1. Alamance Regional Medical Center Albemarle Hospital Alleghany Memorial Hospital Angel Medical Center Annie Penn Hospital Anson Community Hospital Ashe Memorial Hospital, Inc. Beaufort County Medical Center Bertie Memorial Hospital Betsy Johnson Regional Hospital Blowing Rock Hospital Blue Ridge Regional Hospital Broughton Hospital Brunswick Community Hospital Brynn Marr Behavioral Healthcare System Caldwell Memorial Hospital, Inc. Cape Fear Valley - Bladen County Hospital Cape Fear Valley Health System CarePartners Health Services CarolinaEast Health System Carolina Medical Center Carolina Medical Center - Lincoln Carolina Medical Center - Mercy Carolina Medical Center - NorthEast Carolina Medical Center - Pineville Carolina Medical Center - Union Carolina Medical Center - University Carolinas Rehabilitation Carteret County General Hospital Catawba Valley Medical Center Central Carolina Hospital Central Regional Hospital Charles A Cannon, Jr. Memorial Hospital Charles George Department of Veterans Affairs Medical Center Asheville Chatham Hospital Cherokee Indian Hospital Cherry Hospital Chowan Hospital Cleveland Regional Medical Center Coastal Plain Hospital Columbus Regional Healthcare System Davie County Hospital Davis Regional Medical Center Department of Veterans Affairs Medical Center Durham Duke Health Raleigh Hospital Duke University Hospital Duplin General Hospital, Inc. Durham Regional Hospital FirstHealth Montgomery Memorial Hospital FirstHealth Moore Regional Hospital FirstHealth Richmond Memorial Hospital Forsyth Medical Center Franklin Regional Medical Center Frye Regional Medical Center Gaston Memorial Hospital, Inc. Grace Hospital Granville Health System Halifax Regional Medical Center Harris Regional Hospital Haywood Regional Medical Center Heritage Hospital High Point Regional Health System Highland-Cashiers Hospital Holly Hill Hospital Hugh Chatham Memorial Hospital Iredell Memorial Hospital, Inc. J. Arthur Dosher Memorial Hospital John Umstead Hospital Johnston Medical Center Kings Mountain Hospital, Inc. Lake Norman Regional Medical Center Lenoir Memorial Hospital Lexington Memorial Hospital, Inc. LifeCare Hospitals of North Carolina Margaret R. Pardee Memorial Hospital Maria Parham Medical Center Martin General Hospital McDowell Hospital Medical Park Hospital Mission Hospitals Morehead Memorial Hospital Moses Cone Health System Murphy Medical Center, Inc. Nash Health Care Systems New Hanover Regional Medical Center North Carolina Baptist Hospital North Carolina Specialty Hospital Northern Hospital of Surry County Onslow Memorial Hospital Our Community Hospital Outer Banks Hospital Park Ridge Hospital Pender Memorial Hospital Person Memorial Hospital Pitt County Memorial Hospital, Inc. Presbyterian Healthcare Presbyterian Hospital Huntersville Presbyterian Hospital Matthews Presbyterian Orthopaedic Hospital Pungo District Hospital Corporation Randolph Hospital Rex Healthcare Roanoke-Chowan Hospital Rowan Regional Medical Center Rutherford Hospital, Inc. Sampson Regional Medical Center Sandhills Regional Medical Center Scotland Health Care System Select Specialty Hospital Durham Select Specialty Hospital Winston-Salem Southeastern Regional Medical Center St. Luke’s Hospital Stanly Regional Medical Center Stokes-Reynolds Memorial Hospital, Inc. Swain County Hospital Thomasville Medical Center Transylvania Community Hospital UNC Hospitals Valdese Hospital WakeMed WakeMed Cary Hospital WakeMed Fuquay-Varina WakeMed Zebulon/Wendell Washington County Hospital Watauga Medical Center Wayne Memorial Hospital Wilkes Regional Medical Center Wilson Medical Center Yadkin Valley Community Hospital Hospitals Eager to Help in the Assessment and Provision of Community Health Needs Sarah Broome, PhD, Director of Economic Research

2. When Did Community Benefit Start? Why Do Hospitals Measure Them? What Counts as a Community Benefit? How Big ($) are these Categories? Where Is the Public Health Dept. Overlap? What Impact Will Healthcare Reform Have on Community Benefits? Does Your Hospital File a Community Benefit Report with the IRS?

3. Nonprofit hospitals fall under 501(c)(3) “charitable purpose” tax exemption 1956 IRS Revenue Ruling 56-185: “Free care” standard Organized as nonprofit to care for sick Organized as nonprofit to care for sick Maintain open staff Maintain open staff No private inurement No private inurement Serve those unable to pay to the extent of the hospital’s financial abilityServe those unable to pay to the extent of the hospital’s financial ability 501(c)(3) hospitals file IRS Form 990 each year.

4. “Provide as much free care as you can” = ambiguous New ruling: Hospital is tax-exempt if: Full-time E.R. open to all, regardless of ability to pay Full-time E.R. open to all, regardless of ability to pay Care provided to everyone who can pay or on Medicare/Medicaid Care provided to everyone who can pay or on Medicare/Medicaid Community board; open medical staff; and use surplus for building, improve care, medical education, etc. Community board; open medical staff; and use surplus for building, improve care, medical education, etc.

5. The North Carolina Medical Care Commission Is a state commission Is a state commission Issues tax-exempt revenue bonds to finance construction and equipment projects for nonprofit and public hospitals…(usually for a cheaper rate than the private market). Issues tax-exempt revenue bonds to finance construction and equipment projects for nonprofit and public hospitals…(usually for a cheaper rate than the private market). Collects annual information, mostly financial reports, from those holding an MCC bond. Since 2001 annual reports have required community benefits reports. Collects annual information, mostly financial reports, from those holding an MCC bond. Since 2001 annual reports have required community benefits reports. Public has access to any report filed with the MCC.

6. Revenue rulings tie Community Benefits to Nonprofit Status, which affects tax coffers

7. National attention was growing.National attention was growing. NCHA members were asking for a common definition for benchmarking purposes.NCHA members were asking for a common definition for benchmarking purposes. The press was asking for it as they compared individual hospitals’ public reports.The press was asking for it as they compared individual hospitals’ public reports. The Medical Care Commission asked us to help them with their reporting requirement.The Medical Care Commission asked us to help them with their reporting requirement. North Carolina’s State Fiscal Research had started “measuring” it and publishing results.North Carolina’s State Fiscal Research had started “measuring” it and publishing results. All of these prompted the NCHA Board to direct NCHA action.

8. A defendable community benefit report that can be used in multiple settings: The Medical Care Commission required Hospital Community Benefits Report,The Medical Care Commission required Hospital Community Benefits Report, Hospital IRS 990 form,Hospital IRS 990 form, NCHA’s advocacy efforts,NCHA’s advocacy efforts, Hospital press releases and public reports,Hospital press releases and public reports, And, anywhere elseAnd, anywhere else Then, in 2008, IRS re-wrote their form…

9. In response to Grassley’s pressure, the IRS adds “Schedule H” to Form 990 (“H” is for hospital). Their definition of what counts as Community Benefits provided by hospitals Their definition of what counts as Community Benefits provided by hospitals Not exactly the same as everyone else’s. Not exactly the same as everyone else’s. Will not produce comparable reports. Estimates will be sensitive to: Will not produce comparable reports. Estimates will be sensitive to: Costing methodology choice. Legal definition of a hospital.

10. Measured in hospital costs (not charges): Charity Care Costs,Charity Care Costs, Medicaid Losses,Medicaid Losses, Other Means-Tested Government Program Losses,Other Means-Tested Government Program Losses, Medicare Losses,Medicare Losses,…

11. Community Health Improvement Services & Community Benefit Operations,Community Health Improvement Services & Community Benefit Operations, Losses on Health Professions Education,Losses on Health Professions Education, Subsidized Health Services,Subsidized Health Services, Research Costs,Research Costs, Cash and In-Kind Contributions to Community Groups, andCash and In-Kind Contributions to Community Groups, and Community Building ActivitiesCommunity Building Activities Bad Debt Costs

12. Health-related activities Health-related activities That do not generate a bill and That do not generate a bill and That target the community's health as a whole. That target the community's health as a whole. These include health fairs, public screenings, and babysitting training. They do not include any activities that could be interpreted as marketing-related.

13. Direct financial contributions or in-kind donations of supplies, equipment or staff time to not-for-profit or other government entities that provide Community Benefits. Direct financial contributions or in-kind donations of supplies, equipment or staff time to not-for-profit or other government entities that provide Community Benefits. Examples include checks given to SAFE Kids, to clinics and matching funds to not-for-profit groups. Examples include checks given to SAFE Kids, to clinics and matching funds to not-for-profit groups.

14. Community Building Activities are activities provided for the benefit of the community by the hospital that do not directly relate to the health of the residents: Physical improvements and housing Physical improvements and housing Economic development Economic development Community support Community support Environmental improvements Environmental improvements Leadership development and training for community members Leadership development and training for community members Coalition building Coalition building Community health improvement advocacy Community health improvement advocacy Workforce development Workforce development Other community building activities that protect or improve the community's health or safety that are not captured in the categories listed above. Other community building activities that protect or improve the community's health or safety that are not captured in the categories listed above.

15. Source: NCHA FY2008 Annual Survey. No Bad Debt

16. Source: NCHA FY2008 Annual Survey.

17. Source: NCHA FY2008 Annual Survey, based on 83% response rate. Missing respondent values were imputed using licensed beds.

18. Charges by Payer Source: Advocacy Needs Data Initiative, 2009, Financial Report, FY 2009, All NCHA member hospitals

22. New Requirements for Section 501(c)(3) Status New Requirements for Section 501(c)(3) Status Community Health Needs Assessment i.The organization must conduct a “community health needs assessment” not less frequently than every three years and adopt an implementation strategy to meet the community health needs identified through the assessment. ii.A “community health needs assessment” must include input from persons “represent[ing] the broad interests of the community served by the hospital facility,” including those “with special knowledge of or expertise in public health.” ii.A “community health needs assessment” must include input from persons “represent[ing] the broad interests of the community served by the hospital facility,” including those “with special knowledge of or expertise in public health.” iii.The assessment must be made widely available to the public.

23. What is the IRS definition of a “Community Health Needs Assessment?” What is the IRS definition of a “Community Health Needs Assessment?” What are the IRS requirements for an “Implementation Strategy?” What are the IRS requirements for an “Implementation Strategy?” Will a multi-county hospital do one assessment per county? Or one mega-area-assessment? Will a multi-county hospital do one assessment per county? Or one mega-area-assessment? What should multi-campus hospitals do? One assessment? Many? What should multi-campus hospitals do? One assessment? Many? Does this mean Public Health will be switching to every three years??? Does this mean Public Health will be switching to every three years???

24. To start a dialogue with your local hospital about community benefits and assessments, contact: Hospital Foundation Staff Hospital Foundation Staff Public Relations or Marketing Directors Public Relations or Marketing Directors Chief Executive Officers Chief Executive Officers Anyone you are currently working with on community projects Anyone you are currently working with on community projects

25. Alamance Regional Medical Center Alleghany Memorial Hospital Angel Medical Center Annie Penn Hospital Ashe Memorial Hospital Beaufort County Hospital Bertie Memorial Hospital Betsy Johnson Regional Hospital Blowing Rock Hospital Blue Ridge Regional Hospital Brunswick Community Hosp. Caldwell Memorial Hospital Cannon Memorial Hospital Carteret County General Hosp. Chatham Hospital Chowan Hospital Columbus Regional Healthcare System Community Care Partners Duke Raleigh Hospital Duke University Hospital Duplin General Hospital Durham Regional Hospital FirstHealth Montgomery Memorial Hospital FirstHealth Moore Regional Hosp. FirstHealth Richmond Memorial Hospital Forsyth Medical Center Gaston Memorial Hospital Grace Hospital Halifax Regional Medical Center Harris Regional Hospital Heritage Hospital High Point Regional Health Sys. Highlands-Cashiers Hospital Hugh Chatham Memorial Hospital Iredell Memorial Hospital Lenoir Memorial Hospital Lexington Memorial Hospital Margaret Pardee Memorial Hosp. Maria Parham Hospital MCHS - Greensboro Operations Medical Park Hospital Mission Hospital Morehead Memorial Hospital Murphy Medical Center North Carolina Baptist Hospital Our Community Hospital Park Ridge Health Pender Memorial Hospital Person Memorial Hospital Pitt County Memorial Hospital Presbyterian Healthcare Presbyterian Hosp. Huntersville Presbyterian Hospital Matthews Presbyterian Orthopaedic Hosp. Pungo District Hospital Corp. Randolph Hospital Roanoke-Chowan Hospital Rowan Regional Medical Center Rutherford Hospital Scotland Memorial Hospital Southeastern Regional Medical Center St. Luke's Hospital Stanly Regional Medical Center Stokes-Reynolds Memorial Hosp. Swain County Hospital The McDowell Hospital The Outer Banks Hospital Thomasville Medical Center Transylvania Community Hospital WakeMed WakeMed Cary Hospital Watauga Medical Center Wayne Memorial Hospital Wilson Medical Center Yadkin Valley Community Hosp.

26. www.ncha.org/communitybenefits Contact Information Sarah Broome, Ph.D, Director of Economic Research North Carolina Hospital Association 919-677-4137sbroome@ncha.org

27. Alamance Regional Medical Center Albemarle Hospital Alleghany Memorial Hospital Angel Medical Center Annie Penn Hospital Anson Community Hospital Ashe Memorial Hospital, Inc. Beaufort County Hospital Behavioral Health Care of Cape Fear Valley Health System Bertie Memorial Hospital Betsy Johnson Regional Hospital Bladen County Hospital Blowing Rock Hospital Broughton Hospital Brunswick Community Hospital Brynn Marr Behavioral Healthcare System Caldwell Memorial Hospital, Inc. Cape Fear Valley Health System Carolina Medical Center Carolina Medical Center - Mercy Carolina Medical Center - Pineville Carolina Medical Center - Union Carolina Medical Center - University Carteret County General Hospital Catawba Valley Medical Center Central Carolina Hospital Charles A Cannon, Jr. Memorial Hospital Charlotte Institute of Rehabilitation Chatham Hospital Cherokee Indian Hospital Cherry Hospital Chowan Hospital Cleveland Regional Medical Center Coastal Plain Hospital Columbus Regional Healthcare System Craven Regional Medical Center Davie County Hospital Davis Regional Medical Center Department of Veterans Affairs Medical Center Asheville Department of Veterans Affairs Medical Center Durham Dorthea Dix Hospital Duke Health Raleigh Hospital Duke University Hospital Duplin General Hospital, Inc. Durham Regional Hospital FirstHealth Montgomery Memorial Hospital FirstHealth Moore Regional Hospital FirstHealth Richmond Memorial Hospital Forsyth Medical Center Franklin Regional Medical Center Frye Regional Medical Center Gaston Memorial Hospital, Inc. Grace Hospital Granville Medical Center Halifax Regional Medical Center Harris Regional Hospital Haywood Regional Medical Center Heritage Hospital High Point Regional Health System Highland-Cashiers Hospital Highsmith-Rainey Memorial Hospital Holly Hill Hospital Hoots Memorial Hospital Hugh Chatham Memorial Hospital Iredell Memorial Hospital, Inc. J. Arthur Dosher Memorial Hospital John Umstead Hospital Johnston Memorial Hospital Kings Mountain Hospital, Inc. Lake Norman Regional Medical Center Lenoir Memorial Hospital Lexington Memorial Hospital, Inc. LifeCare Hospitals of North Carolina Lincoln Medical Center Margaret R. Pardee Memorial Hospital Maria Parham Medical Center Martin General Hospital McDowell Hospital Medical Park Hospital Mission Hospitals Morehead Memorial Hospital Moses Cone Behavioral Health Center Moses H. Cone Memorial Hospital Murphy Medical Center, Inc. Nash Health Care Systems New Hanover Regional Medical Center North Carolina Baptist Hospital North Carolina Specialty Hospital NorthEast Medical Center Northern Hospital of Surry County Onslow Memorial Hospital Our Community Hospital Outer Banks Hospital Park Ridge Hospital Pender Memorial Hospital Person Memorial Hospital Pitt County Memorial Hospital, Inc. Presbyterian Healthcare Presbyterian Hospital Matthews Presbyterian Orthopaedic Hospital Pungo District Hospital Corporation Randolph Hospital Rex Healthcare Roanoke-Chowan Hospital Rowan Regional Medical Center Rutherford Hospital, Inc. Sampson Regional Medical Center Scotland Memorial Hospital Southeastern Regional Medical Center Spruce Pine Community Hospital St. Luke’s Hospital Stanly Memorial Hospital Stokes-Reynolds Memorial Hospital, Inc. Swain County Hospital Thomasville Medical Center Thoms Rehabilitation Hospital Transylvania Community Hospital UNC Hospitals Valdese General Hospital Wake County Alcoholism Treatment Center WakeMed WakeMed Cary Hospital WakeMed Fuquay-Varina WakeMed Zebulon/Wendell Washington County Hospital Watauga Medical Center Wayne Memorial Hospital Wesley Long Community Hospital Wilkes Regional Medical Center Wilson Medical Center Women’s Hospital of Greensboro North Carolina Hospital Association

29. Source: NCHA FY2008 Annual Survey.

31. No Bad Debt

32. Source: NCHA FY2008 Annual Survey. No Bad Debt

33. Charity Care Costs (in $ millions)

34. Bad Debt Costs (in $ millions)

35. Medicare Losses (in $ millions)

36. Note: This is based on 74 hospitals’ FY04 data. Medicare losses are in the millions of dollars.

37. Medicaid Losses (in $ millions)

39. AHA Medicare NCHA Data Source: NCHA FY2005 Annual Survey.

40. AHA Medicare NCHA Data Source: NCHA FY2005 Annual Survey.

41. AHA Medicare NCHA Data Source: NCHA FY2005 Annual Survey.

42. AHA Medicare NCHA Data Source: NCHA FY2005 Annual Survey.

43. AHA Medicare NCHA Data Source: NCHA FY2005 Annual Survey.

44. AHA Medicare NCHA Data Source: NCHA FY2005 Annual Survey.

45. This is an introduction into a hospital’s world of “community benefit reporting” and “community health needs assessments.” Many NC hospitals have been reporting community benefits for years and most are required now to perform community health needs assessments. Learn about the recent federal changes in the community benefit landscape, Learn about the recent federal changes in the community benefit landscape, How the needs of hospitals now overlap with local health directors and local health educator goals How the needs of hospitals now overlap with local health directors and local health educator goals Which categories of community benefits most relate to local health initiatives, and Which categories of community benefits most relate to local health initiatives, and How to involve your local hospital How to involve your local hospital