Arizona recently made an innovative change in its scope-of-practice rules governing supervision of dental hygienists to enable hospitals to more easily use these providers to help prevent ventilator-assisted pneumonia (VAP) – the leading cause of death from nosocomial infections in critically ill patients. VAP, the second most common nosocomial infection, increases the duration of hospitalizations by seven days and health care costs by approximately $40,000 per hospitalization.1
Preventing VAP is important to reducing both hospital-acquired infections and health care costs. VAP usually occurs when a patient aspirates oral bacteria. The US Centers for Disease Control and Prevention, in recognizing the importance of oral care to VAP prevention efforts, suggests that hospitals, “develop and implement a comprehensive oral-hygiene program (that might include the use of an antiseptic agent) for patients in acute care settings or residents in long-term care facilities who are at high risk for health-care-associated pneumonia.”2
Nurses often provide oral-hygiene care to ventilator-dependent hospital patients, but some hospitals prefer to use dental hygienists to provide that service because of hygienists’ expertise and to give nurses more time for other responsibilities. However, hospitals in Arizona encountered challenges to assigning dental hygienists to this task. States’ scope-of-practice laws usually allow dental hygienists to provide care only under the supervision of a dentist. But hospitals may not have dentists on staff, or if they do, the dentist may not be available to order the care when needed.
In May 2019, Arizona enacted HB 2058, which allows dental hygienists working in hospital settings to practice under the supervision of a licensed physician. In addition, the supervising physician must be available for consultation but does not need to be physically present when the care is administered.
Changing the Scope of Practice Required Innovative Partnerships Among Providers
HB 2058 affects how physicians, oral hygienists, nurses, hospitals, and dentists work together. For example, nurses had traditionally provided oral health care in hospitals and they needed to understand that the change would not reduce their role, but rather free up their time to provide other critical services. Also, physicians needed to understand their responsibilities in supervising dental hygienists. As a result, crafting the legislation required partnerships and cooperation among the associations representing these providers. A volunteer project fostered these partnerships and generated real-life examples that confirmed that the scope-of-practice laws needed to be changed to enable hospitals to use dental hygienists to effectively provide dental hygiene in hospital settings.
Remaining Challenges and Next Steps
Although changing dental hygienists’ scope of practice facilitates their ability to practice in hospitals, challenges remain. For example, allowing hygienists to provide services does not obligate public and private insurers to pay for those services. Even before the bill passed, one regional hospital began hiring dental hygienists to work in its intensive care unit and the hospital then sought reimbursement for the hygienists’ services through medical billing — an action made possible by the change in the scope-of-practice rule. However, because Medicare does not recognize dental hygienists as a provider type, the hospital will not receive payment from Medicare. At this time, it is not known whether other payers will choose to pay for oral hygiene services provided to hospital patients by oral hygienists.
State health officials are tracking the results of this new innovation. They plan to assess patient outcomes, including VAP reduction, costs, and whether more hospitals implement this innovation. Depending on the results, officials are considering developing education programs or training to foster the innovation’s expansion. State policymakers are also considering expanding the physician-supervision model to long-term care facilities.
Acknowledgements: The National Academy for State Health Policy (NASHP) would like to thank officials with the Arizona Department of Health Services who shared their time and insights. The author also thanks Carrie Hanlon, Elinor Higgins, and Trish Riley of NASHP. She also would like to thank Trenae Simpson, M. Parrish Ravelli, and the DentaQuest Partnership for Advancing Oral Health for funding this project.
 Timsit, J.J., et al. (2017) Update on ventilator-associated pneumonia. F1000 Research. 6:2061. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5710313/
 Centers for Disease Control and Prevention (2003). Guidelines for Preventing Health-Care—Associated Pneumonia. CDC Morbidity and Mortality Weekly Report. https://www.cdc.gov/mmwr/preview/mmwrhtml/rr5303a1.htm
Tax exemptions for nonprofit hospitals cost states billions of dollars in lost tax revenue each year. In return, hospitals are required to invest in activities and services that benefit their communities. Some states, including Oregon and Connecticut, are going beyond federal requirements by holding hospitals accountable for making meaningful investments in the community’s health and well-being that meet genuine community needs — determined by the community itself — and align with state health priorities.
The Internal Revenue Service (IRS) defines certain hospital investments as community benefit activities. Examples include providing financial assistance to patients (also called charity care), covering shortfalls resulting from Medicaid participation, funding health professionals’ education programs, and subsidizing services such as neonatal intensive care and trauma services. Hospitals can also count “community health improvement services,” or hospital programs that don’t generate revenue, as community benefits.
Of particular interest to states seeking to bolster population health by improving their residents’ social and economic conditions, is the fact that hospitals can also count some “community building” activities toward their community benefit investments, although some experts have identified a need to clarify the process by which those activities are counted as community benefit. The IRS defines “community building” activities as activities that “protect or improve the community’s health or safety,” including investments in:
- Housing (the IRS addressed these investments in a short update on Dec. 18, 2015);
- Economic development;
- Community support, such as child care and mentoring programs;
- Environmental improvements, such as addressing air or water pollution or protecting the community from other environmental hazards; and
- Leadership development, coalition building, community health improvement advocacy, or workforce development.
Some states — such as Oregon and Connecticut — are using the federal requirements for tax-exempt hospitals to invest in community benefit activities as a springboard to ensure robust and meaningful hospital investments that address the needs of the community.
On June 25, 2019, Oregon Gov. Kate Brown signed HB 3076, which strengthens that state’s community benefits requirements in two ways:
- It requires hospitals to expand the range of income levels that qualify for charity care; and
- It establishes a minimum community benefit spending floor for nonprofit hospitals, set every two years by the Oregon Health Authority (OHA), in collaboration with the hospital or health system.
The law specifies that hospitals reduce to zero the cost to patients of medically necessary care for people whose incomes do not exceed 200 percent of the federal poverty level (FPL) guidelines. For people earning up to 400 percent of FPL, the law establishes a sliding scale – the hospital must reduce charges by at least 75 percent for people earning up to 300 percent of FPL, implement at least a 50 percent reduction for people earning up to 350 percent of FPL, and at least a 25 percent reduction for people earning under 400 percent of FPL. The law allows hospitals to seek reimbursement for those patient costs from other payers, such as those with third-party liability, and requires patients to share information to help hospitals collect payment from other payers.
This financial assistance standard is new for Oregon. Previously, state law did not mandate a minimum threshold that required hospitals to reduce eligible patients’ costs, although some hospitals had their own financial assistance policies.
In addition to the new standard for financial assistance, the law also holds hospitals accountable for investing in community benefits. The OHA must consider several factors when establishing the new community benefit spending floor, including:
- The community needs identified by the community needs assessment (CHNA);
- Community health improvement plans by regional Coordinated Care Organizations (CCOs);
- Current and historical expenditures on community benefits;
- The overall financial situation of the hospital; and
- The hospital’s spending on social determinants of health.
This requirement would make Oregon the sixth state to require a minimum level of community benefits spending, and the only one to tailor the minimum level for each hospital or health system according to a methodology. Another innovative facet of the law is that it requires the state to consider the needs identified in the CHNA when establishing the spending floor. This represents a step toward holding hospitals accountable for tying their community benefits spending to identified community needs, which is not currently an IRS requirement.
The OHA will convene a workgroup to define the methodology used to determine the minimum spending floors, which will be subject to the rule-making process and take effect in January 2021. The spending floors for each hospital or health system will be made public, and enforcement of the provision will largely rely on public scrutiny.
The Oregon bill had strong support from some key state legislators, including bill sponsor state Rep. Andrea Salinas, who participated in extensive stakeholder engagement leading up to the bill’s passage. Additionally, the bill had the support of the Service Employees International Union (SEIU), a union of hospital and other employees. The success of the bill’s champions put the spotlight on Oregon as the OHA crafts and implements a groundbreaking methodology for establishing the minimum for community benefits spending.
Connecticut is using a different, more specific and short-term approach to increase the effectiveness of community benefits investments. In recent hospital mergers and acquisitions, Connecticut used the certificate of need (CON) process to ensure that community benefit spending addresses community social needs and is directly tied to the CHNA and aligns with the State Health Improvement Plan (SHIP).
In a CON agreement tied to the transfer of assets from Milford Health to Bridgeport Hospital between Yale New Haven Health Services Corp. and Health Quest Systems Inc., the Connecticut Office of Health Strategy (OHS) mandated that the Connecticut hospitals:
- Submit to OHS their CHNAs and CHNA Implementation Strategy, which require input from key community stakeholders, health organizations, and local health departments, as well as the use of data and priorities from the SHIP as a framework for the CHNA.
- Adopt evidence-based interventions detailed in the Centers for Disease Control and Prevention’s 6/18 initiative and provide information about how patient outcomes directly related to the Implementation Strategy will be measured and reported to the community.
- Increase the total dollars spent on community benefits by at least 1 percent every year for the next five years, and ensure that spending and activities directly address the health needs identified by the hospital’s CHNA. The five-year annual 1 percent increase in community benefits spending cannot go towards hospital expenses or include spending on Medicaid, but must be used to address the social determinants of health and the population health needs identified in the CHNA.
The hospital is required to submit documentation to OHS showing “how its community benefit and community building activity expenditures addressed each element identified in the applicable CHNA, with brief narrative explanation of relevant activity for that element, and dollars spent.” These CON requirements require hospitals to show in a public document how they are directly tying community benefit spending to community needs. While CON conditions are time-limited, they demonstrate what is possible when states use their policy levers to maximize community benefits investments. In this way, Connecticut’s CoN work may inform broader state community benefits work beyond the CON process.
Oregon and Connecticut provide examples of how states can go beyond the federal requirements to ensure that hospital community benefit spending is substantial, meets community needs, and addresses state goals in exchange for tax exemptions. To support states in this work, the National Academy for State Health Policy (NASHP) has convened a hospital community benefits workgroup of state officials, supported by the Robert Wood Johnson Foundation and the New England States Consortium Systems Organization. Additional NASHP resources are available in this chart, Hospital Community Benefits Comparison Table for Six New England States, and this infographic, How 10 States Keep the ‘Community’ in Hospitals’ Community Health Needs Assessments.
For information detailing how much specific hospitals invest in community benefits and community building activities, explore this Community Benefit Insight tool.
Support for this work was provided by the Robert Wood Johnson Foundation. The views expressed here do not necessarily reflect the views of the foundation.
Non-profit hospitals are federally required to conduct community health needs assessments (CHNAs) every three years and develop a plan to meet those needs in exchange for their tax exempt status. Many states have laws or guidelines that are more detailed than the federal requirements. Scroll down to see 10 states’ guidelines for involving community members in the CHNA process, as well as their enforcement levers. This infographic draws on state documents, as well as CHNA statutes identified in the Hilltop Institute’s Community Benefit State Law Profiles Comparison.
Print this infographic.
Tax-exempt hospitals receive billions of dollars in tax exemptions each year. In exchange, they are required to invest in the health of their communities. But to do that, hospitals must first identify the health needs of the communities they serve. States can work to make sure hospitals truly seek out and act on meaningful input from a wide range of community representatives — not just community members on a hospital’s board or leaders from one or two high-profile community groups.
State Requirements Can Exceed Federal Standards
To identify community needs, federal legislation requires tax-exempt hospitals to conduct community health needs assessments (CHNAs) every three years, and develop a plan to meet those needs. The US Internal Revenue Service (IRS) requires tax-exempt hospitals to solicit and take into account input from at least one state, local, or tribal public health department as well as from medically underserved, low-income, and minority populations in their communities. It also says that hospitals may solicit input from consumer advocates, community organizations, academics, local governments, school districts, providers, health plans, business, and labor representatives.
Many states have aligned their state CHNA requirements or guidelines with IRS requirements and/or with standards set by the Public Health Accreditation Board (PHAB), which accredits state and local health departments.
Many states also have statutes or guidelines governing the CHNA process that go beyond federal requirements. For example,
- New Hampshire’s statute requires hospitals to consult with service providers and local government officials, as well as many of the same entities that IRS and the PHAB mention;
- A Texas statute requires hospitals to consider consulting with health science centers; and
- Massachusetts voluntary guidelines identify neighborhood associations, schools, churches and clergy, law enforcement, and housing authorities as possible sources of community input.
This state action is significant in light of a 2018 study that found that state CHNA requirements are associated with higher hospital spending on community benefits, and suggesting that state-level community benefits regulations are associated with greater hospital spending on community benefits. See the National Academy for State Health Policy’s How 10 States Keep the ‘Community’ in Hospitals’ Community Health Needs Assessments infographic for examples of 10 states’ statutes and guidance.
Table 1 shows states that address community involvement in the CHNA process either through state statute (California, Maryland, New Hampshire, New York, Rhode Island, and Texas), or through voluntary guidance documents (Maine and Massachusetts).
- Four states (California, New Hampshire, New York, and Rhode Island) statutorily require that certain communities or groups be represented in the CHNA.
- Two states (Maryland and Texas) explain in their statutes that hospitals “may consult with” (Maryland) or “shall consider consulting with” (Texas) certain groups or entities when assessing community needs.
- At least five states (Idaho, Illinois, Indiana, Vermont, Washington State) have state CHNA statutory requirements that do not specify any required representation.
Table 1. Representation Required (or Encouraged*) in the Hospital Community Health Needs Assessment Process
|Any appropriate person||√|
|Health care providers||√||√†||√|
|Health science centers||√|
|Local government officials||√||√||√||√†||√|
|Local health department or public health authority||√||√||√**||√†||√|
|Members of the public||√||√|
|Racial or ethnic minority groups||√||√|
|Disadvantaged populations, including low-income||√||√|
*State statute or guidance recommends but does not require representation in the CHNA process
**New Hampshire established Regional Public Health Networks
†Encouraged in the New York State Prevention Agenda
How States Enforce Community Benefits
While hospitals that fail to meet IRS community health needs assessment requirements may ultimately have their federal tax-exempt status revoked — as happened to a hospital in 2017— states have wide latitude to use other levers to enforce their own community benefits guidelines. Currently, few states codify enforcement levers in their statutes. Among those that don’t, some report success in gaining hospital compliance through transparency measures. For example, many states post hospitals’ community health needs assessments on state websites. An annual press release from the Massachusetts Office of the Attorney General also draws attention to the hospitals’ community benefits reports, which encourages hospitals’ timely compliance.
Table 2. State Statutory Levers for Enforcing Community Benefits
|Violators must provide an explanation||√|
With new governors recently taking office in 20 states in early 2019, states have an opportunity to consider hospital community benefits and community health needs assessment policies as part of a statewide, cross-agency effort to improve health using all the levers at a state’s disposal, including tax policy and enforcement. Meaningful investments in community health are possible when states hold hospitals accountable for keeping the community at the center of community health needs assessments.
The National Academy for State Health Policy convenes a Hospital Community Benefits Workgroup composed primarily of officials from state attorneys general offices and state Medicaid and public health departments. The workgroup is currently exploring how states can develop more meaningful hospital community benefits investments that align with state public health priorities and address the health-related needs of communities.
For more information about this initiative, or to share information on your state’s work in this area, please contact Amy Clary at email@example.com. Thanks to the following states’ officials for their help with these materials: California, Connecticut, Maine, Massachusetts, New Hampshire, New York, Rhode Island, and Vermont.
Produced in partnership with the Robert Wood Johnson Foundation and the New England States Consortium Systems Organization.
The Centers for Medicare & Medicaid Services (CMS) took an important first step toward increasing the transparency of hospital finances when it required hospitals to post their charge information, effective January 2019. But, these charges are not prices paid — they are typically the starting point against which commercial payers negotiate discounts.
States with all-payer claims databases (APCDs) have an important tool that allows them to go a step further – they can analyze the differential between “charges” and “prices paid.” This is an increasingly important distinction, particularly as 90 percent of hospital marketplaces are highly concentrated. Research shows that such concentration diminishes the capacity of health plans to negotiate rates and has increased hospital costs from 20 to 40 percent without gaining improvements in efficiency or quality .
New Hampshire Comprehensive Health Care Information System’s APCD releases data that allows the comparison of the difference between what is charged by hospitals and what health plans and consumers pay. The statewide report of charges and allowed amounts for common hospital services in New Hampshire, available at the NH HealthCost website, shows how charges compare to allowed amounts. Analysis of this data, shown in the table, illustrates that the actual amount paid for a service can vary greatly from what is charged, sometimes by more than 100 percent.
|Service Category||Median Price Charged||Median Price
Allowed or Paid
|Percentage Difference between Median Price Charged and Amount Paid|
|Biopsy skin lesion||$ 189.00||$ 69.12||-173%|
|Total hip arthroplasty||$ 37,195.00||$ 20,193.17||– 84%|
|Total knee arthroplasty||$ 14,543.50||$ 5,824.55||-150%|
|Nasal endoscopy dx||$ 1,119.16||$ 437.85||-156%|
|Diagnostic colonoscopy||$ 2,553.00||$ 1,800.61||-42%|
|Fetal non-stress test||$ 369.00||$ 261.34||-41%|
|Low back disk surgery||$ 10,615.75||$ 6,559.99||-62%|
|CT head/brain w/o dye||$ 2,030.56||$ 685.86||-196%|
|Chest x-ray||$ 366.00||$ 146.95||-149%|
|X-ray exam of knee 3||$ 399.00||$ 189.53||-111%|
|MRI joint of lower extremity||$ 2,598.00||$ 1,392.21||-87%|
|Comprehensive metabolic panel||$ 86.92||$ 56.15||-55%|
|Lipid panel||$ 106.00||$ 68.44||-55%|
|Glucose blood test||$ 43.00||$ 12.44||-246%|
|Eye exam new patient||$ 264.65||$ 140.25||-89%|
|Speech/hearing therapy||$ 313.45||$ 157.70||-99%|
|Comprehensive hearing test||$ 235.00||$ 188.85||-24%|
|Cardiovascular stress test||$ 1,154.00||$ 662.88||-74%|
|Office/outpatient visit new||$ 288.50||$ 188.27||-53%|
|Emergency dept. visit||$ 2,300.00||$ 1,374.67||-67%|
Importantly, the charges and prices paid vary by procedure, hospital, and payer and the data that shows these price differences is available through APCDs. NH HealthCost and similar websites in Maine, Colorado, Massachusetts, and Washington all are valuable resources to enhance transparency by identifying the price for services and the variation of those prices within each state.
Working together, CMS and state APCDs can provide important data to fuel conversations about hospital charges and payments, and the policy issues that the data raises.
The Affordable Care Act’s amendment to section 2718(e) of the Public Health Service Act requires each hospital operating within the United States to make public a list of standard charges for items and service provided by the hospital including for diagnostic-related groups. CMS published proposed rules for FY 2015 reminding hospitals of their obligation to comply, and again for FY 2019, ultimately finalizing the rules to improve the public accessibility of charge information in a machine-readable format effective January 2019. https://s3.amazonaws.com/public-inspection.federalregister.gov/2018-16766.pdf.
Josephine Porter is director of the University of New Hampshire’s Institute for Health Policy and Price and co-chairs the All-Payer Claims Database Council (APCD Council).
Trish Riley is executive director of the National Academy for State Health Policy.
Lawrence, Massachusetts, a city that has struggled with poverty and poor health, is now a Culture of Health Prize winner due in part to state policies that bolster the city’s efforts to advance health equity and address social needs. These supportive state policies include guidelines governing the local hospital’s community health needs assessments, its community benefits investments, and its determination of need spending. The Mayor’s Health Task Force works closely with community partners and braids funding from a variety of sources to improve the social and economic factors that affect health. The city’s innovative work and longstanding partnerships offer a blueprint for cities and states interested in unlocking the potential of community-centered, multi-sector partnerships.
Download: Keeping the Community at the Center of Community Benefits Programs: Lessons from Lawrence, Massachusetts
Support for this work was provided by the Robert Wood Johnson Foundation. The views expressed here do not necessarily reflect the views of the foundation.
Hospitals get billions in tax breaks and in return they’re supposed to invest in community health. How can state policymakers ensure that money is spent on the right issues to support state health goals?
Nonprofit hospitals benefited from at least $24.6 billion in tax exemptions in 2011, according to a 2015 analysis that used the most recent data available. In exchange for these exemptions, federal tax policy requires hospitals to invest in activities that benefit the health of their communities. But do these activities truly target the most pressing health needs of area residents?
|Community benefits requirements for nonprofit hospitals:
Policymakers know that 80 percent of people’s health is affected by factors beyond the reach of hospital or clinician care, such as access to nutritious food, safe housing, education, income security, health equity, and other socio-economic factors. Given the importance of these social determinants in shaping people’s lives and health, how can states use their policy levers to ensure that tax-exempt hospitals invest their community benefit dollars in ways that most effectively address and support state health priorities?
The Affordable Care Act (ACA) provides a foundation that states can build on when integrating hospital spending on community health with state priorities. The ACA requires charitable hospitals governed by section 501(c)(3) of the Internal Revenue Code to conduct community health needs assessments every three years, and to adopt a plan to address those needs. It also requires hospitals to establish financial assistance policies and to refrain from charging higher prices to people receiving financial assistance than is generally billed to insured people. The IRS Form 990 Schedule H also requires tax-exempt hospitals to report whether and how they considered community input when creating their community benefits plan.
The interactive Community Benefit Insight tool, supported by the Robert Wood Johnson Foundation (RWJF) in partnership with RTI International and the Public Health Institute, draws on IRS and other data to show how hospitals spend their community benefits dollars. Research shows hospitals spend the majority of their community benefits resources on clinical care — including charity care and Medicaid shortfalls — rather than on community health improvement or community-building activities that can address the social determinants of health. The Community Benefit Insight tool allows users to compare such spending across hospitals and health systems.
States can require hospitals to do more than simply meet the federal requirements. Some states go beyond by requiring hospitals to specifically report how hospitals’ community benefits investments address the social determinants of health or meet the needs of underserved populations. Some states mandate that hospitals spend at least a minimum amount on community benefits.
States also use a range of enforcement strategies to ensure that hospitals comply with state regulations. A new National Academy for State Health Policy (NASHP) table highlights effective state hospital community benefits requirements and related state law requirements in several states. The table can inform state policymakers who want to leverage their states’ community benefits process to improve community health.
States command a range of policy levers that can maximize hospital community benefits spending to address the social determinants of health. To help states deploy these levers effectively and share best practices, NASHP has convened a Hospital Community Benefits Workgroup, composed primarily of officials from state attorneys general and insurance commissioners’ offices, as well as state Medicaid, public health, and justice departments. With support from RWJF and the New England States Consortium Systems Organizations, the workgroup is exploring how states can develop more meaningful hospital community benefits and community-building investments that align with state public health priorities and address the social determinants of health. This mission includes examining:
- How states define and count community benefits;
- How to ensure community health needs assessments are substantive;
- How community health trusts can be used as a tool for community benefits investing; and
- What measurement tools are available to evaluate the benefits of community benefit spending on public health programs.
While the table — and the workgroup — currently focus on the New England states, the list will be expanded to include other states as work progresses. State officials are invited to become involved with the NASHP community benefits workgroup or share their states’ efforts to maximize hospital community benefits investments. Please contact Amy Clary at firstname.lastname@example.org for more information.
Explore the Hospital Community Benefits Comparison Table – New England States, which highlights effective state hospital community benefits requirements and related state law requirements in several states.
Support for this work was provided by the Robert Wood Johnson Foundation. The views expressed here do not necessarily reflect the views of the foundation.