Virginia’s Four Largest Not-for-Profit Health Systems and Medically Underserved Areas Next to their Headquarters

by James C. Sherlock

A challenge to Virginia’s largest not-for-profit health systems: just do it.

Take the lead.

Note the medically underserved areas (MUAs) next to your headquarters and flagship hospitals and provide primary care in those locations.

Virginia has federally-designated MUAs in Arlandria (INOVA), Norfolk (Sentara), Roanoke (Carilion) and Lynchburg (Centra). Those health systems are each headquartered in those cities.

  1. Arlandria is four miles from INOVA Alexandria Hospital. It was just designated in 2022.
  2. The medically underserved census tracts in Norfolk (pictured above) are closer than that to Sentara’s flagship Norfolk General Hospital. Those are just the worst of them. Eight more Norfolk census tracts made the list. Pretty much every poor area of the city. I got tired of outlining them. But you get the idea. Originally designated in 1994. Updated in 2009.
  3. Carilion Roanoke Community Hospital is right at the edge of that city’s underserved tracts. Originally designated in 1998. Updated in 2012.
  4. Underserved areas in east Lynchburg are in the service area of Centra’s flagship Lynchburg General Hospital. Designated in 1994. Updated in 2011.

The leadership of those health systems drive through those areas on the way to work.

Not-for-profit health systems conduct community health needs assessments (CHNA) once every three years to meet federal and state requirements. The CHNAs of those four health systems have recognized that those areas are underserved in primary care for a very long time.

Time for them to take the lead to provide primary care in communities a bicycle ride from their headquarters and major hospital facilities.

Then as a state we can move forward into more challenging areas.

Note Roanoke’s medically underserved areas.

Carilion’s Roanoke CHNA in 2012 illustrated the need (below).

It also illustrated what was needed – access to services

So, we have to ask why, more than a decade on, those same areas are still designated as medically underserved in primary care.

Let’s say for illustration that a few of the answers include:

  1. the area is dangerous;
  2. it’s tough to find suitable medical office locations;
  3. reimbursements from Medicaid and Medicare are paltry;
  4. patients cannot be depended upon to show up to appointments;
  5. language barriers.

I don’t know if these challenges apply to those census tracts in Roanoke specifically, or in the other three cities, but we’ll use them for illustration.

  1.  The area is dangerous. Get the Mayor, the city manager and police to commit to protect medical office locations. Think outside the box. Start primary care – medical and dental – with pediatrics. Get the word out that the office initially is just for kids. Then, when that gets established, add geriatrics. That sort of thing.
  2. Suitable office locations. At least two options to keep costs down and add security at no cost to the healthcare providers:
    • Build a purpose-built facility on school grounds. That is a “thing” now called community schools. Use steel buildings to keep the costs down.
    • Have the city donate a couple of the many properties in the tracts that it has seized for various reasons and convert them to medical offices.
    • In both cases use metal detectors at entrances manned during working hours by police.
  3. Medicaid and Medicare reimbursements and healthcare workers pay. Work with DMAS to see what special payment and educational debt reimbursement programs can be leveraged. Pay healthcare workers what it costs. The travel nurse program worked, and these four areas don’t require overnight travel.
  4. Patients cannot be depended upon to show up. Ask DMAS to get the Medicaid Managed Care contractors they pay to address that to, well, address it. Get social services involved as necessary.
  5. Language barriers. Work with social services and the school nurses to help address that. Employ bi-lingual physicians and nurses. If necessary, bring in native speakers of the requisite languages that are graduates of foreign medical schools licensed by the Accreditation Council for Graduate Medical Education (ACGME).

Partners for the health systems:

  • Virginia Secretary of Health and Human Resources. He controls all of the state health care, health professions and social services agencies. His agencies are already helping Petersburg.
  • City officials. Mayor, City Manager, School Board Chair, Police Chief.
  • Community organizations including neighborhood groups and churches.

What I have just described is substantially how Health Enterprise Zones work. No need to call them that in this case.

Make it an initiative led by the health systems and supported by government.

Given the resources, political power, financial strength and management expertise of those four large health system monopolies, such programs will work if they get behind them.

These four cities are where Inova, Sentara, Centra and Carilion are headquartered.

There are large swaths of other urban areas that are similarly underserved. Hampton and Newport News, for example, are adjacent and share 23 census tracts that are underserved.

Speaking of Sentara, which I occasionally do, there are census tracts in Virginia Beach, tracts in Chesapeake adjoining Norfolk, and the entire city of Suffolk on the list.

Getting healthcare workers to live in other areas of the state that are rural presents a different set of challenges, mostly focused on smaller populations to be served and whether healthcare workers wish to live there, but those also must and can be addressed.

The program in four cities recommended here should be the easy part.

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25 responses to “Virginia’s Four Largest Not-for-Profit Health Systems and Medically Underserved Areas Next to their Headquarters”

  1. Teddy007 Avatar

    Retail, out patient primary care is not a big thing for big hospital chains. At best, those chains would only want to offer such primary care to people who have insurance and know how to make an appointment online.

    1. James C. Sherlock Avatar
      James C. Sherlock

      Want to and have to are two different things.

      One alternative to voluntary support by not-for-profit health systems to primary care for their monopolized populations is a bill in the next GA imposing increasing and ultimately massive fines on those that do not.

      1. Teddy007 Avatar

        That area is Alexandria is served by Neighborhood Health. I did some volunteer work with them or I would have never have heard of them.

        1. James C. Sherlock Avatar
          James C. Sherlock

          First, thank you. Second the federal government, which just last year designated Arlandria a MUA, counted noses and came up with more demand than supply.

  2. Thank you for bringing attention and solutions to this problem. It’s one thing to see lists of medically underserved areas. It’s a shocking realization that so many are so close to major hospital facilities.

    The one point not addressed in the article is whether there are any affordable and reliable sources of transportation between the facilities and the underserved areas. The Middle Peninsula has Bay Transit, a function of Bay Aging which provides a great service. Except when I tried to use it to go a little less than 4 miles to medical appointments, it didn’t work out 3 of 4 attempts, even after changing appointment times to try to fit into the times the bus wasn’t in Gloucester.

  3. LarrytheG Avatar

    Is anything in the Va GA going on with respect to this issue?

  4. LarrytheG Avatar

    This is an objective, non-partisan, non-culture-war, non-racial, non-woke blog post on the merits

    Thank You! Much appreciated!

    It is interesting that we have the resources and processes to identify underserved areas but apparently no such standard response and these areas just remain in their underserved status for years, perhaps decades.

    What’s not at all clear (at least to me) is whose responsibility it is and what, if any existing programs are in place to address those needs.

    Also not clear for the “profitable” non-profits where their “profits” are expended if not for community/charity purposes. I don’t think they’re going to be easily “taxed” to pay carte blanche for community services in underserved areas without some pretty solid proof that they are the sole/primary guilty entities that need to step up.

    Maryland claims that HEZs “work”. I’d not be opposed to see Virginia to give it a shot legislatively with leadership from the Governor and his administrative agencies whose responsibility this is.

    This is is not a unique problem to Virginia and I’d be curious what other states have done and if any of those
    programs have been successful.

    1. James C. Sherlock Avatar
      James C. Sherlock

      Not-for-profits need not be taxed. They can be fined.

  5. Dick Hall-Sizemore Avatar
    Dick Hall-Sizemore

    Thanks for your research and proposed solutions.

    I am assuming that money is behind the failure of the non-profit hospitals to move on this issue. Two suggestions/questions:
    1. As you have pointed out, the non-profit hospital systems have plenty of money, especially INOVA and Sentara. Is there some leverage the state has over them due to their nonprofit status that could be used to pressure them into providing these services? I am thinking of something like Bon Secours’ new office building in Richmond’s East End. Of course that was a product of some wheeling and dealing the system engaged in with the city of Richmond and finally got shamed into building.
    2. The GA could authorize increases in Medicaid rates for services provided in the MUAs. The state also has a large surplus and could spare a little for this purpose.

    Since no one in the GA seems to want to take this issue on and none of them certainly have the depth of knowledge that you do, perhaps you should consider offering to join the ranks of the legislature this fall to carry on this fight.

    1. LarrytheG Avatar

      Interesting that there are these designated underserved areas that do affect real people but none of their elected representatives seem to have a dog in that hunt. Sherlock might well be on to something here where no one seems to know/understand or takes ownership.

      But I can bet dollars to donuts, if legislation is proposed that affects non-profit hospitals, that you’re gonna hear from them for sure.

      1. James C. Sherlock Avatar
        James C. Sherlock

        They own and operate the GA, but perhaps not on this.

        1. LarrytheG Avatar

          Youngkin has a powerful position to expose issues and argue for change as well as surrogates in the GA to submit the legislation.

          I think you do have a point. Where is Mr. Youngkin and GOP leadership on this?

  6. Nancy Naive Avatar
    Nancy Naive

    To paraphrase the old Christian hymn…

    “We are sliding deep in Universal Healthcare… wheeeeeeee

    1. James C. Sherlock Avatar
      James C. Sherlock

      If we do, we can melt down like the British National Health Service wheee! It is slowly transitioning back to a more U.S.-like system as NHS publicly fails.

      1. Nancy Naive Avatar
        Nancy Naive

        Yep, their system sucks at 9th best in the world. I forget, where do we come in?

        Logs and eyes…

      2. Nancy Naive Avatar
        Nancy Naive

        Excuse me. Tenth.

          1. Nancy Naive Avatar
            Nancy Naive

            Facts always get in the way of a good story about a bad opinion.

          2. LarrytheG Avatar

            You can count on WSJ opinion to be true believers! The rest of the developed world does universal health care, lives longer and pays 1/2 what we do but WSJ and Conservatives just hang with their beliefs.

          3. Nancy Naive Avatar
            Nancy Naive

            It makes them money. That $11K/person/year greases an awful lot of slides, most of which should end in perdition.

          4. Nancy Naive Avatar
            Nancy Naive

            You have to look at it practically. Healthcare is 1/6 of the US economy. Even if we just instituted the SAME system as Switzerland, we’d suffer a 8% drop in GDP. Good god, can you imagine the uproar! Look at what a tizzy they were in over two quarters of negative growth…

          5. LarrytheG Avatar

            right. The PERVERSE thing is that excess/wasteful spending on healthcare gets booked as GDP. Money spent on something tangible IS booked as GDP. So we’d drop in GDP per capita rankings if we fixed our healthcare system to be more like other developed countries. Don’t think WSJ will write about that either…. 😉

  7. Nancy Naive Avatar
    Nancy Naive

    To paraphrase the old Christian hymn…

    “We are sliding deep in Universal Healthcare… wheeeeeeee

  8. Nancy Naive Avatar
    Nancy Naive

    Here’s my story and I’m sticking to it. In 2002 a cohort and his wife retired to a boat to “see the world”. They needed healthcare insurance so they purchased international healthcare coverage that had a $250 deductible, a $2M max plan payout, with no preexisting conditions exception per person from Seven Corners out of Indiana or Ohio. It cost a little over $1000/year for each of them.

    It had two stipulations. 1) it covered prescription, hospital and doctors expenses everywhere EXCEPT the US and possessions for 364 days, and they had to be out of the US for more than 6 continuous months each year.

    At a time when a $3000 deductible, $7500 max out of pocket, with a preexisting exception would cost in excess of $4000/year in the US tells you everything you needed to know.

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