Joint Commission on Health Care

June 3, 1997, Richmond

Indigent/Uninsured Study

The first phase of the indigent/uninsured study (SJR 298) included an analysis of a recently completed telephone survey of the insurance status of Virginians. The survey, which was sponsored by the Virginia Health Care Foundation, was conducted by the Virginia Commonwealth University Survey Research Laboratory and replicated a similar survey conducted in 1993. The primary focus of the analysis was to determine what changes in the uninsured population had occurred over the last several years and to assess the reasons why persons are uninsured.

When compared to the uninsured population in 1993, the 1996 survey found that:

• The total number and percentage of Virginia's population who are uninsured have remained relatively stable since 1993 (1993: 14 percent; 1996: 13 percent).
• There has been little change in the uninsured population when analyzed by age and region of the state.
• There was a substantial increase in the percentage of the uninsured whose annual household income is $50,000 or more (1993: 6 percent; 1996: 12 percent).
• There was a substantial increase in the percentage of the uninsured defined as "other minorities" (1993: 4 percent; 1996: 15 percent).
• There was a substantial decrease in the percentage of the uninsured who are African-Americans (1993: 34 percent; 1996: 20 percent). This decrease is due primarily to recent expansions in the Medicaid population.
• There was a significant increase in the percentage of uninsured adults who are employed full-time (1993: 41 percent; 1996: 57 percent).

The following are some of the key characteristics of the 1996 uninsured population as determined by the survey:

• Lower income persons (annual household income less than $20,000 per year), younger adults (ages 18-29), and "other minorities" make up a significantly higher percentage of the uninsured population than the population at large.
• Small employers (with fewer than 5 employees) have the highest percentage of workers who are uninsured (28 percent).
• A substantial portion of Virginia's uninsured population is at or near the federal poverty level (FPL), some of whom may be eligible for Medicaid.
• Cost/affordability of coverage remains the most significant barrier to coverage for the uninsured.

The Phase I report also included an analysis of recent Medicaid expansions to assess their impact on the uninsured population. The following key findings were reported:

• The largest increase in the Medicaid population since 1989 has been children under 21 years of age, and within this category, the number of children ages 1-5 and 6-14 have seen the greatest growth.
• Despite Medicaid expansions for children, the percentage of the uninsured who are age 0-17 has increased slightly since 1993 (1993: 17 percent; 1996: 19 percent).
• Based on household income levels, a sizable portion of uninsured children ages 0-5 and 6-19 may be eligible for Medicaid.
• There is a sizable number of uninsured families at or below 200 percent of the FPL; children under age 18 in these families would be eligible for services through the Virginia Children's Medical Security Insurance Plan being developed by the Department of Medical Assistance Services pursuant to HB 2682 (1997).

Phases II and III of the indigent/uninsured study will be presented at the July 2nd and August 5th joint commission meetings. Based on the survey results, which define the indigent/uninsured populations, the Phase II and III reports will analyze various ways to improve access to care for these citizens.

Telemedicine Issues

Telemedicine is defined broadly as the practice of health care delivery, diagnosis, consultation, treatment, transfer of medical data, and education using interactive audio, video and data communications. An administrator with the Council on Information Management presented a status report on two studies that were conducted regarding telemedicine (HJR 53 and HJR 109, 1996). A task force composed of experts currently participating in telemedicine projects was established to conduct the two studies.

The first study analyzed the barriers to implementation of telemedicine in Virginia and identified the following:

• reimbursement for telemedicine services,
• telemedicine acceptance,
• licensure and credentialing,
• legal and medical malpractice liability,
• confidentiality,
• telecommunications regulation,
• cost, and
• infrastructure planning and development.

The task force concluded that these barriers do not reflect inherent limitations in technology that compromise the clinical process, but rather societal practices and restrictions. The task force further concluded that more research is needed to determine how best to utilize telemedicine in the Commonwealth.

The second study looked at reimbursement issues regarding telemedicine, specifically whether the Commonwealth should develop a reimbursement policy for telemedicine services by state health programs (i.e., state employee benefits program and Medicaid). The task force found that there are three major factors that affect reimbursement for telemedicine: (i) absence of coordinated action by providers and state governments, (ii) lack of acceptance by third-party payers, and (iii) lack of knowledge about telemedicine.

The task force recommended that, given the present lack of experience to support the use of telemedicine as a safe, medically effective set of procedures and the dynamic nature of the technology, a reimbursement policy for telemedicine services by state health programs not be implemented at this time. Other task force recommendations included:

• The General Assembly should recognize the practice of telemedicine as a legitimate means by which an individual may receive certain medical services from a health care provider without person-to-person contact with the provider.
• No state funded health care service program should require face-to-face contact between a health care provider and a patient for substantially equivalent services appropriately provided through telemedicine.
• The Joint Commission on Health Care, in conjunction with the Council on Information Management, should coordinate telemedicine research in the state to promote and support its use.
• State organizations that provide reimbursement for telemedicine should monitor and evaluate the services using accepted research methodologies.
• To monitor the implementation of telemedicine in Virginia, the General Assembly should consider funding health services research regarding quality, efficiencies and cost effectiveness of telemedicine services when provided by state and/or local public providers.

Long-Term Care and Aging Study

The work plan for conducting the long-term care and aging study (SJR 298/HJR 655) was reviewed and discussed at the June 3rd meeting. The central issues that will be addressed by the study include: (i) regulation of nursing home beds within continuing care retirement communities (CCRCs); (ii) past reorganization issues; (iii) respite care; (iv) long-term care insurance; (v) the use of vouchers as proposed in HJR 219 (1996); and (vi) the Program for All-Inclusive Care for the Elderly.

The near-term areas of focus will be basic education and review of key long-term care issues, including activities in other states, organizational issues, the nursing home certification survey process, and regulation of nursing home beds within CCRCs.

Annual Report

In addition to individual study reports, which are published for each study conducted by the joint commission, an annual report is published each year which summarizes the activities of the joint commission, provides information about its legislative package for the year, and discusses health care policy issues facing Virginia and the nation.

The 1996 Annual Report has been published as Senate Document No. 29 and is available from the Joint Commission staff (804-786-5445) or the bill room (804-786-6984).

Website on the Internet

Persons interested in following the work of the Joint Commission on Health Care can do so by visiting its home page on the Internet. The website address is: http://legis.state.va.us/jchc/jchchome.htm. Internet users can (i) find information regarding meeting schedules and agendas, staff reports, legislation, and activities, (ii) download staff reports and presentations, (iii) submit comments on draft reports and proposed legislation, and (iv) send e-mail to the staff.