Nonprofit hospitals should engage more in ‘community building’ efforts

The confluence of the obesity epidemic, the Affordable Care Act (ACA), mandated Community Health Needs Assessment (CHNA) requirements and Gov. Neil Abercrombie’s focus on health care transformation and disease prevention presents Hawaii’s nonprofit hospitals with a strategic window of opportunity.

The new ACA "community building and community benefit requirements" strengthen current provisions by requiring that all nonprofit hospitals develop strategies to reduce morbidity and mortality rates from the leading underlying causes of death: tobacco use and obesity.

The ACA revises the Internal Revenue Service code to establish expanded community benefit responsibilities in order for nonprofit hospitals to retain federal tax-exempt status. The potential reach of these amendments is enormous.

However, these new requirements were not met by Hawaii’s hospitals. Wilcox Hospital on Kauai was the only one that conducted an intensive CHNA process with the public and community leaders, including islandwide focus groups. Such a labor-intensive process has not been done elsewhere in Hawaii, beyond perfunctory and cosmetic Internet surveys. This inch-deep approach is appalling and shortchanges the process; legislative action might be the only recourse to ensure the law is followed.

Wilcox Hospital, its CEO and president Kathy Clark and the Hawaii Pacific Health System’s leadership are to be congratulated for doing it right. Their wisdom in following the law will result in Wilcox Hospital demonstrating that the new requirements can be met.

Hawaii’s other hospitals are doing one statewide CHNA process. To assert that five island communities separated from Oahu by hundreds of ocean miles can be categorized as one "community" strains credulity and compliance. In fact, while multi-facility collaborations between hospitals in a given geographic area are desirable, doing this in a centralized Oahu-centric process could raise antitrust concerns.

"Community benefits" include improvement services and operations, and cash or in-kind contributions for community benefit. The broader "community building" strategies include upstream activities whose express purpose is to improve community health; these cannot generate patient bills nor be marketing designed to attract paying customers.

We need to invest in Hawaii’s health by influencing the social determinants of disease. It is our duty to ensure that Hawaii’s people have environments where healthy options are available, affordable and an "easy choice." Obesity is rampant here: Adult obesity has more than doubled between 1995 and 2010, and childhood obesity increased 29 percent from 1999 to 2011. One in three children born after 2000 is at risk for developing Type II diabetes.

Strategies to reduce obesity rates must address environmental and policy influences on nutrition and physical activity, in addition to individual influences, as has been done so effectively in tobacco control. The causes of poor health and well-being lie outside the health sector. They are socially and economically formed. Significant disparities exist. The health sector must engage others in finding policy innovations. This is the very essence of the CHNA requirements that many of Hawaii’s hospitals are intentionally ignoring, by choosing to not even address the IRS "community building" provisions.

Hawaii has a huge medical and economic burden due to societally influenced factors such as obesity, physical inactivity and tobacco and the diseases they cause. We suggest that the hospitals collectively set up a grant-making fund to engage community groups in desirable prevention efforts like obesity control. Given the absence of community-building strategies in their current portfolio, using this mechanism would help hospitals and could turn out to be a major public health and public relations coup for them.

President Barack Obama and Gov. Abercrombie have wisely emphasized disease prevention and health promotion, and we urge our hospitals to be their partners in this effort. On behalf of Hawaii’s keiki, kupuna and ohana, we implore our hospitals to involve and work with their surrounding communities in their submission of IRS-approved community building provisions this coming fiscal year.