School-based health centers becoming important sources of primary care
School Health Centers
March 31, 1997
More than 900 school-based health centers throughout the United States are providing children with physical exams, immunizations, treatment for illness and injury and acute management of chronic illnesses, such as asthma.
School and state officials say school-based health centers are increasingly becoming important sources of primary care for school-age children. They are serving children from insured or uninsured families, headed by a single parent or two working parents juggling the demands of work and children. As Medicaid programs move to managed care, some of these centers are also joining the ranks of Medicaid providers and forging partnerships with managed care plans.
With federal and state grant funds to schools on the decline, school-based health centers also are taking a more serious look at patient care as a largely untapped revenue source.
State policies
Some states have policies in place to encourage use of school-based health centers. Connecticut is one state that requires Medicaid managed care plans to contract with school-based health centers, although it does not specify rates or define service packages. In Massachusetts, Medicaid risk contractors must form "linkages" with school-based health centers, although these relationships do not have to be contractual.
Other states are taking a more voluntary approach. Colorado encourages but does not mandate alliances between managed care organizations and school-based health centers. Minnesota also makes use of school-based centers voluntary for plans.
In Massachusetts, Boston-based Harvard Pilgrim Health Care came up with a simple response to the state’s mandate for linkages that appears to have worked well for everyone involved, says Steven Friedman, project manager for at-risk populations. Based on utilization data supplied by the centers on the plan’s enrollees — both Medicaid and non-Medicaid — Harvard Pilgrim came up with an annual lump sum payment. That sum is adjusted annually to reflect new data. The plan did not have to make a major outlay because the number of enrollees was quite small, Mr. Friedman says.
But it has generated good will for Harvard Pilgrim, he says, and now the plan is taking a closer look at how it can use school-based health centers to improve certain services, such as immunizations.
Louise Bannister, assistant director of the Primary Care Clinician Plan for the Massachusetts Division of Medical Assistance, says the state is interested in integrating school-based health centers into its Medicaid managed care program, but recognizes that Medicaid plans must be able to make their own decisions about subcontractors or other types of partnerships if they are to be held accountable for their services.
Meanwhile, the state plans to ask Medicaid plans to collect utilization data for enrollees who have access to school-based health centers. The goal, she says, is to determine whether those children are actually receiving more services.
Primary care contracts
In Minnesota, the Health Start school-based health center program in St. Paul has negotiated primary care contracts with four managed care plans, including Minneapolis- based HealthPartners. Those contracts, which have been in place about two years, cover both Medicaid and non-Medicaid children.
Donna Zimmerman, director of government programs for HealthPartners, says her plan pays the centers on a fee-for-service basis. "We capitate for a broader array of services than they provide, although they do have a very comprehensive model," she explains.
"We don’t think it’s appropriate yet to be capitating them." Most of the services provided by the centers are for treatment of minor illnesses, such as colds and sore throats, and reproductive health services. Some centers also offer mental health services and health education.
Key to the partnership with Health Start, says Ms. Zimmerman, were its ties with other providers in the community, particularly St. Paul Ramsey Medical Center, which is part of the HealthPartners system. "That really helped cement the relationship," comments Ms. Zimmerman, who formerly was the director of Health Start. "The fact that we can keep everyone all in one system helps a lot."
In Colorado, Kaiser Permanente recently launched an initiative, School Connections, to serve low-income, uninsured school children. Eligible children whose families agree to pay a $3 monthly premium can receive health care services at their school-based health centers and full inpatient and outpatient services at Kaiser Permanente for a $5 co-pay.
"The school is the access point at which they enroll students into this subsidized product, and then Kaiser is paying a capitated rate for the primary care services provided by the school-based health center," says Bruce Guernsey, director of Colorado’s School Based Health Center Initiative.
The product, now being offered in the Denver area, was developed after Kaiser officials analyzed utilization data for Kaiser enrollees, including those with access to school-based health centers, he says. "I think they (Kaiser) were very impressed with the quality of the visits that were provided in the school-based health centers," Mr. Guernsey says. "There was a lot of health supervision and risk assessment and prevention."
Negotiating with managed care plans is not an easy task for school-based health centers. Centers must be ready to discuss issues such as the scope of services they are prepared to offer, staffing composition, day-to-day operations, quality improvement activities and any data that they may have about the utilization of services by health plan members, Ms. Zimmerman says. Preauthorization is another thorny issue that must be addressed during negotiations, she says.
Negotiations get complicated
These negotiations can get complicated. "Every single company wants a different services package and a different reimbursement rate," says Lynn Noyes, supervisor of school and adolescent health units for the Connecticut Department of Public Health. In Connecticut, about 50 school-based health centers have either executed or are hammering out contracts with 11 Medicaid health plans.
"For school-based health centers, negotiating with managed care plans is hard work that is not always rewarded," states a report by the Robert Wood Johnson’s Making the Grade program, which supports the development of federal and state links with school-based health centers.
School-based centers, accustomed to getting their revenue from public and private grants, are often unprepared for the contractual and administrative issues of a billing environment, Ms. Noyes notes. In Connecticut, for example, where Medicaid managed care enrollees can change plans every 30 days, "keeping track of 11 plans on a monthly basis for all the kids has raised an incredible set of issues," she says.
As Medicaid programs move to managed care, some of these centers are joining the ranks of Medicaid providers and forging partnerships with managed care plans.
For some small centers that serve a very limited Medicaid populations, "it’s probably going to cost them more in new administrative services than they’re ever going to see in reimbursement," Ms. Noyes predicts.
Centers also are investing a lot of time and energy just "learning to speak the managed care language" and the ins and outs of being part of a delivery system. The differences in philosophy, notes Ms. Noyes, can be difficult to bridge. "On the one hand, the school-based health centers are real interested in access, prevention and getting kids into care early, while the managed care organizations’ philosophy is to hold the bottom line," she observes.
—Mary Darby
Contact Mr. Guernsey 303-692-2377; Ms. Bannister at 617-348-5527; Ms. Noyes at 860-509-8057; Mr. Friedman at 617-975-4007; and Ms. Zimmerman at 612-883-5119.
School-based health centers becoming important sources of primary care
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