1. Virginia Commonwealth University Health 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

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 Profile44 4

5. Two-Thirds of Uninsured Americans Are Employed5

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 Margins Fiscal 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. Commonwealth, Communities are aggressively adopting strategies
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. is the provider of majority of health care to the uninsured
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
Pointers:
The state-wide data show that VCU’s Academic Health Center provides nearly 1/3 of the entire Commonwealth’s Indigent Care.
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. The Ecology of Safety Net Care
Healthy
with unmet
needs
Healthy
with
episodic
needs
Chronically ill
Acute
hospitalization
Catastrophic
event
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
FY 2000
Thousands 50
38.781 40 30
19.619
14.814 20
10.056
4.805 10
2.576
0.977
0.885
0.321
Total
Richmond
Henrico
Hanover
VCC Eligible
Chesterfield
Tri-City Area
Other Areas
Full Indigent-Category 1 32

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

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 Visit38

39. Emergency Room VCUHS Visits for the Uninsured
Diagnosis Visits %
Chest Pain , %
Abdominal Pain 1, %
Sprains and Strains 1, %
Back Problems , %
Upper Respiratory
Infections , %
Urinary Tract Infections %
Headaches/Migraines %
Dental Services 1, %
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

41. 41

42. 42

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. Researching models to improve access to behavioral health services
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. REACH Greater Richmond Safety Net Health Care Providers VCUHS Bon HCA
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

51. 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

52. REACH Vision: Safety Net Health Care Delivery System
Acute Care Providers
HCA
VCUHS
Bon
Secours
Acute
Patients
Acute
Patients
REACH
Funding
Support
Funding
Support
Free
Fan Clinic
Community
Physicians
RCDPH
CrossOver
Ministries
Daily
Planet
Craig
Health Center
Vernon J. Harris
Health Center
Primary Care Access 52

53. 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