Graduation Date

Spring 5-6-2017

Document Type


Degree Name

Doctor of Philosophy (PhD)


Health Services Research, Administration, and Policy

First Advisor

David Palm, PhD

Second Advisor

Jane Meza, PhD

Third Advisor

Fernando Wilson, PhD


The Internal Revenue Service issued the long awaited regulatory guidelines for the Community Benefits (CB) spending for private tax-exempt hospitals in December 2008, which required these hospitals to report their policies, practices, and spending on CB activities. The Affordable Care Act amended these rules in 2010 by adding a section on Community Health Needs Assessment.

This study evaluates and tracks spending on the total and different CB activities by all private tax-exempt hospitals in seven states after the implementation of the latest IRS and ACA reporting regulations from 2010 - 2013. Moreover, this study investigates which community health indicators are predictive of spending on community improvement activities. The last part of this study examines the relationship between spending on health improvement activities and changes in a set of health indicators. We collected data from multiple sources and hospitals’ CB data were obtained from revised income tax Form 990.

A total of 328 private tax-exempt hospitals in the states of Kentucky, Minnesota, Mississippi, Nebraska, New Hampshire, New Mexico, and Virginia were included in the first study. The second and third studies included the 223 counties that had at least one private tax-exempt hospital in the seven states. Univariate analyses provided basic analyses. Multivariate regressions analyses, including linear and nonlinear models, examined the relationships between different predictor and response variables while adjusting for multiple covariates. SAS/STAT version 9.4 statistical software was used to execute the analyses. A p-value of ≤ 0.05 was considered statistically significant.

Total annual CB spending increased significantly between 2010 and 2013. There were considerable variations in the amounts and types of CB spending between different private tax-exempt hospitals. Direct patient care spending dominated the amount of spending on CB. Community health improvement initiatives comprised only around 0.55% of total tax-exempt spending on CB activities and varied considerably between counties and states and over time. Community health indicators showed mixed patterns over the study period. There did not appear to be a consistent pattern between the spending on community health improvement initiatives and changes in community health indicators.