Dr. Paul Genecin was named director of University Health Services by President Richard C. Levin in March of 1997. The Yale Bulletin & Calendar recently interviewed Genecin about University Health Services and the 26,000-member Yale Health Plan at 17 Hillhouse Ave.
Q: How does the Yale Health Plan fit into University Health Services?
A: The Yale Health Plan or YHP is most familiar to everyone at Yale as the clinical care center for the University community, including students, faculty, staff and dependents. University Health Services also includes Employee Health, Varsity Athletic Medicine and Health Education, among other health services.
Q: Who is eligible for membership in the Yale Health Plan?
A: All Yale employees who receive benefits are eligible for the Health Plan. The immediate families or domestic partners of these employees are also eligible. Yale students are also members, and their spouses and children may also enroll.
Q: What University health services are available to non-members?
A: There are a number of services open to all members of the Yale University community, whether or not they have elected to join the Yale Health Plan. These include the Travel Clinic, the Contact Lens Department and the many health screening events and educational programs sponsored by our Health Education Department.
Retirees covered by Medicare are participants, but technically are not members of YHP. More than 1,000 retirees come to 17 Hillhouse Ave. for primary care services.
Employee Health is open to all Yale employees for assessment of work-related problems. Its functions include health screening, immunization and worksite-specific preventive medicine.
Q: Are all students considered members of the Health Plan?
A: Yes, in that all undergraduate, graduate and professional students are eligible for primary care through the Yale Health Plan. The care is available to all students at no additional charge if they are enrolled more than half time. Regardless of whether a student purchases YHP hospitalization and specialty care, he or she has access to our primary care services, including Urgent Visit, Internal Medicine, Student Medicine, Mental Health, Obstetrics and Gynecology, the in-patient unit and certain laboratory services.
The University requires enrolled students to have hospitalization and specialty care insurance, but does not require that it be purchased from YHP. However, approximately 80 percent of graduate and professional students and 40 percent of undergraduates choose the Yale Health Plan for their hospitalization and specialty care, and therefore are full YHP members. YHP is much larger and more comprehensive than a typical university health service. Because of our larger scale, we are able to offer this broad spectrum of services at reasonable rates.
Q: How would you describe the mission of the Yale Health Plan?
A: Our mission is to provide excellent clinical care to the Yale community. We're all aware of the news reports about big business HMOs run for profit and oriented toward the bottom line. Many of us are increasingly concerned that the profits of these companies result from squeezing the patients and the clinicians. Some people tend to paint managed care with one brush. YHP is one of the first managed care centers in this region, and it continues to be one of the most innovative. But our mission is strikingly different from that of the for-profit HMOs that come under media scrutiny. We are not a profit center for the University. We do not ration care or give incentives to providers to withhold tests or treatments. We do not have the conflicting mission of paying dividends to shareholders.
Q: How do you choose your staff of health care providers?
A: Yale Health Plan is an attractive place for well-trained, highly motivated clinicians. We have close ties with the School of Medicine, a collegial atmosphere, and a wonderful member population that makes it easy for us to attract outstanding staff. In addition, market forces that affect the kind of work that physicians want to be doing -- including the increasing unattractiveness of private practice for clinicians in the current health care climate -- make YHP an excellent opportunity for doctors, nurses and other health professionals who want to deliver good health care. We want a stable provider staff and we have been fortunate to recruit and retain outstanding clinicians.
All our providers must be board-certified and have academic appointments in the Schools of Medicine or Nursing. Our physicians also have admitting privileges at Yale-New Haven Hospital. There is an advantage for the Health Plan member in being treated by providers with a role in Yale's teaching mission. I am convinced that participation in education keeps our clinicians on the cutting edge.
Q: What is the Health Plan's relationship with Yale-New Haven Hospital and the School of Medicine?
A: Yale-New Haven Hospital is one of the nation's premier hospitals and is a great resource for our members. Many people do not realize, by the way, that Yale-New Haven Hospital is not part of the University. We try to admit out patients to this great medical center whenever hospital services are needed.
Our relationship with the School of Medicine is more of a true partnership. YHP is separate from the School of Medicine, but in most instances, specialty care that is not available from our staff is provided by contract with the clinical departments of the school. Clinicians from the School of Medicine see YHP members at 17 Hillhouse Ave. or we send our patients to clinics at the medical center. Our YHP clinicians and the specialists in the School of Medicine collaborate as a team. There are also instances in which YHP patients are referred to community specialists. We develop clinical partnerships that assure that the care we deliver is well coordinated. We are always looking for the right balance of continuity, choice and convenience for our members.
The clinical partnerships we have built serve not only the faculty or the students or staff. Yale Health Plan is also my health plan, and the plan used by the large majority of YHP employees and their families. When new members of the Yale community ask me about health care, I have no hesitation about recommending YHP, not only as the director, but also as a member.
Q: How do you keep informed of Health Plan members' concerns?
A: We have an active YHP Member Advisory Committee, which includes representatives of faculty, staff, retirees, and the student populations. There is also a student member advisory group that works closely with us on issues of importance to Yale students.
YHP has a variety of ways to communicate with our members, including the many activities of Member Services. We are eager to hear any concerns or suggestions from our members. Our comment card system is a good example. We respond to each and every comment card. In fact, I read every comment card. And we are developing other programs to assure that we hear from our members. These include our Web page, our toll-free telephone line for out-of-area members, and our Q&A column in our Newsletter, Yale Health Care.
YHP is a "staff-model" health care organization, as distinct from a loosely affiliated network of practices at different sites. We are a tangible organization to our members, who receive most of their care at 17 Hillhouse Avenue. YHP members can readily identify aspects of their care that satisfy them, and areas in which they may feel we can do better. We receive feedback in a way that a more diffuse organization cannot. All of us at YHP are in constant contact with our members. This helps us know what people need and what they care about. I think it's an unfortunate trend in the arena of for-profit health care that HMOs have had to grow ever larger in order to make profits or just to survive. We've all been reading about health organizations that have grown so big that their information systems are inadequate to know who is enrolled. If an HMO is that big, the people making decisions are not going to know very much about their members' concerns. In contrast, the entire YHP administration is at 17 Hillhouse Ave. and we strive to keep in touch with our members and to base our programs and policies on their needs.
Q: How are the premium costs for the Health Plan determined?
A: To set premiums we start with the needs of the people that we serve. We consider the health care needs of our members, based on our experience and their characteristics as undergraduates, graduate students, working adults and pediatric patients. We want the right numbers of provider staff and support staff to assure that the proper access is there for the primary care needs of that population. We then consider the needs for specialty care and for services in settings other than the outpatient clinic. These settings include the hospital, outpatient treatment programs, one-day surgery and many others. We consider the cost of out-of-area emergencies that require that people be hospitalized in places beside New Haven. Naturally there are a number of other expenses that go into the calculation, but the simple goal of the Health Plan is to charge a premium that is sufficient to permit us to make the best clinical decisions for our members.
I work in close collaboration with a team of associate directors, each of whom is expert in a different area of the health care field. We carefully consider trends in the local health care market, and the bigger picture in terms of health policy and regulations. We confer closely with the Provost, the Budget Office, with the University General Counsel, Human Resources, and other divisions and departments of the University. The most important point is that our premiums are calculated to cover the costs of health care to the Yale community. We are strictly nonprofit. We believe the combination of our cost and the quality of care we provide are an excellent value.
Q: After one year as director of YHP, what are some of the issues and priorities that you see as most important?
A: Access -- the ability of members to obtain care in a way that makes sense and feels right to them -- is an overarching issue. That covers quite a spectrum; access to appointments for acute illness and routine preventive care, telephone access, parking lot access, pharmacy access -- all of those areas present opportunities for improvement. I also believe that our ongoing commitments to clinical quality are major priorities. Another special focus is communicating a message about healthy living to our student population, providing useful information to our faculty, staff and retirees, and most importantly, perfecting our ability to listen to our members.
Q: What message do you try to communicate to the Yale community about membership at YHP?
A: Since YHP opened 27 years ago, we have enjoyed steady, incremental growth. At this point, our membership is at an all time high, with 75 percent of the faculty and staff populations, so there is not a lot of room for our enrollment to increase dramatically. Naturally we would like to have as high a membership as possible because this enables us to provide the best possible care with the optimal economies of scale. On the other hand, there are a number of people who do not belong to the Health Plan for good reasons such as geography. It makes sense for an employee who lives in Rhode Island and has school-age children to have coverage there. But there are undoubtedly members of the Yale community whose needs would be well served by joining YHP.
Q: Are there particular groups that YHP would like to reach?
A: As I said, Yale requires its students to have hospitalization and specialty care insurance, but does not require that they purchase this coverage at YHP. Quite a number of undergraduates or their parents elect to waive YHP coverage in favor of their home insurance. Of course. YHP provides primary care to all these students, regardless of whether they purchase our hospitalization and specialty care. But as more of the nation's population is covered by managed care plans, an increasing number of undergraduate students with insurance from home find themselves "out-of-area" when they need specialty care or hospitalization in New Haven. We find that many students would have been better off if they had purchased YHP hospitalization and specialty insurance, although we realize that some parents are reluctant to opt for coverage that seems to them to duplicate existing coverage.
Often the problem is something like this: a student suffers a sports-related injury and requires an orthopedic procedure. One-day surgery or an overnight hospitalization is recommended. Often she will find herself in the middle of her academic semester and need to get back to her studies as quickly as possible. If this student is only covered by her parents' insurance with its network of providers in her home city, the student may be forced to postpone the procedure until an academic break or vacation. If the treatment cannot wait, she may have to miss school or even withdraw in order to get treatment at home. In the most disruptive case, her insurance may not approve postoperative care or physical therapy unless they are done within the local (home) network. These factors may make it difficult for the student to stay in school, even if her policy looks adequate on paper. My point is that when students and parents make decisions about hospitalization and specialty care insurance, they should make sure this coverage will be adequate for their needs. While we do not want to mandate coverage by YHP, we do hope that students and families will carefully consider the possible consequences of waiving this coverage. I think it would be ideal if all students enrolled at YHP for full coverage except in the increasingly rare instance in which the parents' plans or alternative insurance fully covers the student while at Yale.
Q: How are changes in Health Plan benefits made?
A: The benefits package is not etched in stone. Past decisions about benefits were made with the best available information of the time, but information and priorities change and we are continuously reevaluating our benefits package to meet today's needs. We never want to reduce or eliminate a benefit, except to exchange it for a better one. We are always looking for ways to improve our benefits. I'll give you an example of one that has recently been implemented. Previously, when you went to the pharmacy, you paid in full for your medicines, filled out and submitted paperwork, and waited for reimbursement. It was a hassle for members. Now, we administer the prescription drug benefit at the cash register in our pharmacy. So, after you've paid your deductible, you only pay 20 percent of the cost of your prescription, rather than paying 100 percent and then waiting for 80 percent of your expense to be reimbursed. The appreciation for this change has been tremendous. It has been expensive for YHP because there were a host of people who never submitted their claims, but it was the right thing to do and it is consistent with the way we administer other benefits. It makes medication immediately affordable to people who previously had to wait for reimbursement. It makes it easier for Mrs. Jones to afford and take her blood pressure medicine, so it's money well spent.
Another example is the limitation on out-of-area emergency room coverage. In the past, the Health Plan would cover thirty-five dollars of the professional fee of the emergency room. We covered the other costs, but you would pay the professional fee beyond thirty-five dollars. It no longer is a relevant limitation and we're eliminating it because it makes access to emergency care out-of-area unnecessarily difficult.
These are only two of the many YHP benefits improvements we have implemented or have on the drawing board. I think our approach to improvements in benefits is consistent with our mission to provide excellent clinical care for the Yale community.
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