Sheldon M. Retchin, M.D., M.S.P.H. Chief Executive Officer VCU Health System

1. Sheldon M. Retchin, M.D., M.S.P.H. Chief Executive Officer VCU Health System

2. The Commonwealth of Virginia Nearly 2/3 of counties are designated as medically underserved An estimated 15% of the population lacks basic health insurance

3. Who Are the Uninsured?

5. Uninsured Virginians Have Greater Unmet Needs 11.9% of the uninsured with fair/poor health are ~3X more likely to go without needed care as those in good/excellent health 25% report they went without needed care Health insurance is the single strongest factor that accounts for health disparities between whites and under-represented minorities

6. Facts about Uninsured Virginians Growing numbers Rising costs for uninsured and insured Problems with access to primary care and specialty services Increases in number of non-acute emergency room visits Impediments to access lead to lower health maintenance and disease prevention: Un-Healthy Virginians

7. VCU Health System Located in urban setting 779 Bed Teaching Hospital Level I Trauma Center Over 31,000 admissions Estimated 80,000 ED visits Over 500,000 Outpatient visits Major Safety Net Health System

8. 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

9. The Ecology of Safety Net Care

10. Emergency Room Visits for the Uninsured

11. VCU Health System Indigent Care Distribution

12. Pieces of the Puzzle VCUHS purchased Medicaid HMO in the mid 1990�s 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

13. Coordinated Care Programs for theUninsured from Across the Country Medicaid Managed Care: There is a concern that the transition to managed care would strain safety net providers� financial resources available to care for the uninsured. Many low-income individuals cycle in and out of Medicaid, so mgd care for uninsured was created in an effort to foster continuity Hospital Mergers: when community hospitals merge and used their increased leverage to compete for medicaid beneficiaries, public hospitals are challenged to come up with a model of care to compete Deregulation: Although not the case in Va., in Boston and NJ for example hosp rates were deregulated and safety net providers became uneasy that private hospitals would underbid them for health plan business and leave them with reduced revenue to subsidize charity care.Medicaid Managed Care: There is a concern that the transition to managed care would strain safety net providers� financial resources available to care for the uninsured. Many low-income individuals cycle in and out of Medicaid, so mgd care for uninsured was created in an effort to foster continuity Hospital Mergers: when community hospitals merge and used their increased leverage to compete for medicaid beneficiaries, public hospitals are challenged to come up with a model of care to compete Deregulation: Although not the case in Va., in Boston and NJ for example hosp rates were deregulated and safety net providers became uneasy that private hospitals would underbid them for health plan business and leave them with reduced revenue to subsidize charity care.

14. Coordinated Care Programs for the Uninsured from Across the Country

15. VCC Program Goals Utilize managed care principles to support a defined population Support financial screening process Establish Primary Care Physician centered care Establish community and specialist relationships to improve access Reduce the overall cost per unit of service Educate patients regarding appropriate mechanisms to access health care services Improve the health status and outcomes of the uninsured population: Healthy Virginians

16. Program Plan Identified patients residing in the designated service who qualified for the Commonwealth�s Indigent Care program Utilized existing Indigent Care program financial screening process to initiate enrollment Virginia Premier Health Plan became third party administrator minimizing administrative costs With completion of the financial screening process, enrollees given �membership card� and Member Handbook Intensive education begun through VPHP�s Member Services division regarding program benefits

17. VCC Target Population Service area chosen was the Greater Richmond Metropolitan Area Projected to enroll approximately 15,000 indigent patients Projected to cover approximately 38% of the uninsured patients seen at VCU Health System

19. 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: Elective Services such as plastic surgery or sterilizations VCC does not yet cover: Home Health Care Dental Services

20. Program Components VCC is NOT an insurance program VCC plans are based upon a sliding fee scale Over 70% of the VCC enrollees have 100% of their care covered The balance of the patients are required to pay co-pays for services: - $5 for Primary Care - $10 for Specialty Care - $50 for ER visits - $50 for diagnostic services such as X-ray�s

21. VCC Today: 4 years later 31 Community PCP�s and Specialists participate Developing contracts with Safety Net agencies to reimburse for services Requesting approval from CMS to utilize DSH funds to allow expansion Utilized Community Access Program grant to develop information system that identifies eligible VCC participants in community sites Enrollment continues to grow Community partnerships are reducing costs

25. Overall Costs Are Decreasing

26. Conclusion VCC partnership with community PCP�s has resulted in a reduction in the cost of primary care Transition of VCC patients to community practices has resulted in a change in the utilization of health care services: Less ER utilization for non-urgent care Improved access to primary care in community, combined with coordinated care programs, provide integrated health system for uninsured: Healthy Virginians

27. Uninsured Virginians have obstacles to effective health care access