Defining hospital community benefit activities using Delphi technique: A comparison between China and the United States

Aijun Xu, Hossein Zare, Xue Dai, Yuanxi Xiang, Darrell J. Gaskin

Research output: Contribution to journalArticlepeer-review

2 Scopus citations


Introduction Currently there is no expert consensus regarding what activities and programs constitute hospital community benefits. In China, the hospital community benefit movement started gaining attention after the recent health care system reform in 2009. In the United States, the Internal Revenue Service and the nonprofit hospital sector have struggled to define community benefit for many years. More recently, under the Affordable Care Act (ACA)’s new “community benefit” requirements, nonprofit hospitals further developed these benefits to qualify for 501(c)(3) tax exempt status. Methods The Delphi survey method was used to explore activities and/or programs that are considered to be hospital community benefits in China and the United States. Twenty Chinese and 19 American of academics, senior hospital managers and policy makers were recruited as experts and participated in two rounds of surveys. The survey questionnaire was first developed in China using the 5-point Likert scale to rate the support for certain hospital community benefits activities; it was then translated into English. The questionnaires were modified after the first round of Delphi. After two rounds of surveys, only responses with a minimum of 70 percent support rate were accepted by the research team. Results Delphi survey results show that experts from China and the U.S. agree on 68.75 percent of HCB activities and/ or programs, including emergency preparedness, social benefit activities, bad debt /Medicaid shortfall, disaster relief, environmental protection, health promotion and education, education and research, charity care, medical services with positive externality, provision of low profit services, and sliding scale fees. Conclusions In China, experts believe that healthcare is a “human right” and that the government has the main responsibility of ensuring affordable access to healthcare for its citizens. Meanwhile, healthcare is considered a commodity in the U.S., and many Americans, especially those who are vulnerable and low-income, are not able to afford and access needed healthcare services. Though the U.S. government recognized the importance of community benefit and included a section in the ACA that outlines new community benefit requirements for nonprofit hospitals, there is a need to issue specific policies regarding the amounts and types of community benefits non-profit hospitals should provide to receive tax exemption status.

Original languageEnglish (US)
Article numbere0225243
JournalPloS one
Issue number11
StatePublished - Nov 1 2019

ASJC Scopus subject areas

  • General


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