HEALTH CARE MODELS FOR THE UNINSURED

Sheryl L. GarlandVice PresidentAmbulatory Care ServicesMedical College of Virginia Hospitals and PhysiciansVirginia Commonwealth University Health SystemNovember 26, 2001

2

One of the largest challenges in the health care industry is providing care for the 44 million uninsured in the U.S.

3

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.

4

A survey conducted by the Robert Wood JohnsonFoundation’s Access Project in 1999 revealed that the majority of organizations engaged in health care access efforts at local levels were participating in partnerships or coalitions to meet their goals.

5

Safety Net Facilities Collective mission of providing care

to patients regardless of their ability to pay

Assume responsibilities to their communities that go beyond the delivery of direct health care services

6

Safety Net Initiatives

“Safety Net” hospitals and health systems across the country are struggling to provide quality health care to low income and vulnerable populations during anera of shrinking reimbursement and limited federal government intervention

7

The National Association of Public Hospitals and Health Systems (NAPH) is an organization that advocates and represents the nation’s urban safety net providers

8

NAPH members strive to meet the key needs in their communities, such as:

Providing inpatient and outpatient care to Medicaid and Medicare beneficiaries, the uninsured and underinsured

Playing an essential community role in providing specialty and tertiary level services

Training a large portion of the nation’s health care professionals

9

Safety Net Initiatives include programs that:

Expand ambulatory care Focus on Disease Management Are unique to targeted populations Represent health outreach initiatives Focus on process improvement and

enhanced quality patient services Promote initiatives to improve the health

of communities

10

The 2001 NAPH Ambulatory Care Survey revealed:

NAPH facilities serve as specialty referral points for patients seen in Community Health Centers

NAPH members have developed programs such in schools, homeless shelters and housing developments

NAPH members participating in survey receive over $18 million in federal grants to operate community health centers

11

As you are aware, the University of VirginiaHealth System (UVA) and the MedicalCollege of Virginia Hospitals and Physicians(Virginia Commonwealth University Health System - VCUHS) receive funding to provide care to the uninsured in theCommonwealth of Virginia

12

In FY 2001, theVCU Health System provided over

$100 million in indigent care to patients

13

In addition to the services provided by theVCU Health System for the uninsuredin the Richmond Metropolitan area,

there are various initiatives underway that provideservices

for uninsured or underinsured populations

14

These endeavors include: Free clinics (medical and dental) Mental Health initiatives Case management for targeted

populations Outreach activities Programs to assist patients in

obtaining prescription medications

15

Hayes E. Willis Health Center of South Richmond Partnership with the Richmond City

Department of Public Health (RCDPH) to integrate public health clinical services into a primary care center started in 1992

Community-based health center that offers Family Medicine, Women’s Health and Pediatric services

Financial and Medicaid/CMSIP eligibility screening at the Center

16

Hayes E. Willis Health Center of South Richmond (cont’d)

Volume has increased from 8,000 patient visits in its first year of operation to approximately 15,000 visits in the current fiscal year

Community Advisory Board provides assistance in establishing the goals for the Center

Program reduced the City Health Department’s budget by $1 million and is one of the lowest cost providers in the VCU Health System

17

RCDPH/MCVH Clinical Services Agreement

In July 1998, the RCDPH contracted with MCVH to provide public health clinical services for Richmond City residents

Communicable Disease Services (STD, TB, etc…), General Relief, Immigration and Refugee Services are provided in one location

18

Goals of the RCDPH/MCVH Clinical Services Agreement

To provide quality health care in the most appropriate site of services

Reduce redundancy of services Reduce the overall cost of providing

health care to residents in the City of Richmond

19

RCDPH/MCVH Clinical Services Agreement (cont’d)

Women’s, Children’s and Family Planning Services have been integrated into primary care locations in the VCUHS and community

A population of approximately 5,000 patients was identified and the “City Care” program was established

20

“City Care” Agreement Allowed the City of Richmond to

reduce its health care expenses by approximately $1.5 million

Richmond City Department of Public Health focuses on Case Management, immunizations and responses to public health problems

21

Managed Care Models That Have Been Implemented Wishard Program in Indianapolis,

Indiana University of New Mexico Boston Medical Center and

Cambridge Health Alliance

22

VCUHS Initiative is the Virginia Coordinated Care for the Uninsured (VCC) Program

Implemented November, 2000 Utilizes Managed Care principles Focuses on the establishment of relationships with

Primary Care Physicians Goal is to reduce the overall cost per unit of

service Strong emphasis on education of patients

regarding appropriate access to health care services

Utilizes care management strategies Strives to improve the health status and health

outcomes for a defined population

23

Virginia Coordinated Care Service Area

C a r o l in e

H a n o v e r

H e n r ic oR ic h m o n d C ity

C o lo n ia l H e ig h tsH o p e w e llP e t e r s b u r g

C h e s te r f ie ld

G o o c h l a n d

P o w h a ta n

A m e lia

D in w id d ieP r in c e G e o r g e

C h a r l e s C it y

N e w K e n t

K in g W i l l ia m

24

Virginia Uninsured Rate

8

12.6 13.4 14.0116.25

19

96

(C

en

su

s)

19

97

(C

en

su

s)

19

98

(C

en

su

s)

19

99

(U

CL

A)

20

00

(U

CL

A)

0

5

10

15

20

Richmond-Petersburg MSA: Projected Number of Uninsured

79.806

131.753144.322

155.419173.678

0

50

100

150

200

Thousands

Percent of Uninsured Virginians

25

Number of Uninsured Patients Receiving Services through the VCU Health System

Number of Uninsured Patients

FY 2000

38.781

19.619 14.814 10.0562.576 0.977 0.885 0.321 4.805

Tot

al

Ful

l Ind

igen

t-C

ateg

ory

1

VC

C E

ligib

le

Ric

hmon

d

Hen

rico

Che

ster

field

Tri-

City

Are

a

Han

over

Oth

er A

reas

01020304050

Thousands

26

Enrollment and Physicians Approximately 13,000 enrollees from

November, 2000 to September, 2001 Year to Date Monthly Average - 7370 27 Community PCP’s representing 20

practices Five community-based safety net

providers Three specialty areas - Neurology,

Ophthalmology, Rheumatology

27

Figure 1. VCC Patient Demographics (Age)

Under 2010%

20 - 3430%

35 - 4425%

45 - 6432%

65 Plus3%

28

Figure 3. VCC Patient Demographics (Race)

Black69%

Other6%

White25%

29

Figure 4. Overall Utilization -- Encounters by TypePreliminary Estimates

0

10,000

20,000

30,000

40,000

50,000

60,000

Month

Nu

mb

er o

f E

nco

un

ters

FY00 (10 months) 2,322 45,528 9,245

FY01 (10 months) 2,082 44,493 8,140

Inpatient Discharges Outpatient Visits Emergency Room Visits

Overall Number of Encounters FY00 (10 months) = 57,095Overall Number of Encounters FY01 (10 months) = 54,715

4.2% decrease from FY00

30

F ig u re 5 . O v e ra l l U ti l i za tio n --

E stima te d T o ta l C o sts

F Y 0 0 F ig u re s A d ju ste d fo r

C o mp a riso n w i th F Y 0 1

F ig u re s In c lu d e B o th F a c i l i ty

$ 0

$ 5 0 ,0 0 0 ,0 0 0

M o n th

F Y 0 0 (1 0

mo n th s)

$ 1 8 ,8 8

5 ,3 1 5

$ 1 3 ,0 4

8 ,0 3 6

$ 2 ,4 0 3 ,

5 8 6

Figure 5. Overall Utilization -- Estimated Total CostsFY00 Figures Adjusted for Comparison with FY01Figures Include Both Facility and Physician Costs

$0

$5,000,000

$10,000,000

$15,000,000

$20,000,000

$25,000,000

Month

Est

imat

ed T

ota

l Co

sts

FY00 (10 months) $18,885,315 $13,048,036 $2,403,586

FY01 (10 months) $19,146,254 $11,787,338 $1,986,595

Inpatient Discharges Outpatient Visits Emergency Room Visits

Overall Total Costs FY00 (10 months) = $34,336,937Overall Total Costs FY01 (10 months) = $32,920,187

4.1% decrease from FY00

31

VCC Outcomes Will continue to monitor utilization and

costs to provide services Program is supported by the Jenkins Care

Coordination Program to modify inappropriate utilization of services

Will benchmark with similar programs to assess effectiveness of project

32

Richmond Coalition of Safety Net Providers (RCSNP) Several Safety Net Providers in the greater

Richmond Metro area have formed a coalition to identify and address access issues for uninsured and underinsured populations in this region

Participants are Fan Free Clinic, Daily Planet, Vernon J. Harris Health Clinic, Irvin Gammon Craig Health Center, Homeward, CrossOver Health Center, Richmond City Dept. of Public Health, VCU Health System and minority community physicians

33

Community Access Program (CAP)

The RCSNP recently received a $1.1 million Community Access Program grant from HRSA

The program will develop a web-based program to input financial and demographic information for uninsured and underinsured populations in this region

34

CAP Grant

Grant is one of 63 awarded this funding cycle across the country

Provides an opportunity to develop infrastructure for community coalitions