The document summarizes bills passed by the 2010 Virginia General Assembly related to health care, the state budget, and health care workforce needs in Virginia. Key points included the creation of the Virginia Health Workforce Development Authority, requiring insurers to cover telemedicine, prohibiting requirements for individuals to have health insurance, cuts to the state budget including Medicaid rate reductions and closure of mental health units, and shortages of physicians, dentists, and mental health professionals in certain areas of the state.

1. 2010 Virginia General Assembly Session & JCHC Workforce Recommendations Delegate Dave Nutter - Member of the Joint Commission on Health Care Stephen Bowman, J.D., M.P.P. - Senior Staff Attorney, Joint Commission on Health Care March 16, 2010

2. Agenda General Assembly Bills Passed State Budget JCHC Health Care Workforce Presentation and Recommendations JCHC Studies for 2010

3. Bills Pending Governor’s Signature

4. Creation of the Virginia Health Workforce Development Authority House Bill 1304 - Delegate Dave Nutter Senate Bill 731 - Senator Roscoe Reynolds Takes over the duties of the Statewide AHEC program Facilitates the development of a statewide health professions pipeline that identifies, educates, recruits, and retains a competent quality workforce

5. Requires Insurers to Cover Telemedicine Services Senate Bill 675 – Senator William Wampler Health insurers and HMOs must reimburse for healthcare services provided through telemedicine Reimbursement for professional services that are already allowed Insurers covered are those regulated by state law Primarily individual and small group policies Not employer self-funded plans Law takes effect January 1, 2011 for: New, reissued, and extended policies

6. Government Can’t Require Individuals to Have Insurance Coverage Senate Bill 283 – Senator Frederick Quayle Senate Bill 311 - Senator Stephen Martin Senate Bill 417 - Senator Jill Vogel House Bill 10 - Delegate Robert Marshall Bills state that no Virginia resident can be required to have health insurance Issue: State law sets the legal groundwork for a constitutional challenge if a federal law requires individuals obtain health insurance

7. Southwest Virginia Health Authority Board Members Added House Bill 1187 – Delegate Clarence Philips Four Additional Board Members Presidents or designees from: East Tennessee State University Quillen College of Medicine Frontier Health University of Appalachia College of Pharmacy Edward Via Virginia College of Osteopathic Medicine

8. Identification Requirement for Individuals Seeking Schedule II Drugs House Bill 964 – Delegate Matt Lohr Pharmacist will: Require identification from any person seeking to fill a Schedule II drug prescription if not known to the pharmacist If a person seeks to pickup Schedule II drug prescription for someone else pharmacist will make a copy of the identification provided regardless if individual picking up the prescription is known to the pharmacist Maintain records of names, addresses and copies of identification documents for at least one year

9. Civil Immunity for Practitioners Reporting Suspicion of Individuals Unlawfully Obtaining Controlled Substances House Bill 1166 – Delegate Clarence Philips Individuals protected are persons that prescribe, dispense, or administer controlled substances Physician, podiatrist, dentist, veterinarian, nurse practitioner and physician assistant Instances civil immunity applies are when a practitioner* Suspects a person obtained or attempted to obtain a controlled substance or prescription for a controlled substance by fraud or deceit, and In good faith reports or furnishes information or records to a law-enforcement *No requirement for practitioner to report

10. State Budget

11. Before We Can Get to the Approved Budget … Transferred program monies for: Nursing scholarship and loan repayment Medical scholarship and loan repayment Reduced funding for: Virginia’s free clinics Community health centers Virginia Health Care Foundation Other health clinics Source: Virginia State Budget website - http://leg2.state.va.us/MoneyWeb.NSF/sb2010 Governor Kaine’s September 2009 Reductions

12. Virginia Budget Process Governor introduces budget House of Delegates approves amendments to budget Senate of Virginia approves amendments to budget General Assembly approves budget Governor may amend budget State must close a $4.2 billion deficit for FY11 – FY12 General Assembly considers Governor’s amendments

13. General Assembly Approved Budget Highlights for Health Care Closes the Adolescent Unit at Southwestern Virginia Mental Health Institute Closure of a 16-bed unit for children and adolescents with acute mental illness by June 30, 2010 Closes the Geriatric Unit at Southwestern Virginia Mental Health Institute Closure of a 40-bed unit for geriatric patients by June 30, 2010 Patients will be transferred to the Piedmont Geriatric Hospital in Burkeville Eliminates Funding for Case Management Obstetrical Service Projects in Five Health Districts Lenowisco, Cumberland Plateau, Three Rivers, Central Shenandoah, and Alleghany Source: Virginia State Budget website - http://leg2.state.va.us/MoneyWeb.NSF/sb2010 APPROVED

14. General Assembly Approved Budget Highlights for Health Care 3% Medicaid Rate Reductions in FY11 and 4% in FY12 Dental services Inpatient hospital Outpatient hospital Hospital capital Practitioners fees Medicaid Nursing Home Rates 3% rate reduction for each year Capital payments reduction by 0.25 percent in FY11 and 0.5 percent the FY12 Source: Virginia State Budget website - http://leg2.state.va.us/MoneyWeb.NSF/sb2010 APPROVED

15. General Assembly Approved Budget Highlights for Health Care Reduces Indigent Care Payments to Teaching Hospitals $7.1 million in general funds $7.1 million in non-general funds Many Medicaid reductions will not become effective if the Federal Medical Assistance Percentage (FMAP) is extended Source: Virginia State Budget website - http://leg2.state.va.us/MoneyWeb.NSF/sb2010 APPROVED

16. Items Considered for Reductions But Not In the Approved Budget Funding Cuts for: Virginia’s free clinics Community health centers Virginia Health Care Foundation Closure of Commonwealth Center for Children and Adolescents in Staunton Source: Virginia State Budget website - http://leg2.state.va.us/MoneyWeb.NSF/sb2010 N OT APPROVED

17. Items Considered for Reductions But Not In the Approved Budget Adding Antidepressants, Antianxiety and Antipsychotic Drugs to the Medicaid’s Preferred Drug List (PDL) Funding reduction for Local Health Department Services by 5% Source: Virginia State Budget website - http://leg2.state.va.us/MoneyWeb.NSF/sb2010 N OT APPROVED

18. Virginia’s Health Care Workforce: Present and Future Need Physicians, Psychiatrists, Dentists, Clinical Psychologists and Pharmacists Virginia Rural Workforce Summit March 16, 2010 Stephen W. Bowman Senior Staff Attorney/Methodologist Joint Commission on Health Care

19. Agenda Demand and Supply Shortages JCHC Recommended Policies

20. Demand and Supply

21. Virginia’s Increasing Population Will Increase the Need for Health Care Services Every year, 281 additional physicians are needed to meet Virginia’s current level of 3.1 per 1,000 (AMA estimate). This does not include physicians needed to replace those retiring or moving. Sources: Virginia Workforce Connection Demographic Information accessed 8-15-09 and JCHC Analysis

22. Aging Demographic: Virginia Is Graying and Older Persons Use More Healthcare Services As compared to the national average of physicians to population: Individuals 65-74 require over 2x Individuals 75+ require over 3x Sources: Bureau of Transportation Statistics http://www.bts.gov/publications/the_changing_face_of_transportation/html/figure_05_18.html U.S. Department of Health and Human Services, http://bhpr.hrsa.gov/healthworkforce/reports/physiciansupplydemand/growthandaging.htm 2025 Percentage of Population over 65 1998

23. 2,425 Students Were Enrolled in Virginia Medical Schools in 2008 Sources: JCHC email correspondence with each institution and SCHEV. Va. Medical School Takes Shape, Smith and Hardy, Richmond Times Dispatch, January 3, 2007 & WSLS video report, McNew, May 22, 2008 http://www.wsls.com/sls/news/local/article/roanoke_medical_school_has_a_name/11444/ PHYSICIAN 678 191 192 160 135 557 50% 643 2,425 Total (2008) 40 (Expected) 200 (Expected) Virginia Tech Carilion School of Medicine (Roanoke) [Opens August 2010] 139 30% 191 680 Edward Via Virginia College of Osteopathic Medicine -VCOM (Blacksburg) 181 58% 192 741 Virginia Commonwealth University School of Medicine (Richmond) 130 54% 145 559 University of Virginia School of Medicine (Charlottesville) 107 64% 115 445 Eastern Virginia Medical School (Norfolk) Total Enrollment (2008) 2008 Graduates % in-state 2008 entering class 2008 entering class-size 2012 entering class-size (Estimated )

24. $50.6 Million General Funds Were Spent Toward Medical School Education in 2007-08 Tuition in-state (2008-2009 ) 2007-08 General funds/per student* 2007-08 General funds* (in millions ) Tuition out-of-state (2008-2009 ) 2007-08 Non-General funds* (in millions ) * Totals do not include Family Practice Program (residencies) and Area Health Center funding Sources: JCHC email correspondence with each institution and SCHEV. Va. Medical School Takes Shape, Smith and Hardy, Richmond Times Dispatch, January 3, 2007 & WSLS video report, McNew, May 22, 2008 http://www.wsls.com/sls/news/local/article/roanoke_medical_school_has_a_name/11444/ PHYSICIAN $ 52.8 $ 0 $ 20.8 $ 31.8 $ 0 $ 50.6 $ 39,740 (average) $ 28,794 (average) Total (2008) Virginia Tech Carilion School of Medicine (Roanoke) [Opens August 2010] $ 0 $ 0 $ 32,900 $ 32,900 Edward Via Virginia College of Osteopathic Medicine -VCOM (Blacksburg) $ 22,833 $ 16.9 $ 38,892 $ 25,390 Virginia Commonwealth University School of Medicine (Richmond) $ 29,733 $ 16.6 $ 42,650 $ 32,650 University of Virginia School of Medicine (Charlottesville) $ 33,786 $ 15.1 $ 44,328 $ 23,980 Eastern Virginia Medical School (Norfolk)

25. Virginia Has 198 Medical Residency Programs in 19 Locations Source: 2007 State Physician Workforce Data Book Note: Medicaid provides limited funding for residencies

26. Comparison of State Funding to Train or Attract Primary Care Physicians to Locate in Virginia State general funds used to train or attract 1 primary care physician that practices in Virginia J-1 Visa Waiver – minimal cost Targets underserved area State-supported family practice residency programs – $185,968 State loan repayment programs - $255,401 Targets underserved area State-supported medical schools - $858,938 Analysis included in the Appendix

27. Dental Services Are More Difficult to Incentivize in Underserved Regions Average Cost of Patient Visit (2004) Dentist – $224 Primary Care Physician – $101 Prevalence of Insurance Dental – 65% Medical – 85% % of Out of Pocket Costs Dental – 49% Overall Medical – 19% DENTIST Sources: Dr K Michael Hood states that the oral-systemic connection is validated once again. - http://www.sbwire.com/news/view/30342 AHRQ Medical Expenditure Survey Panel: Chartbook #17: Dental Use, Expenses, Dental Coverage, and Changes, 1996 and 2004 http://www.meps.ahrq.gov/mepsweb/data_files/publications/cb17/cb17.shtml#ExecutiveSummary , Expenses for Office-Based Physician Visits by Specialty, 2004, http://www.meps.ahrq.gov/mepsweb/data_files/publications/st166/stat166.pdf , Dental Expenditures in the 10 Largest States, 2005, http://www.meps.ahrq.gov/mepsweb/data_files/publications/st195/stat195.pdf and Health Insurance Coverage in the U.S. 2007, http://facts.kff.org/chart.aspx?ch=477 ,

28. Dental Hygienists Legislation Addresses Maldistribution Dental hygienists working in Dental Health Shortage Areas in Lenowisco, Cumberland Plateau, and Southside Health Districts can provide educational and preventive dental care protocol developed by the Department of Health VIRGINIA ACTS OF ASSEMBLY – 2009 SESSION CHAPTERS 99 & 561 An Act to amend and reenact § 54.1-2722 of the Code of Virginia, relating to practice of dental hygienists.

29. Shortages

30. JCHC Recommendations for Physician, Dentist and Mental Health Shortages No Pharmacists A,C,K,L,M Yes Mental Health Professionals (Clinical Psychologist a part of addressing the shortage) N,O Yes Dentists C Yes General Surgery C Yes Emergency Medicine A,C,J,K,L Yes Psychiatry F,G, H,I,J Yes Geriatric Care A,B,C,D,E,J Yes Primary Care Physician Recommendation Shortage

31. Majority of Physicians Are Located in the More Urban Localities Shortage analyses need to focus on state regions and localities not just state averages Physician to population ratios by locality: Highest - 286 per 100,000 Lowest – 58 per 100,000 location of one or more actively practicing physicians (2007) Sources: Physician Supply and Requirements in Virginia, 2010 and 2015, Mick, Nayar, and Caretta, July 2007 and Virginia Department of Health Professions (2007)* * These data were collected for license administration purposes only and cannot be relied upon solely to inform about actual work site location.

32. Southwestern Virginia has 26 Specialties that are less than 75% of Their Respective State Averages PHYSICIAN Source: JCHC analysis. Data source: Virginia Department of Health Professions (Q1, 2008 with data refinement assistance from VDH)* * These data were collected for license administration purposes only and cannot be relied upon solely to inform about actual work site location. Virginia Average: 221 Physicians per 100,000 persons 35 specialty groups analyzed (see appendix for list) All analyses refer to physician to population ratios 185 226 219 217 235 Physician per 100,000 persons 4 14 Northern 3 12 Central 4 17 Eastern 26 30 Southwest 2 11 Northwest # of Specialty areas less than 75% of state average # of Specialty areas less than state average Regions

33. Job Openings Analysis - Primary Care Physicians are Most in Demand in Virginia Primary Care is 33% of all openings Rural and Underserved Areas Primary Care Opportunities accounted for 63% (33) Openings on 3RNet Emergency Medicine and General Surgery Physicians are needed in every region Source: Additional JCHC analysis PHYSICIAN 1. Primary Care 126 2. Cardiology 45 3. Orthopedic Surgery 37 4. Hospitalist 29 5. General Surgery 25 6. Emergency Medicine 23 Source: JCHC Analysis of Physician openings from referenced websites (August 2009)

34. Needs Analysis - Virginia has Primary Care Shortage Areas in 80 Localities Primary Care Health Professional Shortage Areas HPSA Shortage Ratios for Primary Care Physicians PHYSICIAN Sources: VDH Primary Care Health Professional Shortage Areas (HPSA), http://www.vdh.state.va.us/healthpolicy/primarycare/shortagedesignations/index.htm, 3,000:1 Population Groups 3,500:1 Geographic Area 149 Physicians are needed to eliminate designated HPSAs

35. What Influences Medical Student & Resident Choices? Income gap between primary care and specialists Likelihood of students choosing primary care, rural and underserved careers significantly increased by: Rural birth Interest in serving underserved or minority populations Exposure to Title VII in medical school Rural or inner-city training experiences PHYSICIAN

36. Needs Analysis: Virginia has Mental Health Shortage Areas in 86 Localities Psychiatrists HPSA Shortage Ratios 23 Psychiatrists needed to eliminate designated Mental Health HPSA MENTAL HEALTH Sources: Addressing Virginia’s Mental Health Workforce Shortages, VDH, Mental Health Roundtable May 20, 2009 and http://bhpr.hrsa.gov/shortage/hpsaguidement.htm 20,000:1 Population Groups 30,000:1 Geographic Area

37. Needs Analysis: Virginia has Dental Shortage Areas in 61 Localities HPSA Shortage Ratios for Dentists DENTIST Sources: VDH Dental Health Professional Shortage Areas (DHPSA), http://www.vdh.state.va.us/healthpolicy/primarycare/shortagedesignations/index.htm, and http://bhpr.hrsa.gov/shortage/hpsaguidement.htm . Virginia Department of Health Professions (2008)* and analyzed by the National Center for the Analysis of Healthcare Data * These data were collected for license administration purposes only and cannot be relied upon solely to inform about actual work site location. 4,000:1 Population Groups 5,000:1 Geographic Area 162 Dentists needed to eliminate designated Dental HPSA 61 4,711 Virginia 42 563 Southwestern 50 601 Northwestern 81 1,716 Northern 54 972 Eastern 65 859 Central Dentists per 100,000 # of Dentists

38. Estimates of Pharmacist Shortages Have Changed Recently 2008 HRSA Study National Findings Supply is growing faster than was previously estimated in 2002 study Demand is continuing to rise Moderate shortfall of pharmacists “ If per capita consumption …remains unchanged, then projected future supply will be adequate to meet the demands of a growing and aging population” PHARMACIST Source: HRSA: The Adequacy of Pharmacist Supply: 2004 to 2030 (2008)

39. Virginia In-State Pharmacists’ Locations PHARMACIST Note: Mail-order Pharmacies Expand Access Data source: Virginia Department of Health Professions (2008)* and National Center for the Analysis of Healthcare Data * These data were collected for license administration purposes only and cannot be relied upon solely to inform about actual work site location . 6,681 In-State Licensed Pharmacists (86 per 100,000) 89 1,176 Southwestern 71 1,688 Northwestern 80 862 Northern 77 1,394 Eastern 118 1,561 Central Pharmacists per 100,000 Pharmacists

40. JCHC Recommended Policies

41. Primary Care Option A: When state revenue allows, restore funding for the State Loan Repayment Program (SLRP) & Virginia Loan Repayment Program (VLRP). Option B: When state revenue allows, increase dedicated funding for EVMS, UVA and VCU Family Practice Residency Programs.

42. Primary Care Option C: Request by letter of the JCHC Chairman that the Department of Medical Assistance Services (DMAS) develop a methodology and cost estimate for providing enhanced payments to graduate medical programs in Virginia that train physicians in: primary care general surgery psychiatrists, emergency medicine

43. Primary Care Option D: When state revenue allows, introduce a budget amendment to increase Medicaid reimbursement rates to match Medicare reimbursement rates for primary care physicians Option E: By letter of the JCHC Chairman request that medical schools located in Virginia make efforts to increase their enrollment of medical students from rural communities in Virginia and individuals with an interest in serving underserved and minority populations

44. Physicians Treating an Aging Population Option F: When state revenue allows, introduce a budget amendment to develop a Continuing Medical Education course focusing on medication issues of geriatric patients and targeted for primary care physicians Option G: Request by letter of the JCHC Chairman that the Board of Medicine include and promote geriatric care issues

45. Physicians Treating an Aging Population Option H: Request by letter of the JCHC Chairman that the Virginia Chapter of the American College of Physicians include and promote geriatric care issues Option I: Request by letter of the JCHC Chairman that the Virginia Academy of Family Physicians continue to promote geriatric training

46. Telemedicine Option J: Send a letter from JCHC Chairman to the Special Advisory Commission on Mandated Health Insurance Benefits to support SB1458 (Wampler) and HB2191 (Philips) that required health insurers to cover reimbursement for telemedicine services Option K: Request by letter of the JCHC Chairman that the Department of Human Resource Management consider pilot programs for selected telemedicine-covered services within the state employee health insurance program

47. Telemedicine and Mental Health Option L: Request by letter of the JCHC Chairman that the Department of Behavioral Health and Developmental Services (DBHDS) report regarding the Department’s utilization of telemedicine services, effectiveness and location of such services, use by CSB providers, and impediments to greater adoption of such services Option M: Request by letter of the JCHC Chairman that the Department of Health Professions improve the information collected and compiled about clinical psychologists

48. Dentistry Option N: Request by letter of the JCHC Chairman that the Department of Health Professions improve the information collected and compiled about dentists Option O: When state revenue allows i ntroduce a budget amendment (language and funding) to extend basic dental benefits to adults eligible for Medicaid

49. Contact Information The full presentation given to JCHC September 1, 2009 that includes additional data and analyses can be found at the JCHC website http://jchc.state.va.us/ Stephen Bowman E-mail: [email_address] Phone: 804-786-5445 Mail: Joint Commission on Health Care P.O. Box 1322 Richmond, Virginia 23218

50. JCHC 2010 Studies

51. JCHC 2010 Studies* Funding of State Cancer Centers Provision of Care for those Life-Threatening Conditions Indigent Health Care Provided by Private, Specialty, and Not-for-Profit Hospitals Chronic Health Care Homes Systems Catastrophic Health Insurance Coverage Options Mental Health Services and Higher Education Feasibility of Replicating JMU’s Caregivers Community Network Virginia’s HIV Prevention and Treatment Programs Impact of Federal Health Reform (if enacted) * Additional studies may be added

52. APPENDIX: JCHC Health Care Workforce Presentation

53. Supply Data: Virginia Department of Health Professions Licensure Data Virginia licensure data can be very limited Virginia data does not consistently include: Whether professional works in VA Whether professional is in active practice Location of practice(s) Time dedicated to practice location Time dedicated to specialty Age of professional (relevant for retirement estimation) Virginia Department of Health Professions is improving data collected for physicians and nurses and hopes to extend to other healthcare professions Source: Virginia Department of Health Professions Licensees as of June 30, 2008, Physician Supply and Requirements in Virginia, 2010 and 2015, Mick, Nayar, and Caretta, July 2007 and Virginia Department of Health Professions (2007)* 16,191 active physicians (estimate 2005) 9,636 2,434 5,975 31,254 Pharmacists Clinical Psychologists Dentists Physicians

54. Medical Schools : EVMS, UVA, & VCU (2008) Family Practice Residency Programs: EVMS, UVA & VCU Pink Denotes Addressing Maldistribution Best JCHC Analysis - sources: JCHC files J-1 Visa Waiver State Loan Repayment Programs (FY08 ) Investment Needed for 1 Primary Care Physician Practicing in Virginia $255,401 minimal* $185,968 $858,938 State Investment to Develop 1 Primary Care Physician that Practices In-state 100% 100% 100% 38.6% % Physicians Initially Specializing in Primary Care $255,401 minimal * $185,968 $331,396 State Investment to Develop 1 Physician that Practices In-state 76% 40% 61% 35% % Likely to practice Virginia $194,104 admin* $113,441 $115,989 State Funds Per Participant Per Program Completion 4 3 3 4 Average Years to Program Completion $48,526 admin* $37,814 $28,997 Average State Funding per Year per Participant 19 18 233 1,745 Program Participants $921,988 admin* $8,810,557 $50,600,000 State Funding (2008)

55. 51 Other Pediatric Subspecialties Other Medical Specialties Pediatric Psychiatry Rheumatology Pediatric Neurology Pulmonology Pediatric Cardiology Psychiatry Pediatric Subspecialties Physical Medicine and Rehab Pathology Neurology Radiology Nephrology Anesthesiology Infectious Disease Emergency Hematology/Oncology Hospital-Based Geriatrician Other Surgical Specialties Gastroenterology Urology Endocrinology* Plastic Surgery Dermatology Otolaryngology Cardiology Orthopedic Surgery Allergy/Immunology Ophthalmology Medical Specialties OB/GYN Pediatrics Neurosurgery Internal Medicine General Surgery Family Practice Surgical Specialties Primary Care 35 Physician Specialties Analyzed