First he hammered out a script for Massachusetts hospitals to follow in providing charitable benefits to their communities. Then he got HMOs to do the same.
Now the state attorney general is ordering up a logical sequel that has a much more complex plot: prodding hospitals and HMOs to collaborate on community-benefits projects.
As the top enforcer of public charities laws, Attorney General Scott Harshbarger has used his authority over not-for-profit healthcare organizations to gain broad acceptance of voluntary guidelines for serving community needs.
Conceived in the early 1990s, the initiative was among states' reactions to perceptions that hospitals were operating as businesses and did not deserve their charitable tax status.
But while states like Texas mandated minimal largess, Massachusetts officials and healthcare representatives huddled to reach agreement on guidelines that included definite demands but gave some leeway in how targets were achieved.
Massachusetts released the first community-benefits guidelines for not-for-profit hospitals in 1994, followed three years later by a report based on those guidelines.
Guidelines for HMOs debuted in 1996, and the attorney general's office published an account of the first efforts of the state's 12 registered HMOs in February. Though not-for-profit HMOs dominate in the state, Harshbarger got for-profit plans to tally up, too.
The latest wrinkle is the launch of a community-benefits advisory task force including representatives of hospitals, HMOs, community organizations and various state agencies. The first meeting is May 8.
The attorney general's office said it's seeking ways for hospitals and HMOs to collaborate on community-benefits programs. It also wants better coordination of resources to address specific health problems facing underserved populations and more community participation in setting priorities.
"The objectives of the guidelines would be enhanced if individual hospitals and HMOs were to share information or form partnerships with each other in some of their endeavors," according to a statement of the task force's purpose.
That could be harder than it looks, said Lori Allan, vice president for research at the Massachusetts Association of HMOs. "We're talking very different types of entities," she said, noting that even the basic concept of service area will be tough to align. Hospitals have discrete service boundaries, but HMOs operate statewide or across broad regions.
"There is a viewpoint that HMOs are like providers, and a nonrecognition that they are service organizations to provider groups," Allan said. To collaborate with hospitals, HMOs will have to resolve obstacles in identifying target populations.
Then the state will have to recognize that HMOs have fewer places to raise funds for community efforts, she said. For HMOs, "any dollars that go out for any reason are premium dollars," Allan said. Hospitals, on the other hand, have other revenue options, such as endowments and a state uncompensated-care pool.
Though the attorney general's office is pushing for collaboration, its HMO report recognizes that each sector has unique strengths. The agency strongly advocates more subsidies for people who cannot afford the going rates. "HMOs are uniquely situated to operate such programs because unlike hospitals, which are in the business of providing health services, HMOs primarily are in the business of providing health coverage," the report said.