Two Heritage College of Osteopathic Medicine faculty members helped release three reports this year that delve into why issues such as mental illness and opioid abuse are not always top priorities of nonprofit hospitals in Appalachia. 

Researchers from HCOM, including Dr. Daniel Skinner and Dr. Berkeley Franz, and Nationwide Children’s Hospital in Columbus interviewed staff members at 21 hospitals in Appalachian Ohio. The researchers were looking to see how the Affordable Care Act requirement of producing Community Health Needs Assessments has impacted them. 

The research concluded that assessments often do not reflect concerns of the community because it is challenging for nonprofit hospitals to take on efforts due to a lack of funding.

“Whether it’s the community members that are local residents or leaders of public health agencies or community nonprofits, (they) get a chance to have a role in this too,” Franz said. “You give the community the chance to prioritize what they think is the most important issues. The hospitals actually have a secondary process where they come in and do their own prioritization process with what they are actually going to address in their community benefit.”

Nonprofit hospitals have to update the Internal Revenue Service every three years to prove their programs are genuine efforts to address prioritized issues. Through that formal process involving community health needs assessments, hospitals could lose nonprofit status and tax-payer funding if their initiatives do not show progress.

“Our research is not taking this position of these places don’t care,” Skinner said. “They care a lot, but there’s a structure in place here that seems to dis-incentivise taking on some of the harder issues. Because what we really need is a support system for hospitals that can push them, incentivise them (and) support them in taking on the most challenging ones.”

During the assessment process, rural hospitals often don’t have the resources to employ someone for compiling reports. Therefore, a nurse or other employee is tasked with additional work to determine the Community Health Needs Assessments. 

Despite a shortage of resources, hospital staffers were generally positive about the relatively new requirements.

“There are some kinds of unexpected benefits, some of the employees talked about having new data to get new grant money and to be able to have some evidence when they are sort of going after some of these things, even trying to convince their own employees in their hospitals they should be putting money into these areas. They have data to do that now,” Franz said. 

Researchers found there are not only systematic reasons such as funding requirements for skewed prioritization of health needs assessment initiatives, but also sociological factors including stigma. 

“There’s ways to test (implicit bias) even in hospitals,” Franz said. “For example, Project Implicit has tests for stigma against mental illness, and we may work with them to develop a stigma test against opioid users.”

Franz and Skinner are interested in using incentives on a hospital level in order to help increase initiatives regarding opioid abuse. They also have a bigger study planned that will look at stigma of certain topics as one of the variables. 

“Another thing that we have mentioned is the challenge, that I think is important,” Franz. “A lot of hospitals just feel like they have traditional expertise in acute medical care and that some of these issues are really beyond that and they are really having trouble kind of making that leap to a new role in medicine, or what we call population health.”

Their research found some hospitals are nervous about doing population health because they don’t always have people trained in mental health care and addiction or the resources to increase the workload. 

Researchers are trying to expand the study across four Appalachian states — Ohio, Pennsylvania, West Virginia and Kentucky. 

Traditionally, nonprofit hospitals have dealt with fulfilling community benefit work by providing medical treatment to people who cannot afford it at all or without heavy subsidization. Increasingly, public health care is working to shift efforts from reactive care to preventative work to keep people out of emergency rooms.

As a condition of receiving tax benefits, nonprofit hospitals also have to do a certain amount of community outreach care, which is referred to as “community benefit work.”

“What we’re looking at increasingly is, and this has kind of changed, what’s happening with the Affordable Care Act since (it) started to be implemented,” Skinner said. “What we’re looking at is hospitals becoming involved in much more bonafide community work — working on housing conditions, safety, working in the schools.”

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