The Virginia Hospital & Healthcare Association's "Our Lifeline" media campaign

1. Virginia Hospitals: Our Lifeline
Sean T. Connaughton
President and Chief Executive Officer
Virginia Hospital & Healthcare Association

2. Modern Healthcare Magazine
October 5, 2015
“Much of rural America already resembles the country's future—it's older and sicker.
Take Page County at the northern edge of Virginia's historic Shenandoah Valley, for
instance. Despite its proximity to the nation's capital, the population over age 65 has
increased by 28% to about 1 in 5 residents over the past decade. The poverty rate in
the county of about 24,000 is up 21%. And unemployment stands at 6.9%, significantly
higher than the national average.
Access to healthcare for its aging population is crucial, local officials say. And, lucky
for local residents, they still have the 25-bed critical-access Page Memorial Hospital,
located in the county seat of Luray. Without it, residents would have to drive at least
45 minutes to an emergency room or for primary and preventive care.
But the hospital's future is threatened by the ongoing cuts to Medicare and the failure
of the state to expand Medicaid, officials say.”
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3. Becker’s Hospital Review October 8, 2015
Cost cuts under the Affordable Care Act and the lack of Medicaid expansion in some states could spell disaster for rural
hospitals around the country, according to a study published in Health Affairs. Researchers examined more than 1,700
rural hospitals, of which 1,111 were critical access hospitals and 595 were other rural hospitals. Of the critical access
hospitals, 54 percent were located in states that chose not to expand Medicaid, and of the other rural hospitals, 62
percent were located in nonexpansion states. Though both CAHs and other rural hospitals in nonexpansion states
recorded significantly lower total dollar value for uncompensated care than those in expansion states, their results
suggest rural hospitals in nonexpansion states are still more financially vulnerable. Here are four things to know about
their findings:
1. Uncompensated care accounted for a greater percentage of total net patient revenue at hospitals in nonexpansion
states. The study attributed this difference to unreimbursed costs in Medicaid, Children's Health Insurance Program
and other programs.
2. Levels of charity care and bad debt, however, were higher for noncritical access hospitals in nonexpansion states,
compared to those in expansion states. Charity care and bad debt are associated with uninsured and underinsured
patients. Critical access hospitals had similar levels of charity care and bad debt in both expansion and nonexpansion
states.
3. Operating margins at critical access hospitals in nonexpansion states were lower than those in states that have
expanded Medicaid. In fact, critical access hospitals in nonexpansion states had negative operating margins on
average, according to the report. If disproportionate share hospital payments, Medicare reimbursement, Medicaid
rates or bad-debt reimbursement are cut, these hospitals will be under great financial pressure, as they depend more
on Medicare payments and bring in less revenue for outpatient and surgery services, according to the report.
4. The study found hospitals in nonexpansion states are in more sparsely populated regions, giving them a smaller
pool of patients to draw from. Less traffic in the hospital will drive up per patient costs in nonexpansion state
hospitals compared to expansion state hospitals. According to the report, nonexpansion states also have higher
poverty rates, which means more patients will fall into the coverage gap, leading to higher bad debt and charity care.
Patients fall into the coverage gap if their income is above the amount required to be eligible for Medicaid, but below
the amount to be eligible for premium tax credits in the Marketplace.
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4. About Virginia Hospitals

5. Virginia Hospital & Health Care Association
• 30 member health systems
• 107 community, psychiatric,
rehabilitation and specialty hospitals
• 33 VHHA staff, headquartered in
Glen Allen
• Affiliates:
• VHHA Services
• Virginia Hospital Research and
Education Foundation
• Virginia Business Coalition on Health
• Virginia Health Care Waste
Management Cooperative
• Health Providers Insurance Alliance
• ASPR Hospital Preparation Program
• Principled, Innovative and Effective
Advocacy
• Improving Safety, Quality, Value and
Service
• Transforming Data and Analytics
• Broadening Membership and
Members’ Impact
• Cutting Edge Education and
Communication
About VHHA
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Strategic Focus

6. About Virginia Hospitals
• 30 health systems
• 107 community, psychiatric,
rehabilitation and specialty hospitals
• 14,421 hospital beds
• 15 designated trauma centers
• 49 percent are rural hospitals
• 51 percent are urban hospitals
• 77 percent of Virginia hospitals are
not-for-profit
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7. Virginia Hospitals Care For Their Patients
and Communities
• 3.6 million emergency department visits,
1.9 million outpatient visits, 781,625
inpatient admissions, and more than
103,000 babies delivered
• $3 billion in community support
• $627 million in free or discounted care
• $135 million provided for subsidized health
care services
• $213 million paid in federal, state, and local
taxes
• $376 million spent on community programs
such as mobile clinics, immunizations,
health screenings, home health visits, etc.
Charity care costs have increased 57 percent since
2008
2013 Data 3

8. Virginia Hospitals Fuel Our Economy
• 115,000 direct jobs
• $8 billion in payroll
• $17 billion spent on goods and
services
• Health care and social assistance
represent roughly 500,000 jobs, or
11.4 percent of the workforce
• The Virginia Labor Market Index data
shows health care-related positions
account for roughly 950,000 jobs, or 23
percent of all Virginia jobs
• $36 billion in economic activity
2013 Economic Data 4

9. Hospitals Are Among Our Largest Employers
In 82 percent of rural localities, local hospitals are a top five employer.
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10. Virginia Hospitals Face Challenges

11. Patient Payer Mix
More than three-fifths of all inpatient admissions involve the
uninsured, or Medicare and Medicaid enrollees.
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12. Combined Cuts to Virginia Hospitals
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ACA cuts, when combined with 2 percent sequestration Medicare
payment cuts and other related cuts to Virginia hospitals, will approach
$1 billion per year by FFY 2021.
Annual funding cuts of roughly $20 million (FFY 2011) will grow to $675 million in a few years (FFY 2021).

13. • As more Virginians become Medicaid-eligible and enroll in the program, the
proportion of hospital costs attributed to treating this population rises.
• Medicare payments fall short of hospitals’ cost of providing care and will
continue to fall over time.
Virginia’s Population is Aging
Source: Dobson Davanzo financial forecast model Sept. 2015
0%
10%
20%
30%
40%
Cummulative Population Change
2011-2022
Medicare Medicaid All Other
84%
83%
82%
80% 80% 80% 79% 79% 79%
2014 2015 2016 2017 2018 2019 2020 2021 2022
Projected Medicare Payments Relative
to Costs
Medicare – projected growth in VA population over age 65
Medicaid – based on historical enrollment growth 2010-2013
All Other – projected population growth for VA population
- Population projections from the Demographics Research Group,
Weldon Cooper Center, UVA.
Medicare payments include scheduled reductions under the ACA, value based purchasing,
Hospital Readmission Reduction Program, Hospital Acquired Condition Reduction,
ATRA coding adjustment, bad debt reimbursement reduction, LTCH budget neutrality
Adjustment, IPPS prospective and retrospective coding adjustment, HHA prospective
coding adjustment, 2-midnight rule offset, and MACRA
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14. Growing Medicaid Shortfall
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Medicaid reimbursements do not cover the actual costs of health care services.
0.79
0.72 0.72 0.72
0.76
0.78 0.78
0.75
0.72
0.68
0.64 0.64
0.7092
0.6842
0.6592
0.5
0.6
0.7
0.8
0.9
1
1.1
2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014 2015 2016
PercentofInpatientCostsReimbursed
State Fiscal Year
Medicaid Cost to Payment Ratio
Cost of Care

15. Inadequate Provider Reimbursements
Virginia hospitals had a Medicaid shortfall of $341 million
and a Medicare shortfall of $683 million in 2013.
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16. Charity Care Costs Rising
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Virginia hospitals’ charity care costs have increased 57 percent since 2008.
$0
$100
$200
$300
$400
$500
$600
$700
FY08 FY09 FY10 FY11 FY12 FY13
Financial Assistance Provided by Virignia's Hospitals and
Health Systems

17. Bad Debt Costs Increasing
Growth in health savings account (HSA) high deductible health
plans (HDHP) is leading to increasing bad debt costs for hospitals.
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18. Inadequate Provider Reimbursements
Neither Medicare or Medicaid reimburse providers for the full cost of care.
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19. What This Means For Virginia
Moody’s Investors Service has reported hospital revenue growth and operating margins
have recently hit at all-time lows. Fitch Ratings wrote that the Affordable Care Act has
accelerated the transition of patients out of the hospital and into clinics by tightening
reimbursements and emphasizing technology.
One-third of Virginia’s acute care hospitals operated in the red in 2013, including 17 of 37
(46 percent) of rural hospitals.
These trends are leading to increased consolidation. Nineteen Virginia hospitals have been
acquired by, or merged with, another health system. One Virginia hospital recently closed.
Virginia hospitals and health systems continue to work creatively to reduce costs, increase
quality, and provide access to care.
However, if these challenges are not addressed, hospitals may be forced to downsize staff
and reduce services to remain in business.
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20. Financial Forecast Under Status Quo Policies
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21. Financial Forecast Under Status Quo Policies
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22. Rural Hospitals Face Additional Challenges
• Triple Cliff: Continuing resolution funding the federal government and highway funding
authorization expire in early December; debt ceiling will be reached in November
• Need to remain guarded against further cuts to provider reimbursements such as an
extension of sequestration, site-neutral payment cuts, or reductions in graduate medical
education or bad debt payments
• Critical Access Hospitals: potential changes include elimination of CAH designation based
on mileage from other hospitals and/or removal of the necessary provider designation
• There is no longer an appetite to annually address Medicare’s rural extenders…recognize
need for alternative payment models
• Comprehensive package is unlikely in the current Congress, but proposals were circulated
earlier this year
o Senator Grassley proposal would pay CAHs 105 percent of costs for all services, but treat CAHs like
a 24 hour emergency department
o Congressman Graves proposal would eliminate DSH payments, make extenders permanent and
develop a new payment model for rural hospitals
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23. Virginia Hospitals: Our Lifeline

24. Virginia Hospitals: Our Lifeline Campaign
• Research shows a majority of Virginians favorably view local hospitals and health care
providers. However, research also shows that a majority of Virginians believe their local
hospital is financially stable
• It is vital to inform the public about the scope of the problem first to set the stage for finding
policy solutions.
• The Virginia Hospitals: Our Lifeline campaign is a public awareness effort focused on
educating legislators, stakeholders and the public about the importance of hospitals and the
serious challenges facing them.
• The campaign is supported by broadcast (television and radio), print (newspapers and
magazines), outdoor (billboard), transit (bus), and digital (online and social media) advertising
to communicate about Virginia’s local hospitals and health systems.
• The effort also entails significant outreach to our elected officials, stakeholders and the
public.
Visit ISupportVirginiaHospitals.com to learn more!
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25. Virginia Hospitals: Our Lifeline Campaign
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26. Virginia Hospitals: Our Lifeline Campaign
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27. How You Can Help
• Visit ISupportVirginiaHospitals.com to register your support for Virginia
hospitals and sign up for VoterVOICE
• Sign up to participate in the Hospital Grassroots Network (individuals) or
the Hospital Support Network (businesses, stakeholder groups, etc.)
• Follow VHHA on social media and share posts
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28. 2015 General Elections

29. 2015 General Elections
• November 3 – All 140 members of the General Assembly up for re-election
• House of Delegates – few competitive open seats; most incumbents will
return and Republicans will retain a strong majority
• Senate of Virginia – election season defined by several key open seats
vacated by long-serving members such as Chuck Colgan, Walter Stosch
and John Watkins
• The outcome of several close races will determine whether Republicans
increase or their 21-19 majority or the Democrats retake control
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30. Thank You!