Community Benefit Insight - Tax-exempt hospital

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The Children's Hospital of Alabama

The Childrens Hospital Of Alabama

1600 7th Avenue South
Birmingham, AL 35233

Bed count	332	Medicare provider number	013300	Member of the Council of Teaching Hospitals	YES	Children's hospital	YES

EIN: 630307306

Display data for year:

Community Benefit Spending- 2021
(as % of functional expenses, which all tax-exempt organizations report on Form 990 Schedule H)

5.53%

Spending by Community Benefit Category- 2021
(as % of total functional expenses)

* = CBI denoted preventative categories

Community Benefit Spending Compared to Functional Expenses, 2010-2021

Additional data

Community Benefit Expenditures: 2021

All tax-exempt organizations file a Form 990 with the IRS for every tax year. If the tax-exempt organization operates one or more hospital facilities during the tax year, the organization must attach a Schedule H to Form 990. On Part I of Schedule H, the organization records the expenditures it made during the tax year for various types of community benefits; 9 types are shown on this web tool. By default, this web tool presents community benefit expenditures as a percentage of the organization’s functional expenses, which it reports on Form 990, Part IX, Line 25, Column A. (The more commonly heard term, ‘total operating expenses’, which organizations report to CMS, is generally about 90% of the ‘functional expenses’). The user may change the default to see the dollar expenditures.
Amount spent in the following IRS community benefit categories:

Financial Assistance at cost as % of operating expenses	$ 5,848,800 0.78 %
Medicaid as % of operating expenses	$ 17,939,532 2.40 %
Costs of other means-tested government programs as % of operating expenses	$ 0 0 %
Health professions education as % of operating expenses	$ 12,252,753 1.64 %
Subsidized health services as % of operating expenses	$ 501,891 0.07 %
Research as % of operating expenses	$ 97,528 0.01 %
Community health improvement services and community benefit operations* as % of operating expenses Note: these two community benefit categories are reported together on the Schedule H, part I, line 7e.	$ 4,737,701 0.63 %
Cash and in-kind contributions for community benefit* as % of operating expenses	$ 0 0 %
Community building* as % of operating expenses	$ 0 0 %

* = CBI denoted preventative categories

Community building activities details:

Did tax-exempt hospital report community building activities?	Not available
Number of activities or programs (optional)	0
Physical improvements and housing	0
Economic development	0
Community support	0
Environmental improvements	0
Leadership development and training for community members	0
Coalition building	0
Community health improvement advocacy	0
Workforce development	0
Other	0
Persons served (optional)	0
Physical improvements and housing	0
Economic development	0
Community support	0
Environmental improvements	0
Leadership development and training for community members	0
Coalition building	0
Community health improvement advocacy	0
Workforce development	0
Other	0
Community building expense as % of operating expenses	$ 0 0 %
Physical improvements and housing as % of community building expenses	$ 0
Economic development as % of community building expenses	$ 0
Community support as % of community building expenses	$ 0
Environmental improvements as % of community building expenses	$ 0
Leadership development and training for community members as % of community building expenses	$ 0
Coalition building as % of community building expenses	$ 0
Community health improvement advocacy as % of community building expenses	$ 0
Workforce development as % of community building expenses	$ 0
Other as % of community building expenses	$ 0
Direct offsetting revenue	$ 0
Physical improvements and housing	$ 0
Economic development	$ 0
Community support	$ 0
Environmental improvements	$ 0
Leadership development and training for community members	$ 0
Coalition building	$ 0
Community health improvement advocacy	$ 0
Workforce development	$ 0
Other	$ 0

Other Useful Tax-exempt Hospital Information: 2021

In addition to community benefit and community building expenditures, the Schedule H worksheet includes sections on what percentage of bad debt can be attributable to patients eligible for financial assistance, and questions on the tax-exempt hospital's debt collection policy. When searching a specific tax-exempt hospital in this web tool, Section II provides information about bad debt and the financial assistance policy, and whether the state in which the tax-exempt hospital resides has expanded Medicaid coverage under the federal ACA.

Of the tax-exempt hospital’s overall operating expenses, amount reported as bad debt as % of operating expenses	$ 8,169,735 1.09 %
Is the tax-exempt hospital considered a "sole community hospital" under the Medicare program?	NO

Information about the tax-exempt hospital's Financial Assistance Policy and Debt Collection Policy
The Financial Assistance Policy section of Schedule H has changed over the years. The questions listed below reflect the questions on the 2009-2011 Schedule H forms and the answers tax-exempt hospitals provided for those years. The Financial Assistance Policy requirements were changed under the ACA. In the future, as the Community Benefit Insight web site is populated with 2021 data and subsequent years, the web tool will also be updated to reflect the new wording and requirements. In the meantime, if you have any questions about this section, we encourage you to contact your tax-exempt hospital directly.

Does the organization have a written financial assistance (charity care) policy?	YES
Did the tax-exempt hospital rely upon Federal Poverty Guidelines (FPG) to determine when to provide free or discounted care for patients?	YES
Amount of the tax-exempt hospital’s bad debt (at cost) attributed to patients eligible under the organization’s financial assistance (charity care) policy as % of operating expenses	$ 604,626 7.40 %

Did the tax-exempt hospital, or an authorized third party, take any of the following collection activities before determining whether the patient was eligible for financial assistance:
Under the ACA, states have the choice to expand Medicaid eligibility for their residents up to 138% of the federal poverty guidelines. The Medicaid expansion provision of the ACA did not go into effect until January 2014, so data in this web tool will not reflect each state's current Medicaid eligibility threshold. For up to date information, please visit the Terms and Glossary under the Resources tab.
The federal poverty guidelines (FPG) are set by the government and used to determine eligibility for many federal financial assistance programs. Tax-exempt hospitals often use FPG guidelines in their Financial Assistance policies to determine which patients will qualify for free or discounted care.
In addition to the federal requirements, some states have laws stipulating community benefit requirements as a result of tax-exemption. The laws vary from state to state and may require the tax-exempt hospitals to submit community benefit reports. Data on this web tool captures whether or not a state had a mandatory community benefit reporting law as of 2011. For more information, please see Community Benefit State Law Profiles Comparison at The Hilltop Institute.

Community Health Needs Assessment Activities: 2021

The ACA requires all 501(c)(3) tax-exempt hospitals to conduct a Community Health Needs Assessment (CHNA) every three years, starting with the hospital's tax year beginning after March 23, 2012. The 2011 Schedule H included an optional section of questions on the CHNA process. This web tool includes responses for those hospitals voluntary reporting this information. The web tool will be updated to reflect changes in these questions on the 2012 and subsequent Schedule H forms.

Did the tax-exempt hospital report that they had conducted a CHNA?	YES
Did the CHNA define the community served by the tax-exempt hospital?	YES
Did the CHNA consider input from individuals that represent the broad interests of the community served by the tax-exempt hospital?	YES
Did the tax-exempt hospital make the CHNA widely available (i.e. post online)?	YES
Did the tax-exempt hospital adopt an implementation strategy to address the community needs identified by the CHNA?	YES

Supplemental Information: 2021

This section presents qualitative information submitted by the hospital, verbatim from the 990H record.

Statement of Program Service Accomplishments
Description of the organization's program service accomplishments for each of its three largest program services, as measured by expenses. Section 501(c)(3) and 501(c)(4) organizations are required to report the amount of grants and allocations to others, the total expenses, and revenue, if any, for each program service reported.

4A (Expenses $ 614153884 including grants of $ 0) (Revenue $ 796591490)
Inpatient:Children's of Alabama provides specialized medical care for ill and injured children. Ranked among the best children's hospitals in the nation by U.S. News & World Report, Children's serves patients from every county in Alabama and nearly every state. With more than 3.5 million square feet, it is one of the largest pediatric medical facilities in the United States. Children's offers inpatient and outpatient services at its Russell Campus on Birmingham's historic Southside with additional specialty services provided at Children's South, Children's on 3rd and in Huntsville and Montgomery. Primary medical care is provided in more than a dozen communities across central Alabama. Children's is the only health system in Alabama dedicated solely to the care and treatment of children. It is a private, not-for-profit medical center that serves as the teaching hospital for the University of Alabama at Birmingham (UAB) pediatric medicine, surgery, psychiatry, research and residency programs. Children's operates 351 beds, which include 48 NICU bassinets and 100 critical care beds in the following units: Cardiovascular, Pediatric, Neonatal, Special Care, Critical Care, Burn and Stem Cell Transplant. In 2021, Children's Hospital had 15,142 discharges and 98,109 patient days. Inpatient surgery cases totaled 5,734 for 2021. The Children's Critical Care Transport team provides helicopter, jet, and ground transport for critically ill and injured children. Outpatient:Children's Hospital operates 13 outpatient specialty clinics that handle follow-up visits for patients as well as referrals from health departments across the state. These clinics provide services in Hemodialysis, Gastroenterology, Hematology/Oncology, Orthopedics, Urology, Otorhinolaryngology, Neurology, Pulmonary Function, General Surgery, Dental, Behavioral Services, Speech and Hearing, Physical Therapy, Occupational Therapy, Heart Transplant and others. In 2021, these clinics had 280,322 visits and 19,961 outpatient surgeries were performed. The Hospital also provides a statewide and regional referral site for complex emergency patients. The Emergency Department had 53,634 visits in 2021.Pediatric Practices:The Hospital has a network of primary care practices throughout the state known as Pediatric Practice Solutions. It consists of 14 practices supporting approximately 70 general pediatricians. In 2021 these practices provided 332,857 visits.

Facility Information

Schedule H (Form 990) Section C. Supplemental Information for Part V, Section B.

Children's Hospital of Alabama
Part V, Section B, Line 5: Children's of Alabama engaged the Public Affairs Research Center of Alabama (PARCA) in 2019 to conduct the Community Health Needs Assessment (CNHA) designed to identify statewide and local child health concerns for children across the state and best support efforts to address those concerns. For the 2019 CHNA, Children's of Alabama and PARCA expanded the scope and breadth of the assessment by adding four (4) focus groups of diverse community representatives to the existing online survey and face-to-face interviews of key stakeholders. Targeted constituencies for the online survey and focus groups included parents, school nurses, administrators, pediatric/family medicine physician practices, community advocates and youth. Key stakeholder interviewees consisted of state and local officials, executives of child-oriented nonprofits and community members representative of Children's of Alabama's population served. Five hundred fifty-three stakeholders responded to the online survey, an increase of more than 20 percent over previous response rates. Forty-six total stakeholders were represented in the focus groups for the first time and 15 metrics at the state and national level were researched for secondary data information. All total, more than 600 stakeholders participated in the 2019 Community Health Needs Assessment. In late 2021, Children's once again contracted with PARCA to conduct the 2022 CHNA. The same components will be utilized in 2022 with the addition of a telephone survey of more than 750 stakeholders in all 67 Alabama counties.

Children's Hospital of Alabama
Part V, Section B, Line 11: Children's of Alabama continued to address the 2019 CHNA-identified needs even during the COVID State of Emergency from 2020-2022. The CHNA priorities included mental and behavioral health, children with medically complex conditions, nutrition, and parent and youth education. While the COVID pandemic froze in-person outreach efforts for COA and participating collaborators, innovative thinking by staff allowed us to pivot to virtual trainings, outreach efforts, workshops, and meetings to continue meeting the needs of the state-at-large. Programs presented including school nurse training on topics ranging from AED safety to asthma, tracheotomy and gastrointestinal tubes, diabetes, mental health, and bullying. More than 1,200 school nurses participated virtually statewide. Additional programs and opportunities presented both virtually and in-person in 2020-2021 include virtual child abuse prevention/identification webinars by the Hospital's CHIPS Center to school administrators and stakeholders, emergency department training to urban and rural hospitals through the COACHES initiative, baby safety showers aimed at educating parents of newborns, teen driving and general safety trainings by the Children's Health Education and Safety Center. The Alabama Poison Information Center housed at Children's of Alabama addressed a significant number of COVID related calls about symptoms, incidents tied to use of household cleaning products and other COVID related activities. As in year's past, APIC responded to more than 50,000 calls and follow-ups.

Children's Hospital of Alabama
Part V, Section B, Line 16j: Processed incomplete and complete FAP applications.

Children's Hospital of Alabama
Part V, Section B, Line 20e: Signage is posted throughout the facility at entrances and all registration locations including the emergency department, waiting and admitting areas notifying patients and guarantors of the availability of financial assistance.

Supplemental Information

Schedule H (Form 990) Part VI

Part I, Line 7:
The costing methodology used to complete Line 7 was an overall cost-to-charge ratio computed using the IRS Form 990 Worksheet 2, ratio of patient care cost to charges.

Part I, Ln 7 Col(f):
The bad debt expense included on Form 990, Part IX, Line 25, column (a), but subtracted for purposes of calculating the percentage in this column is $8,169,735.

Part III, Line 2:
Receivables from patients, insurance companies and third-party contractual agencies are stated at net realizable value. The Hospital evaluates the collectability of its patient accounts receivable based on the length of time the receivable is outstanding, historical collection experience, review of large balance accounts and trends in health care insurance programs to estimate the appropriate allowance for doubtful accounts and provision for bad debts. For receivables associated with services provided to patients with third-party insurers, the Hospital estimates contractual allowances based on the terms of third-party insured contracts and estimates an additional allowance for doubtful accounts on patient responsible balances after third-party payments. For receivables associated with self-pay patients, the hospital records a significant provision for bad debts in the period of service based on its past experience, which indicates that many patients are unable or unwilling to pay the portion of their bill for which they are financially responsible. These allowances are recorded on an estimated basis and adjusted as needed in future periods. Doubtful accounts are written off against the allowance after adequate collection effort is exhausted and recorded as recoveries of bad debts if subsequently collected.

Part III, Line 3:
Bad debts attributable to patients eligible for charity care were calculated based on the outstanding patient balance in excess of a reasonable amount the average person could pay without creating a medical hardship. For 2020 this amount is $24,600, which approximates the income limit for a family of 4 in the federal poverty guidelines. Charity care determinations are based on completing the required application and meeting defined criteria of the hospital. Many times, patients fail to complete paperwork required despite efforts to educate and inform patients of this option. However, based on socio-economic and other known factors, it is highly likely that these patients would meet established charity care criteria if the application process was completed.

Part III, Line 8:
Medicare cost & charges primarily relate to renal (ESRD) and SSI patients covered under Medicare. Given our small Medicare population, the costs/charges could fluctuate significantly year over year based on level of care. These would not be considered a community benefit.

Part III, Line 9b:
A guarantor will receive four bills before the account is turned over to a collection agency. After 120 days, if there is no attempt to pay - the account will be sent to a collection agency.

Part VI, Line 2:
Children's engaged the Public Affairs Research Center of Alabama (PARCA) in 2019 to conduct the community health needs assessment (CHNA) designed to identify statewide and local child health concerns for children across the state and how to best support efforts to address the concerns. Stakeholders from all 67 counties (service areas described below) were asked to complete an online survey of health needs for children in Alabama. In addition, selected statewide stakeholders participated in face to face interviews. In 2019, four primary service area face to face focus groups were convened for the first time to help identify issues. The assessment's geographic focus targeted Children's primary service area of Bibb, Blount, Chilton, Jefferson, Shelby, St. Clair, and Walker counties and the secondary service area which is defined as the remaining 60 counties statewide. Stakeholders and responding parties included parents, youth leaders, school nurses, administrators, pediatricians, family practice physicians, community advocates, business leaders, and the community at large. Top responses from the assessment by stakeholders included child and adolescent mental and behavioral health, nutrition, parent and guardian education, and children with special healthcare needs. Children's of Alabama's CHNA and assessment findings were released on December 20, 2019. In 2021, Children's reengaged PARCA for the 2022 Community Health Needs Assessment.

Part VI, Line 3:
Each patient that presents as a self-pay patient is directed to a financial counselor. The financial counselor educates patients and their families about government and financial assistance programs and assists with related applications. If a patient is not counseled by a financial counselor on the date of service, statements are sent with the information needed to apply for financial assistance by the business office. In addition, the Financial Assistance Policy is posted on the Hospital's website and there is signage throughout the Hospital informing patients of the availability of a financial assistance program.

Part VI, Line 4:
The Hospital's primary service area is Birmingham / Hoover metropolitan statistical area as defined by the U.S. Office of Management and Budget. The Hospital's secondary service area is defined as the rest of the state, and we care for patients from every county in the state. demographic data including race, gender, and age is captured through the registration process. For 2021, Caucasians, African Americans, Hispanics, and other races accounted for 55%, 35%, 8%, and 2%, respectively, of the patients served while 38%, 34%, and 28% were ages 0-4, 5-12, and 13+ years, respectively. Economic demographic data is not specifically captured.

Part VI, Line 5:
Children's of Alabama is Alabama's primary site for pediatric health care and health education and training through its affiliation with the School of Medicine at The University of Alabama at Birmingham, two-year community colleges and four-year universities in Alabama and beyond. Children's is Alabama's sole level one pediatric trauma center, transplant programming, and houses the largest pediatric burn center in the Southeast. Our community health promotion to the larger, non-patient community of youth and adult stakeholders, parents, and guardians focused in 2020-2021 on CHNA responses including, but not limited to, mental and behavioral health, obesity and nutrition, parent and guardian education, and children with special healthcare needs. Programs such as ThinkFirst and the Center for Health Education and Safety's 'Ur Keys 2 Drive' aimed to inform adolescents and teens on the importance of safe driving, biking and ATV usage. School nurse workshops educated more than 1,200 school nurses in 2021 alone on a wide range of topics. Children's Intervention & Prevention Services Center (CHIPS) addressed thousands of youth and adult stakeholders in schools on the prevention of child abuse. The Hospital's Alabama Poison Information Center (APIC) fielded thousands of calls from the public representing counties statewide and other states on poisonous interactions and COVID-related questions. In accordance with the IRS' 501(c)3 requirements defining community health promotion, Children's has an open medical staff and is governed by a diverse board comprised of statewide community leaders. Children's retains a strong focus on collaboration of health promotion with key stakeholders statewide. For 2020-2021, Children's of Alabama continued addressing the needs of the larger pediatric community through the promotion of its mission and commitment to those who rely on the hospital's care.

Operating expenses	$ 748,464,111
Total amount spent on community benefits as % of operating expenses	$ 41,378,205 5.53 %