Virginia is a Medicaid expansion state that has taken steps to address high and varied health costs by creating an all-payer claims database (APCD) that tracks trends in costs and utilization of healthcare services, provider and health plan comparisons and population health. The APCD is maintained by the Virginia Department of Health and includes medical and pharmacy claims data for roughly 4.5 million residents with coverage through the commercial market, Medicaid and Medicare. Given that low-value care can contribute to waste, patient harm and high healthcare costs, the Virginia Center for Health Innovation used 2017 claims data from the APCD to identify more than 2 million unnecessary services costing $747 million.
Virginia is a leading state in the Southeast region for overall health system performance, according to the Commonwealth Fund. This score is based on measures of access and affordability, prevention and treatment, potentially avoidable hospital use and cost, and health status and healthy behaviors. However, the state did perform poorly on other measures: adults with mental illness reporting unmet need; breast cancer deaths; high out-of-pocket medical spending and potentially avoidable emergency department visits. Additionally, Virginia ranked second in the nation, behind Oregon, for hospital patient safety in 2019. Fifty-three percent of the state’s hospitals received an “A” grade from Leapfrog Hospital Safety Grade.
In 2016, Virginia developed a State Innovation Model Health Improvement Plan calling for Accountable Care Communities in Virginia to improve healthcare quality, improve the health of populations and reduce the per capita cost of healthcare. A two-year progress report indicated that the state has already made improvements to or met 2020 goals for certain Plan for Well-Being measures, but is worse off (compared to the 2016 baseline) for others.
Over six years ending in June 2018, the University of Virginia Health System and its doctors sued former patients more than 36,000 times for over $106 million, seizing wages and bank accounts, putting liens on property and homes and forcing families into bankruptcy, a Kaiser Health News and Washington Post analysis has found. Uninsured patients are left to cover bills that are sometimes twice what a commercial insurer would have paid due to insurer discounts and negotiated rates. Under a Virginia program designed to help state and local governments collect debt, the health system also seized $22 million in state tax refunds to patients with outstanding medical bills in the last six fiscal years — most of it without court judgments, in addition to billing them for legal costs and interest on their unpaid bill. This nonprofit hospital system offers charity care and other community benefits to patients, but savings of only $4,000 in a retirement account can disqualify a family from aid, even if its income is barely above poverty level. Health system representatives have defended themselves, stating that suing patients and using collections agencies are last resorts. Contributing to the problem, standards for community benefit requirements are vague—the American Hospital Association merely requires hospitals to have a financial assistance policy and make “reasonable efforts” to determine whether a patient qualifies before initiating collections.
A survey of Virginia adults found that more than half of Virginia adults had problems affording healthcare during the last year, according to Virginia Business. Altarum’s Consumer Healthcare Experience State Survey also found that 78 percent of respondents worry about affording healthcare in the future. Data revealed that there was high support for government-led change crosses party lines. The top three healthcare priorities respondents want to see action on are addressing high costs (55 percent); preserving consumer protections (36 percent); and getting health insurance to those who cannot afford coverage (35 percent). The majority of respondents, regardless of political affiliation, indicated they supported government action to make it easier to switch insurance (89 percent); and requiring up-front patient cost estimates from healthcare providers (88 percent) and insurers (90 percent). Advocates agree that even with Medicaid expansion, healthcare affordability is still a top issue for all Virginians.
Using a $2.2 million grant from Arnold Ventures, the Virginia Center for Health Innovation (VCHI) is launching a statewide pilot to reduce the use of low-value services, according to Health Data Management. In 2012, the American Board for Internal Medicine identified 550 tests and procedures as having a low value. Accessing insurance claims data, VHCI looked at 42 measures for 5 million patients using a health-waste calculator and found more than 2 million unnecessary services, costing approximately $747 million. The pilot will be implemented across 900 clinical sites in Virginia and will involve an employer task force on low-value healthcare. VCHI will initially focus on providers and seven sources of low-value care and then will expand to include a set of consumer-driven measures.
The Virginia Department of Medical Assistance Services has asked the governor to include $19.1 million in his budget proposal to boost Medicaid reimbursements for primary care doctors in order to prevent a physician shortage, according to the Richmond-Times Dispatch. With Medicaid expansion set to begin on January 1, state legislators are concerned about the widening gap between reimbursement rates to doctors in Medicaid and those in Medicare and inconsistent access to care under the Medicaid program. For the current fiscal year, Medicaid reimbursement was 71 percent of the rates paid by Medicare. The state expects to enroll 360,000 people under expanded Medicaid eligibility.
An analysis from the Catalyst for Payment Reform, the Virginia Center for Health Innovation and the Virginia Association for Health Plans found that 67 percent of healthcare payments to Virginia physicians and hospitals by commercial insurers in 2016 were tied to value. The report was based on an examination of data from commercial and Medicaid managed care plans insuring 4.6 million Virginians. Other key findings include: 80 percent of value-oriented commercial insurer payments were in hospital contracts, 41 percent of value-based Medicaid managed care payments were in primary care, and the most commonly used value-based payment model was Shared Savings.
According to a report by Virginia Health Information (VHI), healthcare costs vary dramatically depending on where consumers live, highlighting the need for local cost of care information. For example, a colonoscopy in 2016 averaged as little as $1,075 in Southwest Virginia physician offices and as much as $2,940 in Central Virginia hospitals, according to Augusta Free Press. In a 2017 national report card published by Altarum, Virginia was just one of six states earning a passing grade in pricing transparency.
Virginia and Tennessee have issued certificates of public advantage (COPAs), a legal mechanism through which states can approve mergers that reduce or eliminate competition in return for commitments to make public benefit investments and control healthcare cost growth, according to the Milbank Memorial Fund. The report describes Virginia and Tennessee's experiences after they used their COPA laws to approve a large health system merger that spanned the states' border. While it’s too early to know what will happen as a result of these states’ COPA decisions, state health policymakers and other stakeholders can learn from Tennessee and Virginia as they address future proposed hospital system mergers.
Virginia has submitted a 1115 waiver application that would add work requirements, premiums and emergency department co-pays to beneficiaries above the federal poverty level to their expanded Medicaid program, according to Modern Healthcare. Under the waiver proposal, eligible Medicaid enrollees would need 20 hours per month of work-related activities for the first three months that they're eligible for the program, which would gradually increase to 80 hours per month. The state also wants permission to impose a monthly premiums for beneficiaries above the federal poverty level, assessed on a sliding income scale.
After premiums in Charlottesville, Virginia, rose more than 300 percent in 2018 and became the most expensive in the country, advocates successfully challenged Optima and state regulators about how premiums were set, according to The Washington Post. As a result of their efforts, the city’s rates are coming back down ahead of open enrollment for 2019 and Anthem has decided to reenter the Virginia market. The group of consumer advocates also helped pass legislation to allow solo entrepreneurs to purchase health insurance on the small-group market.
The percentage of people in Virginia’s far southwest region—one hit hardest by the opioid crisis, poverty and unemployment—receiving treatment for opioid abuse rose from 67 percent in 2016 to 73 percent by April 2018. According to FierceHealthcare, the state launched the Addiction and Recovery Treatment Services (ARTS) Medicaid benefit last year, which will be accessible to more people now that Virginia is expanding Medicaid. State leaders found that counties with the highest rates of ‘deaths of despair,’ or ones from overdoses, suicides, or alcohol-related conditions, were among those with the highest number of people in poverty or with lowest high school graduation rates. For that reason, state Health and Human Resources representatives have re-characterized them as “deaths of disparity.” A Commonwealth Fund report found that these deaths increased by over 50 percent in the past decade. More understanding is needed to address disparities contributing to deaths, especially as Virginia rolls out Medicaid expansion.
Virginia has launched a single, statewide Emergency Department Care Coordination (EDCC) program to connect 129 hospital emergency departments across the state, allowing physicians to access patient records and tap into the state’s prescription monitoring program in order to control emergency department utilization costs and direct patients to the appropriate care provider. According to FierceHealthcare, Virginia began working on the EDCC program last year as part of legislation to redirect patients to the appropriate care setting, including lower-cost telehealth visits and clinics, as opposed to expensive EDs. The total budget for the program for fiscal year 2018 is $3.9 million, for which the federal government is chipping in $3.5 million in HITECH Act funding.
Virginia has launched a single, statewide Emergency Department Care Coordination (EDCC) program to connect 129 hospital emergency departments across the state, allowing physicians to access patient records and tap into the state’s prescription monitoring program, according to FierceHealthcare. Virginia began working on the EDCC program last year in an effort increase care coordination and to control ED utilization costs and direct patients to the appropriate care provider, including lower cost telehealth visits and clinics. The total programing budget for the program for fiscal year 2018 is $3.9 million, of which the federal government is chipping in $3.5 million in HITECH Act funding.
Virginia Gov. Ralph Northam has signed a new state budget that expands Medicaid to as many as 400,000 low-income adults. According to U.S. News & World Report, the General Assembly voted to expand access to Medicaid last week, ending a long-running partisan stalemate on the issue. Virginia will become the 33rd state to approve Medicaid expansion.
Most plans on the individual insurance market are likely to see steep price increases next year, with one going up nearly 85 percent. Doug Gray, executive director of the Virginia Association of Health Plans, stated that the most immediate reason for rising costs is President Donald Trump’s decision to cut cost-sharing reduction payments after Congress failed to repeal the Affordable Care Act, according to Richmond Times Dispatch. Virginia legislators expressed dismay at the rising prices and blamed them on the Trump administration’s actions. Gray added that the insurance rates also reflect the rising cost of hospital stays and prescriptions, among other things.
Medicare data was added to Virginia’s All-Payer Claims Database (APCD), which can be used to inform decision-making focused on improving the healthcare delivery system, according to a press release from the Virginia Hospital & Healthcare Association. The database now includes information from federal health insurance plans such as Medicare, some commercial health insurers, healthcare subscription plans, health maintenance organizations, some third-party administration submissions, pharmacy benefits managers, and the Virginia Department of Medical Assistance Services (DMAS). The APCD’s purpose is “to facilitate data-driven, evidence-based improvements in access, quality, and cost of healthcare and to improve the public health through understanding of expenditure patterns and operation and performance of the healthcare system.”
An analysis of 44 low value healthcare services in the Virginia All-Payer Claims Database revealed more than $586 million in unnecessary costs in 2014. The study found that low value, low cost services drove the bulk of wasteful spending, accounting for nearly twice the spending as low value, high cost services. Researchers assert that strategies to reduce waste should focus on low value, low cost services, as they are less controversial than low value, high cost services and can have a sizable impact on reducing unnecessary healthcare spending.
Virginia has been picked as one of three states for Catalyst for Payment Reform's (CPR) state scorecard which will analyze how well health-care payment reform is working, according to an article in Virginia Business. Virginia Scorecard 2.0 will be co-sponsored at the state level by the Virginia Center for Health Innovation (VCHI) and the Virginia Association of Health Plans. Scorecard 2.0 will measure how much payment reform there is in Virginia, as well as what type, as well as the impact that payment reform is having on the healthcare system. To calculate the healthcare system impact, CPR has added 12 metrics to the Scorecard that, together with the original measurements, gauge the economic signals that insurers are sending to health-care providers, how the health-care system is changing and whether there is an impact on outcomes.
The Federal Trade Commission (FTC) recommended Virginia regulators reject the proposed merger of two large regional health systems. according to Modern Healthcare. FTC official Mark Seidman said the deal would cause an anticompetitive healthcare climate in the state, leading to higher prices and lower quality of care for patients.
Hospitals must provide a payment estimate for scheduled elective procedures, tests, or services to patients who request it at least three days in advance of a schedule service, according to the Virginia Chapter of the American Association of Healthcare Administrative Management. The law, which went into effect July 1, 2016, aims to improve price transparency of medical services. The new law shouldn’t be too burdensome for providers, given that patients must request the information, according to an article in the Journal of Health Care Finance.
Low-income and at-risk populations often need services and support outside the scope of a single state agency in order to live productive, healthy lives, according to a NASHP report. State health policymakers could learn how to combine funding streams to meet health and social needs by using Virginia’s Children’s Services Act as a guide.
Modern Healthcare reports that Virginia submitted an 1115F managed care waiver. If approved, the waiver will transition blind, elderly and disabled people into capitated health plans. It will also enable the state to use federal Medicaid funding to create financial incentives for providers to pursue delivery-system reforms, including infrastructure development, system redesign, and clinical-outcome and population-focused improvements.
Virginia Health Information (VHI) analyzed health waste within Virginia using the MedInsight Health Waste Calculator. VHI reported the amount of wasteful spending by geographic region and compared it to the state average. For 43 measures, the report shows service use and spending by geographic region.
The Washington Post reports that Virginia's certificate-of-public-need law, which requires the state health commissioner's pre-approval for hospital expansions, surgery centers and certain medical services, will likely be at the center of a partisan showdown in the upcoming legislative session.
Mathematica Policy Research found that the National Capital Region, which includes Virginia, has a complex hospital market with multiple overlapping submarkets. The hospital sector, especially in Northern Virginia, is characterized by significant geographic segmentation. In addition, fee for service is still dominant, and accountable care organization activity is nascent and scattered.