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Policy Implications of Policy Implications of Insurance Billing for Campus Insurance Billing for Campus
Health ServicesHealth ServicesACHA
May 31, 2012
Christopher Payne, MHA, PT
Strategic Planning and Analysis
Cornell University Health Services (CUHS)
From Cornell•Janet Corson Rikert, AVP of Campus Health•Valerie Lyon, AD Business and Finance•Julie Belden, Data Analyst•Financial Aid Office•Institutional Research and Planning
AcknowledgementsAcknowledgements
The content presented today is not intended to serve as legal advice, even for NYS schools. Cornell’s experiences may serve as a guide, but your situation should be carefully assessed within the context of your own data, and your unique setting and regulatory environment.
Independent external consultation is highly recommended.
DisclaimerDisclaimer
•Describe university policy issues related to campus health services
•Describe useful data for including policy issues in an insurance billing analysis
•Describe a process for evaluating insurance billing options, including policy implications
Session GoalsSession Goals
Before diving in…Before diving in…Evaluation Element CUHS – Ithaca Campus
Setting Rural, isolated, no academic medical center
Students 21,131 (33% grad, 30% from NY)
Faculty/Staff 9,645
Grant aid ~50% of students receive grant aid; grant aid does not cover Student Health Insurance Plan (SHIP) premium
Scope of Campus Health Services
Integrated medical/mental health for studentsEpisodic faculty/staff care plus Occ. Med.Pharmacy, lab, xray, Travel MedicineCampus public healthMedical oversight (research, other)
Community health care resources
Limited primary care and specialty careLimited psychiatry; ample counselingLimited public health No nearby national lab vendor processing
OM6%
Student Allocation41%
Capitation16%
Student FFS7%
Gift/ Reserve7%
Pharmacy FFS15%
Other FFS8% Student Allocation:
Partially subsidizes the basic costs of medical and mental health visits
Gift/Reserve:
One-time funds are supporting costs related to increasing demand; funds will be exhausted by FY14
CUHS Funding: FY12 Total: $18.9MCUHS Funding: FY12 Total: $18.9M
Before diving in…Before diving in…
OM6%
Student Allocation41%
Capitation16%
Student FFS7%
Gift/ Reserve7%
Pharmacy FFS15%
Other FFS8%
Student FFS (“fee for service”, paid out of pocket):
•$10 office visit co-payment (all students)
•‘Related charges’ (e.g., lab tests, procedures, xrays) for students who waive the Student Health Insurance Plan (CUSHIP)
Capitation:Part of CUSHIP premium, covers ‘related charges’ for students enrolled in the plan, limiting their out of pocket costs to the $10 user fee
CUHS Funding: FY12 Total: $18.9MCUHS Funding: FY12 Total: $18.9M
Before diving in…Before diving in…
OM6%
Student Allocation41%
Capitation16%
Student FFS7%
Gift/ Reserve7%
Pharmacy FFS15%
Other FFS8%
Occupational Medicine (allocation)
Other fee for service revenue, e.g., travel medicine, faculty/staff care
CUHS Funding: FY12 Total: $18.9MCUHS Funding: FY12 Total: $18.9M
Before diving in…Before diving in…
Policy IssuesPolicy Issues
• University mission
• Access to health care for college students
• Responsibility for campus community
• Responsibility to surrounding community
• Primary : Education
• Individual student health and campus public health are critical to the primary mission
“When health is absent, wisdom cannot reveal itself, art cannot become manifest, strength cannot fight, wealth becomes useless, and intelligence cannot be applied.”
– Herophilus of Chalcedon, physician to Alexander the Great
Policy IssuesPolicy IssuesUniversity MissionUniversity Mission
At Cornell:
“Promote the health and well-beingof students as a foundation for
academic and life success.”
Cornell Strategic Plan
Goal: Educational Excellence
Policy IssuesPolicy IssuesUniversity MissionUniversity Mission
Policy IssuesPolicy IssuesAccess to CareAccess to Care
•Characteristics of student health consumers– Novice, unfamiliar with providers– Many are just beginning to explore independence– Often late in recognizing the need for care– Often ambivalent about seeking help– Ambivalence is heightened for common health
risks (mental health, sexual health, alcohol/other drug use)
– Spontaneous users, easily discouraged by financial or privacy barriers, inconvenient location, long waits
Policy IssuesPolicy IssuesAccess to CareAccess to Care
At Cornell•Unplanned use
– 80% of freshmen users’ first visit is walk-in– 64% of all users walk-in at least once per year
•2011 Survey– 21% of respondents delayed or avoided care due to financial
concerns (28% if receiving grant aid)
– 13% of respondents who were enrolled in parental health plans avoided care due to privacy concerns (insurance statements, HSAs and HDHPs)
•Percent of students accessing services (penetration)– 54% primary care (physician, mid-level, RN)– 15% mental health
•We recruit and transplant students into an environment with inherent risks:
– Social – stress, substance use, sexual health, diet, sleep
– Academic – high expectations for performance
• Students’ common health risks (mental health,
sexual health, alcohol/other drug use) are also public health risks
• Population health
Policy IssuesPolicy IssuesResponsibility for Campus CommunityResponsibility for Campus Community
Policy IssuesPolicy IssuesResponsibility for Campus CommunityResponsibility for Campus Community
At Cornell
•2011 survey– 1% attempted suicide– 8% seriously considered suicide– 39% experienced inability to function due to stress
•33% of entering students report a significant health condition in their health history
Percent of 2012 Incoming Class Percent of 2012 Incoming Class with Significant Health Conditionswith Significant Health Conditions
(Cornell University, self-reported via health history)(Cornell University, self-reported via health history)
0% 10% 20% 30% 40% 50%
Professional
Graduate
Undergraduate
0% 5% 10% 15%
Asthma
Migraine
Mental Health
Metabolic
Cardiac
Gastrointestinal
Infectious Disease
Eating Disorder
Percent of 2012 Incoming Class Percent of 2012 Incoming Class with Significant Health Conditionswith Significant Health Conditions
(Cornell University, self-reported via health history)(Cornell University, self-reported via health history)
2 – 3% of Cornell’s student population is diagnosed with an eating disorder each year
15% of Cornell’s student population accesses mental health services each year
Cornell University TrendsCornell University TrendsMental Health VisitsMental Health Visits
Cornell University TrendsCornell University TrendsStudents With Eating DisordersStudents With Eating Disorders
Cornell University TrendsCornell University TrendsAfter-Hours CallAfter-Hours Call
•Impact on community resources– Emergency room and urgent care centers– Specialists– Mental health providers– Public health department
• Insurance billing challenges (frequently out of network, high cost-sharing, difficult collections)
• Impact of unaddressed health conditions
Policy IssuesPolicy IssuesResponsibility to Surrounding CommunityResponsibility to Surrounding Community
At Cornell•Local providers participate with 10 insurance plans, several of them isolated regional plans
• When out of network, some offices require payment in full
• Many students have insurances with ‘regional’ rather than ‘local’ providers (30 – 60 minutes away, limited public transportation)
Policy IssuesPolicy IssuesResponsibility to Surrounding CommunityResponsibility to Surrounding Community
Evaluation Element CUHS – Ithaca Campus
University Mission Student health mentioned as foundational
Access to care Data: Surveys, utilization statistics (walk-in, penetration)
Responsibility for Campus Community
Data: Surveys, health history statistics, utilization statistics (diagnosis and visit trends)
Responsibility to Surrounding Community
Data: Local provider insurance plan participation and billing policies; distance to regional network providers; percent of students that have in-network coverage in the local area (pending from Cornell)
Policy IssuesPolicy IssuesSummarySummary
Useful DataUseful Data
• Already mentioned– Surveys, including questions about:
• Stress, suicidal ideation• Delay or avoidance of care due to financial concerns• Grant aid status (for cross-reference with above question)• Avoidance of care due to privacy concerns related to
parental insurance
– Health History data– Utilization data (penetration rates, diagnosis incidence, walk-in
statistics, trends over time)
– Information about your local health care provider community
Useful DataUseful Data• Student Health Insurance Plan (SHIP) data
– ACHA/ACA-compliant plans are typically among the best coverage that students can have for access at their health center
– Students who waive often face challenges related to provider networks and cost-sharing
– When students waive, what do they waive with?• Volume of plans and networks• Plans with high deductibles:
– HSAs/HRAs are often non-existent or underfunded
– Parental monitoring can accentuate privacy concerns
• HMOs: Networks can be very restrictive• Self-purchased plans – often low-value
Useful DataUseful DataAt Cornell
•SHIP enrollment: 50%– 32% undergraduate
– 64% professional
– 96% graduate (mandated, funded)
•SHIP waivers (undergraduate)– Over 1,000 plans; network volume not easily assessed
– 16% HMO (20% for students receiving grant aid)
– 25% with deductible of $1,000 or more (21% for students receiving grant aid)
– 8% self-purchased, overlaps above numbers (9% for students receiving grant aid)
Useful DataUseful Data• Partnership with Financial Aid Office
– Previously discussed:• SHIP waiver data by grant aid status• Survey data by grant aid status (if de-identified, add grant
aid question)
– Utilization rates by SHIP and grant aid status• Visits per population member• Penetration rate
– Retrospective analysis– Partnership (FA Office and/or Institutional Research)
Useful DataUseful Data
At Cornell•Partnering with Financial Aid since 2006•Consistent patterns•Of note: Introduced $10 office visit copay in 1996
– 16% drop in utilization in first year– Sustained 10% drop after 3 years– Limited reporting capacity at that time, unable to
directly evaluate impact on lower-income students
0.00
1.00
2.00
3.00
4.00
Most Wealthy Least Wealthy
Visits by students enrolled in CUSHIP
Visits by students not enrolled in CUSHIP
Cornell University - Undergraduate Visits per Population Cornell University - Undergraduate Visits per Population Member, by CUSHIP* Status and Wealth (all services)Member, by CUSHIP* Status and Wealth (all services)
(31% of undergrads)
(69% of undergrads)
Not Receiving Grant Aid
N = 6,951
Parental Contribution
$13K - $81K
N = 2,782
Parental Contribution
$1K - $13K
N = 2,622
Parental Contribution
None
N = 1,580
*Cornell University Student Health Insurance Plan
$10 office visit copay
$10 office visit copayplusOut of pocket costs for lab, xray, procedures
Useful Data - SummaryUseful Data - SummaryEvaluation Element Cornell (Ithaca Campus) Your Institution
Students 21,131 (33% grad, 30% from NY)Faculty/Staff 9,645
Grant aid~50% of students receive grant aid; grant aid does not cover Student Health Insurance Plan (SHIP) premiumIntegrated medical/mental health for studentsEpisodic faculty/staff care plus Occ. Med.Pharmacy, lab, xray, Travel MedicineCampus public healthMedical oversight (research, other)Limited primary care and specialty careLimited psychiatry; ample counselingLimited public health No nearby national lab vendor processing
University Mission Student health mentioned as foundational
% of freshman users with first visit as walk-in
80%
% ofall student users with at least one walk-in visit
64%
% of students who delay or avoid care due to financial concerns
21% (28% for students receiving grant aid)
% of students who waive SHIP that avoid care due to privacy concerns
13%
% of students that access primary care services
54%
Scope of Campus Health Services
Community health care resources
Access to care
Setting
ProcessProcessAwarenessAwareness
• Is student health mentioned in:– Mission, vision, values– Strategic plan– Web materials– Leadership statements
• Do campus conversations occur:– Leadership level– Task forces or committees– Student assemblies– Student news organizations
ProcessProcessInternal AssessmentInternal Assessment
• Campus– Demographics– Insurance coverage– Grant aid– Utilization statistics and surveys
• Community– Available resources– Network participation– Billing practices
ProcessProcessExternal ConsultationExternal Consultation
• External consultation highly recommended– Complex data analysis– Regulatory issues vary by state– External validation is key to convincing internal
stakeholders
• Should complement your internal analysis
ProcessProcessExternal ConsultationExternal Consultation
• Be prepared to provide:– Volumes by CPT code– Current charges– SHIP enrollment and waiver data
• Be prepared to require analysis that goes beyond revenue generation:– Assessment of impact on out of pocket costs– Consideration of impact on access
ProcessProcessExternal ConsultationExternal Consultation
At Cornell•NYS does not allow health fees (exposed or embedded) to function as a secondary payer
– Would have included this option in analysis, if it were permitted
– Planning to pursue legislatively– Diminishing returns due to increasing cost sharing– Careful design may increase revenue without
creating privacy concerns
ProcessProcessExternal ConsultationExternal Consultation
At Cornell•About 10,500 students waive CUSHIP•Participating with 8 additional insurance networks would cover 80% of students who waive CUSHIP
– 40% would have high-benefit, low-deductible AND in-network plans
– 60% would have lower-benefit, high-deductible AND/OR out-of-network plans
ProcessProcessExternal ConsultationExternal Consultation
At Cornell
Percent of
Students who
Waive SHIP
Full insurance billing including mental health
Exclude mental health, eliminate MH copay,
accept all negotiated rates
Additional Revenue*
Change in out of
pocket costs
Additional Revenue*
Change in out of pocket
costs
High-benefit, low-deductible and in-network
40% $0.65M 65% $0.35M 77%
Low-benefit, high-deductible and/or out-of-
network
60% $1.05M 72% $0.53M 13%
Total 100% $1.70M 24% $0.88M 19%*Gross revenue: Does not account for additional billing, costs, est. 10%
ProcessProcessVettingVetting
Two fundamental questions:•Why can’t we bill insurance?
– We could, with the following financial and policy implications…
•Won’t health care reform help?– Still evolving; we do know that cost of mandated
services is quickening the trend toward high deductible plans
ProcessProcessVettingVetting
At Cornell•Workgroup analysis, broadly representative
– Multiple sessions, building knowledge base, open books, examining overall funding model
•Findings/Recommendations:– Current level of cost sharing has a negative impact– Insurance billing model would increase cost sharing– Health fee recommended– Revisit insurance billing if health fees allowed as
secondary payer
ProcessProcessVettingVetting
At Cornell•Reviewed and supported by:
– Executive Group/Senior Staff– Academic Deans
•In progress– Students– Trustees
cmp9@cornell.educmp9@cornell.edu
DiscussionDiscussion
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