Indianapolis Star, December 14, 2008 - Nonprofit facilities get millions in tax breaks for providing free care and other community benefits. But some say those benefits come up way short.

Each year, Central Indiana's four major nonprofit hospitals receive tens of millions of dollars in tax breaks in return for providing outreach programs and care for the poor.

But those hospitals' current level of "charity care" -- care for which they expect no payment -- raises questions about whether they deserve those tax breaks and whether measures should be taken to protect taxpayers.

A review of federal, state and hospital records by The Indianapolis Star reveals that the area's four nonprofits -- Community Health Network, St. Francis Hospital & Health Centers, St. Vincent Health and Clarian Health -- devoted less than 3 percent of revenue each to charity care in 2006, the most recent year for which such information is publicly available. All told, they spent $78.8 million that year on charity care, of which Clarian's Downtown hospitals contributed more than half.

By comparison, the area's public taxpayer-funded hospital, Wishard Memorial Hospital, provided roughly $149.1 million in free care in 2006 -- nearly twice the total of the four nonprofits combined, or the equivalent of 35 percent of its patient revenue.

This imbalance isn't happening by accident. Across America, nonprofit hospitals are moving to the suburbs, where they can attract patients far more likely to be insured -- and are far less likely to encounter patients in need of the free or subsidized care that merits their nonprofit tax breaks.

Taxpayer-funded hospitals, which, like Wishard, are more often in inner cities, are left to pick up the ever-increasing slack and cost.

The situation has drawn the attention of state and federal lawmakers, who see a need for hospitals to better justify their nonprofit status.

"My bottom line is that I think there are problems," said Sen. Charles Grassley, R-Iowa, who is pressuring hospitals to defend their tax-exempt status. "You need to do the charitable things that charities have tax exemption for."

Some states have minimum requirements. In Texas, for example, hospitals are required to devote at least 4 percent of revenues to charity care -- a threshold that none of the four Central Indiana hospital providers met in 2006.

Neither the IRS nor the state of Indiana, however, requires any set amount of charity care to receive or maintain nonprofit status.

In 1969, the Internal Revenue Service set standards for tax-exempt status and an expectation for community benefit, including charity care.

Indiana requires nonprofit hospitals to file an annual community benefit report with the Indiana State Department of Health. The report is for information only and ostensibly shows what the hospitals have done to benefit the community. But hospitals define community benefit differently, making it difficult to compare charity care levels for different providers or over time.

Last year, state Rep. Thomas E. Saunders, R-Lewisville, introduced legislation that would have required hospitals and other nonprofits to prove their property was used for charitable purposes to remain eligible for tax exemption.

He said he soon learned from lobbyists that such rules had little support. The bill died.

"I wasn't a very popular person last year," he said.

Saunders said he intends to keep pressing the issue but has no plans to reintroduce legislation. "I just wanted it to be debated," he said, "and it didn't get debated."

Grassley sent letters earlier this year questioning certain charity care or billing practices at two high-profile, tax-exempt hospitals: M.D. Anderson Cancer Center in Houston and the University of Chicago Medical Center in Illinois.

University of Chicago hospitals performed $10 million worth of charity care in the most recent fiscal year, yet received $59 million in tax exemptions, according to the Center for Tax and Budget Accountability, a Chicago nonprofit.

The concern has caught the attention of the IRS, as well. Starting next year, tax-exempt hospitals nationwide will have to provide more detailed financial information to the agency about the charity care and community benefit they provide. Still, there will be no quantifiable requirement.

Arguments against thresholds

Although some argue that hospitals should meet certain charity care thresholds -- such as 5 percent of patient revenues -- to receive tax breaks, others say such requirements would only lead to more problems.

Hospitals and doctors likely would demand higher rates if they incurred more losses from charity care, some say.

Already, uninsured patients often are charged the highest prices for care because they do not receive discounts negotiated by large insurers. More pressure would be placed on those with any ability to pay, forcing some people into bankruptcy.

Some hospitals would never reach the charity care goal because they are in areas that would make that impossible.

"You could have a hospital in an affluent area seeing every charity care case that walks through that door and not hit that number," said Douglas Leonard, president of the Indiana Hospital Association.

Calculating benefit

Indeed, based on 2006 figures, a 5 percent minimum would be daunting for some.

Charity care at St. Vincent's Indianapolis and Carmel hospitals was more than $12 million in 2006, but the hospitals had more than $907 million in revenue -- putting their charity care at 1.36 percent. At 5 percent, the two hospitals would have provided more than $42 million in care to the poor.

Charity care at St. Vincent's flagship 86th Street hospital on the Far Northside was about 1.5 percent of total revenue of $765 million in 2006.

But St. Vincent Health Chief Executive Officer Vince Caponi said it's unfair to base his hospital's tax-exempt status on charity care alone. He says the treatment of Medicaid patients, for which the hospital is not fully reimbursed, and other community programs also must be considered.

"As a faith-based organization, charity is very important to us," Caponi said. "It's something that quite frankly we budget for every year."

St. Francis' parent organization, Mishawaka-based Sisters of St. Francis Health Services, said it would have paid $178.6 million in federal and state taxes in 2007 had its hospitals not been tax-exempt.

That year, Sisters of St. Francis said it provided $71.6 million in charity care at its Indiana and Illinois hospitals. But the hospital reported $215.9 million in community benefit, which included unpaid Medicaid costs and other expenses.

Community Health Network, which operates four nonprofit hospitals in Central Indiana, performed $9.2 million in charity care in 2006, yet received $33.75 million in tax exemptions. Community had total 2006 revenue of about $995 million.

But Community officials also stress that charity care represents just a portion of what the network does to justify its tax-exempt status. The hospital system calculates its total community benefit, including health outreach programs and its shortfall from treating Medicaid patients, at $69.48 million.

No one suggests that using Medicaid shortfalls to calculate community benefit is inappropriate. However, the rates negotiated with insurers are set, in part, to help offset that shortfall.

Also, just as nonprofit hospitals in the suburbs tend to serve far fewer patients who are uninsured, they also serve far fewer who are on Medicaid.

Location, hospital officials acknowledge, determines who their patients will be -- and location has created tension.

In 2011, St. Francis plans to close its Beech Grove hospital, which has served the blue-collar community for generations.

Such a move might improve the bottom line, but St. Francis' parent organization, in its 2006 IRS filing, states that its primary purpose for tax exemption is to continue the healing ministry of Christ, and to provide "service to the less fortunate among us."

Greg Anderson, vice president of finance for St. Francis, said his system plans to keep some outpatient services in Beech Grove.

"We are not going to abandon this community," Anderson said.

Yet he acknowledged that St. Francis' withdrawal from Beech Grove could result in indigent patients ending up in emergency rooms at taxpayer-funded Wishard or other nearby hospitals, including Methodist and Community Hospital East.

The move doesn't sit well with Daniel Evans, Clarian's chief executive officer.

"Our facilities are where the poor people are," Evans said. "If you close your Downtown operations and move to the extremes of the county, it's natural that you would provide less charity care."

For Clarian, taking on a larger share of indigent patients is a hit to the bottom line. But at Wishard, it's a hit to taxpayers.

To help with the cost of providing care to uninsured patients, Wishard receives support from Marion County property taxes, although that funding has decreased as its load has increased.

In 2006, Wishard received $50.3 million in property tax support, or 12.6 percent of expenses, according to records provided by the Marion County Health and Hospital Corp. In 2009, Wishard said, it expects to receive $24.9 million, accounting for 5.4 percent of expenses.

But at Wishard, it's not just an issue of gobbling up taxpayer dollars or financial strain, but also figuring out how to handle all the patients.

According to Matthew Gutwein, chief executive officer of the Health and Hospital Corp., which operates Wishard, patient admissions have climbed about 12 percent since 2004. Wishard's inpatient units now typically run at 98 percent of capacity, Gutwein said, and a hospital is considered "full" at 80 percent of capacity because of the need to have spots available for new patients.

"Given that we are a public hospital, we are constrained by the amount of resources that we have available to us," he said. "We can only provide the amount of care for which our resources allow."

Additional Facts

CHARITY CARE VS. REVENUE

Values of charity care and community benefit at Indianapolis-area hospitals for fiscal 2006:

St. Vincent Indianapolis
• Charity care: $11,602,852.
• Community benefit: $62,254,034.
• Total revenue: $764,813,801.
• Charity care as a percentage of total revenue: 1.52 percent.

St. Vincent Carmel
• Charity care: $779,645.
• Community benefit: $3,203,908.
• Total revenue: $142,910,114.
• Charity care as a percentage of total revenue: 0.55 percent.

St. Vincent Indianapolis and Carmel combined
• Charity care: $12,382,497.
• Community benefit: $65,457,942.
• Total revenue: $907,723,915.
• Charity care as a percent of revenue: 1.36 percent.

Clarian Health
Methodist Hospital, Indiana University Hospital, Riley Hospital for Children
• Charity care: $44,621,837.
• Community benefit: $444,606,044*.
• Total revenue: $1,735,879,965.
• Charity care as a percent of revenue: 2.57 percent.

Community Health Network
Totals for East, North, South and Anderson hospitals; Community Home Health Services; Community Business Innovation.
• Charity care: $9,200,000.
• Community benefit: $69,481,000.
• Total revenue: $995,835,646.
• Charity care as a percentage of total revenue: 0.92 percent.

St. Francis Hospitals & Health Centers
• Charity care: $12,583,435.
• Community benefit: $38,258,940.
• Total operating revenue: $508,126,645.
• Charity care as a percent of operating revenue: 2.48 percent.

-- Sources: IRS filings, St. Francis community benefit report

* Clarian's community benefit calculation includes financial shortfall from Medicare, a significant amount of money not counted toward community benefit by the other hospitals.

EXECS' SALARIES AT NONPROFITS

Pay for leaders of the top nonprofit hospital systems operating in metropolitan Indianapolis in fiscal 2006.

Vincent Caponi
• Chief executive officer, St. Vincent Health
• Compensation: $852,033.
• Employee benefit plans: $79,232.
• Expense accounts: $2,399.
• Total: $933,664.

Dan Evans
• Chief executive, Clarian Health
• Compensation: $879,729.
• Employee benefit plans: $412,984.
• Total: $1,292,713.

William Corley
• Chief executive, Community Health Network
• Compensation: $874,126.
• Other benefits: $10,641.
• Total: $884,767.

Kevin Leahy
• President, Sisters of St. Francis Health, Mishawaka (parent of St. Francis Hospital & Health Centers)
• Compensation: $987,036.
• Contributions to benefit plans: $43,695.
• Total: $1,030,731.

-- Sources: IRS 990 filings


By Daniel Lee, Star Reporter, This e-mail address is being protected from spam bots, you need JavaScript enabled to view it , (317) 444-6311

indystar.com
Source: http://www.indystar.com/article/20081214/BUSINESS/812140387

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