Policy Implications of Insurance Billing for Campus Health Services

1. Policy Implications of Insurance Billing for Campus Health Services ACHA May 31, 2012 Christopher Payne, MHA, PT Strategic Planning and Analysis Cornell University Health Services (CUHS)

2. Acknowledgements 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

3. Disclaimer 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.

4. Session Goals • 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

5. Before diving in…

6. CUHS Funding: FY12 Total: $18.9M Before diving in… 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

7. CUHS Funding: FY12 Total: $18.9M Before diving in… • 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

8. CUHS Funding: FY12 Total: $18.9M Before diving in… Occupational Medicine (allocation) Other fee for service revenue, e.g., travel medicine, faculty/staff care

9. Policy Issues • University mission • Access to health care for college students • Responsibility for campus community • Responsibility to surrounding community

10. Policy IssuesUniversity Mission • 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

11. Policy IssuesUniversity Mission At Cornell: “Promote the health and well-beingof students as a foundation for academic and life success.” Cornell Strategic Plan Goal: Educational Excellence

13. Policy IssuesAccess 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

14. Policy IssuesAccess 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

15. Policy IssuesResponsibility for Campus Community • 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

16. Policy IssuesResponsibility 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

17. Percent of 2012 Incoming Class with Significant Health Conditions(Cornell University, self-reported via health history)

18. Percent of 2012 Incoming Class with Significant Health Conditions(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

19. Cornell University TrendsMental Health Visits

20. Cornell University TrendsStudents With Eating Disorders

21. Cornell University TrendsAfter-Hours Call

22. Policy IssuesResponsibility to Surrounding Community • 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

23. Policy IssuesResponsibility 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)

24. Policy IssuesSummary

25. Useful 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

26. Useful 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

27. Useful Data At 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)

28. Useful 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)

29. Useful 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

30. Cornell University - Undergraduate Visits per Population Member, by CUSHIP* Status and Wealth (all services) *Cornell University Student Health Insurance Plan (31% of undergrads) $10 office visit copay $10 office visit copay plus Out of pocket costs for lab, xray, procedures (69% of undergrads) Parental Contribution $13K - $81K N = 2,782 Not Receiving Grant Aid N = 6,951 Parental Contribution $1K - $13K N = 2,622 Parental Contribution None N = 1,580

31. Useful Data - Summary

32. ProcessAwareness • 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

33. ProcessInternal Assessment • Campus • Demographics • Insurance coverage • Grant aid • Utilization statistics and surveys • Community • Available resources • Network participation • Billing practices

34. ProcessExternal 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

35. ProcessExternal 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

36. ProcessExternal 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

37. ProcessExternal 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

38. ProcessExternal Consultation At Cornell *Gross revenue: Does not account for additional billing, costs, est. 10%

39. ProcessVetting 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

40. ProcessVetting 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

41. ProcessVetting At Cornell • Reviewed and supported by: • Executive Group/Senior Staff • Academic Deans • In progress • Students • Trustees

42. cmp9@cornell.edu

43. Discussion