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Sheryl L. Garland, M.H.A.Vice President, Community Outreach

VCU Health SystemAdministrative Director

VCU Center on Health DisparitiesNovember 23, 2009

The Role of Academic Medical Centersin Safety Net Health Care Delivery Systems

Slide 2Slide 2

Who Are the Uninsured?

The Health Care Reform debate not only raises questionsregarding affordability, but also uncovers serious concerns

about access to care for the 46 million uninsured.

Slide 3Slide 3

Statistics on the Uninsured

• Approximately 64% are below 200% FPL; 35% arebelow the poverty line

• 52% are below the age of 30; 18% are below 18

• 62% of the uninsured have no education beyond highschool

• Minorities represent approximately 35% of thepopulation, but 54% of the uninsured

• 80% of the uninsured are native or naturalizedcitizens

• 80% of the uninsured are employed (66% work fulltime and 14% work part-time)

The Uninsured: A Primer, Key Facts about Americans without Health Insurance, Kaiser Commission On Medicaid andthe Uninsured, October 2009, pages 4-6.Health Coverage in Communities of Color: Talking about the New Census Numbers, Fact Sheet from Minority HealthInitiatives, www.familiesusa.org/assets/pdf/minority-health-census-sept2009/pdf., p.1.

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According to the Institute of Medicine:

“In the absence of universal comprehensivecoverage, the health care safety net has served asthe default system for caring for many of the nation ‘suninsured and vulnerable populations.”

Institute of Medicine, America’s Health Care SafetyNet: Intact but Endangered (Washington,D.C:National Academy Press, 2000) p.2.

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Health Care Safety Net

• Varies by community

• Includes variousconfigurations ofproviders such as publicand private hospitals,community health centers(FQHC’s), local healthdepartments, free andschool-based clinics andphysician 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.

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• Maintain an “open door”

• Provide a significant proportion of the preventive,acute and chronic health care services deliveredto uninsured, Medicaid and other vulnerablepopulations in their region

America’s Health Care Safety Net: Intact, but Endangered”, Institute of Medicine Report, 2000

Safety Net Health Systems HaveTwo Distinguishing Characteristics:

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The uninsured disproportionately seekcare at Safety Net Hospitals

• Safety Net Hospitals represent 30% of all hospitals,but have 57% of discharges for the uninsured*

– 20% of Safety Net Hospitals are teaching hospitals

– 50% of Safety Net Hospitals have <100 beds

• High utilization of Emergency Rooms for non-acuteillnesses

• Provide specialty care for patients referred fromprimary care Safety Net facilities and providers

*Andrews, R., Stull, D., Fraser, I., Friedman, B., Houchens, R., “Serving the Uninsured: Safety-Net Hospitals, 2003”, AHRQ Publication No.07-0006, January 2007, p.6.

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VCU Health System andUVA Medical Center

receive reimbursement fromthe Commonwealth

to provide care to theUninsured

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Virginia’s Indigent Care Program

• Established in the late 1970’s to providecoverage to the uninsured and underinsured

• Virginia’s Medicaid program only coversthose who are pregnant, under 18, aged,blind or disabled

• Indigent Care Program marries federalDisproportionate Share Hospital (DSH)dollars and State General funds

• Eligibility criteria:

- Reside in the Commonwealth

- U.S. Citizen

- At or below 200% FPL

- Meet asset test criteriaSlide 10Slide 10

About The VCU Health System

• VCU Health System: onlyacademic medical center inCentral Virginia, with 30,000admissions and > 500,000outpatient visits annually.

• MCV Hospitals: 779licensed beds, with 80,000emergency visits each year;region's only Level I TraumaCenter.

• MCV Physicians: 550-physician, faculty grouppractice.

• Virginia Premier HealthPlan: 110,000 memberMedicaid HMO.

• Carolina Crescent HMO:30,000 member Medicaid HMO

Slide 11Slide 11

VCU Health System’s Payer Mix - FY08

Medicare

24.2%

DMAS/Self Pay

47.9%

Wellpoint

17.0%

Commercial

11.0%

Total Government72.1%

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Healthywithunmetneeds

Healthywithepisodicneeds

Chronically ill

The Ecology of Safety Net Care

Acutehospitalization

Catastrophicevent

Presentation: Governor’s Covering the Uninsured Conference, Dr. Sheldon M.Retchin, 2003

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Slide 13Slide 13

Evolution of VCU Health SystemSafety Net Partnerships

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VCUHS Partnership Timeline

Virginia GeneralAssembly passes

SJR179

1991

RUPCI determinesthere is a need for

primary care inSouth Richmond

RCHD turns overmanagement of

the SRHCTo VCUHS

SRHC is renamedthe Hayes WillisHealth Center

VCUHSlaunches the

City Care program

Community andVCUHS

reps examine thefeasibility

of expanding CityCare to

Uninsured adults

The VCCprogram is

established inpartnership

withcommunity

PCP’s

1994 1996 1998 1999 2000

RCHD andVCUHS

partner to createSouth Richmond

Health Center

1992 2009

VCUHSreviewsmodels

for HealthCare Reform

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Assessment of Primary Care Capacity

• In 1991, the Virginia General Assemblypassed Senate Joint Resolution (SJR) 179

• Required all health departments to review theavailability of primary care in their healthdistricts

• Study concluded that there was adequateprimary care in Richmond City, however,there was a maldistribution of providers

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Richmond Urban Primary Care Initiative (RUPCI)

• In 1991, a coalition of community leaders andhealth care providers includingrepresentatives from private practices, theRCDPH and the VCU Health System wasformed with a goal of improving access toprimary care for City residents

• The group recommended that a primary careclinic be established in South Richmond

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South Richmond Health Center

• In 1992-93, RCDPH and VCU Health Systempartnered to establish the South RichmondHealth Center (SRHC)

– Received funding from the Virginia Health CareFoundation, the Jenkins Foundation and theRobert Wood Johnson Foundation

• In 1994, the RCDPH established a contractwith VCUHS to manage the clinic andintegrate traditional public health services intoa primary care model

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Clinical Services for Low Income Patients

• Women’s and Children’s Services

• Family Medicine

• Screening and Treatment for STD’s

• Arthur Ashe HIV/AIDS Early InterventionProgram

• Case Management Services

• WIC

• Lab

• Pharmacy

• Financial Counseling

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Hayes E. Willis Health Center

• In 1996, the Center was renamed for its firstMedical Director, Dr. Hayes Willis

• Annually serves over 4,000 patients

• Approximately 80% of patients

are uninsured or have Medicaid

• Approximately 10% of patients

are Hispanic

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Expansion of the RCDPH/VCUHS Partnership

• In 1998, the RCDPH asked VCUHS to develop amodel to integrate public health services intoprimary care settings throughout the City

• The “City Care” program developed partnershipswith community providers to provide primary careand traditional public health services in theirpractices to 5,000 low income patients

• VCUHS received a 5-year grant from the JenkinsFoundation for $1.3 million to collaborate withRCDPH to identify patients who inappropriatelysought care in the Emergency Department

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Goals of the City Care Program

• Continuity of care for low income patients

• Reduction in the inappropriate utilization ofthe VCU Health System’s Emergency Room

• Reduction in the cost of health care services

• Leverage funding (Indigent Care

and Health Department) to

provide services

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VCC Program

• In 1999, Community and VCUHSrepresentatives began to discuss the conceptof expanding the City Care model to otheruninsured populations

• Fall of 2000, the Virginia Coordinated Carefor the Uninsured (VCC) program waslaunched

– Program applied managed care principles to theCommonwealth’s Indigent Care program

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VCU Health System Indigent Care Distribution

FY2008 Projected Distribution of $108.5 Million

Indigent Care Cost in $

67,400,000 to 67,500,00017,100,000 to 67,400,0003,600,000 to 17,100,0001,250,000 to 3,600,000

10,000 to 1,250,0001 to 10,000

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Geographic Distribution of theVCUHS Indigent Care Population

Locality PercentageRichmond City 50.1%Henrico/Chesterfield 19.3%Petersburg/Tri-Cities Area 3.5%Rest of the State 21.5%Out of State .1%Unknown 5.5%

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Virginia Coordinated Care for the Uninsured (VCC)

• Primary objective is to coordinate healthcare services for a subset of the patientswho qualify for the Commonwealth’sIndigent Care program

• Target population is uninsured in theGreater Richmond and Tri-Cities areas

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VCC Program Goals

• Utilize managed care principles to supporta defined population

• Establish primary care home

• Reduce the overall cost per unit of service

• Educate patients regarding access to care

• Improve the health status and outcomes ofa population

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Program Plan

• Utilizes existing Indigent Care program financialscreening process to initiate enrollment

• Virginia Premier Health Plan serves as third partyadministrator for the program (TPA)

• Assigns patients to a “medical home”– Partners with 50 community physicians and Safety Net

Providers to provide primary care homes for patients

• Provides education to patients

• Utilizes Jenkins Care Coordination program to assignOutreach Workers to the VCUHS ED

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11,427

14,024 14,65516,422

18,43019,296 19,479

20,573

22,968

0

5,000

10,000

15,000

20,000

25,000

En

roll

ee

s

FY01 FY02 FY03 FY04 FY05 FY06 FY07 FY08 FY09

VCC Enrollment

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Chesterfield

Henrico

Joyce L. Whitaker, M.D., LTD.

Vernon J. Harris Community Health Center

Charles City Medical Group

Frank S. Royal, MDLei Charlton, MD

Main Street Medical

Dominion Medical Associates

Carolyn Boone, MD

Joseph W. Boatwright, III, MD

Dominion Medical Associates

Green Medical Center

June Tunstall, MD

AWK Durrani, MD, PC

Frank M. Sasser, Jr., MD

Charles City Medical Group

Petersburg Health Alliance

Hopewell-Prince George Health Center

VCU Health SystemMCV Hospitals and Physicians

VCC Community Primary Care Sites

Hanover

Richmond

Hopewell

Petersburg

Virat Bakhashi, MD

Hayes E. Willis Health Clinic

Daily Planet Health Clinic

Shirdhar Bhat, MD

Cheryl Belle, MD

Lillie R. Bennett, MD

Northside MedicalCenter

Yvette Johnson-Threat, MD

CrossOver Health Center

Leon Brown Jr., MD

Addie J. Briggs, MD

Virat Bakhshi, MDBarrington Bowser, Jr., MD

Fan Free Clinic

AppomattoxArea Health Center

Karol Mansilla, MD

King William Dawn Community Physicians

Charles City Regional Health Services

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Emergency Room Visits: Reason for Visit

27%

17%

4%8%

18%

2%2%

22%

Not Emergency Primary Care Emergency/Avoidable

Emergency/Not Avoidable Injury Psych

Alcohol/Drug Unclassified

Visits = 30,273

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Jenkins Care Coordination Highlights

• Original goal was to assist VCC patients with

the transition from VCUHS clinics to community

“medical homes”

• Reduced ED utilization by 14% in the first 3

years of the program (19% for patients enrolled

for more than 18 months)

• Expanded the program through a grant from

the Jesse Ball duPont Fund in 2004 to also

assist Self-Pay “frequent flyers” who visited the

ED

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VCC ER Visits/1000 Enrollees

894

862 865

885

828823

830

780

800

820

840

860

880

900

FY02 FY03 FY04 FY05 FY06 FY07 FY08

Vis

its

/10

00

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0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

Fiscal Year

Classification of ED Visits for VCC Patients

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%

FY01 FY02 FY03 FY04

VCC Population Changes in ED Utilization

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Inpatient Services

• Many admissions were for services that couldbe provided in community hospital settings

• The CMI for the VCC program in FY01 was1.22 as compared to the Hospital average of1.5

• Most prevalent discharge diagnoses for theVCC population were:

– Psychoses

– Disorders of the Pancreas

– Chest Pain

– Alcohol or Substance Abuse

– Diabetes

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Bon Secours - Richmond CommunityHospital (RCH)Partnership

• From January 2004 – May 2009, VCUHSpartnered with BSR –RichmondCommunity Hospital to provide inpatient,diagnostic, ancillary and emergencyservices for the VCC patients

• Goal of the partnership was to reduce theoverall cost of caring for the VCCpopulation by providing care in a lower costsetting

• Resulted in a reduction in the avg.cost/discharge for patients with similardiagnoses

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238 241225

163150 152

116

0

100

200

300

Dis

ch

arg

es

/10

00

FY02 FY03 FY04 FY05 FY06 FY07 FY08

VCC Discharges/1000 Enrollees

7

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1.22 1.241.33 1.36

1.51.6

0

0.2

0.4

0.6

0.8

1

1.2

1.4

1.6

CM

I

FY01 FY02 FY03 FY04 FY05 FY05

Fiscal Year

Case Mix Index

VCC

VCUHS

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VCC Today• Anticipate enrollment to exceed 23,000 in FY10

• Continue to expand partnership with CommunityPhysician Practices and Safety Net Providers– Currently working to provide access to VCUHS Electronic Medical Record

• Community partnerships are driving costs down (primarycare visits dropped from $180 to $90/visit)

• Program is reducing utilization of services

• Program is a model for health care reform

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VCC and Health Care Reform

New care delivery models and organizations

AccountableCare

Organizations(ACOs)

NAPH

CoordinatedCare Network

HealthcareInnovationZone (HIZ)

Patient CenteredMedical Home

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Accountable Care Organization

Safety Net Health SystemSafety Net Health System Community PartnersCommunity Partners

Accountable Care Organization

Reward Quality & Outcomes

-Inpatient-Outpatient-Post-Acute-Preventative

Goal: Improve patient outcomes while slowing the growth of healthcare costs

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Conclusion

• The role the Academic Medical Center playsis critical in a Safety Net System due to theresources (financial, human, clinical)available

• Health care reform will have a significantimpact on Safety Net Systems in the future

• The development of partnerships is a criticalcomponent in the creation of

cost effective, quality health

care delivery models for the

uninsuredSlide 42Slide 42

“University-based urbanacademic medical centers….

function mosteffectively and for the greater goodwhen their care is a complement to,

and not a substitute for,community health care providers.”

Hill, Laurence and Madara, James, “Role of the Urban Academic Medical Center in US Health Care”,Journal of the American Medical Association, November 2, 2005 – Vol 294, No. 17, p.2219.