Information continues to dribble out about the impact of Medicaid expansion on Virginia hospitals, although there still seems to be no consensus on whether or not the costs of a hospital “assessment” will be passed on to privately insured patients. The uncertainty reinforces the impression that Governor Ralph Northam and GOP lawmakers bought a proverbial “pig in the poke” when they agreed to enlarge Virginia’s largest entitlement program.
The latest evidence on the hidden cost of Medicaid expansion comes from Don Halliwell, chief financial officer of Carilion Clinic, the health system serving much of western Virginia. Halliwell tells the Roanoke Times that the health system will pay about $27.5 million a year once expansion is fully underway, but he cannot tell how much the system will reap in return.
“It is a victory for our communities and a victory for our patients, but boy, it’s complicated,” Halliwill said. “We know the direction and what has been stated as the intentions. But how it will play out we just don’t know.”
Left unaddressed in the article is the question of how much Virginia will need to spend to raise Medicaid reimbursements to physicians — an issue that was deferred by this year’s legislation. Reimbursement rates of about 71% of cost are so low that many primary care doctors refuse to accept money-losing Medicaid patients. There is a growing awareness that expanding Medicaid coverage to Virginia’s near-poor population is meaningless if patients can’t find doctors to treat them.
Luanne Rife does not address that issue, but her article in the Times otherwise does the best job I’ve seen yet of exploring the financial implications of Medicaid expansion at the provider level.
If everyone who will soon qualify for Medicaid signs up, Carilion will gain at least 17,000 paying patients in its core service area and a share of another 17,000 people living in outlying areas.
Most of these patients are now what Carilion calls “self pay.” Last year, this group represented about 6 percent, or $255 million, of Carilion’s charges for inpatient and outpatient services. Much of it is written off.
In the first year of Medicaid expansion, the hospital assessment on all acute care hospitals (with the exceptions of the University of Virginia, Virginia Commonwealth University and the Childrens Hospital of the King’s Daughters) will pay an assessment of 1.1% on net patient revenue, or an estimated $190 million statewide. In the second fiscal year the tax will increase to 2.3%. In exchange, states the Times article, the state will boost reimbursements for Medicaid services from 70% of hospital costs to 88%.
With higher reimbursements and thousands more paying patients, budget makers figured that after assessments, hospitals across the state would net $263 million the first year and $617 million in the second full year of expansion.
Hospitals with few Medicaid patients might pay more than they gain, and there is speculation they will pass along their losses to commercial insurance payers.
What does that mean for Carilion? Halliwell isn’t sure. “I can only speak for myself, but I don’t see a way where we would be in a position where our assessment would be greater than the benefit,” he said. “If your assessment was greater than the benefit then you would have excess costs. A system would have to figure out a way to pay for it. I wouldn’t speak for them, but it could be passed on.”
Bacon’s bottom line: The politicians don’t know what the impact will be. The hospitals don’t know. Nobody knows. All anyone can say is that in the aggregate, more Medicaid money will flow into hospitals as will flow out. While hospital lobbyists engineered what looks like a political deal for their industry, the hospitals themselves have not figured out how the money flows will work internally. One thing you can bet on, more money will mean bigger hospital profits — including those of the so-called nonprofit hospitals.
Here are some benchmark figures for the Carilion Medical Center, the flagship operations in Roanoke, to monitor in the years ahead as Medicaid expansion unfolds (2016 figures):
Charity care — $142 million
Bad debt — $71 million
Net patient revenue — $1,174 million
Operating income –$66 million
“Surplus” (profit) including non-operating gains — $100 million