and for many of those organizations the Affordable Care Act is bringing the importance of having a strategy into focus. While community benefit has existed in some form since the founding of non-profit healthcare — -and really is the reason these organizations still hold not-for-profit tax status — -the function has been carried out primarily as an income statement function. Far and away the leading community benefit line item has been and continues to be charitable care and the unfunded care cost of government healthcare programs.

The United States spends most of its healthcare dollars on access to care, which accounts for only 10% of health status. (New England Healthcare Institute, 2005)

The Affordable Care Act has renewed the attention community benefit receives from organization leadership. The requirement of a Community Health Needs Assessment and accompanying Implementation Plan is propelling organizations to more intentionally affect community health outcomes. It has also renewed organizational attention to public health, particularly the determinants of health.

The vast majority of healthcare delivery organization expenditures is spent on providing medical care. Spending on the provision of medical services will continue to dominate the share of organization expenditures. And it should. It is what these organizations do best and the majority do it well.

But access to care isn’t what keeps people healthy. Access to medical care only accounts for around ten percent of the average individual’s health status. What does account for a person’s health status is where they live, work, and play.

Community benefit spending, then, should focus on catalyzing place-based health improvement. While charity care must continue to be part of every organization’s community benefit strategy, healthcare delivery organizations should be strategically spending in the following areas related to place-based health improvement:

• Advocacy
• Convening
• Programming
• Investment

Accepting the determinants of health model demands an expanded definition of health. That expanded definition must include the concepts of social, mental, emotional and spiritual health to accompany the traditional definition of physical health. The expansion of this definition requires a reimagined approach to community health, particularly community health improvement.

There is no better beacon of community health than that of the hospital and the provider. At a macro level it’s imperative for the combined resources of the healthcare delivery system to provide the catalytic gusto to reframe the definition of health. On an individualized micro level, the healthcare system must begin, in earnest, connecting people to the places they live and the resources those places contain to support health and health improvement.

Creating a reality-based dream vision for health improvement

The professional world of health improvement has an illness afflicting projects across the nation: its efforts are not reaching far enough. Organizational realities put limits on dreaming — it’s not that the profession doesn’t see the overwhelming need for a large, coordinated, and effective approach to helping people lead healthier lives — it’s that the fee-for-service business approach still dominates healthcare delivery. That institution frowns on dreaming because, up to this point, it hasn’t been measurable. An existence too beholden to reality, to the here and now (the opposite of dreaming as it were) produces small vision in abundance.

The fee-for-service perspective is predicated on a fairly straightforward approach to problem solving (i.e., value creation) in that it sets out to solve problems for which there is a relatively straightforward solution. In the fee-for-service world, business problems are solvable with traditional tools; the entire business is built upon the diagnosis and treatment of an identified problem. This is a very straightforward approach for the vast majority of medical problems. Broken arm? X-ray, bone set, cast. Breast lump? Mammogram, lumpectomy, chemo. Chest pain? Interventional radiology, cath lab, beta blocker.

These are necessary interventions. They are needed and required to produce health. But interventions like them have become the predominant way to produce health, when in reality, they should be but only part of a much grander approach to helping people be well. Contrary to perception, the collective combination of small vision solutions does not create a grand solution. The perspective must be larger.

Its within this framework that solving community health issues can be seen a problem too large to address as the siloed, traditional operations approach is insufficient to take on social issues. Combined with an unwillingness to reach outside these traditional parameters and boundaries of healthcare delivery, declining health status is an issue that continues to grow. It is this fatalistic perspective that stops the unbounded thinking and doing necessary to create healthier communities.

Health improvement is different than providing medicine, though medicine is integral to health improvement. The approaches to each are inherently different: the provision of medicine happens in an instance, or set of instances, in the clinic or the hospital. Whereas the provision of wellness happens when the individual takes knowledge from a clinic or hospital visit and activates that knowledge outside the confines of medical supervision and in common regularity. Health improvement requires the patient to do something for the patient. The traditional approach to medicine has made customary the provider intervening on behalf of the patient.

Surely health improvement must start with the individual; and it is one that must extend beyond the individual to the places where individuals spend their time. It’s a problem — or diagnosis — that healthcare delivery doesn’t currently have the tools to address. Health improvement must address the social determinants of health; its solutions will cross silos, combine approaches, and demand broader perspective taking. It is within these environments identified constraints can propel the necessary creativity to create something grander.

Addressing the unhealth problem (realistically a combination of many problems) requires dreaming and a resulting dream vision. It’s not something that medicine or healthcare delivery should or can tackle on its own. It’s a locally-based, collaborative effort requiring participation from every sector of life. It requires healthcare delivery organizations to refrain from implementing a series of small visions and take the lead in implementing a new reality, a different set of strategies and tactics.

Paradoxically, the dream vision must, too, be based in reality. Funding does not and will not appear based upon prognostications and soapbox discourse. Health improvement leaders and healthcare delivery organizations must come together to create a united effort. Health improvement must become more professionalized, uniformly committed to measurement, and address value creation for all stakeholders. Healthcare delivery organizations must show a desire and commitment to approaching the issue by appointing leaders able to establish and implement a dream vision, creating funding mechanisms to experiment and innovate, and approaching partnerships with a renewed veracity and leadership.

The approach of the past two decades to community benefit is not enough. The dream vision of health improvement must assist healthcare delivery organizations in navigating a tumultuous operational environment by providing measured value. The healthcare delivery organization must help the dream vision of health improvement by more fully becoming the community leader it so often is deemed to be.