Transcript The Medical College of Virginia Hospitals and Physicians

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
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
Who Are the Uninsured?
3
The Uninsured Represent a Broad
Demographic Profile
44
4
Two-Thirds of Uninsured Americans
Are Employed
5
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
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
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
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
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
Members of the National Association
of Public Hospitals and
Health Systems (NAPH)
provide a disproportionate amount
of care to the
uninsured and underinsured.
11
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
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
Sources of Financing for Unreimbursed Costs at
NAPH Hospitals and Health Systems, 2000
Medicaid DSH
28%
Local/State
Subsidy
39%
Other
24%
MCR DSH
5%
MCR IME
4%
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
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 governmentsponsored programs (Medicaid and Medicare)
Increasing competition in many health care
markets for “paying” patients
15
Hospital Margins
Fiscal Year 2002
4.50%
4.00%
3.50%
3.00%
2.50%
2.00%
1.50%
1.00%
0.50%
0.00%
-0.50%
4.50%
-0.30%
NAPH
Members
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,” September 2004, p.1
16
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
Across the
Commonwealth,
Communities are
aggressively
adopting strategies
to address the
issue of caring
for the Uninsured
18
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
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
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
The VCU Health System
is the provider of majority of
health care to the uninsured
in the Central Virginia region.
22
Leading Providers of Charity
Care
2000
Percentage of Entire Charity Care
for the Commonwealth
34.2%
16.5%
7.0%
Inova
6.0%
6.2%
UVA
Carillion
VCU Health
System
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
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
VCU Health System Indigent Care Distribution
In d ig e n t Ca re Co st in D o lla rs
4 7 , 2 7 0 , 0t o
0407 , 3 0 0 , 0 0 0
2 , 0 0 0 , 0 t0o 1 5 , 0 0 0 , 0 0 0
7 0 0 , 0 0t o1 2 , 0 0 0 , 0 0 0
1 5 0 , 0 0t o1 7 0 0 , 0 0 0
1 0 , 0 0t o
1 1 5 0 ,0 0 0
5 , 0 0 t1o
1 0 ,0 0 0
0 to
5 ,0 0 0
FY03 Budget $107.3M in Indigent Cost
25
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
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
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
The Ecology of Safety Net Care
Catastrophic
event
Acute
hospitalization
Healthy
with
unmet
needs
Healthy
with
episodic
needs
Chronically ill
Presentation: Governor’s Covering the Uninsured Conference, Dr. Sheldon M. Retchin, 2003
29
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
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
Number of Uninsured Patients Receiving Services
through the VCU Health System
Number of
Uninsured Patients
4.805
Other Areas
0.321
Hanover
0.885
Tri-City Area
0.977
Chesterfield
2.576
Henrico
10.056
Richmond
14.814
VCC Eligible
Full Indigent-Category 1
19.619
Total
50
40
30
20
10
0
FY 2000
Thousands
38.781
32
The VCC Service Area
C a r o l in e
G o o c h la n d
H anove r
K in g W il lia m
H e n ric o
P o w h a ta n
A m e lia
R ic h m o n d C it y
N e w
K e n t
C h a r l e s C it y
C h e s te r fie ld
H o p e w e ll
C o lo n ia l H e ig h t s
D in w i d d i e
P e te rs b u rg
P r in c e G e o r g e
33
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
Program Components
 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
35
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
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
Emergency Room Visits: Reason
for Visit
22%
27%
2%
2%
18%
17%
8%
4%
Visits = 30,273
Not Emergency
Primary Care
Emergency/Avoidable
Emergency/Not Avoidable
Injury
Psych
Alcohol/Drug
Unclassified
38
Emergency Room VCUHS Visits for the
Uninsured
Diagnosis
Chest Pain
Abdominal Pain
Sprains and Strains
Back Problems
Upper Respiratory
Infections
Urinary Tract Infections
Headaches/Migraines
Dental Services
Total ED Visits = 30,191
Visits
1,001
1,346
1,567
1,127
%
3.9%
4.9%
7.1%
3.7%
1,131
765
822
1,095
3.7%
2.5%
2.7%
3.6%
39
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
VCC ED Utilization
12000
10000
9956
8160
Visits
8000
7798
7436
6000
4000
2000
0
FY01
FY02
FY03
FY04
41
Classification of ED Visits for VCC Patients
100%
90%
80%
70%
60%
50%
40%
30%
20%
10%
0%
FY01
FY02
FY03
FY04
Flags Only
1.6%
1.7%
2.3%
2.3%
ED Care Needed - Not Preventable/
Avoidable
18.2%
19.0%
20.5%
20.4%
ED Care Needed - Preventable/ Avoidable
5.0%
5.7%
6.2%
6.3%
Emergent - Primary Care Preventable
30.7%
34.8%
36.6%
35.0%
Non Emergent
44.5%
38.7%
37.6%
36.2%
Fiscal Year
42
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
 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
Greater Richmond Safety Net Health Care Providers
VCUHS
HCA
Bon
Secours
RCDPH
Free
Fan Clinic
Craig
Health Center
Community
Physicians
Vernon J. Harris
Health Center
CrossOver
Ministries
Daily
Planet
45
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
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
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
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
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
Conclusion
 The role the Academic Medical Center plays is
critical in a Safety Net System due to the
resources (financial, human, clinical) available
 Communities in Virginia continue to create
opportunities to enhance access to care for the
Uninsured
 Providers in the Greater Richmond Metro area are
partnering to develop a Safety Net Health Care
Delivery System
51
Vision: Safety Net Health Care Delivery System
Acute Care Providers
HCA
VCUHS
Acute
Patients
Bon
Secours
Acute
Patients
Funding
Support
Free
Community
Fan Clinic Physicians
Funding
Support
CrossOver
Ministries
Vernon J. Harris
Health Center
Daily
Planet
Craig
Health Center
RCDPH
Primary Care Access
52
The lesson learned…..
“You can’t stay in your corner
of the forest and wait for people
to come to you….you have to
go to them sometimes.”
Winnie the Pooh
53