Rural health project at Ho-Chunk House of Wellness explores the impact of billable health insurance
By Katie Ginder-Vogel
Jenevieve Van Order grew up in Arbor Vitae, Wis., several miles from the Lac du Flambeau reservation. Van Order, a fourth-year PharmD student at the University of Wisconsin–Madison School of Pharmacy, is a descendant of the Lac Courte Oreilles Band of Lake Superior Chippewa, “or, as we call ourselves, Ojibwe,” she says.
Her classmate Taylor Hauser, also a fourth-year PharmD student, also hails from a rural Northern Wisconsin community near tribal lands, Argonne, Wis. Although she is not a tribal member herself, many of her family members and friends are.
Both students have experienced first-hand the difficulty of obtaining health care in these rural areas, so they plan to return to their rural communities to practice pharmacy.
“We didn’t have much money growing up, and where I grew up, in Forest County, going to the doctor would often require my parents to take off work to go to the nearest hospital, in a neighboring county,” says Hauser, who is a member of Rho Chi, the academic honor society for pharmacy students.
“We had an amazing pharmacist who was very accessible, and if he could answer our health questions to save us a trip to the doctor or money on prescriptions, he would,” she says. “Seeing the accessibility of pharmacists as health care providers and their ability to affect patient care drew me in. I want to return home and serve my community.”
“This project is important for accessibility reasons, to increase awareness of health care disparities, promote further research on the topic, and inspire action to close the gap.”
—Taylor Hauser
So it made sense that when Van Order and Hauser signed up for the School’s new Rural Health option in the PharmD program, they were already envisioning a project, ideally a collaboration between the School of Pharmacy and the Indian Health Service (IHS), the federal agency responsible for providing health services to American Indians and Alaska Natives. Ultimately, they locked on to studying billable health insurance and how helping patients enroll could impact IHS clinics, such as the Ho-Chunk House of Wellness.
Assistant Professor Ed Portillo (PharmD ’14), who leads the rural health program, was immediately enthusiastic and supportive, and over the summer of 2019, he met with the two students and Melissa Metoxen, community and academic support coordinator for the Native American Center for Health Professions (NACHP) in the UW–Madison School of Public Health, to map out the project.
“Taylor and Jenny have formed strong partnerships with our colleagues at the Ho-Chunk House of Wellness, which has resulted in opportunities for expanded patient access to timely health care,” says Portillo.
Gathering data
The Indian Health Service covers 2.1 million patients in the U.S. The Ho-Chunk House of Wellness in Baraboo is one of their Wisconsin clinics, but there is no IHS hospital in the state, which can limit the types of health services available.
Indian Health Service clinics benefit when patients have billable health insurance (BHI) because the clinics can be compensated for covered services, freeing up IHS funds for other clinic initiatives, like hiring more staff or special health programs. However, many patients who are eligible for billable health insurance, like Medicare, Medicaid, employer-offered health insurance, or an Affordable Care Act plan aren’t enrolled. Van Order and Hauser decided to dig into that problem and figure out why the enrollment numbers are so low.
“This project is important for accessibility reasons, to increase awareness of health care disparities, promote further research on the topic, and inspire action to close the gap,” says Hauser.
Portillo reached out to his School of Pharmacy classmate Hussain Harun (PharmD ’12), a pharmacist at Ho-Chunk House of Wellness, to see if he would be interested in becoming their preceptor, and he accepted.
Van Order and Hauser visited the clinic, whose broad services include dental, optical, primary care, pharmacy, behavioral health, a fitness center, and an aquatic center, in October 2019.
“We wanted to truly understand the process at the clinic,” says Van Order. “We met with Hussain and the pharmacy staff and talked about what they see as problems and what data Hussain specifically hoped to get from the project.”
Harun told the students that his team was trying to determine the number of their patients who have and do not have billable health insurance.
Van Order and Hauser then went on to meet with the patient registration staff to learn what happens when patients come for their annual visits. They also talked with the benefits specialist team, who help patients enroll in insurance by checking eligibility for employer health plans, Medicare, Medicaid, or an Affordable Care Act plan. The students concluded their visit with an IT staffer to make sure the data they wanted — about which patients had insurance — could be pulled and got the go-ahead.
Following their clinic visit, Van Order and Hauser got to work, sending evaluations to clinic employees, gathering additional information about enrollment processes for billable health services, and collecting data on patients’ tribal affiliations and health service fees. They conducted 21 surveys that assessed employees’ views of billable health insurance. They also pulled all the clinic’s insurance claims for the 2019 calendar year.
Hauser took charge of analyzing the extracted data and calculated BHI coverage rates and cost of care.
“Taylor did most of the data analysis, spending about 16 hours analyzing a 37,000-line spreadsheet,” says Van Order.
“There were 37,000 claims made at the Ho-Chunk House of Wellness in 2019, and I was able to break down the claims to calculate our results,” says Hauser.
Understanding lagging enrollment
Hauser and Van Order learned that 30.8 percent of the patients at the Ho-Chunk House of Wellness lack billable health insurance.
“While the rate of American Indian and Alaska Native patients without billable health insurance is lower at the House of Wellness, compared with the national average for American Indian and Alaska Native patients, there is still a huge disparity compared to the overall national averages,” says Van Order. “According to the 2017 U.S. Census, 6.3% of non-Hispanic whites, 7.3% of Asians, 10.6% of African Americans, and 16.1% of Hispanics were uninsured.”
Van Order and Hauser found that the Ho-Chunk House of Wellness spent almost half a million dollars to cover care for uninsured patients. If even the five most frequent visitors to the clinic in 2019 had BHI, that alone would have saved the clinic $36,000.
“That money could be used for innovative programs for the community or hiring new employees,” says Hauser. That’s a valuable piece of information that shows the financial impact of insurance.”
“The Ho-Chunk Nation and the Indian Health Service cover everything BHI does not,” says Van Order. “It still doesn’t cost the patient anything, but the clinic has the potential to save a great deal of money if patients have insurance. It was eye-opening to see all this.”
Because increasing BHI enrollment would clearly benefit the Ho-Chunk House of Wellness, not to mention Indian Health Services clinics nationwide, Van Order and Hauser also dug into the problems with getting patients enrolled, as a way to develop an education plan to increase enrollment numbers.
Their employee surveys revealed that 95 percent of Ho-Chunk House of Wellness employees agreed that increasing rates of BHI would save the clinic money, and 85.7 percent of employees agreed that BHI helps patients. But less than a third — 28.6 percent — said they were comfortable answering patients’ questions about how to obtain BHI, and many employees identified lack of knowledge as one reason patients may not enroll.
“We figured all this out with our data set, and this is something Hussain is really excited about,” says Van Order. “He says this information, when we give it back to the Ho-Chunk Nation, is really going to help people understand the need to increase patient and clinic staff education on billable health insurance.”
Next steps: education and encouragement
Van Order and Hauser hope to publish their findings and help IHS clinics across the country. They’ve also identified the ideal next phase of the project: a patient and staff education program that could increase enrollment in billable health insurance. They have several specific ideas for launching a public health campaign about BHI, including creating brochures for waiting rooms, inviting benefits coordinators to community health fairs, and publishing a list of FAQs online.
“We also talked about how the Ho-Chunk community and many Native communities hold elders in high esteem, so having an elder talk about the importance of billable health insurance, making things culturally targeted for the patient population, could help,” says Van Order. “Making a video and sharing it on social media could also work.”
When it comes time to implement new processes to encourage patient enrollment, Van Order and Hauser envision a direct referral program or direct handoffs from one clinic staff member to another.
“My desire and passion is to work in Native communities and clinics, and in Wisconsin, most of those clinics are in rural areas.”
—Jenevieve Van Order
“If someone comes to an annual visit and tells registration they don’t have billable health insurance, registration could walk them over to the benefits coordinator after the appointment, so there isn’t a breakdown in transition of care from the clinic appointment,” says Van Order. “That avoids putting responsibility for follow-up on patients and takes transportation challenges into account.”
Harun and Portillo plan to continue the project next year, and Van Order and Hauser, who will be out on their fourth-year Advanced Pharmacy Practice Experience (APPE) rotations next year, hope to offer support.
“I’m glad we were able to give the next group some data they can utilize to make an impact,” says Hauser. “We are willing to mentor and answer questions for the next students to take over.”
“It’s been awesome to work on this project,” says Van Order. “We didn’t want to come in and do research and not help find a solution, so that’s why I think it’s so important that Hussain wants to continue with next year’s rural health cohort, and we’re happy to help.”
Reflections on rural health
Both students have a longstanding commitment to helping improve health care in diverse and underserved communities. Van Order has served on the Multicultural Affairs Program in Pharmacy (MAPP) board throughout pharmacy school and is president this year. She has also served on the School of Pharmacy’s Student Climate and Inclusivity Committee for three years and initiated bringing Operation Diabetes to UW–Madison’s Wunk Sheek Powwow in 2018, for which she also conducted cultural sensitivity training for the student pharmacist volunteers.
This year, Van Order worked with School of Pharmacy Assistant Dean of Diversity and Inclusion Initiatives Lisa Imhoff and Portillo, among others, to bring UW–Madison’s Our Shared Future heritage marker to the School of Pharmacy.
Throughout pharmacy school, the two have also been involved with NACHP and are Wisconsin Area Health Education Center scholars, participating in didactic and community-based experiential training in Wisconsin rural communities and/or with underserved populations. For these students, the School’s Rural Health PharmD option was a perfect fit.
“My desire and passion is to work in Native communities and clinics, and in Wisconsin, most of those clinics are in rural areas,” says Van Order. “This is something I wanted to work hard on. It truly helped prepare me for APPEs, in terms of project management, time management, setting achievable goals, and giving presentations.”
One of Van Order’s APPE rotations will be at the tribal clinic where she grew up, and she’s considering applying for a residency with the IHS.
“I’ll be able to serve my people and community in the clinic,” she says. “I want to make sure that by the time I return to be a pharmacist in my community, I will have as much knowledge and as many skills as I can possibly offer.”
Hauser says she learned project management skills in the program, specifically, how to tailor a project to target community areas that could potentially be improved.
“Projects completed by our Rural Pharmacy Practice students truly exemplify the Wisconsin Idea and demonstrate the impact strong collaborative partnerships can have on health care delivery across rural Wisconsin.”
—Ed Portillo
“We were given the skills to evaluate the needs of a community and develop and implement sustainable solutions,” she says. “Dr. Portillo and the program’s guest speakers reiterated the importance of continuous quality improvements and of measuring outcomes over time, to make sure they’re still making an impact.”
“Projects completed by our Rural Pharmacy Practice students truly exemplify the Wisconsin Idea and demonstrate the impact strong collaborative partnerships can have on health care delivery across rural Wisconsin,” says Portillo.
Professor Dave Mott (BS ’88, MS ’92, PhD ’95), William S. Apple Distinguished Chair and chair of the Social and Administrative Sciences Division, who worked with Van Order and Hauser to develop their project, says the two student pharmacists understand the big picture.
“They are phenomenal. They were interested in the process, in doing the needs assessment, and in figuring out how they were going to get there,” he says. “I think their process is really going to help other IHS clinics address this situation, so all IHS resources can be allocated better. They’ve established a great network of colleagues in the IHS space and beyond.”