1. Sheryl L. Garland, M.H.A. Vice President, Community Outreach VCU Health System November 28, 2005 Role of Academic Medical Centers In Safety Net Health Care Delivery Systems

2. Slide 2 Outline  Overview of Healthcare Safety Net  Role of the Academic Medical Center  Partnership Opportunities  OB Dilemma in the Greater Richmond Area

3. Slide 3 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.

4. Slide 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 “America’s Health Care Safety Net: Intact, but Endangered”, Institute of Medicine Report, 2000 10

5. Slide 5 The nation’s 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 (CHC’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.

6. Slide 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. Slide 7 Outline  Overview of Healthcare Safety Net  Role of the Academic Medical Center  Partnership Opportunities  OB Dilemma in the Greater Richmond Area

8. Slide 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. Slide 9 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 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. Slide 10 VCU Health System Part of Virginia Commonwealth University’s 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

11. Slide 11 VCU Health System 2000 Percentage of Entire Charity Care for the Commonwealth VHI Definition of Charity Care: Charity Care represents (unreimbursed) charges to individuals at 100% of the federal non-farm poverty level Sources: VHI 2000 Hospital Financial Data Report, VCUHS Financial Services, VCUHS Strategy & Marketing 34.2% 16.5% UVA 6.0% 6.2% 7.0% Carillion Sentara Inova Leading Providers of Charity Care

12. Slide 12 VCU Health System Indigent Care Distribution FY03 Budget $107.3M in Indigent Cost

13. Slide 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. Slide 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. Slide 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. Slide 16 Healthy with unmet needs Healthy with episodic needs Chronically ill The Ecology of Safety Net Care Acute hospitalization Catastrophic event Presentation: Governor’s Covering the Uninsured Conference, Dr. Sheldon M. Retchin, 2003 29

17. Slide 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

18. Slide 18 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

19. Slide 19 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. Slide 20 Number of Uninsured Patients Qualifying for the Indigent Care Program at the VCU Health System Number of “Indigent” Patients FY 2000 38.781 19.619 14.814 10.056 2.576 0.977 0.885 0.321 4.805 Total Full IndigCategory 1 VCC Eligible Richmond Henrico Chesterfield Tri-City Area Hanover Other Areas 0 10 20 30 40 50 Thousands

21. Slide 21 The VCC Service Area 33

22. Slide 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. Slide 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. Slide 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 36

25. Slide 25 Emergency Room Visits for Uninsured: Reason for Visit Visits = 30,273 FY2002 48% of visits could have been avoided

26. Slide 26 Emergency Room VCUHS Visits for the Uninsured DiagnosisVisits% Chest Pain 1,001 3.9% Abdominal Pain 1,346 4.9% Sprains and Strains1,567 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 39

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30. Slide 30 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

31. Slide 31 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

32. Slide 32 Outline  Overview of Healthcare Safety Net  Role of the Academic Medical Center  Partnership Opportunities  OB Dilemma in the Greater Richmond Area

33. Slide 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 43

34. Slide 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

35. Slide 35 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 44

36. Slide 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. Slide 37 HCA VCUHS Bon Secours Community Physicians CrossOver Ministries Daily Planet Craig Health Center Vernon J. Harris Health Center Free Fan Clinic RCDPH Greater Richmond Safety Net Health Care Providers 45

38. Slide 38 HCAVCUHS Bon Secours Community Physicians CrossOver Ministries Daily Planet Craig Health Center Vernon J. Harris Health Center Free Fan Clinic RCDPH Vision: Safety Net Health Care Delivery System Acute Patients Acute Patients Funding Support Funding Support Primary Care Access Acute Care Providers 52

39. Slide 39 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. Slide 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. Slide 41 Hayes E. Willis Health Center Community-based health center in South Richmond 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 49

42. Slide 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 50

43. Slide 43 Outline  Overview of Healthcare Safety Net  Role of the Academic Medical Center  Partnership Opportunities  OB Dilemma in the Greater Richmond Area

44. Slide 44 The OB Dilemma

45. Slide 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. Slide 46 Of the 890 Self Pay Mothers Over 36% reported receiving “late” prenatal care (after the 1 st 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. Slide 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. Slide 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 Commonwealth’s Indigent Care program

49. Slide 49 REACH Members Identified Issues Difficulty making appointments for prenatal care at area health departments No “free clinics” or FQHC’s in the region offering service Accessing care at VCUHS was problematic

50. Slide 50 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 L&D tours for Healthy Homes patients in 2004 Virginia League for Planned Parenthood began development of a Prenatal clinic for Hispanic women in 2005

51. Slide 51 REACH Perinatal Care Model ACCESS POINTS Health department Safety net providers Planned Parenthood Emergency department Private practices Community Initial Screening & RISK ASSESSMEENT (Coordinating Agency) Medicaid Eligible (Refer to Private Practice) Non-Medicaid Eligible Due to income or citizenship (Refer to Passport Program) Perinatal Passport Program Risk Assessment Clinical, perinatal services Medicine Laboratories Inpatient care (non-delivery) Care coordination/case management Specialty care Interpretation Transportation Emergency care Health education Family planning Social Service referrals Transfer of records to delivery site Assistance with Medicaid applications High Risk Assigned Care Coordinator Assigned OB Low Risk Assigned Care Coordinator Assigned OB Delivery Site Identified (Records Transferred Pre-Delivery) Mom Family support (e.g., Healthy Start) Family planning Health education Primary care home BABY FAMIS/FAMIS Plus Pediatrician

52. Slide 52 Estimated uninsured below 2x poverty by zip code 2000 Census

53. Slide 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

54. Slide 54 Outcomes 367 women have enrolled in CrossOver’s 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

55. Slide 55 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 Women’s Health is researching opportunities to apply for national grants to support this partnership

56. Slide 56 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

57. Slide 57 “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.