Dramatic shifts toward managed health care continue as the nation's health delivery marketplace becomes more competitive. These shifts affect all health care organizations, including public school health programs and school-based health centers. Following is a summary of current developments and trends likely to affect school health services.
Health Care Reform
The Players:
• Hospitals
• Insurers, including Medicaid
• Managed Care Organizations
• Integrated Delivery Systems
• Disease Management Companies
Public and private health purchasers continue to seek competitive bids, demand price concessions, and negotiate insurance coverage options to save money. This is fueling the general movement away from a fee-for-service system, toward one that integrates financing and health delivery systems.
Increasing capitation payment to health providers demands management of costs and quality of care, and accountability for outcomes. Forming new partnerships with church, school, and community health agencies can help providers assess needs, manage risk, and improve health outcomes. Today however, providers are spending more effort on market positioning and managing cost than on restructuring their processes of care.
Progress toward lasting health care change is slow due to these factors:
• There is an inadequate supply of people with the clinical and business/analytical skills needed to effect process change.
• The mechanisms that can effectively change how care is delivered are still under development.
In especially short supply are CEO/administrators and MIS (Management Information Systems) specialists with clinical application experience. Nonprofit organizations, especially public hospitals, will find it increasingly difficult to compete against for-profit firms for qualified leaders.
Until long-lasting delivery strategies and responses of health care organization evolve, the ultimate outcome for health care change remains unclear.1
Managed Care
Integrated systems of care demand that organizations provide directly or arrange for a continuum of care. This means new partnerships and alliances with similar and dissimilar organizations.
As a major manifestation of health care reform, managed care organizations continue to grow nationally. Trends are toward providing a diversified and broad delivery system to the public/private health care purchaser. Here are the four most common models for managed care:
• Staff model, such as Kaiser Permanente. The oldest form of managed care, these organizations own/operate clinics and employ salaried physicians.
• Capitated group networks. These are groups of primary care or multi-specialty clinics which contract with managed care entities to provide care on a price-per-enrollee basis and assume the financial risks.
• Independent practice associations (IPAs). The fastest growing type of managed care, IPAs are groups of individual medical practices or privately owned clinics which agree to provide primary care for a defined population, sharing the financial risk and following certain rules for referrals and prescribing of medication. Financial arrangements may include capitation or discounted fee-for-service.
• Preferred provider organizations (PPOs). Structured the same as IPAs, these groups of individual practices or clinics use a specific panel of referral services, follow utilization rules and accept fixed-fee reimbursement without bearing any financial risk.2
Medicaid
To be uninsured often means failure to get preventive care, inadequate maintenance of chronic conditions, and adverse outcomes.
Medicaid insurance provides a health safety net for low income women and children, as well as for disabled and elderly Americans. Medicaid provides long term care coverage and supplements Medicare health insurance. In 1994, more than 1 in 8 Americans, including 17 million children, were covered by Medicaid.
In most states today, a major focus of health care reform is mandatory enrollment of Medicaid beneficiaries in managed care plans. One-third of all Medicaid-insured are now in managed care, however quality standards and patient education about choice are often inadequate.3
Although federal legislation in the late 1980's and early 1990's expanded Medicaid eligibility and encouraged preventive medical services for children, Congressional debate over the last two years has focused on reducing coverage and eliminating federal standards for covered medical services.5 The Personal Responsibility and Work Opportunity Reconciliation Act of 1996 imposes arbitrary time limits on welfare recipients, which could result in a loss of Medicaid coverage for families with dependent children.4
Medicaid Implications for School Health
• Health services to special education students now represent the greatest part of health services delivered in schools. The Medicare Catastrophic Coverage Act of 1988 allows Medicaid funds to be used for health services under a student's Individualized Education Plan (IEP).
• Tighter eligibility standards for older children means that poor adolescents are less likely to have medical insurance and are at greater risk for unmet health needs.
• Under the Early Periodic Screening, Diagnosis and Treatment (EPSDT) program, schools can be reimbursed for preventive medical services given to Medicaid-insured children.
Implications for Schools
With shrinking sources of public and private funding, school-based health centers must form relationships to obtain third party reimbursement. Below are two possible types of partnerships with managed care plans (who have commercial and may have Medicaid enrollees).
• Contract with managed care providers as a co-manager of primary care. Each provider may allocate operating funds to the school based on the number of students enrolled, or schools could charge on a fee-for-service basis.
• Join other community based providers in a network and jointly contract with managed care plans to provide primary medical care to high-risk groups, such as adolescents. Or, joining a community mental health/social service network and provide child/adolescent mental health services for managed care plans.
Meeting contractual obligations is costly, so schools should team with the health plans who enroll the largest numbers of their students. Negotiations should address these issues:
• Which services the school program can provide without prior authorization and how reimbursement to the school will be structured.
• School's use of the plan's other primary care providers, specialist, pharmacies, and laboratory services.
• Maintenance of confidentiality for services for which adolescents can give their own consent.
• Coordination of quality improvement efforts for the plan's student members, including improved access to care and early screening/preventive services.
• Credentialing criteria the school must meet.
• Inclusion of typically non-reimbursed interventions as a medical benefit offered by the plan, for example, school behavioral interventions for a student accident or suicide attempt.2
Schools may also wish to apply for direct reimbursement for services to Medicaid-insured students not enrolled in a managed care plan or enrolled in a plan with the school does not partner. The following are considerations for working with state Medicaid personnel.5
• States may have Medicaid limitations or exclusions; not all services may be reimbursable.
• Schools must be able to prove there is no duplication between the requested Medicaid reimbursement and (1) any public grant support for the health service rendered, (2) any Medicaid payment the state has made in advance to a contracted managed care organization.
References:
1. Inadequate Supply of Qualified People will Slow the Pace of Health System Change, Issue Brief, Center for Studying Health System Change, Washington DC, 3/97.
2. Brellochs, C, Zimmerman D, Zink T: School-Based Primary Care in a Managed Care Environment, Adol Med: State of the Art Reviews, 7:2 1996.
3. Medicaid: Health
Care Safety Net for the Nation's Poor, Testimony by Karen Davis, President,
The Commonwealth Fund before U.S. Senate Committee on Finance,
6/19/96.
4. Edelman P: The
Worst Thing Bill Clinton Has Done, Atlantic Monthly,
3/97
5. Lear, J, Montgomery, L., Schlitt, J: Key Issues Affecting School-Based Health Centers and Medicaid, J Schl H, 3:66 1996
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