Grassley Renews Probe of Nonprofit Hospitals

The Iowa Republican has asked the IRS for data on how many of the nation’s approximately 3,000 tax-exempt hospitals are in compliance with charity care requirements.


Grassley asked for information about whether tax-exempt hospitals are meeting the statutory requirements laid out in section 501 of the Internal Revenue Code.

The lawmaker is renewing his probe of tax-exempt hospitals after hearing reports that ‘at least some of these tax-exempt hospitals have cut charity care, despite increased revenue.’

Senate Finance Committee Chairman Chuck Grassley has renewed efforts to ensure that nonprofit hospitals are earning their tax-exempt status by providing enough services for low-income people.

In a letter to Internal Revenue Service Commissioner Charles Rettig, the Iowa Republican asked for data on how many hospitals are in compliance with the requirements for tax-exempt status and the status of IRS examinations of those not in compliance.

“Making sure that tax-exempt hospitals abide by their community benefit standards is a very important issue for me,” Grassley said in his letter.

“As chairman of the Senate Judiciary Committee, I oversaw an investigation into the billing practices of the Mosaic Life Care hospital. That investigation resulted in debt relief of almost $17 million for thousands of low-income patients.  This issue is still just as important to me now that I am chairman of the Senate Finance Committee,” Grassley wrote.

The Mosaic Life inquiry examined the billing and debt collection practices at the health system after news reports indicated it had sued low-income patients who should have qualified for charity care.

Grassley told Rettig that he was renewing his probe of tax-exempt hospitals after hearing “reports” that “at least some of these tax-exempt hospitals have cut charity care, despite increased revenue, calling into question their compliance with the standards set by Congress.”

He asked Rettig for information about whether tax-exempt hospitals are meeting the statutory requirements laid out in section 501 of the Internal Revenue Code, and he cited in his letter an article in Politico that suggested nonprofit hospitals were profiting from the Affordable Care Act while simultaneously cutting their charity care.

In February 2018, Grassley sent a letter to the IRS to inquire about how the agency reviews nonprofit hospital compliance.

Acting Commissioner David J. Kautter responded in April 2018 that the IRS reviews the status of about 1,000 U.S. tax-exempt hospitals each year by reviewing Forms 990, hospital websites, and other information in order to identify the hospitals with the highest likelihood of noncompliance.

Kautter said the IRS assigns either a compliance check or examination to those hospitals that appear to be most at risk of noncompliance.

Melinda Hatton, general counsel for the American Hospital Association, said her organization was confident that nonprofit hospitals are meeting their mission.

“In 2015, an AHA analysis of Schedule H filings reported that 13.3% of tax-exempt hospitals and health systems total expenses were devoted to community benefits programs, and that half of that spending was attributable to expenditures for providing financial assistance to needy patients and absorbing losses from Medicaid and other means-tested government program underpayments,” she said.

Hatton said an analysis by Ernst & Young for the AHA found that hospitals’ and health systems’ community benefit activities outweigh the value of their federal tax exemption by a factor of 11 to one. “According to the report, non-profit hospitals in 2013 were exempt from an estimated $6 billion in federal taxes and provided an estimated $67.4 billion in community benefits,” Hatton said.

“Making sure that tax-exempt hospitals abide by their community benefit standards is a very important issue for me.”




Amid labor talks, union unveils billboards highlighting Cedars-Sinai profits, CEO pay

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Healthcare workers at Los Angeles-based Cedars-Sinai Medical Center revealed a series of billboards that highlights profits and CEO pay at the hospital.  

The workers, who are represented by Service Employees International Union-United Healthcare Workers West, announced the billboards April 2 amid contract negotiations. The billboards are scheduled to appear throughout April at seven locations that are all within 1.5 miles of the hospital.

A union news release says the billboards aim to draw attention to “excessive profits and CEO compensation,” as well as the amount of charity care the nonprofit hospital provides.

“The public deserves to know that this elite hospital with huge profits and obscene CEO compensation, isn’t acting in the public’s best interests,” Dave Regan, president of SEIU-UHW, said in the release. “On top of paying no income or property taxes, Cedars-Sinai skimps when it comes time to care for the poorest people in our community.”

The hospital  addressed the union’s claims.

“The Cedars-Sinai Board of Directors believes in providing every one of our employees with compensation that is based upon merit of their individual performance, a rigorous review of each position’s responsibilities, and comparisons with other organizations for positions with similar responsibilities. For the president and CEO, the review process is even more extensive,” the statement said.

“[CEO]Tom Priselac’s compensation appropriately reflects his more than two-decade tenure of successfully presiding over the western United States’ largest nonprofit hospital. Under his leadership, Cedars-Sinai has earned national recognition for delivering the highest quality care to patients and has been ranked among the top medical centers in the country.

“Over the last 10 years alone, Cedars-Sinai has invested nearly $6 billion to benefit the local community by, among other things, providing free or part-pay care for patients who cannot afford treatment; by losses caring for Medicare and Medi-Cal patients; and by providing a wide range of free health programs and clinics in neighborhoods as well as education, health and fitness services in dozens of local schools.”

SEIU-UHW represents more than 1,800 service and technical workers at the hospital. The last contract with Cedars-Sinai expired March 31.




Illinois hospital will have to meet constitutional charity standards, judge rules

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An Illinois judge has ruled that the operator of Carle Foundation Hospital in Urbana must meet constitutional standards for charitable organizations in order to receive tax exemptions, The News-Gazette reports.

The Carle Foundation is seeking retroactive property tax exemptions for 2004-2011 and a refund for taxes it paid to local authorities during that time. However, Champaign County Judge Randy Rosenbaum agreed with the recent Illinois Supreme Court ruling that hospitals seeking tax exemptions must not only offer as much charity care as they would have paid in taxes; they also must extend charity care to an indefinite number of people and not create any barriers to it.

Hospitals looking for a tax exemption  also must show they do not have any capital, stock or shareholders. Carle Foundation attorneys  have argued that they need only show that the hospital complies with the terms of the hospital tax-exemption law.

John Colombo, a retired law professor at the University of at Illinois Urbana-Champaign, said that the ruling is important for the Carle Foundation’s upcoming trial, but does not clearly define charitable use for the future of Illinois hospitals.

“The Illinois Supreme Court is going to have to say at some point, ‘Here’s what it takes for an Illinois hospital to be tax-exempt,'” said Mr. Colombo.



Jersey City hospital to pay ‘voluntary’ taxes after city challenged tax-exempt status

Jersey City Medical Center will pay Jersey City $550,000 annually in exchange for the city dropping an appeal of the hospital's tax-exempt status.

After city officials appealed Jersey City Medical Center’s tax-exempt status, the Downtown hospital has agreed to kick in $550,000 annually to the city’s coffers for the next six years.

The agreement, which is part of a legal settlement between the hospital and the city, comes three years after a tax court judge ruled that Morristown Medical Center should pay Morristown property taxes because it fails to meet the legal test that it operates as a nonprofit. That ruling led dozens of towns statewide to sue hospitals seeking tax revenue.

JCMC, now part of the RWJBarnabas Health system, owns four properties in Jersey City, tax records show. Its main campus, located on Grand Street in an upscale area of the city, is assessed at $126 million. If the hospital were not tax-exempt, it would pay $800,000 in property taxes this year, city attorney Nick Strasser told the City Council on Oct. 9.

The settlement, approved by council members on Oct. 10, comes in two parts. The first includes JCMC’s agreement to pay $300,000 in “voluntary” property taxes annually until 2023, retroactive to 2016. In exchange, the city will end its challenge of the hospital’s tax-exempt status and the hospital will drop its counterclaim.

A second agreement has JCMC agreeing on annual “health care collaboration” payments to the city, also retroactive. The payments for 2016 and 2017 will be $1 million total and from 2018 through 2023 they will amount to $250,000 annually.

The tax agreement does not preclude the city from challenging the hospital’s tax-exempt status after 2023.

A bill under review by state lawmakers would require nonprofit hospitals in New Jersey pay a “community service contribution” equal to at least $2.50 per bed daily. If that becomes law, the agreement between the city and JCMC would allow JCMC to reduce that contribution by the amount JCMC will pay under the settlement.

JCMC has about 320 beds.

At the council’s Oct. 9 caucus, Councilwoman Joyce Watterman asked if the settlement was the best the city could do.

“It’s perhaps not the best we could do but it’s definitely not the worst we could do,” Business Administrator Brian Platt told her. “The worst is actually zero, is what we get now.”

The council approved the JCMC agreements 8-0-1. Council President Rolando Lavarro abstained from voting. His wife, Veronica, works at Barnabas in media relations.

“Jersey City Medical Center is pleased that the City of Jersey City has accepted this agreement,” Veronica Lavarro said in a statement. “We look forward to our collaborative work to reduce health disparities and improving health equity in Jersey City.”


Illinois Supreme Court: Hospitals’ property tax exemption is constitutional

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The Illinois Supreme Court ruled Sept. 21 that non-profit hospitals in the state do not have to pay property taxes as long as the value of the charitable services they provide is equal to or greater than the taxes they would have paid, according to The Chicago Tribune.

The ruling was an affirmation of a lower court decision that previously upheld the constitutionality of the property tax exemption, which was challenged in the lawsuit against the Illinois Department of Revenue by Cook County taxpayer Constance Oswald.

“When you give these hospitals a pass on paying real estate taxes, people within the counties where the hospitals are located have to make it up,” Edward Joyce, Ms. Oswald’s lawyer, told The Tribune.

But advocates for nonprofit hospitals argued the law allows them to fully dedicate themselves to delivering care to underserved patients.

“For nonprofit hospitals, property tax exemption fosters [transformation] by permitting them to focus their time, energy, and financial resources on new strategies to better serve all of the residents of our state.” said A.J. Wilhelmi, president and CEO of the Illinois Health and Hospital Association. “Taxing nonprofit hospitals would hurt the communities they serve by diverting dollars that are better used to care for patients and to upgrade equipment, modernize facilities and hire needed staff.”



A Little-Known Windfall for Some Hospitals, Now Facing Big Cuts

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Most hospitals are nonprofit and justify their exemption from taxation with community service and charity care. But the Trump administration could require some of them to do more to help the poor, and the hospitals that are in the cross-hairs are those benefiting from an obscure drug discount program known as 340B.

The 340B program requires pharmaceutical manufactures to sell drugs at steep discounts to certain hospitals serving larger proportions of low-income and vulnerable people, such as children or cancer patients. The participating hospitals may charge insurers and public programs like Medicare and Medicaid more for those drugs than they paid for them and keep the difference.

By one estimate, the program saved hospitals $6 billion in 2015 alone. The original intent of the program, enacted in 1992, was for hospitals to use the revenue to provide more low-income patients a broader range of services.

Many institutions that serve mostly low-income and uninsured populations say they need the program. “Most nonprofit hospitals have very slim profit margins, and they’ve come to rely on this revenue,” said Melinda Buntin, chairwoman of the Department of Health Policy at Vanderbilt School of Medicine. A hospital lobbying group said that for some rural hospitals, the funding cut “could actually be the difference between staying open and closing.”

But there is concern that 340B has come to include hospitals that don’t need the extra help and are not using its windfall as originally intended.

The program has grown considerably, most recently as a result of an expansion included in the Affordable Care Act. As of 2004, about 200 hospitals benefited from the 340B program; by 2015, over 1,000 were participating. The program now encompasses 40 percent of all hospitals and an even larger number of hospital-affiliated clinics and pharmacies.

It might seem odd to give discounts on drugs to help hospitals offer care to low-income patients. How can we be sure they’ll use the money for that?

An increasing number of hospitals are not.

A study published in JAMA Internal Medicine found that the early participating hospitals were more likely to be located in poor communities with higher levels of uninsured people, to spend more of their budget on uncompensated care, and to offer more low-profit services than hospitals that started participating later.

“The 340B program may produce the results intended at some hospitals,” said Sayeh Nikpay, an assistant professor at Vanderbilt University and a co-author on the study. “But as the program grew, it benefited many hospitals with less need for assistance in serving low-income populations.”

Other research corroborates that hospitals aren’t using the 340B program as intendedA study in The New England Journal of Medicine was unable to find any evidence that profits from 340B have led to more access to care for low-income patients, or reductions in mortality rates among them. Another study in Health Affairs found that 340B hospitals have increasingly expanded into more affluent communities with higher rates of insurance.

The 340B program may have also inadvertently raised costs — for example, by encouraging care in 340B-eligible hospitals that could have been provided less expensively elsewhere. A study in Health Services Research found that hospital participation in 340B is associated with a shift of cancer care from lower-cost physician offices to higher-cost hospital settings.

The program may also encourage providers to use more expensive drugs. The more hospitals can charge insurers and public programs for a drug — relative to how much they have to pay for it under the program — the greater the revenue they receive. They also receive more revenue when the drugs are prescribed more often.

In January, Medicare lowered the prices it pays for 340B drugs by 27 percent. Although this move chips away at how much hospitals can benefit financially, it does little to address how much insurers and individuals pay for prescription drugs or the value they obtain from them. In addition, the move does nothing to increase hospital spending that could help the poor.

It may even harm some health care organizations, leading to lower-quality care at those institutions that are helping the poor. Studies have shown that, by and large, when hospitals lose financial resources, they make cuts that could harm some patients.

This can happen if cuts lead to reductions in workers who perform important clinical functions. A study in Health Services Research found that hospitals cut nursing staff in response to Medicare payment cuts in the late 1990s. Heart attack mortality rates improved less at hospitals that had larger cuts.

Another response to reduced revenue is cuts to specific services, which would harm patients who rely on them. A study by economists from Northwestern’s Kellogg School of Management found that some hospitals that endured financial setbacks during the Great Recession cut less profitable services like trauma centers and alcohol- and drug-treatment facilities.

Another study looked at a 1998 California law that required hospitals to comply with seismic safety standards — imposing a large cost on those institutions, without providing additional funding. Hospitals that were hit harder financially by this law were more likely to close; government hospitals responded by reducing charity care.

Hospitals could absorb cuts without harming care if they could become more productive — by doing more with less. Historically, there is very little evidence they have been able to do that.

Two powerful lobbies are now battling each other, with the pharmaceutical industry arguing that 340B has grown well beyond its original intent. Hospital lobbying groups are fighting back and also squaring off against the government, suing over the planned federal cuts.

Those are big clashes over a program that began modestly a quarter of a century ago to help the poor, albeit in a most convoluted way.



Geisinger reports net income increase despite issues with ACA health plan

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Dive Brief:

  • In a new financial report, Geisinger Health System reported a gain of nearly $200 million in net income to $324.9 million for the first half of fiscal year 2018 compared to the previous year, for an excess margin of 9%.
  • Operating income for the first six months was up from $51.9 million a year ago to $61.2 million in the current fiscal year and net revenue increased 8.1% to $3.3 billion. However, Geisinger’s operating margin dropped from 3% for the first three months of the fiscal year to 1.8% through half the year.
  • One area of concern for the integrated healthcare system was its Affordable Care Act (ACA) health plan. Geisinger Health Plan (GHP) struggled after the company didn’t get $11 million in cost-sharing reduction (CSR) payments following President Donald Trump’s decision to stop payments in October.

Dive Insight:

Geisinger’s net revenue growth is connected to an increase in net patient service revenue after the provision for bad debts of nearly 5% and an increase in premium revenue of 11%.

“Net patient service revenue benefited from the realization of growth plans centered on market share growth and the opportunistic capture of high-acuity, clinical service volumes. Premium revenue benefited primarily from rate increases,” Geisinger said in the report.

ACA marketplace volatility, namely the end of CSR payments, as well as higher utilization affected GHP. The company believes the higher utilization is connected to GHP members concerned they would lose coverage if Congress repealed the ACA. Despite Congress’ and the president’s threats and a few close votes, the repeal didn’t happen. But before that effort stalled, Geisinger said many members got healthcare services just in case.

“Similarly, provider tiering in benefit plan changes for self-insured employees were announced in the fall of 2017. These benefit changes caused certain employees to accelerate medical services through providers that fall under higher out-of-pocket tiers beginning Jan. 1, 2018. These one-time impacts, while negatively affecting second-quarter results, are expected to improve operating profits beginning in the third fiscal quarter,” Geisinger said in the report.

Geisinger expects to resolve the CSR non-payment issue this year after raising the average premium rate by 31% to help offset the loss of payments. GHP also gained more than 20,000 members in its exchange plans, a 39% increase, for 2018, which should help offset losses.

GHP had 559,643 members in its health plans through the first half, which was a 0.4% increase compared to a year ago.

Concerning utilization, Geisinger had an increase of 3.5% in discharges and 2.6% in discharges and observations/23-hour stays compared to a year ago. “This growth was attributable to success in expanding clinical programs. Based solely upon hospitals controlled for two years or more, Geisinger experienced a 2.9% increase in discharges when compared to the year-earlier period,” the report states.

However, percent of occupancy based on physically available beds dipped from 60.2% to 59.9%.

Meanwhile, outpatient visits were on the rise. Outpatient emergency room visits increased from nearly 174,000 the previous year to almost 181,000 in fiscal 2018. Clinic outpatient visits increased from 1.65 million to 1.77 million.

Geisinger is the latest nonprofit to offer updates about finances. Over the past week, other major nonprofits have released financial information, including:

All had positive notes in their reports. Cleveland Clinic and Mayo Clinic said operating income and revenue bounced back in 2017 after rough numbers in the previous year. UPMC said its clinical and insurance sides had strong performances as net income hit $1.3 billion. Profits for these companies have been scrutinized as critics question whether they are giving enough back to their communities as nonprofit organizations.