Sheldon M. Retchin, M.D., M.S.P.H.

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Virginia Coordinated Care for the Uninsured
Program

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

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The Commonwealth of Virginia

• 7.1 million people
• Approximately 30 of Virginians are below
  200 of the FPL

• Nearly 2/3 of counties are designated as
  medically underserved
• An estimated 15 of the population lacks basic
  health insurance

An Opportunity for Unprecedented Growth,
Virginia Primary Care Association, Sept. 2002
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Who Are the Uninsured?
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Unmet Health Care Needs Among the
Insured and Uninsured
Change from 1997 to 2001 is statistically
significant at plt.05. Source HSC Community
Tracking Study Household Survey
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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

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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

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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

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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

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The Ecology of Safety Net Care
Presentation Governors Covering the Uninsured
Conference, Dr. Sheldon M. Retchin, 2003
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Emergency Room Visits for the Uninsured
Diagnosis Sprains and Strains 7.1
Abdominal Pain 4.9 Chest Pain
3.9 Back Problems 3.7 Upper
Respiratory Infections 3.7 Dental
Services 3.6 Urinary Tract Infections
2.5 Headaches/Migraines 2.7
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VCU Health System Indigent Care Distribution
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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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Coordinated Care Programs for theUninsured from
Across the Country
Market Changes Spurring New Programs

• Medicaid Managed Care

• Hospital Mergers

? Of approximately 44 million uninsured, roughly
half are considered low-income, with
annual earnings of less than 200 percent of
the federal poverty level ?

• Deregulation

Source Center for Studying Health System Change,
Issue Brief January 2000
KCMU / Urban Institute
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Coordinated Care Programs for the Uninsured from
Across the Country
Managed Care Programs for the uninsured are
being established in communities across the
country as an innovative way to improve health
status and control costs

• Goals
• Provide more preventive care and
• primary services Healthy Virginians
• Manage the use of more expensive
• inpatient and emergency care

Source Center for Studying Health System Change,
Issue Brief January 2000
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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

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Program Plan

• Identified patients residing in the designated
  service who qualified for the Commonwealths
  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 VPHPs Member
  Services division regarding program benefits

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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

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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
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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

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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-rays

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VCC Today 4 years later

• 31 Community PCPs 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

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Annualized
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Overall Costs Are Decreasing
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Conclusion

• VCC partnership with community PCPs 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

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Uninsured Virginians have obstacles to effective
health care access
However coordinated care programs like VCC are a
vital sign for the uninsured to ensure that
they, too, are Healthy Virginians