As Chief Administrative and Financial Officer, I write on behalf of Virginia Commonwealth University Health System Authority (VCU Health System).  We appreciate the opportunity to comment and express our concerns related to the Department of Medical Assistance Service’s Notice of Intent to Amend the State Plan – Avoidable ER Claims and Hospital Readmissions.

VCU Health System is the academic health system for Virginia Commonwealth University, one of the Commonwealth of Virginia’s premier public research universities. VCU Health System’s mission – as informed by the Code of Virginia – is to preserve and restore health for all people in Virginia and beyond through innovation in service, research, and education. VCU Health System is also the Commonwealth’s largest safety net provider, delivering comprehensive, compassionate care to all patients regardless of insurance status.

VCU Health System’s role as an urban academic medical center, safety net provider, and research institution has assumed added significance in response to the COVID-19 public health emergency. Since the crisis began, VCU Health System has repurposed hospital beds and other resources to prepare for a potential surge in cases, provided life-saving care to severely ill COVID-19 patients, and conducted clinical trials to study the effect of remdesivir on the virus, all while continuing to meet its safety net obligation.

Particularly in light of the significant number of Medicaid patients we serve, we continue to have serious concerns regarding the 2020 Virginia Acts of Assembly, Chapter 1289, Item 313.AAAAA and Item 313.BBBBB. These items stem from the misguided premise that hospitals are not adequately incentivized to reduce avoidable emergency department (ED) visits or hospital readmissions. In reality, VCU Health System invests a great deal of resources to prevent these events. We rely on hospital- and clinic-based social workers and community outreach staff to identify and resolve non-clinical patient issues (e.g., social determinants of health) that may trigger an avoidable ED visit or hospital readmission. We collaborate with community primary care providers, federally qualified health centers, and free clinics to promote regular medical homes for every patient. Just last month, VCU Medical Center launched a telehealth urgent care line, allowing individuals to be remotely treated on-demand by an ED-based provider.  We have also implemented a pilot program with several local EMS agencies to provide virtual clinical support to EMS providers when rendering care on the scene, in turn ensuring that only the most urgently ill patients are transported to our ED.

From a readmissions perspective, we diligently conduct follow up phone calls to discharged patients to ensure that they are adhering to discharge instructions and any prescribed medications.  Additionally, we meet monthly with partner nursing facilities, home health agencies, the local Long Term Acute Care Hospital, and other community partners to discuss readmissions and any issues or concerns that the post-acute facilities may have.  We have also implemented a 24 hour, 7 day week Nurse Navigation Center designed to navigate high risk or complex patients after a hospital discharge.  They utilize a variety of tools intended to enhance patient outcomes and reduce avoidable hospital readmissions, such as equipment sent to the patient’s home to monitor vital signs, telehealth visits, phone calls, and home based medical care, medication assistance, or health coaching as needed.

VCU Health System ardently believes that addressing patients’ needs outside the hospital is critical to preventing avoidable ED visits and hospital readmissions. However, hospitals should not singularly bear this burden.  Despite our many concerted efforts to engage patients and other care providers, as detailed above, we cannot solely prevent all inappropriate ED visits and/or readmissions.  Accordingly, we urge the agency to consider how other health care stakeholders, including Medicaid Managed Care Organizations (MCOs) can assist, noting that many of the investments described above are not currently MCO-reimbursable services.  Currently, there are multiple pilots underway in the Commonwealth with the goal of reducing waste and low value care.  VCU Health System is an active participant in several of these endeavors, and we believe that these initiatives will ultimately have a more significant impact on the overall cost of care, given the higher correlation to increased costs.

Thank you again for the opportunity to comment.  We stand prepared to assist the Commonwealth in identifying innovative ways to ensure that equitable, high quality and cost effective care is made available to all Virginians.

Sincerely,

Melinda S. Hancock