Social performance in nonprofit hospitals encompasses their contributions to community health improvement, including community benefit spending, charity care, health education, subsidized services, and public health initiatives. While these hospitals are mandated to provide community benefits in exchange for tax exemptions, significant variability in social performance raises concerns about their alignment with societal expectations. Previous research has examined factors influencing community benefit spending, yet little is known about the interplay of organizational, community, and state-level characteristics in shaping such activities. We use an institutional logics perspective and discuss the role of corporate, religious, market, community, and state logics. Using a pooled cross-sectional sample of US nonprofit acute care hospitals from 2020-2021, we obtained data related to community benefit spending and other hospital factors from the Lown’s Institute, IRS 990 filings via GuideStar, and AHA Annual Surveys, while county and state-level data were obtained from the Hilltop Institute database and County Health Rankings and Roadmaps. Hierarchical linear modeling with year fixed effects was utilized to partition variance in community benefit spending across these levels. We found that organizational factors explained the majority (50%) of variance in community benefit spending, while county- and state-level factors contributed 7.5% and 11.6%, respectively. Key findings included a negative association between vertical pay dispersion (CEO-to-worker pay) and community benefit spending and a similarly negative association with religious affiliation. The relationship between pay dispersion and community benefit spending underscores concerns about misaligned priorities and the need for greater accountability in nonprofit hospitals' financial and social performance. On the other hand, community health needs and state laws on spending reporting have limited influence on hospitals’ spending.
