Policy Analysis Colleen Paramesh FNP University of WisconsinMilwaukee

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Policy Analysis Colleen Paramesh, FNP University of Wisconsin-Milwaukee

Policy Analysis Colleen Paramesh, FNP University of Wisconsin-Milwaukee

Problem • UW-La Crosse Two-year Budget Cuts: $2, 708, 061 • UW-La Crosse Student

Problem • UW-La Crosse Two-year Budget Cuts: $2, 708, 061 • UW-La Crosse Student Health Center Budget Deficit: $179, 000 University Proposed Resolution Insurance Fee-for-Service based revenue model • Decreased Segregated Fee (SEG) to cover behavioral health services • Contract third party billing services Dependent Variables Affordable Health Care Act mandating insurance coverage for all US citizens • State insurance laws regulating billing • State law prohibiting SEG fee as a secondary payor • Individual health care insurance policy terms and conditions • Need for increased administrative staff to comply with government and insurance regulations “The University of Wisconsin System's colleges, universities, and extension networks could lose another $65. 6 million over two years, according to UW System spokesman David Giroux. ” (Stein & Herzog, 2011)

Circumstances Impacting Student Health Increased Out of Pocket Expenses Student Financial Resources Confidentiality Privacy

Circumstances Impacting Student Health Increased Out of Pocket Expenses Student Financial Resources Confidentiality Privacy & Parental Knowledge Screening Variance of Insurance Coverage Fair Access Quality of Life Social Equity

Evidence Confidentiality Fair Access Healthcare can be delayed or foregone completely when: ü Students

Evidence Confidentiality Fair Access Healthcare can be delayed or foregone completely when: ü Students do not have access to affordable healthcare ü Insurance policies limit or minimally reimburse care ü Insurance deductibles are large ü Parental knowledge of care compromises confidentially through insurance billing statements viewed by parental guarantor ü Out-of-pockets expenses are required at time of service Ø Cornell University found that without the SEG fee to cover unpaid expenses, out-of-pocket expenses for the student rose by 60%. Screening and interventions for high-risk behaviors are decreased when routine healthcare access is limited due to: ü Financial concerns ü Insurance rules and regulations ü Parental knowledge of care for students under their parents insurance when insurance billing statements can be viewed by guarantor. High-risk behaviors impacted: § Problem drinking § Sexually transmitted infections § Preventative and emergency contraception § Mental health services (AHRQ, 2011; AMA, 2007; HBC, 2013; Mackenzie et al. , 2011; Siegers & Carey, 2010; UWL 2013)

Evidence SEG Only • Each student receives the same fees for the same care

Evidence SEG Only • Each student receives the same fees for the same care Social Equity Single Visit Payment Scenarios SEG and Insurance Only • Students pay different fees based on insurance coverage (UMN) • $0 Student Payment Scenarios • Out Of Network Coverage (OON) • In Network coverage (INC) • $21. 72 Average if Co-payment Insurance Only • Full Charges: • OON • INC (higher deductible) • Reduced Charges • INC (deductible met) • $ 21. 72 Average if Co-payment (ACHA 2013; KFF, 2010; UWL) Colleges that utilize insurance billing models have seen decreased utilization secondary to: financial concerns large deductible poor communication of the healthcare system privacy being compromised for students covered under parents insurance through insurance billing statements poor communication of the healthcare system variability of insurance policies limiting reimbursement and coverage (HBC)

Issue Statement With the recent mandate of required health insurance for all United States

Issue Statement With the recent mandate of required health insurance for all United States citizens, and recent budget cuts, the University of Wisconsin. La Crosse has proposed a change for the Student Health Center (SHC) from a self-funded model to a fee-for-service model to meet the operational and capital expenditures budget.

Stakeholders Students Parents University Value: § Accessible care Value: § Affordable care Value: §

Stakeholders Students Parents University Value: § Accessible care Value: § Affordable care Value: § Fiscal sustainability § Confidential treatment for sensitive issues § Qualified providers and quality care § Quality healthcare that meets students needs § Affordable care that § Accessible care does not require out-of-pocket expenses § Healthcare center that attracts students

Policy Objectives § Provide affordable care § Accessible services with no out of pocket

Policy Objectives § Provide affordable care § Accessible services with no out of pocket expense at time of service § Confidentiality for reproductive and mental health care § Attract students and contribute to the reputation of the University § Provide access to qualified healthcare professionals § Fiscal sustainability

Comparative Evaluation Costs SEG Fee Only Insurance + SEG Fee Insurance Only Example Ankle

Comparative Evaluation Costs SEG Fee Only Insurance + SEG Fee Insurance Only Example Ankle injury Provider visit: $0 Ankle X-ray: $30 Physical Therapy $10 Consult (PT) TOTAL: $40 Student Expense: $40 Example Ankle injury Provider visit: Ankle X-ray: Physical Therapy Consult (PT) TOTAL: Student expense: $0 Ø OON Ø INC Example Ankle injury Provider visit: $89 Ankle X-ray: $180 Physical Therapy $100 Consult (PT) TOTAL: $369 Student expense: $369 Ø OON Ø INC, deductible not met Ø $43. 44 Co-pay SHC pays 3 rd party: $ 59. 04 -$118. 08 SHC collects: $43. 44 -$177. 12 SEG fee writes off : $73. 80 -$221. 40 (UWL) $89 $180 $100 $369 Ø $73. 80 -$221 INC, deductible met SHC pays 3 rd party: $ 59. 04 -$118. 08 SHC collects: $43. 44 -$369 SEG fee writes off : $0 (UHC, 2013; UMN 2012; UWL). (UHC; UMN; UWL).

Comparative Evaluation Goals SEG Fee Insurance + SEG Fee Privacy for sensitive issues Behavioral

Comparative Evaluation Goals SEG Fee Insurance + SEG Fee Privacy for sensitive issues Behavioral health: § Maintained without parental knowledge. Reproductive health: § Maintained without parental knowledge as (UWL). SEG fee covers reproductive health without billing under parents insurance (HBC). Reproductive health: § Not maintained for students covered under parents insurance , as parents will have knowledge through insurance billing statements (HBC). Fair access No limitations Usage dependent on: § Financial situation § Insurance policy rules and fees § Parental knowledge of access through insurance billing Social Equity No discrepancy based on Discrepancy based on: insurance status of ability § Co-pay status to pay (UWL). § Financial resources Usage dependent on: § Financial situation § Insurance policy rules and fees § Parental knowledge of access through insurance billing Insurance Only Discrepancy based on: § Insurance fees and coverage § Co-pay § Financial resources (HBC; UHC; UMN; UWL)

Comparative Evaluation SEG Fee only Insurance + SEG Fee Insurance Only Screening No restrictions

Comparative Evaluation SEG Fee only Insurance + SEG Fee Insurance Only Screening No restrictions Annual insurance coverage allowances are not restricted with SEG fee as secondary payor: ü Preventative health ü Reproductive health ü Domestic violence screening ü Substance abuse screening Restricted by: Annual insurance coverage allowances for: ü Preventative health ü Reproductive health ü Domestic violence screening ü Substance abuse screening Liability No changes Coverage and internal policies will need to accommodate: ü HIPPA regulations ü Accrediting agency regulations ü Insurance laws Budget No changes Increased staffing to accommodate: ü Coding ü Insurance provider status ü Compliance monitoring ü Third party billing (HBC; HCG)

Recommendations • Adopt the Insurance plus SEG fee policy. • Seek Wisconsin insurance law

Recommendations • Adopt the Insurance plus SEG fee policy. • Seek Wisconsin insurance law change to utilize the SEG fee as the secondary payor for behavioral health and reproductive health. • Maintain the SEG fee at the existing level to cover behavioral health services and reproductive health screening, testing, and treatment. • Hire one additional administrative staff member to manage coding and compliance regulations and complete staff training. • Contract with a third party billing company to manage insurance billing and collections. • Create a marketing campaign to educate parents, students, and staff about the coverage and costs of the Student Health Center

Summary Insurance + SEG Fee Option Controls Out of Pocket Expenses Insurance Unrestricted Coverage

Summary Insurance + SEG Fee Option Controls Out of Pocket Expenses Insurance Unrestricted Coverage Access for Does not Sensitive Health Maintains Impact Services Issues Confidentiality Screening Fair Access Quality of Life Social Equity

References Agency for Healthcare Research and Quality (AHRQ). (2011, April) Co-pays, deductibles, and co-insurance

References Agency for Healthcare Research and Quality (AHRQ). (2011, April) Co-pays, deductibles, and co-insurance percentages for employersponsored health insurance in the private sector, by industry classification, 2009 [Statistical brief #323]. Retrieved from Agency for Healthcare Research and Quality: www. meps. ahrq. gov American College Health Association. (2013, January, 30). Draft federal regulations to be released designating self-funded student health plans as minimum essential coverage [Policy update]. Retrieved from American College Health Association: www. acha. org American Medical Association (AMA). (2007, ). Health insurance coverage for college students [Report Council on Medical Services CMS Rep. 4 -A-07]. Health. Care. gov (HCG). (2013). Affordable Care Act [Fact sheet]. Retrieved from Healthcare. gov: www. healthcare. gov Hodgkins Beckley Consulting, LLC. (HBC). (2013). Considering insurance billing for college health and counseling services [Executive Summary Report]. Retrieved from Lookout Mountain Group: www. lookoutmountaingroup. net Kaiser Family Foundation (KFF). (2010). Average person monthly premiums in the individual market, 2010 [Fact sheet]. Retrieved from Statehealthfacts. org: www. statehealthfacts. org Mac. Kenzie, S. , Wiegel, J. , Mundt, M. , Brown, D. , Saewyc, E. , Heiligenstein, E. , . . . Fleming, M. (2011). Depression and suicidal ideation among students accessing campus health care. American Orthopsychiatric Association, 81, 101 -107. Seigers, D. , & Carey, K. (2010). Screening and brief interventions for alcohol use in college health centers: A review. Journal of American College Health, 59(3), 151 -158. Stein, J. & Herzog, K. (2011, October 19). UW system, state government face deeper cuts. Journal Sentinal Online Retrieved from www. jsonline. com United Health Care (UHC). (2013). Choice Plus benefits summary-800 E [Fact sheet]. Retrieved from United Healthcare: www. unitedhealthcare. com University of Minnesota (UMN). (2012). Billing information [Fact sheet]. Retrieved from Boynton Health Service: www. bhs. umn. edu University of Wisconsin-La Crosse (UWL). (2013). Student Health [Fees and Costs]. Retrieved from University of Wisconsin-La Crosse: www. uwlax. edu/studenthealth