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Virginia Medically Underserved Areas for General Assembly Consideration

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sherlockj
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by James C. Sherlock

We have a new General Assembly session. With that comes lots of healthcare bills.

I will not examine each one, but I have a suggestion for criteria to be applied by the Senate and House committees that do.

Ask yourselves how, if at all, each bill helps the federally designated medically underserved areas (MUAs) in Virginia.

Then ask how can any bill be a priority for funding ahead of those that do help that problem.

Then remember that providing primary care to underserved areas is proven to save a ton of Medicaid money net where it has been tried, as in Maryland, because of inpatient care avoidance.

Then ask the not-for-profit health systems that serve those areas to testify how, exactly, they can be medically underserved when that is what the health system tax exemptions are meant to prevent, and free cash flows have been extraordinary for decades.

And, finally, if you have no bills that help provide additional primary care to those areas, you aren’t doing it right.

Medically Underserved Areas. MUAs as defined by the Health Resources and Services Administration (HRSA) have a shortage of primary care health services within geographic areas such as:

  • a whole county;
  • a group of neighboring counties;
  • a group of urban census tracts; or
  • a group of county or civil divisions.

I have downloaded a list of MUAs in Virginia and sorted it by need. Need, or extent of under-service, is indicated by the Index of Medical Underservice Score in the spreadsheet. The lower the number, the higher the need.

You will find some surprises there. Bipartisan surprises.

The least served areas for primary care are the Cedar Mountain and Jefferson SubDivision Service Areas in Culpeper County with an index of 42.3. Areas with a score of 50 or less (very underserved) starting with those two rural sub-divisions of Culpeper County are (rural unless designated):

  1. Cedar Mountain and Jefferson Subdivision Service Areas in Culpeper County 42.3
  2. Greensville (entire county) 42.7
  3. Isle of Wight (entire county 42.9 (non-rural)
  4. Northumberland (entire county) 43.4
  5. Caroline (entire county) 43.8
  6. Buchanan (entire county) 46.8
  7. Mecklenburg (entire county) 47
  8. Clarke (entire county) 48
  9. Emporia City (entire city) 48.4
  10. Greene County (entire county) 48.8
  11. Norfolk (ten census tracts) 48.8 (non-rural)
  12. Patrick County (entire county) 49
  13. Brunswick County (entire county) 49.4
  14. Northwest Roanoke City (seven census tracts) 50 (non-rural)

While the full list needs help, I think some bipartisan support might be found to help provide additional primary care to at least those 14 areas. In total they probably have roughly equal numbers of Democratic and Republican voters.

HEZs. I have recommended before and will again a version of Maryland’s Health Enterprise Zones (HEZs).

They have proven to save a fortune in Medicaid costs every year far in excess of the costs of the HEZs by avoided inpatient costs.

Get the not-for-profit health systems to testify. Perhaps even Virginia’s tax exempt not-for-profit healthcare systems can pitch in both to support such a bill and help directly with the problem.

In addition to Culpeper, Emporia and census tracts in Norfolk and Roanoke, census tracts in Charlottesville, Lynchburg, Hampton, Chesapeake, Virginia Beach, Newport News, Chesterfield County, Albemarle County, Fauquier County, Arlington County, and Alexandria; additional tracts in Norfolk; and all of Petersburg, Danville and Franklin City made the list.

Last I checked, all of those except Fauquier County and Danville had not-for-profit hospitals.

I did not check for this article hospital service areas in all of the medically underserved rural counties, but many of them are served by non-profit health systems as well. Committee staffers can complete the list.

The General Assembly health committees may wish to inquire of those non-profits how there could be areas underserved by primary care in their service areas. Since that is what the tax exemptions are meant to prevent. And they have been making money hand over fist for decades.

Should be an interesting session. Hope I can tune in.

Bottom line. Just a couple of thoughts.

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Comments

31 responses to “Virginia Medically Underserved Areas for General Assembly Consideration”

  1. Paul Sweet Avatar
    Paul Sweet

    How do they define “lack of access to primary care services” – doctors per unit population, distance, travel time, percentage of uninsured, other?

    1. James C. Sherlock Avatar
      James C. Sherlock

      Medically Underserved Area Designation involves application of the Index of Medical Underservice (IMU) to data on a service area to obtain a score for the area.

      The IMU scale is from 0 to 100, where 0 represents completely underserved and 100 represents best served or least underserved. Under the established criteria, each service area found to have an IMU of 62.0 or less qualifies for designation as an MUA.

      The IMU involves four variables: ratio of primary medical care physicians per 1,000 population, infant mortality rate, percentage of the population with incomes below the poverty level, and percentage of the population age 65 or over. The value of each of these variables for the service area is converted to a weighted value, according to established criteria.

      The four values are summed to obtain the area’s IMU score.

      The spreadsheet has all IMU scores 62 or less in Virginia.

  2. Eric the half a troll Avatar
    Eric the half a troll

    “Ask yourselves how, if at all, each bill helps the federally-designated medically underserved areas (MUAs) in Virginia.

    Then ask how can any bill be a priority for funding ahead of those that do help that problem.”

    So you believe every healthcare bill should only be evaluated on how it benefits these counties…? Just trying to understand your position.
    https://uploads.disquscdn.com/images/8c0e1047e352c06c0c53b926a7efba68bfc1490986f23517a59c59c2c4774c98.jpg

    1. James C. Sherlock Avatar
      James C. Sherlock

      I did not use the work “only”, as you know. So try another question.

      1. Eric the half a troll Avatar
        Eric the half a troll

        … first and foremost…?

        1. James C. Sherlock Avatar
          James C. Sherlock

          The article answers that clearly.

    2. James C. Sherlock Avatar
      James C. Sherlock

      By the way, that list in the graphic is not up to date. I gave you the up-to-date federal designations, which are the only ones that matter.

  3. LarrytheG Avatar
    LarrytheG

    Here’s something else that is related to rural hospitals:

    https://uploads.disquscdn.com/images/038b67513e4ea4647a6c23c2dd1a7ff5f087a3d5d9af53847859d00317eef62c.jpg

    https://uploads.disquscdn.com/images/a67251870b6b6119dfe741bcc48a479d1138382281c9514c22218449a35e9bd9.jpg

    https://richmond.com/eedition/richmond/page-a1/page_3b6377b3-229e-5330-8805-319e13f88009.html

    Insurance companies will reimburse twice as much for a
    procedure in a less rural hospital than a rural one.

    ” Rural Virginia hospitals are lifelines in the communities they serve, and yet a third are at risk of closing within the next few years, according to national policy experts with the Center for Healthcare Quality and Payment Reform.

    The grim forecast is the result of years of battering economic winds faced by these hospitals, many of which attract too few patients to remain profitable, but enough to remain a necessary resource.”

    https://uploads.disquscdn.com/images/23dc75707c364e71797051e797ddc9eda70b11dd0ba5b94ed8eae0b0f3ec286a.jpg

    https://uploads.disquscdn.com/images/51625b01d0e5637e363b59238393c8656a0e908f722a4bd91afd392ff90cf65c.jpg

    1. James C. Sherlock Avatar
      James C. Sherlock

      We have 14 rural acute care hospitals and six designated critical access hospitals in Virginia.

      Eighteen of those 20 are parts of larger systems. In 2020, the last year for which we have numbers, five of the 20 lost money.

      Four of the five are parts of large, profitable systems that use them to funnel profitable cases that they can’t handle to the system medical centers. So they should be OK

      So we are left with one hospital of concern that stands alone and lost money. That was Buchanan General in Grundy. It is not a critical access hospital. I just checked. Buchanan is hiring.

      That doesn’t mean pressure is off, but Virginia’s remaining rural hospitals were in good financial shape generally at the end of 2020, the biggest COVID year.

      1. LarrytheG Avatar
        LarrytheG

        So what you are saying is in opposition to what The Center for Healthcare Quality and Payment Reform (CHQPR) is saying? Are you familiar with these folks? Have you read their report? Agree? Disagree?

  4. Carter Melton Avatar
    Carter Melton

    Expanded availability of nurse practitioners, PAs, and and ” comprehensive” telemedicine connectivity with a major medical center solves a lot of the problem.

    1. LarrytheG Avatar
      LarrytheG

      I agree and it ought to be a priority for Mr. Youngkin but it still does not address the rural hospital issues for people who do need a hospital.

  5. LarrytheG Avatar
    LarrytheG

    So here’s the question. Virginia is said to have a tremendous “surplus” and Youngkin wants big tax cuts.

    What should be done about this problem?

    Is this something Virginia should spend taxes on?

    How do we reconcile the cry for tax cuts with needs like this?

    Do we go ahead and cut taxes then try to figure out what to do about this?

    This is the problem with the myopic approach to tax cuts IMO.

    1. James C. Sherlock Avatar
      James C. Sherlock

      Neither of my suggestions costs state money. HEZs are a proven money saver. The not-for-profit health systems need to help fix these problems with their own money.

      1. LarrytheG Avatar
        LarrytheG

        DO HEZs solve the rural health care issues in Md?

        1. James C. Sherlock Avatar
          James C. Sherlock

          Yes.

          1. LarrytheG Avatar
            LarrytheG

            I’m looking at a map and don’t see any HEZs in western md. right?

          2. James C. Sherlock Avatar
            James C. Sherlock

            That would be an issue if the poorest rural areas were all in Western Maryland. They are not. Caroline County is the poorest. If you are looking at the right map, you will see Caroline County on the HEZ map in Eastern Md. Enjoyed talking to you. We have dinner guests coming.

          3. LarrytheG Avatar
            LarrytheG

            I see the two rural counties int he east but none in the west. Is Western Md not at issue?

          4. James C. Sherlock Avatar
            James C. Sherlock

            Look up the steps for getting to be part of and HEZ and see what is written there.

      2. LarrytheG Avatar
        LarrytheG

        ” The not-for-profit health systems need to help fix these problems with their own money.”

        That’s not really a viable answer, is it?

        Or if it is, then is it something govt should take the lead on and make happen, or just say it’s not the govt problem because the not-for-profits need to fix it?

        Should Youngkin advocate a tax on not-for-profit hospitals to be used to subsidize the rural hospitals?

        Seems like just blaming the non-profits is not really an answer.

        1. James C. Sherlock Avatar
          James C. Sherlock

          Of course it is a viable answer, Larry.

          The GA leadership can tell them if they don’t fix it, the state will tax them and use their money to fix it.

          1. LarrytheG Avatar
            LarrytheG

            like they did with the Medicaid Expansioni?
            😉
            Is there a bill?

          2. James C. Sherlock Avatar
            James C. Sherlock

            The hospitals helped pay for Medicaid expansion and made a billion dollars net of their contributions from it in the first year.

          3. LarrytheG Avatar
            LarrytheG

            here’s a NYT Editorial that supports your position: https://www.nytimes.com/2020/02/20/opinion/nonprofit-hospitals.html?unlocked_article_code=Wy3o8ZrZjztQMqbgf007XSs4vXIMnR2HVhtAKzO6GORqeq8tH0KQ7qPjv8IsaVs6TFV3M3GqdLiCLO3Oxc2z-LkINYxwcfs8Qy6wWuZmVAoLUTplFg9CiyScmpUlSeXAODPq9_MHkJAT1BoqsXJLgvnFvGCY4tFeBaIOieO-i6vl8RomKDzdPn1zs0WQgonEWXdlQQZjEp7i9dEPQUDc_nI9Mg-EF0VzoXE_qBSZRzgZNuWVxH6vs0NmQUcEBJPriQ4SUukBplhdSyPLZ2czw6lJJHiiyQ8kTwpKkGntlWwvylCOFOAi6nKtRcVUX3OydruCRYcuDZW2UhIYgw&smid=share-url

          4. LarrytheG Avatar
            LarrytheG

            You’ve overcome some of my skepticism, not all.

            From what I read Marylands, HEZs do work and save the state money but I presume there are incentives the state provides.

            On the tax on the not-for profit hospitals to pay for rural, one would have to be convinced that the “profit” these hospitals are getting is not already being plowed back into charity or community services so I’d have to be convinced that the “profits” instead go for more/higher paid administrative/corporate . Need to see that data.

            Finally, I don’t think the private sector is going to fix the rural hospitals and health care issues, it falls to govt to deal with it.

            Are there any states that effectively deal with it? I don’t think HEZs will fix the rural hospital problem. They hospitals are already heavily subsidized and they’re still in danger of closing down if they don’t cut staff or services which, in turn, harms rural access to those services.

          5. James McCarthy Avatar
            James McCarthy

            Taxing a not for profit will never pass federal court muster. You’re dreaming.

      3. James McCarthy Avatar
        James McCarthy

        Hospitals are skilled at manipulating treatment codes to pass costs onto insurance carriers. It ain’t their money!! It’s Uncle Sam’s or premium $$$$$.

        1. LarrytheG Avatar
          LarrytheG

          I’ve noticed at the hospital that I have had some work done that if after the reimbursement calculation is done, if there is a balance, they then add a line that says “discount” and the balance due line goes to zero.

          I don’t know that they do that for everything no matter the cost but at least for two procedures, that’s what they did.

        2. Nancy Naive Avatar
          Nancy Naive

          Do you mean things like this?

          https://www.kellergrover.com/medicare-advantage-fraud/?gclid=EAIaIQobChMIt7nFtZ_J_AIVBrbICh331Ae2EAAYAiAAEgJkpPD_BwE

          And that’s just one… one you’ve never heard of, and there’s a thousand just like ‘em.

  6. Nancy Naive Avatar
    Nancy Naive

    Can’t help thinking about “Northern Exposure” whenever someone suggests HEZs. Forgiving student loans for service in zone seems like such a good idea.

    Maybe a State owned facility staffed up with medical school loan escapees.

    Nah, that could lead to medical failures like found in, oh, Scandinavian countries, or South Korea.

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