Health In Our Commonwealth

SETTING STRATEGY: POPULATION HEALTH FOR THE 21ST CENTURY

Virginia’s Health and Human Resources Secretary oversees 12 agencies that provide critical planning, program and oversight to Virginia’s health and social services system. Unfortunately, there often is a lack of coordination amongst agency functions. When agencies and partners are provided conflicting or duplicative directions from the Governor, Cabinet Secretary, General Assembly or federal government, they are not able to effectively serve the best interests of Virginians. Virginia’s health and human resources functions need a reset and a long-term strategy.

As governor, Ed will direct his Secretary of Health and Human Resources to establish a strategic plan for population health known as “ HEALTH IN OUR COMMONWEALTH.” This plan will be more than the typical agency or secretariat strategic plan. Rather, the Administration will partner with the Virginia Chamber’s Blueprint 2020 project, leaders in academia, healthcare stakeholders and internationally recognized health research organizations to chart a course for a healthier Virginia. This process will provide once-in-a-generation leadership to bring institutions and organizations together after nearly a decade of uncertainty.

The HEALTH IN OUR COMMONWEALTH Strategy will:

• Elevate and standardize metrics. Include agreed upon metrics, enhanced transparency, management, program and operations objectives.
  Delineate budgets beyond agency. In order to fully explore efficiencies and improve resource delivery for high-need programs, Ed will capture a view of state budgeting beyond agency lanes and into issue categories. For example, a family may receive TANF benefits, WIC benefits and Medicaid services — requiring their interaction with the Department of Social Services, Department of Health, and Department of Medical Assistance Services. We can capture a picture of resources beyond the single agency view. This will help in setting long-term strategy, making resource decisions, and preventing fraud and abuse to focus resources where they are needed.
• Set Strategy Beyond Four-Year Increments. In order for Virginia to improve outcomes, provide clarity and increase partnership with stakeholders, we must put forward a long-term strategy that sees beyond one single four-year term of office. This will include budgeting and program reforms.
• Put the Patient at the Center. If we agree to put the patient at the center of our approach, we can empower Virginians and their doctors to do what is in the best interest of the patient.
• Formal Public-Private Partnerships. Virginia should advance formal public-private partnerships to deliver healthcare more effectively.

BENDING THE COST CURVE

Establish a Health Economics Unit in the Legislative and Executive Branches

In order to properly incentivize providers, patients and payers, Ed will advance Virginia as a health economics leader. This will properly compel state and private sector investments in areas that are most likely to bend the cost curve.

The Health Economics function will be a joint legislative-executive organization that will operate within a public-private partnership in higher education, but have a physical presence on Capitol Square. Universities and private partners will be invited to put forward proposals to establish the health economics unit within the transition period for funding and approval during the 2018 General Assembly session.

Transparency for Patients

The rising cost of health care is a problem facing all Virginians. The complexity of Virginia’s health care system and insurance coverage has grown along with its cost, making it difficult for consumers to have a clear understanding of the true cost of the care they receive.

Ed believes Virginia’s health care system should be more transparent to ensure all Virginians have access to clear information regarding the costs of their care so they can make informed decisions regarding the services and treatment they receive. As a matter of policy: Virginians should clearly understand their expected out-of-pocket costs prior to receiving care, with the exception of life saving trauma care.

One of the ways to increase transparency for patients is to enact consumer protections to reign in “balance billing” practices here in the Commonwealth. As one study said: “When obtaining care at emergency departments and in-network hospitals, patients treated by an out-of-network provider may receive an unexpected ‘balance bill’ for an amount beyond what the insurer paid.” Oftentimes patients find themselves in these situations, such as when an out-of-network specialist is brought in during a procedure at an in-network provider. The patient is not informed at the time care is rendered that the insurance company will not cover the services of the out-of-network provider and the patient will have to bear the cost. A recent study by the Kaiser Family Foundation found that “among insured, non-elderly adults struggling with medical bill problems, charges from out-of-network providers were a contributing factor about one-third of the time.”

Currently, 21 states have protections against balance billing practices. As governor, Ed will work collaboratively with the General Assembly to find a solution for the Commonwealth.

Insurance Competition Across State Lines

Currently healthcare insurance companies are unable to sell their products across state lines. This market-limiting approach makes healthcare insurance more costly by not allowing for greater competition.

As governor, Ed will work with payors, the Bureau of Insurance, and the General Assembly to craft and pass legislation permitting Virginia to enter into a compact with surrounding states to sell healthcare insurance across state lines. Virginia and our surrounding states can work together to develop protocols to ensure mandated benefits in states are offered. More consumer choice will lead to lower costs and happier, more empowered patients. An additional problem is establishing provider networks and reimbursement contracts in the new states in which they are selling policies. Ed has talked to governors about this and they are open to such an agreement.

Incentivizing Consumers to Price Shop

During the 2017 legislative session Delegates Scott Garrett and John O’Bannon provided leadership to add language to the 2016-2018 Budget to direct the Department of Human Resource Management (DHRM) to “identify the requirements, costs, and benefits of implementing a shared-savings incentive program for state-employed, public sector or retired enrollees who elect to shop and receive health care services at a lower cost than the average price paid by their carrier for a comparable health care service. Under such a program, the Department shall develop a plan to reimburse the insured for using a lower cost site of service. The cash payment incentive could be calculated as a percentage or as a flat dollar amount, or by some reasonable methodology determined by the Department.”

As governor, Ed will direct his Secretary of Health and Human Resources to review the DHRM report that is scheduled to be submitted to the Joint Money Committee leadership in November 2017. This type of innovative approach will help bend the cost curve in healthcare and benefit our hard working state employees.

INCREASING ACCESS

Certificate of Public Need (COPN)

Reform  Virginia’s current COPN program needs significant and meaningful reform. Reducing unnecessary regulations will remove uncertainty, encourage investment, and improve access to care. Virginia patients will directly benefit from these reforms, which will empower health professionals to offer more choices for where to receive health care services.

With that said, while choice and competition are positive factors, we must acknowledge that healthcare is not a pure free market, and recognize the important role hospitals and other providers play in the delivery of quality services and a strong health care safety net in communities across Virginia. When we reform our COPN laws, we need to include significant and equitable charity care requirements for providers to ensure balance in serving this need.  We must also work to prevent waste and abuse by discouraging overutilization and unnecessary costs for patients by limiting self-referrals and other measures. As governor, Ed will advance meaningful COPN reform by working with stakeholders to improve access, lower costs, and protect our most vulnerable.

Increase the Number of Residency Programs Offered

Virginia has made great strides in recent years to expand the number of medical schools training physicians. We need to do more to ensure those physicians are able to remain in Virginia. Research shows that medical professionals will often settle in the states where they most recently trained. The next step in ensuring Virginia has access to providers is to ensure we have the second and final step in a physician’s training available in Virginia. Currently, Virginia suffers a net export of at least 353 medical students a year to out of state residencies. This accounts for 39 percent annually. Virginia needs to keep its medical residents in the Commonwealth and stop being a net exporter of medical residents.

Expand Micro-Hospitals 

Ed will work to encourage micro-hospitals across Virginia’s rural localities. While small, often 8-10 beds, these hospitals fill a major gap in Virginia healthcare system by improving access to inpatient care for Virginians living in rural localities. Utilizing micro-hospitals and telehealth, Virginians living in rural areas will no longer need to travel great distances to receive emergency and basic inpatient care. Micro-hospitals will allow Virginians to receive care at the right time in a setting closer to their home that is appropriate for the care they need.

Health Technology and IT 

More than 70 percent of the world’s internet traffic flows through Virginia. We are home to thousands of technology workers and innovative companies. Virginia should be a leader in advancing health technology solutions.

If done right, we can improve care and lower costs through advanced health technology and IT coordination. Virginia has long been a leader in health technology and IT. As governor, Ed will establish the HealthTech Coordinating Committee and will pursue innovative IT solutions to make Virginia’s Health and Human Resources agencies more efficient and to improve the health care of all Virginians.

Expand Telemedicine

The use of telemedicine for patient care has grown rapidly over the past several years.  It improves access to care in rural areas of the Commonwealth, is cost effective and increases the efficiencies of health care providers who can now care for patients in different regions of the Commonwealth without requiring expensive and time consuming travel for the patient.

The University of Virginia’s Center for Telehealth is an international leader in telehealth delivery. Ed believes use of telemedicine will continue to grow across the Commonwealth and will work to remove barriers and expand the availability of telemedicine and the services provided through it. Ed will work with the Department of Medical Assistance Services, Virginia’s private health plans and stakeholders across the Commonwealth to expand the services available through telemedicine.

Telemedicine can only reach its full potential if we expand broadband across Virginia. Ed detailed a comprehensive plan for closing the “Digital Divide” at edforvirginia.com/broadband.

Reduce Dental Service Provider Shortages for Adults and Children

The United States Department of Health and Human Services uses the Health Professionals Shortage Areas (HPSA) designation to determine shortages for primary medical, dental and mental health providers. Virginia is designated as a HPSA for dental coverage with only 45% of the need met for dental coverage.

Increasing the availability of dental providers is important for the health of Virginians. Failure to have access to dental care can lead to negative health outcomes, including an increased risk of heart disease and strokes. As governor, Ed will reduce dental service provider shortages by working with the dental community and consumer representatives to define a viable approach to making dental services more available to all Virginians.

For children who receive their first preventive visit prior to age one, dental costs are approximately 40 percent lower than those who have their first visit after turning one.  Ed will direct his Secretary of Health and Human Resources and the Department of Medical Assistance Services to look at ways to increase preventive care for newborns in the Commonwealth.

MAKING MEDICAID MORE EFFECTIVE

Medicaid Rate Improvements Strategy

Virginia’s Medicaid providers care for the most vulnerable of our fellow Virginians. In order to ensure they continue to receive the care they need, Virginia’s next governor must ensure the state is able to meet its existing obligations to update hospital payment and other provider rates through structural reforms. As governor, Ed will advance policy that will address the structural underpinnings that put our hospitals and healthcare system at risk and address the rising costs of uncompensated care.

Medicaid Reform

Virginia’s Medicaid program serves children, expectant mothers, the disabled, and older adults, among others. As Virginia continues to transition from a fee-for-service to a value-oriented managed care system to better coordinate patient care, the Department of Medical Assistance Services (DMAS) will undergo a function transformation. DMAS will soon be an oversight agency charged with managing complex managed care contracts with an eye toward outcomes for Virginians rather than an agency focused on approving complex fee-for-service requests. The basic function of the Medicaid-administration agency will change, and Ed Gillespie is prepared to lead DMAS through this necessary transition.

Virginia’s medicaid system will always face a complex federal overlay – whether it is the Affordable Care Act (ACA) or a subsequent reform or replacement. In Medicaid policy, if we acknowledge that the Federal government will not solve our problems and shift to an innovate-first policy, more Virginians will be cared for and tax dollars will be spent more wisely.

The Affordable Care Act (ACA) stifled growth, drove insurers out of the market, increased out-of-pocket expenses, and punished employers. Fortunately, we have leadership at the Centers for Medicare and Medicaid Services (CMS) that is eager to find state-based solutions, grant appropriate authority and improve patient lives.

As governor, Ed will partner with other states in pursuing Federal authority to innovate and provide patient-centric reforms. Ed will work with managed care organizations, health care providers, hospitals and other players in the system to develop and advance innovations to address the ever-expanding costs of the Medicaid system. He will also monitor the implementation of the JLARC recommendations on managing spending in Medicaid and work with the General Assembly to identify ways to continue the progress of reform.

There are additional areas where the state can advance innovation models. At the state level, Ed will advance policy to review and consider:

• Demonstration models geared toward outcomes
• Increase resources for Substance Use Disorder treatment
• Patient-Centered Medical Home Model Reforms
• And additional authority to create patient-value, properly incentivize and reward providers, and aligned incentives for payers

BECOME A RESEARCH HUB FOR CANCER TREATMENT

Fund Cancer Research

In recent years the General Assembly has increased funding for Virginia’s two NIH-designated cancer centers. As governor, Ed will increase funding for cancer research, affirming Virginia’s position as a leader in providing critical cancer research.

State funding for cancer research benefits Virginia on many levels. First, it is estimated that nearly 43,000 Virginians will be diagnosed with cancer this year and nearly 15,000 Virginians will die from cancer. Continued funding for cancer research is necessary if we are to maintain our progress in defeating the disease. Virginia has two National Cancer Institute (NCI)-designated cancer centers; UVA Cancer Center and the VCU Massey Cancer Center. Both have attracted world-class researchers. Without continued funding, cancer researchers will leave Virginia for other institutions and areas of research.

Notably, funding for cancer research has a direct economic impact on the Commonwealth in terms of jobs and economic growth. Virginia’s growing Life Sciences industry will benefit from additional investment in cancer research.

Virginia should also be a leader in advancing research to prevent and treat childhood cancer. As governor, Ed will direct his Secretary of Health and Human Resources and Secretary of Education to convene medical and research institutions to identify strategies to advance the research and treatment of childhood cancers. Ed will direct a report to the governor and General Assembly by July 1, 2018.

VIRGINIA AS A HEALTHCARE DESTINATION

Virginia should be a medical and healthcare destination domestically and internationally. Consider Minnesota and the Mayo Clinic, Maryland and Johns Hopkins — bringing in millions of dollars in spending to their respective states.

As governor, Ed will direct his Secretary of Health and Human Resources to study which healthcare specialities and advancements in Virginia are the most likely to attract out-of-state patients and market these specialities and advancements. If done right, we can create a patient experience for those traveling to Virginia for care by coordinating between hospitals and hotels, short-term housing options, promoting airport improvements (additional routes to improve access) and addressing special-needs transportation. These advancements in care and increased specialization will also provide opportunities to Virginians in need of care.

SYSTEM-LEVEL REFORMS IN GOVERNMENT

Intellectual and Developmental Disabilities

Part of our commitment to the sanctity of life is the assistance provided by the Commonwealth to those with significant intellectual and developmental disabilities, including Down Syndrome, Autism, Fragile X syndrome, cerebral palsy, fetal alcohol syndrome and similar disorders.

One important priority for providing for the care and treatment of those with intellectual and developmental disabilities is a significant and systematic upgrade of the Commonwealth’s services to the ID/DD population, as promised under a 2012 settlement agreement with the Department of Justice. According to reports of an independent reviewer, needed improvements in Commonwealth’s services to the ID/DD population include:

• Continued emphasis on the Commonwealth’s initiatives to increase greatly needed provider capacity for those with very significant medical and behavioral needs. This includes both residential providers and integrated day support providers. Providers should be in or near the served individual’s community whenever possible.
• Full implementation of expanded waiver slots and related changes so that services are available to all who qualify under the agreement.
  Effective provision of behavior supports in family homes and other residential settings to promote behavioral stability and avert crises.
  Improvements in crisis services to children and adults that are fundamental to the new system to minimize unnecessary hospitalization, imprisonment, and other forms of re-institutionalization.
• Facilitation of enhanced performance measures, transparency, and administrative effectiveness and accountability in services for the ID/DD population. As the Independent Reviewer has noted, general data on access to services and the results of programmatic changes also should be publicly available.
• Advancement in quality and risk management measures, since the Commonwealth is not in compliance with three quarters of the settlement provisions in this area.
• Improvements in standards for the licensing of providers, given that the safety and well-being of those with ID/DD should be the top priority.

Implementation of the settlement agreement is legally and morally imperative. Providing assistance to the most severely disabled should take priority over any other policy options regarding Medicaid.

Manage State Owned Psychiatric Hospitals as a System

As governor, Ed will create a system to manage state owned psychiatric hospitals in Virginia similar to private sector health systems. With the consolidation of management, the incentivizing of outcomes and improved collaboration and efficiencies Ed will make our public health system more reliable and cost effective for patients and families.

Best in the Nation: Foster Care and Adoption Outcomes

There is perhaps no role with greater significance than being a parent. Unfortunately, some children are not able to receive the necessary nurturing and care from their biological parents. And all too often this is because of traumatic experiences due to abuse, neglect, addiction, poverty, prison and lack of social support.

According to a study conducted by the Centers for Disease Control and Prevention (CDC) and Kaiser Permanente, adverse childhood experiences (ACE) harm children’s developing brains so profoundly that the effects continue to show up decades later. The authors of this study identified 10 ACEs: physical abuse, sexual abuse, verbal abuse, physical neglect, emotional neglect, parental mental illness, alcohol or substance abuse, imprisonment, witnessing abuse, and separation. ACEs do not usually occur singularly — i.e. if an individual has one, there is an 87 percent chance that he or she has two or more. Having an ACE score of four (meaning an individual has at least four ACEs) increases likelihood of suicide by 1200 percent. We must recognize that many children in our social services and foster care system have ACEs and deserve extraordinary care.

The Commonwealth does a good job of keeping at-risk children out of the foster care system and with friends or family members in kinship placements. However, Virginia ranks first in the nation in percentage of youth who age out of foster care. These children turn 18 or in some cases 21, and on top of the trauma of being in foster care in the first place, they then must try to make it in the world with little or no support system. According to the Annie E. Casey Foundation, each individual who ages out of foster care costs taxpayers $300,000 over his/her lifetime.

The next governor of Virginia can and must do more to support foster and adoptive families, especially adoptive families who adopt out of foster care. We should be the best state in the nation for outcomes for children.

• Celebrate Foster Care and Adoptive Families
  As governor, Ed will use the convening power of the Governor’s office to bring together key stakeholders in the faith and charitable communities to recognize, honor and celebrate foster and adoptive families. Too often our fellow Virginians who care for our most vulnerable children are overlooked. Also, often the best recruiters for future foster families are current foster families who are prepared, have a good experience and feel appreciated for their efforts. We must change the cultural perceptions and recognize these families for their societal contributions.
• Trauma Informed Care Program
  As governor, Ed will pilot a Trauma Informed Care Program within Virginia’s foster care and adoption program to ensure children are receiving necessary support for traumatic experiences prior to entering the system and throughout their time in the system. A particular focus will be on children dealing with the devastating effects of the opioid crisis. The goal will be to provide trauma-informed training for current foster families and recruit new trauma-informed families for the system.
• Establish the Governor’s Awards for Social Work
  Virginia’s social workers deserve our sincere appreciation. They are witness to disturbing realities that children face – including countless Adverse Childhood Experiences. Virginia’s social workers are on the front lines of these battles, often experiencing vicarious trauma as a result of witnessing hardships faced by children. As governor, Ed will work to better recognize and reward excellence in social work. He will launch the Governor’s Awards for Social Work to celebrate the significant contributions social workers make in our communities.
• Conduct a Needs Review of Child Services Departments
  As governor, Ed will direct his Secretary of Health and Human Resources in conjunction with his Secretary of Education, to conduct a comprehensive study of assigned tasks of all child service related departments. These related agencies, offices and departments need clear standards with actionable, attainable goals, as well as the technology and resources to be able to achieve these goals.
• Support Children Who Age Out of Foster Care
  Children who age out of foster care have concerning outcomes. Until Virginia ends the “aging out” phenomenon, we must wrap around these children to ensure that they have the social support and social capital that they need to succeed. Ed will work with the appropriate state agencies and existing non-profits who are excelling in this area to better support these children and improve outcomes.
• Explore Kinship Care Solutions
  More than ever, families and family friends of at-risk children are the solution to keeping children out of the foster care system. Kinship families are standing in the gap to nurture, love and support children who are in crisis. Ed will explore ways that Virginia can better support kinship families to ensure that they have the training and support they need to provide the appropriate level of care to children in their homes.
• Partner with the Faith and Non-Profit Community
  As governor, Ed will partner with the faith and non-profit community to accelerate outcomes for children in our foster care and adoption system. Organizations such as Possibilities Project, Great Expectations, Adoption Share, VOICES for Virginia’s Children and many others play important roles in advancing improvements to the foster care and adoption system.
  Virginia’s Kids Belong (VKB) is the Virginia chapter of a national non-profit with roots in Virginia. Virginia’s Kids Belong employs the collective impact model to coordinate private and public sector expertise to benefit children and families who touch Virginia’s child welfare system. Their work in other states has helped child welfare systems reach and exceed goals for foster and adoptive family recruitment. VKB also places an emphasis on birth and kinship family support with reunification as a priority. This public-private partnership will be a priority of a Gillespie Administration as it works to improve permanency outcomes for Virginia’s most vulnerable children.
• Partner with the Open Table Model for Foster Youth Transitioning Out of Foster Care
  Ed will partner with the Faith community to grow the Open Table network in Virginia. The Open Table model is used by congregations and their members to form communities – called Tables – that utilize their vocational and life experiences as tools that individuals can use to develop and implement plans to change their lives. The model was first pioneered in Arizona to address poverty and has since evolved to include foster care, adoption, prisoner reentry, human trafficking, and addiction and recovery. According to the model, “each Table is composed of a group of volunteers that make a year-long commitment to act–through relationship—as a team of life specialists, encouragers and advocates. Over the course of a year, the Table works together to set goals, foster accountability and implement a plan to create change.

Expand the Trauma Informed Community Network (TICN)

The Trauma Informed Community Network (TICN) is made of professionals who are committed to supporting and advocating for trauma informed care for children and families. Already in limited existence around Virginia, this group consists of the Virginia Department of Social Services, mental health organizations, school systems, law enforcement, medical facilities, colleges and universities and many more.

As governor, Ed will work to support and expand the scope and membership of the TICN.

HELPING SENIORS TO AGE-IN-HEALTH

Daily Dial Program

Living alone can be difficult for many elderly. Without constant access to a phone and oftentimes family far away, they fear that a medical emergency could be drastic or even fatal. In small towns across America, police departments are offering a service that provides an automated phone call everyday. This enables a timely alert to emergency situations.

As governor, Ed will establish a daily dial program for seniors to help them continue to live independent and safe lives.

Aging-at-Home Volunteer Teams

Modeled after Maine’s a successful program, the Aging at Home Volunteer Teams will help to serve Virginia’s aging communities by providing volunteer retrofitting services to homes as well as provide information about aging wrap-around services to support Virginia’s aging population

As governor, Ed will lead in the establishment of this program as a public-private partnership to help seniors continue to be independent.