| STATE STRATEGIES TO REPLICATE SCHOOL-BASED
HEALTH CENTERS
VERMONT: BUILDING A STRATEGY ROOTED IN AN INSURED
POPULATION
In Vermont where a small school-based health center program
has been launched, the centers are viewed as advancing public
health policy via the schools. To date, three centers have been
established in rural communities. The centers are not expected
to serve as medical homes but rather assure the provision of
key physical and mental health services as well as preventive
health services. Since 95 percent of the state's school-age
children are insured before the State Child Health Insurance
Program is implemented and the state is well supplied with pediatric
and family practice physicians, state officials believe there
will be no difficulty linking children to medical homes. One
of the school-based health center roles will be to make sure
all children have community-based primary care providers.
Because health centers will be fulfilling public health functions,
it is not expected that they will receive significant patient
care revenues. Instead, the basic state funding strategy focuses
on using state-administered EPSDT dollars and dollars used to
pay for "related health services" for special education students.
The EPSDT dollars have been carved out of the Medicaid program
to support a Medicaid claiming process which pays schools for
providing administrative functions on behalf of the Medicaid
program. Schools are also paid for providing comprehensive,
preventive health services to Medicaid-enrolled students. The
program, named the EPSDT School-Based Health Access Program,
generates a million dollars a year. The state requires that
if a school is going to participate in the Medicaid claiming
program and seek a school-based health center, the school must
direct 40 percent of funds generated by refinancing towards
the school-based health center. Schools are also being reimbursed
for health related services provided to Medicaid-insured students
enrolled in special education. The state also obligates schools
with school-based health centers to allocate 40 percent of their
"related services" revenues to school-based health centers.
While the state is optimistic that the state-administered
Medicaid dollars will provide a substantial portion of the support
needed to sustain existing centers, securing funds for program
expansion is a different challenge with which the state continues
to grapple.
RHODE ISLAND: JUST GETTING STARTED
Drawing on the experience of its first four school-based health
centers, Rhode Island began developing its statewide replication
strategy a year ago. To date the state has not decided which
school-based health center model it is implementing, rather
it has focused on short-term financing issues, including helping
centers find additional funds to cover operating costs not supported
by the state grant and assisting grantees to maximize billing
-- which means helping them in their relationships with managed
care plans.
The first priority has been to assure that the centers are
included in the managed care provider networks. When RIteCare,
the state's two-year-old Medicaid managed care program, was
launched, the RIteCare contract defined school-based health
centers as essential community providers and required plans
to contract with centers in their service areas. Translating
this requirement into reimbursement to the centers for care
provided has been hard work. The managed care plans are concerned
about health center quality and sometimes, probably for financial
reasons, a child's primary care provider does not want to permit
a child to receive service at the centers. However, the state
has developed quality standards for the centers and implemented
a Continuous Quality Improvement program as a way to encourage
managed care cooperation. Four of the five managed care plans
have signed contracts with the school-based health centers and
some, though limited, RIteCare dollars are accruing to the centers.
Although the state is still early in its formulation of financing
strategies, data from the centers indicate that even with a
generous child health insurance program, the state will have
to identify, at a minimum, $750,000 per year to help fund the
20 school-based health centers the state hopes to establish
in all middle and high schools in five core Rhode Island urban
areas. Negotiating the relationships between health plans and
the centers and securing long-term state funding are the twin
challenges the Rhode Island financing strategy faces.
OREGON: NEGOTIATING A LOCALLY-DRIVEN STRATEGY
Oregon sees school-based health centers as primarily fulfilling
a public health mission, with the localities rather than the
state defining what the public health priorities are. However,
state support for an emphasis on preventive services is reinforced
by data from its Office of Medical Assistance Programs that
documented that for young people ages 14-19 enrolled in the
Oregon Health Plan for Fiscal Year 1996, only five percent had
seen their primary care provider for a preventive health service.
Supporting expanded use of preventive care is a key component
of state interest in school-based health centers.
The state's approach to replicating school-based health centers
is to pursue a community designed and financed model that draws
on technical assistance and limited funding from the state as
well as benefits from a supportive statewide policy environment.
Future funding of school-based health centers may look something
like this: The state will provide partial support to all school-based
health centers; a typical grantee might receive 30 percent of
its operating budget. State participation not only will guarantee
part of the core budget but will also serve as a mechanism for
accountability. Third-party reimbursement and/or support from
the sponsoring agency will total about 30 percent; the county
will contribute 10 percent as will private donors such as business
partners, and the schools will be expected to provide 20 percent
of operating costs.
Oregon does not require that managed care plans contract with
school-based health centers and the centers have faced significant
difficulty in negotiating contracts with the plans. However,
the state has submitted a request to HCFA that would permit
the state to use a larger portion of the SCHIP dollars to directly
fund safety net providers. With the state controlling more of
the SCHIP funds, the state could expand support to those providers
caring for SCHIP enrollees.
Oregon, like Vermont, is a state with a large proportion of
insured children -- at least 92 percent. While the state continues
to broaden its insurance coverage for children and adolescents,
focus is turning to delivery system issues. Increasingly the
mantra is heard that insurance alone does not assure that care
is delivered.
The Oregon replication strategy requires that school-based
health centers engage a number of partners to establish a sufficient
funding base. The state notes that their experience demonstrates
that the strategy can work. During the past six years the number
of centers has more than doubled, growing from 18 to 39 -- with
additional new centers scheduled to open in the current school
year.
NORTH CAROLINA: INCREASING ACCESS TO CARE
THROUGH SCHOOL-BASED HEALTH CENTERS
North Carolina has also doubled the number of its school-based
health centers, growing from 20 to 40 over the past five years.
In this large state with 100 counties, there are substantial
areas that are medically underserved. In some low-income areas,
as many as 25 percent of children are uninsured. And in North
Carolina as in Oregon, even insured children face barriers to
care. For example, less than 20 percent of adolescents enrolled
in Medicaid have received the comprehensive primary care services
available through EPSDT. For these reasons, the state is supporting
school-based health centers as a way of increasing low-income
and uninsured students' access to care and assuring that preventive
care is provided.
Financing strategies are based on (1) building financial linkages
between school-based health centers and managed care arrangements
as well as other third party payers, (2) partnering with private
foundations, and (3) increasing state funding.
The Medicaid managed care program, a mostly primary care case
management program, is called Carolina Access. Participating
physicians are paid fee-for-service with the primary care physicians
receiving an administrative fee for their gate-keeping activities.
Only one county, the largest -- Mecklenberg County (Charlotte)
-- has a capitated program. The state Office of Medical Assistance,
private providers, and the Health Department School Health Office
have joined together to develop standards for school-based health
centers. Centers that meet standards will not have to receive
prior approval to bill Medicaid for the services provided. Two
standards have already resulted from these discussions include:
1) at least 80 percent of all students enrolled in the school-based
health centers should have an age-appropriate well-care visit,
and 2) all enrolled students should have a well-care visit within
one year of enrolling.
The SCHIP legislation, which was expected to supplement the
Medicaid portion of the centers' patient care revenue stream,
has excluded school-based health centers from participation.
Despite intense lobbying by representatives of communities with
school-based health centers, at least for this first year, the
North Carolina SCHIP will not reimburse centers for care provided
to its enrollees.
A second financial strategy to support the centers has been
to work collaboratively with foundations. The largest foundation
in the state, The Duke Endowment, and several others are providing
seed dollars for planning and start-up for both school-based
and school-linked programs as well as supporting traditional
school health services.
A third and final strategy is to increase state funding for
school-based health centers for the first time since its initial
funding in 1991. The state hopes to do this both through the
Maternal and Child Health block grant dollars and through an
increase in funding for the adolescent health initiative in
the budget for the next biennium.
NEW YORK: RE-TOOLING A 20-YEAR OLD PROGRAM
TO SUPPORT SCHOOL-BASED HEALTH CENTERS
With 159 centers, New York has the largest school-based health
center program in the country. To receive state funding these
centers must meet standards that emphasize the provision of
comprehensive services and, in partnership with its sponsoring
institution, the capacity to serve as a medical home. The standards
also indicate that the centers are intended to serve public
health functions, including provision of health education and
preventive care.2
At present the school-based health centers receive $10 million
in state grant funds (including general fund, Maternal and Child
Health Block Grant, and Making the Grade dollars); and $6 million
in Medicaid fee-for-service revenues. Centers are also supported
with approximately $6.3 million in in-kind contributions by
sponsoring institutions. This financing strategy for school-based
health centers, however, is now in transition.
New York is committed to financing indigent health care through
managed care and this means that the state is also committed
to integrating school-based health centers into Medicaid and
SCHIP managed care programs. For the past two years the state
has granted the centers a temporary carve-out from its mandatory
Medicaid managed care program . It was expected that the centers
would use this time to negotiate contracts with the plans. The
carve-out is expected to end shortly. Due to delays and difficulties
in negotiations, the contract deadline has been postponed twice.
Recently it was postponed again from October 1 until at least
December 31,1998.
In New York the centers have been reimbursed at the hospital
outpatient rate, sometimes up to $70 per visit -- which accounts
for the $6 million in Medicaid revenues. Managed care plans
are refusing to pay that rate, which has created a stand-off
between the plans and the school-based health centers. The centers
contend that they cannot survive the reduction in Medicaid payments;
the state argues that the reduction will be offset by an increase
in coverage for uninsured children through Child Health Plus
(the New York SCHIP). The plans maintain that they will not
pay $70 a visit and do not need the centers to offer an adequate
provider network. Both parties have been unyielding. A great
deal of work remains to be done to resolve the competing claims
of school-based health centers and managed care plans.
MARYLAND: ADJUSTING TO CHANGED POLICY ASSUMPTIONS
When Maryland became involved in Making the Grade, its vision
for school-based health centers was based on a devolution strategy
called the Systems Reform Initiative (SRI) which was intended
to support greater local control of state dollars spent at the
community level. Given the local control aspects of devolution,
the state did not articulate its own mission for school-based
health centers. Under devolution, at the state level categorical
dollars would be pooled and those funds would be distributed
to the 24 Maryland local jurisdictions. These jurisdictions
would make funding decisions based on the needs of their communities.
The state believed local communities would see school-based
health centers as an answer to some community needs. With the
state already supporting school-based health centers with generous
fee-for-service Medicaid reimbursement that covered mental health
as well as physical health services, the assumption was that
together these resources would provide basic funding for the
centers when combined with in-kind contributions from the school
system and grants for special activities. Both the SRI and Medicaid
funding strategies have since unraveled.
Implementation of the Systems Reform Initiative has been a
slow process with delays in amassing the required "savings"
for investment in the program as well as difficulties in putting
the administrative structure in place. Thus the Systems Reform
Initiative is no longer seen as a major funding source and the
state has begun to re-engineer its financing vision.
The other pillar of Maryland's funding strategy, its generous
fee-for-service Medicaid strategy, collapsed a year ago when
HealthChoice, the Medicaid managed care program, was implemented.
Managed care plans participating in HealthChoice are required
to reimburse the centers for up to four acute care visits per
semester with one follow up per acute visit. But to receive
payment for any services, the school-based health centers must
negotiate contracts with each participating plan. To date no
contracts have been signed. The lack of success in contracting
under HealthChoice is significant because the Maryland SCHIP
program has been folded into HealthChoice. While schools have
been identified as a place for SCHIP enrollment, no special
funds from the "ten percent" dollars will be available to support
direct service delivery.
A significant shift from the original financing vision is
the greater role for private partners. Initially the state focused
almost exclusively on public funding and public policy setting.
Recently, private entities, especially large health care systems,
have expressed interest in the school-based health centers.
One of these systems is now subsidizing two school-based health
centers. The state plans to nurture this development as an alternative
model for financing the centers.
Despite the bumpy road, five new centers opened this year
bringing the Maryland total to forty-three. Part of the growth
is due to the state's distribution of a $300,000 seed fund over
the past two years and the new partnerships with private providers.
The state's primary challenge will be to sustain these fledgling
efforts. Ultimately the Health Department needs to develop a
budget package to help support the centers. However, before
it submits a request to the legislature, the department needs
a solid year of billing in all the jurisdictions with school-based
health centers to document the gap between third party revenues
and the total operating cost of a center. The state is concerned,
however, that the jurisdictions most effective at billing are
covering only 30 percent of their budgets. The remaining costs
are supported by a mix of local support, grants, and in-kind
contributions.
LOUISIANA: BUILDING A STATE-SUPPORTED NETWORK
OF SERVICES FOR SCHOOL-AGE CHILDREN.
Funding for school-based health centers is solidly based on
line item support in the state budget. Louisiana's original
financing strategy involved Medicaid reimbursement, pooled funding,
use of block grants, a local match and some state funds. In
the first few years the state even spent time on Medicaid managed
care. But Louisiana is still not doing anything with managed
care and what the state has learned over time is that its best
finance strategy is a political one. School-based health centers
work with their legislators who become advocates for funding
more centers. As a result Louisiana has an annual state appropriation
of $3.25 million to support school-based health centers. And
this is added to a Maternal and Child Health Block Grant allocation
of between $600,000 and $1 million annually plus Making the
Grade funds and local match contributions.
The policy has worked: the number of school-based health center
sites has increased from four in 1991 to 30 in 1998. About 60
to 65 percent of each site's budget is derived from state resources.
Local match is running between 30 and 35 percent; Medicaid revenue
is only about three percent despite the fact that about a third
of the centers' population is Medicaid eligible. Like North
Carolina, the state views its centers as meeting public health
objectives -- assuring access to preventive care and addressing
the primary problems of the population being served. If they
have adequate weekend and after-hours back-up from their sponsoring
institution, the centers may also serve some patients as their
medical home.
School-based health centers did well during the SCHIP hearings
in Louisiana. Everyone who testified before the Governor's commissioner,
whether they represented a university or a provider group, included
school-based health centers in their strategy. The centers are
part of the delivery system in the state. With Medicaid being
extended to kids up to age 18 and covered up to 133 percent
of the federal poverty level (FPL) in year one of a three-year
expansion to 200 percent FPL, the state anticipates a potential
third-party payment turn-around. A worry is that maybe the students
will not come to the centers when they have other options. Advocates
don't think so but that remains to be seen. Customers will vote
with their feet.
CONNECTICUT: RE-TOOLING AN ESTABLISHED STATE
PROGRAM, PART II
Connecticut refers to its school-based health center program
as having a multiple personality: the centers integrate medical,
public health and social service models.
The state's financing strategy is based primarily on a grants
program that funds 45 of the 51 school-based health centers
in the state. The grants are supported by a state general appropriations
budget of just under $4.5 million. An emerging second strategy
is an increasing emphasis on patient care revenues. Like other
states, the conversion of Medicaid to a managed care program
has engaged the Health Department and the school-based health
centers in efforts to link the centers to managed care plans.
While it has taken two and a half years, nearly all the required
contracts between school-based health centers and managed care
are in place. The state Medicaid managed care Request for Proposals
required plans to include school-based health centers in their
networks, but the state learned that that was just the first
step. Intense negotiation among the plans, school-based health
centers, the Medicaid Office and the Health Department was essential
to secure those contracts. Now the state has launched its SCHIP
program, HUSKY (Health Care for Uninsured Children and Youth),
a non-Medicaid insurance product with a more limited service
package than Medicaid that requires co-pays. The state must
now take the lead in a second round of negotiations to assure
that the new HUSKY contracts are concluded.3
Despite success in the contracting process, the revenues generated
as a result have ranged from a negative ten percent due to the
cost of billing up to a positive ten percent (of operating costs).
Most health centers are realizing five percent of their operating
costs or less. Currently most sites receive between 60-65 percent
of their budget from the state and 30 - 35 percent from local
resources. Medicaid revenues average three percent.
Although revenue returns are disappointing, other benefits
are emerging. Oxford Health Plan contributed health education
materials for an asthma support program through a school-based
health center in Stamford. The state is also discussing with
HealthRight, another Medicaid managed care plan, the possibility
of an EPSDT project in New London and Groton. EPSDT compliance
in Connecticut has historically been low, particularly for adolescents.
Under this arrangement HealthRight will utilize its outreach
workers who do home visiting to inform parents about EPSDT.
If the children are not already enrolled in the local school-based
health center, the outreach worker will enroll them. HealthRight
will provide the school-based health center with a monthly list
of its enrollees who need an EPSDT exam. The school-based health
centers will provide the service and the plans will pay the
centers.
The Connecticut legislature created an oversight council to
track the implementation of Medicaid managed care. School-based
health centers have a number of supporters on that council who
are concerned about managed care's impact on safety net providers.
The council has played an advocacy role to make sure school-based
health centers do not fall through the cracks during managed
care implementation.
A debate occurring within the Health Department is whether
the recent infusion of money for child health insurance will
make the state investment in the health care delivery system
unnecessary. Among some legislators there is a feeling that
with HUSKY, all kids have been covered so state support of a
delivery system is unnecessary. The Health Department will have
to gather data to respond to that concern.
COLORADO: SHAPING PRIORITIES IN A MARKET-ORIENTED
ENVIRONMENT
Colorado's strategy to support school-based health centers has
been strongly market-oriented, encouraging the health plans
to use publicly-funded health insurance dollars -- both Medicaid
and SCHIP -- to support the centers. To a lesser extent, the
state is also attempting to identify dollars that can pay for
uncovered costs. This strategy reflects a belief that at least
in larger Colorado communities there are sufficient resources
-- whether from a local hospital or school or foundation --
to support a significant portion of a school-based health center
budget. Three pieces of legislation passed in 1997 provide a
foundation for creating public revenue streams for the centers:
Senate Bill 5 increases Medicaid managed care enrollment to
75 percent of Medicaid beneficiaries by the year 2000 and also
defines school-based health centers as essential community providers
(ECP). Managed care plans contracting with Medicaid are encouraged
to make good faith efforts to contract with ECPs that provide
services in their service areas;
Child Health Plan Plus (the Colorado SCHIP) implements insurance
expansion through a private model. It also uses the ECP definition
of Senate Bill 5. Given the high rate of uninsured kids seen
by many of the centers, with an increasing number of contracts
in place between the plans and the health centers, CHP Plus
has great potential to expand their third party revenue;
Senate Bill 101, "Medicaid Reimbursement for Schools," authorizes
participating school districts to become Medicaid providers.
Thirty percent of the dollars recovered could be used by the
schools to purchase health insurance for students or purchase
primary care services directly for low income students. This
means Colorado schools could use Medicaid to help support their
school-based health centers. Unlike Vermont, however, the schools
aren't required to do so.
Colorado also has some significant private initiatives.
Kaiser School Connections is a dues subsidy program supported
by Kaiser. Three school-based health center programs participate
through 10 of their sites. The initiative basically represents
a splitting of the primary care capitation -- with the school-based
health centers receiving 60 percent of the cap, and 40 percent
for Kaiser. Kaiser provides the medical supervision in collaboration
with the school-based health centers. Another private initiative
is with PacificCare in Denver. PacificCare provides a grant
to participating school-based health centers in return for
HCFA 1500 billing data to build a utilization history as a
basis for an on-going capitation arrangement with the school-based
health centers.
Other financing comes from local in-kind support and private
foundation participation. The state requires its grantees
to secure substantial local contributions. These dollars provide
a financial base, help fund mental health, and document community
support.
Foundation dollars continue to be important. School-based
health centers receive contributions from United Way, the
recently-created Rose Foundation, HealthOne, Blue Cross/Blue
Shield and others. Blue Cross will likely be privatized next
year, resulting in the creation of a new, very large foundation.
The hope is that this foundation will help support the centers
as well.
A new contributor to state policy is the Colorado Association
for School-based Health Care (CASBHC). This provider association
includes nine of the twelve entities that sponsor school-based
health centers. To facilitate contracting between school-based
health centers and managed care, CASBHC has developed standards
for three levels of certification for school-based health
centers. The certification categories describe the service
package for different types of school-based health centers
without forcing them into a one-size-fits-all approach. Certification
categories cover scope of services, physical plant, availability,
quality assurance, and financing. Along with these categories,
CASBHC has developed some quality assurance protocols and
clinical outcome indicators that are based on HEDIS measures.
DOCUMENTATION AS THE BOTTOM LINE
The experiences of the nine Making the Grade states demonstrate
a variety of efforts to secure access to existing public and
private funding streams as well as generate state fiscal support
for school-based health centers. At present, the onus appears
to be on school-based health centers to prove their worth,
a task which will require documentation of the numbers of
children they are serving, their insurance status, and services
provided to them. This information will provide evidence needed
to lobby for inclusion in health plan networks, and for state
or local revenues to cover those health promotion and education
services that are often excluded from insurance coverage.
"Do not," urged Rosenberg, "confuse political support, which
also is essential to secure public dollars, with whether you
provide a necessary service. To those of you who currently
enjoy strong political support but whose mission is less than
clear, I can only urge you to make good use of this time to
do the data gathering essential to document functions you
are fulfilling."
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