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Virginia Coordinated Care for the Uninsured (VCC) Program

Presentation to the Senate Finance Committee’s Subcommittee on Health and Human Resources

January 27, 2014

Sheryl L. Garland, MHA

Vice President, Health Policy and Community Relations

VCU Health System

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THE VCU MEDICAL CENTER

VCU HEALTH SCIENCE SCHOOLS Allied Health Professions Dentistry Medicine Nursing Pharmacy

VCU HEALTH SYSTEM MCV Hospitals Children’s Hospital of Richmond MCV Physicians Virginia Premier Health Plan

More than 15 affiliated centers and institutes, including the VCU Massey Cancer Center, Virginia’s first NCI-designated cancer center

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VCU Health System is a Major Regional Referral Center for Virginia and the mid-Atlantic

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VCUHS is the largest Safety Net Provider in the Commonwealth

Indigent Care Cost in $

67,400,000 to 67,500,00017,100,000 to 67,400,0003,600,000 to 17,100,0001,250,000 to 3,600,000

10,000 to 1,250,0001 to 10,000

Distribution of Indigent Care Funds

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Strategy needed to manage the care of the uninsured

• High volume (over 60%) of Emergency Department visits for the uninsured were for primary care treatable conditions

• Need to control the cost of care for the population

• “Social Determinants of Health” impacting health outcomes

• Disproportionate percentage of vulnerable patients served

74% uninsured orgovernment sponsored

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Medicaid/ Uninsured

49%

Medicare25%

Commercial26%

Source of Patients by PayerFY13

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Virginia Coordinated Care for the Uninsured (VCC)

• Established in the Fall of 2000 

• Vision:  utilize managed care principles to coordinate health care services for a subset of the patients who qualify for the VCUHS Indigent Care program 

• Target population: uninsured in the Greater Richmond and Tri‐Cities areas

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Program Goals

• Establish medical homes with community‐based primary care providers

• Improve the health of the uninsured population

• Enhance the patient care experience

• Reduce the per capita cost of care delivered

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VCC Enrollment Criteria

• Patients who qualify for the VCUHS Indigent Care program

• At or below 200% FPL

• U.S. Citizen

• Reside in Virginia

• Asset test

• Additional criteria

• Live within the VCUHS Primary Service Area

• Uninsured

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Program Model• Virginia Premier Health Plan serves as the program’s Third Party 

Administrator 

• VCUHS Financial Counseling staff conduct financial screening

• VCC Care Coordination staff conduct health assessments to determine level of interventions needed

• Patients are enrolled for a 12‐month period

• Community‐based private practices and safety net providers provide medical homes

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Program Model• Primary care provider reimbursement 

– 110% of Medicaid rates  + $5.00 PMPM Care Management Payment (private practices only)

– Funding provided from VCUHS operating margin (no DSH)

• Indigent Care funding is used to cover inpatient, outpatient, and Emergency Department services provided at VCUHS 

• VCC Care Coordination staff provide case management and patient navigation support  

– Nurse case managers, Social Workers, and 

Outreach Workers 

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VCC Population• Over 80% of the population is below 133% FPL

• Approximately 70% of the patients are minorities

• 52% are females; 59% are between 40‐64 

*Conditions represent primary and secondary diagnoses from MCV Hospital, MCV Physician, and VCC Claims. Prevalence rates presented for each condition and do not add to 100%

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VCC Enrollment Trends

0

5,000

10,000

15,000

20,000

25,000

30,000

35,000

FY2001

FY2002

FY2003

FY2004

FY2005

FY2006

FY2007

FY2008

FY2009

FY2010

FY2011

FY2012

FY2013

*Cumulative Enrollees are accumulated throughout the Fiscal year;

Changed VCC enrollment criteria in November 2011

Num

ber

of E

nrol

lees

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VCC ED Visits per 1000 Enrollees

1034985

935

844

967928 919

866 878

691652 657 613

0

200

400

600

800

1,000

1,200

FY

2001

FY

2002

FY

2003

FY

2004

FY

2005

FY

2006

FY

2007

FY

2008

FY

2009

FY

2010

FY

2011

FY

2012

FY

2013

Note: Enrollment criteria for the VCC changed in November 2011

ED

Vis

its/1

000

Enr

olle

es

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VCC Inpatient Discharges per 1000 Enrollees

220 225239 237

197

177 181

131

164

117 121 121111

0

50

100

150

200

250

300

FY

2001

FY

2002

FY

2003

FY

2004

FY

2005

FY

2006

FY

2007

FY

2008

FY

2009

FY

2010

FY

2011

FY

2012

FY

2013

Note: VCC Enrollment criteria changed in November 2011

Dis

char

ges/

1000

Enr

olle

es

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Continuous Enrollment Yields Positive Outcomes

38% reduction

45% reduction

One Yr Enrollment

One Yr Enrollment

Multiple Year Enrollment

Multiple Year Enrollment

Continuously Enrolled

Continuously Enrolled

Vis

its/Y

ea

rD

isch

arg

es/

Ye

ar

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Bradley, C, Gandhi, S, Neumark, D, Garland, S, Retchin, S, Lessons For Coverage Expansion: A Virginia Primary Care Program For the Uninsured ReducedUtilization And Cut Costs, Health Affairs 31, No. 2 (2012): 350-359

Reductions in costs were also achieved 

$-

$1,000

$2,000

$3,000

$4,000

$5,000

$6,000

$7,000

$8,000

$9,000

Year 1 Year 1 Year 2 Year 3 Year 1 Year 2 Year 3

$6,833

$7,604

$5,768

$4,726

$8,899

$6,106

$4,569

Multiple Year Enrollment Continuously EnrolledOne Yr Enrollment

VCC PopulationAverage Cost/Year

(2000 – 2007)

Ave

rage

Co

st/Y

ea

r

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Virginia Coordinated Care for the Uninsured

• Provides “medical homes” to over 23,000 patients who qualify for VCU Health System’s Indigent Care program (below 200% FPL)    

• Has reduced costs and utilization for an uninsured population

• Partnered with 50 community‐based physicians to improve access and quality of care

• Recognized as a model for managing care for uninsured patients

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Lessons learned that may inform coverage programs for the uninsured in the future

• Managing care for the uninsured can reduce costs and  inappropriate use of services; but it takes time

• Incorporating care coordination into a model of care is critical to assist patients and providers

• Adequate reimbursement rates are needed to sustain a comprehensive provider network

• Patient‐centered interventions that address the unique needs of patients improve outcomes– Access to behavioral health services

– Health literacy initiatives (ie, education regarding when to use the ED)

– Address social determinants of health (ie, transportation, etc.)

– Risk stratification strategies to support ”right care, right place, and right time”

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