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