Sheryl L. Garland, M.H.A.

1

Role of Academic Medical Centers In Safety Net
Health Care Delivery Systems

• Sheryl L. Garland, M.H.A.
• Vice President, Community Outreach
• VCU Health System
• November 28, 2005

2
Outline

• Overview of Healthcare Safety Net
• Role of the Academic Medical Center
• Partnership Opportunities
• OB Dilemma in the Greater Richmond Area

3
In March 2000, the Institute of Medicine
released a study entitled Americas 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, Americas
Health Care SafetyNet Intact but Endangered
(Washington, D.C National Academy Press, 2000)
p.21.
4
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

Americas Health Care Safety Net Intact, but
Endangered, Institute of Medicine Report, 2000
10
5
The nations health care safety net for low
income and uninsured has grown somewhat
stronger.The safety net varies from community to
community and can include various configurations
of public and private hospitals, community health
centers (CHCs), 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.
6
Strategies Used to Strengthen Safety Nets

• Develop strong partnerships
• Create managed care programs for the uninsured
• Construct prescription formularies
• Develop disease case management and care
  coordination programs
• Increase enrollment in Medicaid and SCHIP
  programs (FAMIS)
• Capture all public and private funding sources
• Develop low cost health insurance options for
  working poor

7
Outline

• Overview of Healthcare Safety Net
• Role of the Academic Medical Center
• Partnership Opportunities
• OB Dilemma in the Greater Richmond Area

8
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 12-15 of the population lacks basic
  health insurance

An Opportunity for Unprecedented Growth,
Virginia Primary Care Association, Sept. 2002
20
9
Virginias Indigent Care Program

• Established in the late 1970s to provide
  coverage to the uninsured
• Virginias Medicaid program only covers those who
  are pregnant, under 18, aged, blind or disabled
• Indigent Care Program marries federal DSH dollars
  and State General funds (50/50 match)
• Eligibility criteria
• - Reside in the Commonwealth
• - U.S. Citizen
• - At or below 200 FPL
• - Meet asset test criteria

10
VCU Health System

• Part of Virginia Commonwealth Universitys
  Medical Center
• Formerly known as 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

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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
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
12
VCU Health System Indigent Care Distribution
FY03 Budget 107.3M in Indigent Cost
13
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
14
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
15
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
16
The Ecology of Safety Net Care
Presentation Governors Covering the Uninsured
Conference, Dr. Sheldon M. Retchin, 2003
29
17
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
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Pieces of the Puzzle

• VCUHS purchased Medicaid HMO in the mid 1990s
• In 1999, a work group explored idea of using
  managed care principles to coordinate care for
  the uninsured
• Virginia Coordinated Care for the Uninsured (VCC)
  program
• launched in November, 2000

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Goals of the VCC Program

• 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
20
Number of Uninsured Patients Qualifying for the
Indigent Care Program at the VCU Health System
Number of
Indigent Patients
FY 2000
Thousands
50
38.781
40
30
19.619
14.814
20
10.056
4.805
2.576
0.977
0.885
10
0.321
0
Total
Hanover
Henrico
Other Areas
Tri-City Area
Richmond
Chesterfield
VCC Eligible
Full IndigCategory 1
21
The VCC Service Area
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22
VCC Program

• VCC is NOT an insurance program
• VCUHS partnered with Primary Care Physicians in
  the Greater Richmond and Tri-Cities Communities,
  as well as the academic medical center
• Enrollment for first year was 11,000
• All ancillary and diagnostic services provided at
  VCUHS and BSR-Richmond Community Hospital
• All inpatient admissions referred to the VCUHS
  and BSR-Richmond Community Hospital

34
23
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
24
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

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25
Emergency Room Visits for Uninsured Reason for
Visit
48 of visits could have been avoided
Visits 30,273
FY2002
26
Emergency Room VCUHS Visits for the Uninsured
Diagnosis Visits Chest Pain
1,001 3.9 Abdominal Pain
1,346 4.9 Sprains and Strains 1,567
7.1 Back Problems 1,127
3.7 Upper Respiratory Infections 1,131
3.7 Urinary Tract Infections 765
2.5 Headaches/Migraines 822
2.7 Dental Services 1,095
3.6 Total ED Visits 30,191
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Bon Secours - Richmond Community Hospital
Partnership

• Richmond Community Hospital (RCH) is a 100-bed
  community Disproportionate Share Hospital (DSH)
  that has excess capacity
• In January 2004, partnership developed to provide
  inpatient, diagnostic, ancillary and emergency
  services for the VCC patients
• Goal is to reduce the overall cost of caring for
  the VCC population by providing care in a lower
  cost setting

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VCC Today

• Enrollment in FY05 was approximately 17,000
  patients
• 31 Community Physicians and 9 Safety Net
  Providers participate
• Community partnerships are driving costs down
  (primary care visits dropped from 180 to
  90/visit)
• In the process of requesting CMS approval to
  utilize DSH funds to support the Bon Secours
  Richmond Community Hospital affiliation

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Outline

• Overview of Healthcare Safety Net
• Role of the Academic Medical Center
• Partnership Opportunities
• OB Dilemma in the Greater Richmond Area

33
Other Innovative Partnerships

• 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 - Hayes
  E. Willis Health Center
• Collaboration with CrossOver Health Ministries to
  provide continuity of care for undocumented
  pregnant women

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34
Collaboration with REACH

• REACH stands for Richmond Enhancing Access to
  Community Healthcare
• REACH is a non-profit organization that serves as
  a catalyst for community Safety Net providers to
  enhance access to health care services for the
  uninsured and underinsured in the Greater
  Richmond Metro area

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• Developed a coalition with 9 Safety
• Net provider organizations
• Primary goal is to identify mechanisms to improve
  access to health care for the uninsured and
  underinsured in the region
• Enrollment of undocumented pregnant patients
• into Emergency Medicaid
• Collaborating with area providers to develop a
  low cost pharmaceutical model for uninsured
• Researching models to improve access to
  behavioral health services

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36
Healthy Community Access Program (HCAP)

• With VCU as the fiscal intermediary, REACH has
  been awarded over 2.5 million from HRSA
• 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
37
Greater Richmond Safety Net Health Care Providers
VCUHS
HCA
Bon Secours
RCDPH
Free Fan Clinic
REACH
Craig Health Center
Community Physicians
Vernon J. Harris Health Center
Daily Planet
CrossOver Ministries
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38
Vision Safety Net Health Care Delivery System
Acute Care Providers
HCA
VCUHS
Bon Secours
Acute Patients
Acute Patients
REACH
Funding Support
Funding Support
Community Physicians
Free Fan Clinic
RCDPH
CrossOver Ministries
Daily Planet
Craig Health Center
Vernon J. Harris Health Center
Primary Care Access
52
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The Healing Place Social Detoxification Unit

• Partnership established a 6-bed detoxification
  unit for patients who were seen in the VCUHS ER
• Provided an alternative treatment program for
  those with a primary diagnosis of alcohol or
  substance abuse problems
• A total of 428 patients were cared for over a 12
  month period
• For a subset of 165 clients, there was a
  reduction of 182 ED visits and 16 fewer inpatient
  admissions for a cost savings of approx. 150,000

48
40
Hayes E. Willis Health Center

• Began as a collaboration between Richmond City
  Department of Public Health and VCUHS in 1993
• Goal was to integrate traditional Public Health
  services into a primary care setting in South
  Richmond
• Grew out of SJR 179 study that found there was
  adequate primary care capacity, but an unequal
  distribution of services

41
Hayes E. Willis Health Center

• Community-based health center in South Richmond
  that offers Family Medicine, Womens Health and
  Pediatric services
• Center also provides screening and treatment for
  STDs
• Houses the Arthur Ashe Early Intervention Program
  

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42
Hayes Willis Center Plays a Major Role

• Approximately 4,000 patients with 15,000 annual
  visits
• Approximately 45 of the patients have no
  insurance another 34 are Medicaid recipients
• 10 of patients are Hispanic
• In the process of researching federally qualified
  health center status

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43
Outline

• Overview of Healthcare Safety Net
• Role of the Academic Medical Center
• Partnership Opportunities
• OB Dilemma in the Greater Richmond Area

44
The OB Dilemma
45
2002 Birth Data for Richmond Metro Area

• Approximately 12,200 births
• Approximately 890 were classified as Self Pay
• It is guestimated that approximately 400 of
  these mothers did not qualify for Medicaid (Self
  Pay)
• Over 37 of the Self Pay births were for
  mothers classified as Hispanic

Horan, Stephen, Ph.D., 2002 Birth Profile for
Metro Richmond, February 3, 2004
46
Of the 890 Self Pay Mothers

• Over 36 reported receiving late prenatal care
  (after the 1st trimester)
• Approximately 13 delivered infants with Low
  Birth Rates (as compared to 7.9 for patients
  with private insurance)
• Over 17 were under the age of 20

Horan, Stephen, Ph.D., 2002 Birth Profile for
Metro Richmond, February 3, 2004
47
Results of 2003 Immigrant Health Needs Assessment
for the Greater Richmond Area

• The greatest health needs for Hispanic and Asian
  women were OB/Gyn services and preventative care
• Between 2000 and 2001, there was a 25 increase
  in births for Hispanic women
• Approximately 20 of all Hispanic births
  experienced complications during the same time
  period

Immigrant Health Needs Assessment for the Greater
Richmond Area, August 2003
48
VCU Health System Issues

• Cost for uncompensated care
• for OB patients in 2003 was
• approximately 1 million
• Over 200 births in 2003 were to
• mothers with no Social Security Number
• Over 65 of the mothers with no SSN were
  Hispanic
• Patients who were not U.S. Citizens did not
  qualify for the Commonwealths Indigent Care
  program

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REACH Members Identified Issues

• Difficulty making appointments for prenatal care
  at area health departments
• No free clinics or FQHCs in the region
  offering service
• Accessing care at VCUHS was problematic

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The Community Responds

• Cross Over Ministry initiated the Healthy Homes
  Campaign Health Care and Education for Mothers,
  Babies and Families in 2003
• REACH convened the Access to Perinatal Care Task
  Force in 2004
• VCU Health System began developing programs
  specifically to support the Hispanic OB
  population in 2004
• Virginia Premier Health Plan offered
  transportation to VCUHS LD tours for Healthy
  Homes patients in 2004
• Virginia League for Planned Parenthood began
  development of a Prenatal clinic for Hispanic
  women in 2005

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REACH Perinatal Care Model
52
Estimated uninsured below 2x poverty by zip
code2000 Census
53
Perinatal Access Program

• In 2004, the Perinatal Access Program was piloted
  with Cross Over Ministry, REACH and VCU Health
  System as partners
• Cross Over Ministry developed case management to
  enhance services for Hispanic women
• Volunteer physicians, including faculty from the
  VCU Department of OB/Gyn provided prenatal care
  and ultrasounds
• REACH Community Health Advocates assisted
  patients with Emergency Medicaid applications
• VCUHS agreed to provide OB services
• Lab Corp provided free prenatal labs

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Outcomes

• 367 women have enrolled in CrossOvers Healthy
  Homes campaign since its inception
• Over 200 moms delivered babies at the VCUHS
• Over 70 of the mothers had their deliveries
  covered by Emergency Medicaid
• REACH received a March of Dimes grant to provide
  prenatal education classes in Spanish
• VCUHS provides IS link to CrossOver to
• access patient discharge summaries

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Moving Forward

• Perinatal Access Partnership for Non-Medicaid
  Eligible Women received Honorable Mention by the
  National Association of Public Hospitals and
  Health Systems for its 2005 Community and Patient
  Safety Award
• Virginia League for Planned Parenthood has
  implemented a prenatal program for Hispanic women
  utilizing the same model
• VCU Center of Excellence in Womens Health is
  researching opportunities to apply for national
  grants to support this partnership

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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

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University-based urban academic medical
centers. function most effectively and for the
greater good when 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.