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

VCU Health SystemNovember 26, 2007

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

Slide 2Slide 2

Who Are the Uninsured?

Growing concern for many health care administrators is where willthe 47 million uninsured in the U.S. get health care services?

Slide 3Slide 3

Statistics on the Uninsured

• Over 50% are below 200% FPL; 25% are below thepoverty line

• 41% are between the ages of 18 – 34

• 21% are under the age of 18

• Majority are white; however the uninsured aredisproportionately Hispanic (14% of the population –30% of the uninsured)

• 46% work full time and 28% work part-time

Source: Overview of the Uninsured in the United States: An analysis of the 2005 CurrentPopulation Survey, Department of Health and Human Services, Office of the Assistant SecretaryFor Planning and Evaluation, http://aspe.hhs.gov, 2005

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Slide 4Slide 4

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.

Slide 5Slide 5

Growth of the Health Care Safety Net

• Safety Net system hasgrown

• 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.

Slide 6Slide 6

• 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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Slide 7Slide 7

Academic Health Centers in the Safety Net

• According to the AAMC, the 400 teachinghospitals at Academic Health Centersrepresent 6% of the nation’s hospitals

• Last year teaching hospitals accounted for 42% of the nation’s Medicaid discharges

• 51% of newborns are delivered at teachinghospitals

Source: Dr. Sheldon M. Retchin, Testimony to the Committee on Oversight and Government Reform,U.S. House of Representatives, November 1, 2007

Slide 8Slide 8

The Uninsured seek care at AcademicHealth Centers

• High utilization of services by the uninsured inEmergency Rooms

• Provide specialty care for patients referredfrom primary care Safety Net facilities (freeclinics and federally qualified health centers)

• Academic Health Centers continuouslystruggle with “social admissions”

Slide 9Slide 9

Opportunities for Academic Health Centers

• Current method for funding care of the uninsuredis inefficient and ineffective

• Academic Health Centers can play leadership rolesin identifying innovative approaches

• Need to sustain funding for care of the under- anduninsured while novel approaches are explored(i.e., federal waivers)

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Slide 10Slide 10

Throughout theCommonwealth,communities are

adopting strategiesto address theissue of caring

for the uninsuredthrough the

development ofSafety Net Health

Care DeliveryModels

Slide 11Slide 11

Virginia’s Indigent Care Program

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

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

• Indigent Care Program marries federal DSHdollars and State General funds (50/50match)

• Eligibility criteria:

- Reside in the Commonwealth

- U.S. Citizen

- At or below 200% FPL

- Meet asset test criteria

Slide 12Slide 12

About The VCU Health System

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

• MCV Hospitals: 779 licensedbeds, with 80,000 emergencyvisits each year; region's onlyLevel I Trauma Center.

• MCV Physicians: 550-physician, faculty grouppractice.

• Virginia Premier HealthPlan: 107,000 memberMedicaid HMO.

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Slide 13Slide 13

A Regional Medical Center

FY 2003 – 2006 YTDPatient Discharges byZIP Code

11,000

105

1

Slide 14Slide 14

Payer Mix

Medicare

24.2%

DMAS/Self Pay

47.9%

Wellpoint

17.0%

Commercial

11.0%

Total Government72.1%

Slide 15Slide 15

VCU HealthSystem

20002000Percentage of Entire Charity CarePercentage of Entire Charity Care

for the Commonwealthfor the Commonwealth

VHI Definition of Charity Care: Charity Care represents (unreimbursed) charges to individuals at 100% of the federalnon-farm poverty level

Sources: VHI 2000 Hospital Financial Data Report, VCUHS Financial Services, VCUHS Strategy & Marketing

34.2%34.2%

16.5%16.5%

UVA

6.0%6.0%6.2%6.2%

7.0%7.0%

Carillion Sentara

Inova

Leading Providers of Charity Care

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Slide 16Slide 16

VCU Health System is theprovider of the majority of health care for the

uninsured and underinsured in theCentral Virginia region.

In FY 2006, theVCU Health System provided over

$107 million in indigent care to patients

Slide 17Slide 17

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

FY08 Projected Distribution of $108.5 million

Slide 18Slide 18

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 19Slide 19

Innovative Partnerships

• Virginia Coordinated Care for the Uninsured(VCC)

• REACH

• Perinatal Access Program

• Hayes E. Willis Health Care Center

Slide 20Slide 20

Virginia Coordinated Care for the Uninsured(VCC)

Slide 21Slide 21

Virginia Coordinated Care for the Uninsured(VCC)

• Established in the Fall of 2000

• Primary objective was to coordinate healthcare services for a subset of the patients whoqualified for the Commonwealth’s IndigentCare program utilizing managed careprinciples

• Target population is uninsured in the GreaterRichmond and Tri-Cities

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Slide 22Slide 22

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

Slide 23Slide 23

Program Plan

• Utilized existing Indigent Care programfinancial screening process to initiateenrollment

• Virginia Premier Health Plan served as thirdparty administrator for the program (TPA)

• Assigned patients to a “medical home”

• Provided intensive education to patients

• Assigned Outreach Workers to the VCUHSEmergency Department to educate patients

Slide 24Slide 24

Chesterfield

Henrico

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

Vernon J. Harris East EndCommunity Health Center

Charles City Medical Group

Manchester Pediatric Associates

Frank S. Royal, MD

James River Physicians

Dominion Medical Associates

Dominion Medical Associates

Carolyn Boone, MD

Joseph W. Boatwright, III, MD

Dominion Medical Associates

Green Medical Center

Hopewell Medical Group

AWK. Durrani, MD, P.C.

Richard W. Dunn, MD

Montpelier Family Practice

Charles City Medical Group

Petersburg Health Alliance

Convenient Health Care

VCU Health SystemMCV Hospitals and Physicians

VCC Community Primary Care Sites

Hanover

July 2001Geographic Distribution

Richmond

HopewellColonial Heights

Petersburg

Richmond CommunityHospital

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Slide 25Slide 25

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

Slide 26Slide 26

Jenkins Care Coordination Program

• In 1998, received a 5-year grant from the JenkinsFoundation, for $1.3 million

• Collaborated with the Richmond City Department ofPublic Health (RCDPH) to identify patients whoinappropriately sought care in the EmergencyDepartment,

• Program Goals:

– Coordinate services across organizationalboundaries

– Increase appropriate and cost-effective utilizationof health resources

Slide 27Slide 27

Jenkins Care Coordination Highlights

• Assisted VCC patients with the transition from

VCUHS to community “medical homes”

• Reduced ED utilization by 4.6% for the entire

population (19% for patients enrolled for more

than 18 months)

• Received a grant from the Jesse Ball duPont

Fund in 2004 to expand the program to assist

Self-Pay “frequent flyers” who visit the ED

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Slide 28Slide 28

VCC ED UTILIZATION

9956

8160 7798 7900

10670 10993

0

2000

4000

6000

8000

10000

12000

FY01 FY02 FY03 FY04 FY05 FY06

Vis

its

Slide 29Slide 29

VCC ED UTILIZATION/1000 ENROLLEES

871

582540

483

583 583

0

100

200

300

400

500

600

700

800

900

1000

FY01 FY02 FY03 FY04 FY05 FY06

Vis

its

/100

0E

nro

llees

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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

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Slide 31Slide 31

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

Slide 32Slide 32

This data led to the development of theidea to partner with a community hospitalto provide services for the VCC patients

with lower acuity

Slide 33Slide 33

Bon Secours - Richmond CommunityHospital (RCH)Partnership

• In January 2004, VCUHS partneredwith RCH to provide inpatient,diagnostic, ancillary and emergencyservices for the VCC patients

• Goal of the partnership was toreduce the overall cost of caring forthe VCC population by providingcare in a lower cost setting

• Resulted in a reduction in the avg.cost/discharge (117 admissions) forpatients with same diagnoses

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Slide 34Slide 34

VCC Today

• Enrollment in FY06 was approximately 19,000patients

• 31 Community Physicians and 9 Safety NetProviders participate

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

• 20% Reduction in ED visits over a 4-year period

• In the process of requesting CMS approval toutilize DSH funds to support program

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11,427

14,024 14,440

16,37118,311 18,867

0

5,000

10,000

15,000

20,000

NU

MB

ER

OF

EN

RO

LL

EE

S

FY01 FY02 FY03 FY04 FY05 FY06

VCC ENROLLMENT

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$477

$468

$498

$511

$440

$450

$460

$470

$480

$490

$500

$510

$520

PMPM

FY03 FY04 FY05 FY06

Fiscal Year

VCC Total Per Member Per Month Costs

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Slide 37Slide 37

185

173

159151

0

20

40

60

80

100

120

140

160

180

200

FY03 FY04 FY05 FY06

VCC Discharges/1000

Slide 38Slide 38

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

Slide 39Slide 39

REACH

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Slide 40Slide 40

• REACH stands for Richmond

Enhancing Access to Community Healthcare

• A non-profit organization whose mission is toenhance access to health care services forthe uninsured and underinsured in theGreater Richmond Metro area

• Board comprised of 9 Safety Net providerorganizations and 3 Richmond area healthsystems

Slide 41Slide 41

• Received a Healthy Community

Access Program (HCAP) grant

• Coordinated access to prenatal care forundocumented women

• Developed a low cost pharmacy model

• Worked with RAM to create a modelimprove access to physician specialtycare

• Develop a Community Health ServicesPlan (CHSP)

Slide 42Slide 42

Greater Richmond Health Safety Net

Today’s Model

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Slide 43Slide 43

Community Health Services Plan Model

Corporations

Government

InsuranceCompanies

HealthCenters

ElectedOfficials

HealthSystems

CommunityPhysicians

HealthDepts.

Safety Net to CHSP

InsuranceCompanies

HospitalsHealth

Clinics

CommunityPhysicians

HealthDepts.

ElectedOfficials

Corporations

Government

Slide 44Slide 44

REACH’s Vision

Future Model

Slide 45Slide 45

Perinatal Access Program

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Slide 46Slide 46

2003 Immigrant Health Needs Assessmentfor the Greater Richmond Area revealed

• The greatest health needs for Hispanic andAsian women were OB/Gyn services andpreventative care

• Between 2000 and 2001, there was a 25%increase in births for Hispanic women

• Approximately 20% of all Hispanic birthsexperienced complications between 2000-2001

Slide 47Slide 47

VCU Health System Issues

• Annual cost for uncompensated care for OBpatients in 2003 was approximately $1 million

• Over 200 births in 2003 were to mothers withno Social Security Number

• Over 65% of the population were classified asHispanic

• Patients who are not U.S. Citizens do notqualify for the Commonwealth’s Indigent Careprogram

Slide 48Slide 48

Perinatal Access Program

• Pilot program developed in 2003 with communitypartners

• Cross Over Ministry established a clinic to providefree prenatal care to Hispanic women

• Volunteer physicians (including VCU faculty)provided prenatal care and ultrasounds

• REACH Community Health Advocates assistedpatients with Emergency Medicaid applications

• LabCorp provided free prenatal labs

• Patients were referred to VCUHS for delivery

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Slide 49Slide 49

Outcomes

• Approximately 850 moms referred frompartner agencies to the Community HealthAdvocate since 2003

• Over 330 Latina women referred fromCrossOver for delivery between 2003 – 2006

• Over 70% of the mothers had their

deliveries covered by Emergency

Medicaid

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Findings: Deliveries - Patients w/o SSNs

0

50

100

150

200

250

300

350

Nu

mb

er

of

Acco

un

tsN

=406

COMM

ERCIA

L

INDIG

ENTCARE

MEDIC

AID

MEDIC

AIDM

NG

DCAR

E

MNGD

CARE

OTH

ER

PAYERS

SELFPAY

SELF

PAYPEND

ING

TRIGO

NM

NG

DCARE

TRIGON

TSI

Patients Not Reporting SSNs: FY05WHITE

UNKNOWN

OTHER

HISPANIC

BLACK

ASIAN-PACISLAND

AM INDIAN-ALASKA

0

20

40

60

80

100

120

140

Nu

mb

er

of

Ac

co

un

ts(N

=23

7)

COM

MER

CIA

L

IND

IGEN

TC

ARE

ME

DICA

ID

ME

DICA

IDM

NG

DCA

RE

MNG

DC

ARE

SELF

PAY

SELF

PAY

PENDIN

G

TRIG

ON

MNG

DCA

RE

TRIG

ON

TSI

Patients Not Reporting SSNs:FY02

WHITE

UNKNOWN

OTHER

HISPANIC

BLACK

ASIAN-PACISLAND

In FY02 Self Pay Hispanicswithout SSNs were 5% of

all deliveries

In FY05 Self Pay Hispanics withoutSSNs were 2% of all deliveries

Slide 51Slide 51

Total Cost – Self Pay Deliveries

Total Cost bySelf Pay Type

$-

$200,000

$400,000

$600,000

$800,000

$1,000,000

$1,200,000

$1,400,000

FY02 FY03 FY04 FY05

Fiscal Year

To

tal

Co

st

Self Pay - UnauthorizedHispanic

Self Pay - All Deliveries

Self Pay - Other Than Unauth. Hisp

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Slide 52Slide 52

Hayes E. Willis Health Centerof South Richmond

Slide 53Slide 53

Hayes E. Willis Health Center ofSouth Richmond

• SJR179 - assessment of primary care inlocalities

• 1994 - Partnership between Richmond CityDepartment of Public Health and VCUHS

• Community-based primary care centeroperated by VCUHS with a CommunityAdvisory Board

• Arthur Ashe Early Intervention Program

• Financial screening on site

Slide 54Slide 54

Hayes E. Willis Health Center

Major provider of primary care in South Richmond

Approximately 4,000 patients with over 10,000annual visits

Approximately 45% of the patients have noinsurance; another 34% are Medicaid recipients

Serves a large Hispanic population (approximately10% of the patients)

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Slide 55Slide 55

Conclusion

Slide 56Slide 56

Conclusion

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

• Communities in Virginia continue to createopportunities to enhance access to care forthe Uninsured

• Providers in the Greater Richmond Metroarea are amongst those working to develop aSafety Net Health Care Delivery System

Slide 57Slide 57

“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.