Wally R. Smith, MD, Donna K. McClish, PhD,Patricia Carcaise-Edinboro, PhD, Gloria Bazzoli,

PhD, Alton Hart, MD, MPH, Arline Bohannon, MD, Peter Boling, MD, Sheldon Retchin, MD,

MPH, MSHA Virginia Commonwealth University

AHRQ MD-10-012

Early Results of Costs and Utilization, Virginia Coordinated Care Delivery System

Background• Uninsured

– Utilization patterns similar to Medicaid, underinsured• Poor• Lower social support• Less transportation, education, delayed

gratification• May use ED rather than PCP

• Health Care Reform– Reduces the number of uninsured, underinsured

• Of the 46 million uninsured, estimated 32 million will soon be covered

– Expands Medicaid program to approximately 16 million newly insured

Do the Newly Insured Poor Change Utilization Patterns?

• Not in some studies of providing managed care insurance-like programs to uninsured

• Barriers and Weaknesses of previous programs– Short duration– Dose of managed care variable

• Little case management• Poor PCP (geographic or time) availability• Few barriers to ED access• Comorbidity mix unfavorable

Virginia Coordinated Care 2000-present

• Patient-Centered Medical Home Insurance-like program for uninsured– Uses managed care principles

• All patients qualify for the Indigent care program supported by federal DSH and State General funds

• Primary care provided by community PCP’s funded by VCUHS profits from commercial plans

• FFS and Management fee paid to PCPs in urban communities surrounding VCU– Catchment area within 30 miles of VCU

• Patients given card with PCP’s name• Case managers support, assist with ∆’s, • Enrollment files managed by Medicaid HMO

owned by VCU Health System

Initial Evaluation of VCC• Lower ED visit rates• Patients saw PCP• VCC off-loaded patients to

community physicians• Community physicians happy with

management fees• Case management dose small• Short-term evaluation only

VCC Preliminary Data (January 1, 2001, to December 31, 2003)

Variable No. (%) N=2389 Before

Enrolment After Enrolment

Any inpatient discharge

420 (17.6) 330(13.8)

Any emergency department visit

1765 (73.9) 1024(42.9)

Any primary care visit

557 (23.3) 788 (33.0)

Any specialty care visit

1729 (72.4) 1895 (79.3)

P <.001 for all comparisons.

How Did VCC Enrollment, Costs, and Utilization Grow from 2003-2005?

• Utilization?• Per Member Per Month (PMPM)

Costs?• Uptake by community PCP’s?• Relative costs?

VCC Enrollment, Utilization, Costs FY03 - FY05

FY03 FY04 FY05 Increase 03-05

Enrollees 14,655 16,361 18,289 25%

Memb Mos 112,773 127,254 146,422 30%

Private Practice Memb Mos 48,195 53,218 61,805 28%

PMPM $477 $467 $497 4%

Total Cost ($M) 53.8 59.5 72.8 35%

PMPM Costs by Svc Type

FY03 FY04 FY05$10.00

$60.00

$110.00

$160.00

$210.00

$260.00

$310.00

$266.67$253.70

$272.68

$24.29 $22.38 $29.03

$152.44 $151.43 $148.54

$29.00 $30.56 $34.51

Inpt All EDs*Outpt Pharmacy

Axis Title

PM

PM

Co

st

* Missing ED data for Richmond Community Hospital FY03, all data for FY05 incomplete

Uptake of Primary Care, Specialty Care

FY03 FY04 FY0525.0

30.0

35.0

40.0

45.0

50.0

36.7

41.0

44.7

43.7

39.5

37.6

35.2

36.4

39.2

% Using Pri Care

% Using Spec Care

% w/ all other visits

%

Uptake by Community Primary Care

FY03 FY04 FY050.0

5.0

10.0

15.0

20.0

25.0

30.0

35.0

40.0

15.5

7.0

1.0

16.2

31.5

37.1

% Using VCU Pri Care Univ

% Using Comm Pri Care

%

PMPM Costs by Place of Primary Care

FY03 FY04 FY05$0.00

$5.00

$10.00

$15.00

$20.00

$25.00

$30.00

$35.00

$40.00

$45.00

$21.93$20.01 $20.69

$4.67 $8.00$9.00

$15.55

$4.97 $0.34Univ Pri Care PMPM

Comm Pri Care PMPM

Spec Care PMPM

Conclusions-1• There was a 12% annual increase, and a

25% increase overall, in VCC enrollment from FY 2003-2005.

• Simultaneously, community practitioner member months increased 28%.

• Per member per month costs rose slightly for pharmacy and ED, but were flat for inpatient and outpatient services.

Conclusions-2• Overall, the percentages of VCC pts

seeking primary care slightly increased, but so did the percentage w all other visits. Specialty care utilization percentages dropped slightly.

• Uptake %’s by community primary care mirrored dropoff %’s by VCU primary care.

• Community primary care PMPM rose, but was more than offset by decreases in university primary care PMPM, leading to a decrease in PMPM for these segments combined. Specialty care PMPM remained flat.

ED PMPM Details

FY03 FY04 FY05$0.00

$5.00

$10.00

$15.00

$20.00

$25.00

$30.00

$35.00

All EDs*VCU EDRCH EDP

MP

M* Missing ED data for Richmond Community Hospital FY03, all data for FY05 incomplete

Hadley 2008 spending vs VCC 2005

$-

$100

$200

$300

$400

$500

$600

Hadley 2008 Adult Per month spending actualHadley 2008 Adult Per month spending simu-lated if fully in-sured2005 VCC PMPM

Group