HEALTHforALL of WNY, INC.
Buffalo, NY

April 2000

        §       Background  

The Uninsured Trust Fund Initiative Coalition covers a region with a population of more than 1.6 million at the western end of New York State (NYS).  This region includes the metropolitan area of Buffalo and Niagara Falls (Erie and Niagara Counties), as well as sic very rural surrounding counties (Allegany, Cattaraugus, Chautauqua, Genesee, and Wyoming Counties).  The center city area are nearly 40% minority and, along with the remote and rural area, are among the poorest communities in NYS.  The WNY Uninsured Initiative Coalition is composed of representatives from hospital systems, industry, charities, insurance and rural health networks, public health, social services, government and academia.

Many members of the Coalition have been working together on an eight-county regional basis for over six years.  Starting as a Medicaid Managed Care Coalition of local Departments of Social Services facilitated by the SUNY at the Buffalo Department of Family Medicine, their monthly meetings grew to include over 100 organizations.  The Coalition has consistently focused on the unmet healthcare needs of the region's low-income resident's.  This evolved into the WNY Public Health Coalition that has recently become the WNY Community Health Network.

In 1997, under the leadership of the WNY Healthcare Association, a comprehensive analysis of the uninsured problem in WNY was published and distributed to the Coalition.  At the same time another Coalition member, the Catholic Health System, sponsored a preliminary concept for financing healthcare for uninsured poor woman as part of their Woman's Health Services Program.  Their "Uninsured Women's Initiative" has evolved into a proposal to serve all uninsured adults.

Another very active member of the Coalition is the Lake Plains Community Care Network, a rural health network serving Orleans, Genesee, and Wyoming counties to the east.  Their membership of employers, public health departments, physician organizations, hospitals, and social services are embarking on the launch of a locally designed healthcare plan.  Funded in part as a Kellogg Foundation demonstration project, their strategy is to eventually offer such a plan to their uninsured.  This proposal offers the Lake Plains Community Care Network a viable means of financing such a plan.  Their experience in the collaborative design of a local insurance plan will be invaluable to this initiative.

In 1998, the State of New York launched the Child Health Plus Program for low-income children under the age of 19.  The state recently passed legislation for a Family Health Plus Program for very low-income adults (below 120% of the FPL).  The program will reach about 40% of the uninsured adults in the eight county region.  The HealthforAll proposal addresses the gap left by these government programs.  We ultimately hope to serve over 50,000 low-income uninsured adults.

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§       Guiding Principles

We plan to offer a benefit that the community can afford!  This requires benefits that focus on basic requirements and preventive services.  If the plan costs low-income working people too much, they won't buy it until they need it.  A viable safety-net plan needs to attract both "health dollars" and "sick dollars" to survive.

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§       Initial Project Objectives

Mission

To offer healthcare access to all and share the burden of that access across the community.

Goal

To develop an insurance program for low-income, uninsured adults (ages 19+) in WNY.

• Designed as an affordable product to fill gaps left by government programs for the uninsured, such as NYS Child Health Plus and Adult Health Programs.

• Designed with basic health benefits and preventive services.

• Based on shared responsibility for the burden of healthcare expense and control.

Planning Objectives for 2000

• Organizational Development

• Trust Fund Business Alliance

• Government Partnership

• Product Development

• Case Management & Outreach

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§        Financing & Outreach Strategy

Financing Strategy

Possible Approaches:

• The Uninsured Trust Fund - A fund to subsidize premium gap unmet by other sources of financing (approximately 90% of premium).

• A Business/Consumer Alliance - A strategy to offer buying power incentives to consumers to increase local sales and generate a contribution to the Trust Fund.

• Shared Discount - A strategy sponsored by private industry to promote local products and services and sustained by ongoing "cause marketing" campaigns and investment strategies.  Conceivably 50% of the "product" discounts would go to the consumer and 50% would be contributed to the Uninsured Trust Fund.  Seed money would likely come from the public and private foundation grants.

• Same Price w/Contribution - An alternative campaign in which the consumer would buy the sponsor's product at the same price as the competing brands.  The company would contribute a portion of the proceeds of the WNY Uninsured Trust Fund.  For example, if there are two brands of milk in the grocery store of equal price, one offers a portion of the sales to the Uninsured Trust Fund, and the other does not.  In this case many consumers would choose to buy the product that helps their neighbors.

• The State - The state provides 33% of the premium, partly matching Employer & Trust Fund Contributions.

• The Employer - The Employer pays part of the premium; an average of 30% needed to obtain other matches.

• The Enrollee - The Enrollee pays the premium based on the income a sliding scale (18%-28%).

• Administrative Savings - Child Health Plus eligibility guidelines can be sued to minimize enrollment costs.

• Community Fee Schedule - A local provider panel that agrees to a shared discount off a standard fee.

Shared Provider Support - The Community Fee Schedule

Each premium dollar will buy care at less than usual cost of care.  Local providers will be asked to accept a 25% discount off a standard fee schedule such as the Medicare rate for the low-income enrollees in this program.

Outreach Strategy

Preliminary Management and Administrative Strategy

Third Party Administrator (TPA) will handle claims processing and member services and will be accountable to both the Trust Fund and the Insurance Company.  The Trust Fund will "own" the encounter data and may conduct independent actuarial review of the premium and switch insurance companies with advance notice if necessary.  This approach is planned to provide adequate fiduciary safeguards for the Trust Fund.

Local Medical Direction & Care Management - Medical direction utilization review, pre-admission certification and intensive care management will be subcontracted using registered providers/protocols that are locally controlled.  This approach is intended to provide for higher quality, patient-centered care, especially in the rural area where the traditional insurance company has little staff presence to optimize case management.

Delivery System

Preferred Provider Organization (PPO) - No one insurance company has an adequate provider network in all communities in WNY.  This is especially true in the rural area that border Rochester to the east and Pennsylvania to the South.  Therefore, we envision forming a Preferred Provider Organization (PPO) of all providers in the region who accept the Trust Funds community fee schedule with a 25% discount off a standard fee schedule.  This will be an Insurance Company driven product and will provide reimbursement for patients who are not able to pay.

High-Risk Intervention & Patient Education Team (PET) - We propose that all enrollees complete a Health Risk Assessment at the time of enrollment.  The purpose of the assessment will be to identify high-risk patients for intervention before acute episodes occur.  The Care Management will orchestrate the formation of a Patient Education Team (PET) of public health and hospital wellness educators located in each sub-region.  The high-risk patient enrollee will receive patient advisory information under the cover of his/her primary care physician (PCP) and a request that he/she make an appointment to discuss the information further.  The PCP will refer the high-risk patients who indicate the readiness to changes to the local Patient Education Team for health behavior changes, intervention and follow-up between office visits.

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§       Challenges

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§       Demographics

In 1998, the WNY Public Health Coalition collectively sponsored a region-wide Health Risk Assessment (HRA) survey, which has provided very precise estimates of the number of uninsured  It also provides great detail about health risks behavior and access problems.

The HRA survey was based on nearly 100,000 random-digit dialed phone calls conducted by the SUNY at the Buffalo Department of Family Medicine.  Every resident in the 8 counties had an equal chance of being called, resulting in a random sample of 4,017 individuals.  From this survey, we estimate that over 210,000 are uninsured, of which nearly 132,000 are adults over the age of 18.

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§        Contact Us

Amber Slichta, RN, BS  
Executive Director  
HealthforAll of WNY, Inc.  
Department of Family Medicine
462 Grider Street, Bldg. CC #186  
Buffalo, NY 14215  
Phone: (716) 898-4743
Fax: (716) 898-3536
E-mail:  amber.slichta@verizon.net