of WNY, INC.
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
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
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
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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offer healthcare access to all and share the burden of that access across the
develop an insurance program for low-income, uninsured adults (ages 19+) in WNY.
as an affordable product to fill gaps left by government programs for the
uninsured, such as NYS Child Health Plus and Adult Health Programs.
with basic health benefits and preventive services.
on shared responsibility for the burden of healthcare expense and control.
Objectives for 2000
Fund Business Alliance
Management & Outreach
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& Outreach Strategy
Uninsured Trust Fund - A fund to subsidize premium gap unmet by other
sources of financing (approximately 90% of premium).
Business/Consumer Alliance - A strategy to offer buying power incentives
to consumers to increase local sales and generate a contribution to the
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.
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.
State - The state provides 33% of the premium, partly matching Employer
& Trust Fund Contributions.
Employer - The Employer pays part of the premium; an average of 30%
needed to obtain other matches.
Enrollee - The Enrollee pays the premium based on the income a sliding
Savings - Child Health Plus eligibility guidelines can be sued to
minimize enrollment costs.
Fee Schedule - A local provider panel that agrees to a shared discount
off a standard fee.
Provider Support - The Community Fee Schedule
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.
Management and Administrative Strategy
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.
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.
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.
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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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.
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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Slichta, RN, BS
of WNY, Inc.
of Family Medicine
Grider Street, Bldg. CC #186
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