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THE ROLE OF ACADEMIC MEDICAL CENTERS IN A SAFETY NET HEALTH CARE DELIVERY SYSTEM

THE ROLE OF ACADEMIC MEDICAL CENTERS IN A SAFETY NET HEALTH CARE DELIVERY SYSTEM. Sheryl L. Garland Vice President Community Outreach Virginia Commonwealth University Health System November 29, 2004.

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THE ROLE OF ACADEMIC MEDICAL CENTERS IN A SAFETY NET HEALTH CARE DELIVERY SYSTEM

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  1. THE ROLE OF ACADEMIC MEDICAL CENTERS IN A SAFETY NET HEALTH CARE DELIVERY SYSTEM Sheryl L. Garland Vice President Community Outreach Virginia Commonwealth University Health System November 29, 2004

  2. One of the largest challenges in the health care industry today is identifying ways to provide care for the 45 million uninsured in the U.S. 2

  3. Who Are the Uninsured? 3

  4. The Uninsured Represent a Broad Demographic Profile 44 4

  5. Two-Thirds of Uninsured AmericansAre Employed 5

  6. According to the National Association for Public Hospitals and Health Systems (NAPH), the Health care market is in turmoil due to several factors including…fewer people working, increases in health care premiums, more employers shifting health care costs to their employees or not offering health insurance coverage at all. Jennifer Tolbert, Safety Net Financing: A Policy Source Book for Healthcare Executives (Washington, DC: National Association of Public Hospitals and Health Systems, June 2003) p. 3. 6

  7. Across the country initiatives are being developed to: • Obtain coverage for the uninsured by changing institutional policies and programs • Increase access to services at the local level • Focus on prevention and public health “Action Where It Counts: Communities Responding To The Challenge of Healthcare for the Uninsured” The Access Project, June, 1999. 77

  8. Growth of the Health Care Safety Net • Safety Net system has grown over the last 8 years • Varies by community • Includes various configurations of providers such as public and private hospitals, community health centers (FQHC’s), local health departments, free and school-based clinics and physician charity care. Laurie E. Felland, Kyle Kinner, John F. Hoadley, “The Health Care Safety Net: Money Matters but Savvy Leadership Counts”, Issue Brief No. 66, August 2003, p.1. 8

  9. In March 2000, the Institute of Medicine released a study entitled “America’s Health Care Safety Net: Intact but Endangered” that defined A Safety Net as: “Those providers that organize and deliver a significant level of health care and other health-related services to uninsured, Medicaid and other vulnerable patients.” Institute of Medicine, America’s Health Care SafetyNet: Intact but Endangered (Washington, D.C: National Academy Press, 2000) p.21. 9

  10. Safety Net Health Systems Have Two Distinguishing Characteristics: • They maintain an “open door”, usually offering access to both inpatient and outpatient services to uninsured or under-insured patients • They represent a significant proportion of the preventive, acute and chronic health care services delivered to uninsured, Medicaid and other vulnerable populations in their region “America’s Health Care Safety Net: Intact, but Endangered”, Institute of Medicine Report, 2000 10

  11. Members of the National Association of Public Hospitals and Health Systems (NAPH) provide a disproportionate amount of care to the uninsured and underinsured. 11

  12. NAPH Members Are Committed to Caring for the Uninsured • Member institutions represent only 2% of hospitals nationally • NAPH members provided over $5.4 billion (24%) of total hospital uncompensated care in 2002 • Uncompensated care represents 21% of the costs at NAPH member hospitals, compared to an avg of 5.4% for all hospitals. Ingrid Singer, Lindsay Davison, Jennifer Tolbert and Lynne Fagnani, America’s Safety Net Hospitals and Health Systems, 2002: Results of the 2002 Annual NAPH Member Survey (Washington,DC: National Association of Public Hospitals and Health Systems, September 2004) p.2. 12

  13. Current Financing Programs for Safety Net Hospitals • Medicaid Disproportionate Share Hospital (DSH) • Medicaid Non-DSH Supplemental Payments (Upper Payment Limit (UPL)) • Medicare DSH • Medicare Graduate Medical Education • 340B Drug-Discount Program • State and Local funding 13

  14. Jennifer Tolbert, Safety Net Financing: A Policy Source Book For Healthcare Executives (Washington, DC: National Association of Public Hospitals and Health Systems, June 2003) p. 10 14

  15. Safety net health systems can no longer “cost shift” and use profits from other payers to cover the costs for the uninsured: • Growth in managed care plans • Changes in reimbursement from government- sponsored programs (Medicaid and Medicare) • Increasing competition in many health care markets for “paying” patients 15

  16. Hospital MarginsFiscal Year 2002 Ingrid Singer, Lindsay Davison, Jennifer Tolbert and Lynne Fagnani, “America’s Safety Net Hospitals and Health Systems, 2002: Results of the 2002 Annual NAPH Member Survey,” September 2004, p.1 16

  17. Strategies Communities Can Use to Address the Uninsured Issue • Strengthen community “Safety Nets” through relationships between providers (e.g., hospitals, physicians, clinics, health departments, agencies) • Apply managed care principles for ideal allocation of resources for preventive, acute, emergent and chronic care • Construct prescription formulary that is evidence-based • Improve coordination of services through case management and care coordination • Enhance community collaborations to increase enrollment in Medicaid and FAMIS • Exhaust all opportunities to capture public and private funding sources • Develop low cost health insurance options for working poor 17

  18. Across the Commonwealth, Communities are aggressively adopting strategies to address the issue of caring for the Uninsured 18

  19. Virginia’s Indigent Care Program • Established in the late 1970’s to provide coverage to the uninsured • Virginia’s Medicaid program only covers those who are pregnant, under 18, aged, blind or disabled • Marries federal Disproportionate Share Hospital (DSH) dollars and State General funds (50/50 match) • Eligibility criteria: - Virginia resident - U.S. Citizen - At or below 200% FPL and meet asset test 19

  20. The Commonwealth of Virginia • Population is approximately 7.1 million people • Approximately 30% of Virginians are below 200% of the FPL • Nearly 2/3 of the counties are designated as full or partially medically underserved areas • An estimated 15% of the population lacks basic health insurance “An Opportunity for Unprecedented Growth”, Virginia Primary Care Association, Sept. 2002 20

  21. Virginia’s Indigent Care Program • Allocates approximately $160 million • between 2 Academic Medical Centers • – UVA and VCUHS • An Indigent Care“Trust Fund” has been • established for all other facilities to offset • their Charity Care expenses. 21

  22. The VCU Health System is the provider of majority of health care to the uninsured in the Central Virginia region. 22

  23. Leading Providers of Charity Care 34.2% 2000 Percentage of Entire Charity Care for the Commonwealth 16.5% 7.0% Inova 6.0% 6.2% UVA VCU Health System Carillion Sentara Sources: VHI 2000 Hospital Financial Data Report, VCUHS Financial Services, VCUHS Strategy & Marketing VHI Definition of Charity Care: Charity Care represents (unreimbursed) charges to individuals at 100% of the federal non-farm poverty level 23

  24. VCU Health System • Part of the Virginia Commonwealth University Medical Center • Serves as the corporate umbrella for MCV Hospitals and Physicians • Located in downtown Richmond, Virginia • 779 Bed Teaching Hospital • Level I Trauma Center • Over 31,000 admissions • Estimated 80,000 ED visits • Over 500,000 Outpatient visits • Approximately 600 housestaff • Over 700 full time faculty in the School of Medicine 24

  25. VCU Health System Indigent Care Distribution FY03 Budget $107.3M in Indigent Cost 25

  26. The total population of the Richmond Metro area exceeds 850,000 “Examining Access to Health Care in the Greater Richmond Area”, Presentation at the RACE for Health 2003, Stephen Horan, Ph.D., Community Health Resource Center 26

  27. More than 186,000 have incomes below 2x poverty (22%) “Examining Access to Health Care in the Greater Richmond Area”, Presentation at the RACE for Health 2003, Stephen Horan, Ph.D., Community Health Resource Center 27

  28. More than 48,000 (estimated) are below 2x poverty and uninsured “Examining Access to Health Care in the Greater Richmond Area”, Presentation at the RACE for Health 2003, Stephen Horan, Ph.D., Community Health Resource Center 28

  29. Catastrophic event Acute hospitalization Healthy with episodic needs Chronically ill Healthy with unmet needs The Ecology of Safety Net Care Presentation: Governor’s Covering the Uninsured Conference, Dr. Sheldon M. Retchin, 2003 29

  30. With the increasing pressures to identify funds and reduce the cost of caring for the uninsured and the underinsured, the VCU Health System has developed innovative strategies to continue to provide services to these populations 30

  31. Virginia Coordinated Care For the Uninsured (VCC ) Program Goals • Utilize managed care principles to support a defined population • Support a centralized/automated Financial Screening process • Establish Primary Care Physician (PCP) centered care • Partner with Community Primary Care Physicians and Specialty Physicians • Reduce the average cost per unit of service • Improve the health status of the population 31

  32. Number of Uninsured Patients Receiving Services through the VCU Health System Number of Uninsured Patients FY 2000 Thousands 50 38.781 40 30 19.619 14.814 20 10.056 4.805 2.576 10 0.977 0.885 0.321 0 Total Henrico Hanover Richmond Chesterfield Other Areas Tri-City Area VCC Eligible Full Indigent-Category 1 32

  33. C a r o l i n e H a n o v e r G o o c h l a n d K i n g W i l l i a m H e n r i c o P o w h a t a n R i c h m o n d C i t y N e w K e n t C h e s t e r f i e l d C h a r l e s C i t y A m e l i a H o p e w e l l C o l o n i a l H e i g h t s P r i n c e G e o r g e P e t e r s b u r g D i n w i d d i e The VCC Service Area 33

  34. Virginia Coordinated Care For the Uninsured (VCC ) Program Summary • VCC is NOT an insurance program • Implemented November 15, 2000 • Annual enrollment for FY04 was 16,000 patients (original projection was 15,000) • Approximately 90% of the VCC patients are cared for by Community providers • 26 community primary care physicians and 5 specialists participate in the VCC program • 6 community safety net providers care for VCC patients 34

  35. Primary and Specialty Care visits Medications Well Child Visits Ancillary and Diagnostic Services Family Planning Outpatient Services Inpatient Services VCC does NOT cover: Home Health Care Dental Services Elective Services such as cosmetic surgery or sterilizations Program Components 35

  36. VCC Patient Utilization Issues • Utilization of the Emergency Room for non-acute services remained high • VCC population had a lower average inpatient acuity than other patients • 50% of the population enrolled in VCC remained with the program for 12 months or less 36

  37. Jenkins Care Coordination Program Provided Assistance • In 1998, received a 5-year grant from the Jenkins Foundation for $1.3 million to coordinate services for uninsured and underinsured patients who inappropriately utilize the VCUHS Emergency Department • Program Goals: • Coordinate services across organizational boundaries • Increase appropriate and cost-effective utilization of health resources 37

  38. Emergency Room Visits: Reason for Visit Visits = 30,273 38

  39. Emergency Room VCUHS Visits for the Uninsured DiagnosisVisits% Chest Pain 1,001 3.9% Abdominal Pain 1,346 4.9% Sprains and Strains 1,567 7.1% Back Problems 1,127 3.7% Upper Respiratory Infections 1,131 3.7% Urinary Tract Infections 765 2.5% Headaches/Migraines 822 2.7% Dental Services 1,095 3.6% Total ED Visits = 30,191 39

  40. Jenkins Care Coordination Program: Progress Toward Goals • Over 15,000 patient interventions/contacts made through 3 quarters of this fiscal year • Ability to make appointments with a Primary Care Nurse Practitioner within 72 hours after an ED visit • Provided follow-up to VCC patients who visited the Emergency Room more than 3 times resulting in a 9% reduction in total visits for this group 40

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  43. Other Innovative Partnerships Have Been Developed to Sustain the Safety Net System • Richmond Enhancing Access to Community Healthcare (REACH) initiatives • Healthy Community Access Program (CAP) grant • The Healing Place – Social Detoxification Unit • Richmond City Department of Public Health Clinical Services Contract • Collaboration with CrossOver Health Ministries to provide continuity of care for undocumented pregnant women • Transition of the Hayes Willis Health Center to a federally qualified health center (FQHC) 43

  44. Developed a coalition with 9 Safety Net provider organizations in the Greater Richmond Metropolitan area including VCUHS • Primary goal is to identify mechanisms to improve access to health care for the uninsured and underinsured in the region • Collaborating with Bon Secours and HCA to develop a low cost pharmaceutical model for uninsured • Researching models to improve access to behavioral health services • Identifying options for small employers to offer low cost health care benefits 44

  45. Greater Richmond Safety Net Health Care Providers VCUHS HCA Bon Secours RCDPH Free Fan Clinic REACH Craig Health Center Community Physicians Vernon J. Harris Health Center Daily Planet CrossOver Ministries 45

  46. REACH Initiatives • Enrollment of undocumented pregnant patients into Emergency Medicaid (approximately 240 applications submitted between Feb. and Oct.; over 50% have been approved, 50% are pending) • Coordinating community resources to improve access to pre-natal care for undocumented women • Collaborating with community health care providers to develop a low cost pharmaceutical model for uninsured • Researching models to improve access to behavioral health services • Identifying options for small employers to offer low cost health care benefits 46

  47. Healthy Community Access Program (HCAP) • With VCU as the fiscal intermediary, REACH has been awarded over $2.5 million from HRSA; there have been 6 HCAP grants awarded in Virginia • Funding has been utilized to develop a web-based program (MOREAccess)to assist Safety Net providers in financially screening patients to determine eligibility for programs such as Medicaid or FAMIS 47

  48. The Healing Place Social Detoxification Unit • Partnership with The Healing Place to establish a 6 bed detoxification unit for patients who are seen in the VCUHS Emergency Room • Purpose is to provide an alternative treatment program for those with a primary diagnosis of alcohol or substance abuse problems • A total of 428 patients have been cared for over a 12 month period • For a subset of 165 clients, there has been a reduction of 182 ED visits and 16 fewer inpatient admissions for a cost savings of approx. $150,000 48

  49. Hayes E. Willis Health Center of South Richmond • Community-based health center that offers Family Medicine, Women’s Health and Pediatric services • Center also provides screening and treatment for STD’s • Houses the Arthur Ashe Early Intervention Program • Financial and Medicaid/FAMIS eligibility screening at the Center 49

  50. Hayes E. Willis Health Center is a major provider of Primary Care Services in South Richmond • Approximately 4,000 patients with 15,000 annual visits • Approximately 45% of the patients have no insurance; another 34% are Medicaid recipients • Serves a large Hispanic population (approximately 10% of the patients) • In the process of applying for federally qualified health center status 50

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