• Overview: Facts about School-Based Health Services
• Improving Access to Health Care
• School-Based Health Services and Maine's Legislators
• The MCA's School-Based Health Initiative
• Problem Behavior Prevention and School-Based Health Centers: Programs and Prospects
• American Academy of Pediatrics Report on School- Based Health Centers
• Maine School-Based Health Center Evaluation Project (I of 2)
• Maine School-Based Health Center Evaluation (2 of 2)Project
• Child Health
• Starting a School-Based Health Center
• School-Based Health - Fast Facts
• School-Based Health Centers In Maine
• Stories: Case in Point
• Resources
• National Assembly on School-Based Health Care

School-Based Health

Maine School-Based Health Center Evaluation Project (I of 2)

Evaluating Health Care Access for Youth

Adolescents have the lowest utilization of health care services of any age group.¹ Often the young adult is not even certain of his or her needs, of where and when to obtain health care. In response, communities are developing school-based health centers (SBHCs) where adolescents can receive primary care diagnosis, treatment of acute conditions, management of chronic illnesses, health education, and mental health/substance abuse counseling. Staffed by professionals knowledgeable about adolescents' unique developmental issues and concerns, SBHCs provide confidential, age appropriate/sensitive services. They are easily accessible because most adolescents attend school. This is especially important in rural Maine where transportation is problematic and health facilities (hospitals and medical practices) can be a significant distance away. As such, SBHCs provide an effective way to deliver appropriate health care services to school-aged children.

Despite the promise of this model, SBHCs have not been adequately evaluated. Most studies have not included all costs affected by school clinics or chosen appropriate comparison groups for evaluating effects. Typically studies are small and are underpowered to detect differences (see, Key, which only included 43 SBHC students and 48 controls)² . Yet despite the paucity of well-designed evaluation studies, many feel that the evidence does support the conclusion that SBHCs improve children's access to care and reduce costs. There are well-designed studies that have been conducted in inner-city elementary schools, most recently showing a reduction in hospitalization and missed days of school in children with asthma. ³

Yet SBHCs continue to struggle for sustainability. There are only 26 school-based health centers in the State of Maine and slightly more than 1,500 nation-wide. A major problem is financing. SBHCs are woefully under-funded. Direct support for Maine's SBHCs (FY 2002) totaled $572,300, representing approximately one-third of their budgets. Traditional revenue sources – schools, local health centers, and state, Federal, and foundation grants – are insufficient to make up the difference. Less than one-half of Maine's SBHCs bill commercial insurers although nearly 40% of the students maintain private insurance. Not surprisingly, therefore, fees and reimbursement during the year 2000 comprised just 10% of the SBHCs budgets.

After two years of legislative bills and studies on the funding and reimbursement in SBHCs with few results, the Maine Children's Alliance convened a group of concerned organizations, including representatives from the Bureau of Health, Medicaid, the four major commercial insurers, and school-based health centers. In turn, they formed the Maine School-Based Health Care Access Project whose basic principle is all children should be able to attain high quality health care. The Project also recognized the importance of sustainability. SBHCs must acquire the financial support and income -- and the attendant administrative infrastructure -- to ensure their continued existence. As a result, the Maine School-Based Health Care Access Project is conducting a rigorous evaluation of two critical questions:

1. If SBHC care were reimbursed – by Medicaid and by the commercial insurers – will health outcomes improve?

2. Will the program be cost neutral, i.e. would the additional, upfront reimbursement costs be offset by lower expenses resulting from decreased hospitalizations, emergency room visits, and specialty care?

The target population for the Maine School-Based Health Care Access Project is the approximately 8,500 high school-aged adolescents (approximately 11% of all adolescents in Maine) who attend the eight participating school districts and nine participating health centers. For the purposes of this evaluation, only high school students will be targeted because only a few SBHCs provide the same level of services to middle or junior high school students. Four of the SBHCs are located in Lewiston-Auburn and Portland. As a result, the teenagers served in this project have a higher percentage of racial and ethnic minorities than the overall state population, which is 98% Caucasian. The other SBHCs are in semi-rural and rural areas, where access to primary care providers is limited and socio-economic status varies widely. The State's Bureau of Health estimates that 35% of the adolescents receiving services at SBHCs are on Medicaid. In Portland, the figure is even higher: the Program Manager for the city's Department of Health estimates that over 50% of SBHC recipients of services are on Medicaid.

The primary mission of the Maine School-Based Health Care Access Project (Project) is to create universal health care for all children, including those who are currently uninsured and/or underserved. It is vitally important that SBHCs attain financial stability, because in many locations they are the only source of health care services for adolescents without insurance or Medicaid. It is the Project's contention that reimbursement for services delivered at SBHCs will provide sufficient support to ensure their survival. As a result, they will continue to serve the uninsured and underinsured population. In addition, by providing universal primary health care at SBHCs, the health disparities between those who have insurance and those who do not, between those on Medicaid and those utilizing commercial providers, between those who have transportation and can travel to see a physician and those who cannot, will decrease significantly.

The Maine School-Based Health Care Access Project is evaluating the impact insurance reimbursement has on school-based health care services: Does reimbursement lead to improved outcomes in a cost effective/cost efficient or cost neutral manner?

The intention is to bring high quality health care to all children living in Maine, regardless of income, insurance status, or proximity to a health care facility. By providing primary health care and prevention services in a school setting, treatments will be age-sensitive and developmentally appropriate. Confidentiality will be maintained in an environment in which teenagers feel comfortable and accepted. Adolescents will learn how to define their own needs and, in return, receive health care that is individualized, understandable, and appropriate. The evaluation will determine if high quality services, leading to improved outcomes, can be provided universally to all students in a cost efficient/cost neutral manner.

The working hypotheses of the Project are:

• Reimbursement for school-based health services leads to increased utilization and access.
  
  
• Available primary care and prevention services result in appropriate level of treatment and prevent more costly interventions such as emergency room visits, hospitalizations, and complex medical procedures.
  
  
• Increased access produces improved short and long-term health care outcomes.
  
  
• Availability of school-based health services leads to increased levels of satisfaction on the part of both parents and school staff.
  
  
• Availability of school-based health services will lead to increased utilization of behavioral and psychiatric services.
  
  
• When short and long term health care benefits are factored into the overall financial analysis, the reimbursement for school-based health care will be cost neutral or result in savings.
  

In addition, through the technical assistance provided by the commercial insurers, the SBHCs will be able to develop organizational capacity and the administrative infrastructure to become increasingly self-sufficient.

Strategic Activities

There are two primary sets of strategic activities: 1) Organizing and facilitating the various participants and key stakeholders, and 2) Conducting the evaluation.

In 2001, the Maine Children's Alliance convened the school-based health center providers, representatives from Medicaid, the commercial insurance providers and representatives from the Bureau of Health to address access, sustainability and funding. All agreed on the importance of adolescents receiving timely and quality health care services.

In Maine, SBHCs provide services to all students regardless of insurance or ability to pay. Medicaid already reimburses services provided at some SBHCs and the four commercial insurers – Aetna Health Inc., Anthem Blue Cross and Blue Shield in Maine, CIGNA HealthCare of Maine, Inc., and Harvard Pilgrim Health Care – responded by agreeing to a pilot project in which they would reimburse for school-based health services consistent with their existing member contracts. This vital and potentially ground breaking decision is, nationally, the first statewide effort of its kind to develop contractual partnerships between school-based health centers and commercial insurers.

The letters of commitment indicate strong support from each of these organizations. A letter of support from the Executive Director of the National Assembly on School-Based Health Care (NASBHC) also identifies the statewide project as one that is groundbreaking, carrying important implications for child advocates, schools, and insurers. The Maine School-Based Health Care Access Project expects to present the findings from this evaluation at NASBHC's national conference. In turn, NASBHC has expressed a willingness to disseminate the information and results gained from the Project.

Nine school-based health centers agreed to participate in the project. To implement the program, the commercial insurers are providing technical support to increase the administrative capacity of the SBHCs to: a) bill for services; b) become credentialed; c) join the necessary networks; and, d) complete other essential steps to receive payments for services. This will help the SBHCs develop the necessary infrastructure to become self-sustaining facilities. During the summer of 2002, meetings were held with all interested SBHC clinical and administrative staffs, and subsequently all nine of the participating high school SBHCs completed the requisite applications, provider credentialing, and reimbursement contracts.

To conduct the evaluation, the Maine Children's Alliance contracted with Daniel Meyer, PhD, Director of Research at Maine-Dartmouth Family Practice Residency (MDFPR) in Augusta, Maine and Associate Professor of Community and Family Medicine at Dartmouth Medical School. Dr. Meyer will enlist the services of the Maine Health Information Center (MHIC), a private non-profit health data organization and one of the oldest and most respected such organizations in the United States. The MHIC is developing the nation's first comprehensive Health Care Claims Data Bank through the new Maine Health Data Processing Center, a unique public/private partnership between the Maine Health Data Organization and the Maine Health Information Center.

Dr. Meyer served as a member of the Maranacook Community School (MCS) SBHC Advisory Committee since 1985 and as an unpaid evaluation consultant to MCS designing and implementing yearly student, student user and parent surveys. These data have been used both to assist in SBHC planning and during the pursuit of state and private health insurance funding for SBHCs. He is currently revising these surveys in consultation with the Project Advisory Group. For the past year, Dr. Meyer has been a part-time fellow in the Dartmouth Center for Enhancement of Child Health under Drs. Allen Dietrich and Ardis Olson. He has used that opportunity to undertake a study of on-line adolescent health assessments in three Maine school health education classes. Through the fellowship Dr. Meyer developed closer contacts with statistical experts in the Department of Community and Family Medicine who will provide informal statistical consultation for the Maine School-Based Health Care Access Project.

Results and Outcomes

The Maine School-Based Health Care Access Project expects to achieve the following:

• Process results: The Maine School-Based Health Care Access Project will track the process of all interventions and work activities. This includes: a) Documenting the process of gaining access to the claims data and mailing lists for survey work (this will provide logistical details important for others wishing to replicate this project in other states); b) Documenting timely completion of all claims data analyses; c) Implementing and analyzing parent, student, Health Care user and clinician surveys according to the project timeline; and d) Maintaining minutes of all Advisory Group meetings. In addition, MSBHCAP staff will attend all required Maine Health Access Foundation grantee meetings and produce the requisite project progress and fiscal reports in a timely manner.
  
  
• Initial or short-term project outcomes: These will include results of first year's data analysis regarding: a) utilization; b) costs; c) process; d) outcomes of care, e) comparison of students with access to school-based services to those without services.
  
  
• Intermediate project outcomes: These will consist of the results documented during the final six months of the two-year project. The focus will be on utilization, costs, process and quality of care. As detailed in the Evaluation Section below, we expect: a) Access and utilization of primary care services will be higher in the school-based health center communities; b) Total health care costs will be equivalent; and, c) Healthcare outcomes and client satisfaction will be higher in SBHC communities.
  
  
• Long-term project outcomes: The Project has two sets of long-term outcomes: 1) To demonstrate that reimbursement for school-based health services increases access to primary care services, leading to improved health outcomes while maintaining cost neutrality; and, 2) As a result, health insurers will continue to reimburse school-based health services resulting in stable funding and sustainable budgets for SBHCs in Maine. This will provide an impetus for other schools to start SBHC services both in Maine and across the country.
  

Evaluation

For the Maine School-Based Health Care Access Project, Dr. Meyer will develop a multifaceted evaluation design, collecting data from the following sources:

• Claims data, from both Medicaid and commercial insurers. Data from school-based health center communities will be compared to communities in which there are no school-based health centers. The evaluation will review primary care and specialty service visits, emergency room utilization, and hospitalizations. Claims data will also be used to compare between SBHC and non-SBHC communities total medical hospitalization costs and medication costs. While the primary care claims data for the uninsured will be incomplete, claims are submitted for all hospital and emergency department services in order to document uncompensated care.
  
  
• Parent and student surveys to evaluate perceptions of access, quality of care, outcomes, and satisfaction.
  
  
• Provider surveys of primary care providers (PCP) in SBHC and non-SBHC communities and SBHC personnel to measure perceptions of access, quality of care, satisfaction and SBHC/PCP coordination.
  

The evaluation will address five areas: a) access to primary care services; b) total health care costs; c) utilization of health care; d) outcomes of care; and, e) satisfaction with the process and outcomes of care. The Comprehensive Health Care Claims Data Bank will be utilized to analyze access, utilization, selected outcomes and total costs. In addition, Dr, Meyer will use systematic surveys of students, parents, and providers to analyze additional health outcomes and satisfaction with the process and outcomes of care.

As noted above, nine high schools with SBHCs have completed – or are in the process of completing -- the credentialing and contracting process with the health plans which are required prior to processing and paying claims. It should be noted that several schools have already begun submitting claims during the current academic year. In order to participate in this demonstration, school-based health centers must provide at least a total of 8 hours of primary care services over two school days; many have primary care services available at least half of each school day, and school nurses provide basic school nursing services each day. After hours, weekend and summer coverage is referred to the student's community primary care provider.

The formal evaluation of the demonstration will begin in the 2003-2004 academic year and the health plans have made a commitment to continue for at least two years. Thus, we base our analysis plan on the assumption that there will be approximately 8,500 students in communities with SBHCs and 8,500 students in communities without such centers. Claims data are considered essentially complete three months after the date of a claim, so we will be able to begin formal first school year's analyses about September 2004.

For the survey methodology, we will sample 25% of addresses of parents/students from the SBHC communities based on zip codes. We intend to administer mailed surveys to samples of both parents and students in the spring of each project year. The Maine Health Information Center (MHIC) regularly manages the Medicaid claims data and has ongoing memoranda of agreements for projects such as this. In order to send surveys to Medicaid clients, the project team will provide the surveys and funds. The Bureau of Medical Services will actually distribute the surveys and reminders. Unidentified completed surveys (except for community identifier) will be returned to MHIC for data entry and analysis. MHIC's regular survey research methods will be used: an initial mailing, a two-week reminder postcard and then in two weeks a second survey will be sent to non-responders. A response rate of at least 50% is anticipated.

In addition, the community primary care providers will be surveyed in May of each project year to evaluate the perceived impact of SBHC on care of adolescents in their practices. A total of 100 surveys will be mailed to these clinicians using a master list of providers.

The following lists the hypotheses for each outcome area, the data elements to be used, and the source of the data.

Outcome area # 1: Test to determine if availability of school-based health services leads to increased utilization of primary health care services.

Data elements: Total primary care office visits for 13 to 18 year olds.

Source of data: Maine Health Care Claims Data Bank
Expected outcome: 10% increase/difference in mean office visits between students in communities with SBHCs and those without.

Outcome area # 2: Test to determine if availability of school-based health services result in appropriate level of treatment and decrease of more costly interventions such as emergency room visits, hospitalizations, and complex medical procedures.

Data elements: Claims data by category: emergency department visits, emergency department costs, medical hospitalizations, hospital days and hospital costs. We will test for differences in rates of all emergency department visits, total average costs of emergency department visits and rates and cost differences for the ambulatory care sensitive visits. Also, even though hospitalizations are uncommon events in adolescence (12 per 10,000 in Maine during 2000), the Project will analyze the claims data for differences in admission rates, average length of stay, and costs of medical hospitalizations.

Source of data: Maine Health Care Claims Data Bank
Expected outcomes: Even though SBHCs are only open at most during school hours, we anticipate at least a 5% difference in total emergency department visit rates during the Project and a 20% difference in the ambulatory care sensitive visit rates.

Outcome area # 3: Test to determine if availability of school-based health services improves short and long-term health care outcomes.

Data elements: Health Care Claims Data Bank, e.g. asthma controller medications in prescription data, ED visits for asthma, immunization visits/varicella; comprehensive annual physical visits, visits for STDs, infectious disease other, reproductive health, orthopedics, abrasions, lacerations;
Survey data of parents and students -- overall assessment of health and functioning, number of days of school missed due to illness in past three months, number of times left school due to illness in past three months, self-reports of inquiries about exercise, smoking, Body Mass Index (BMI), reported number of visits to primary care clinician and SBHC.
Source of data: Maine Health Care Claims Data Bank and student and parent surveys

Expected outcomes: 10% difference in prescription and immunization rates between samples from communities with SBHCs and those without. Similarly, for the survey measures (except for BMI), such as reductions in days of school missed or left due to illness and better health habits, the Project anticipates a 10% difference in the sample on these variables.

Outcome area # 4: Test to determine if availability of school-based health services results in increased levels of satisfaction with health services by parents and school staff.

Data elements: Students/parents: satisfaction with primary health care services at Primary Care Physician (PCP) office and SBHC, accessibility of services at these sites, perceived quality of primary care services.
Primary Care Physicians: perceptions of rates of utilization of their services by adolescents, perceptions of impact of SBHC services on student health, attitudes toward existence of SBHCs, if available in their communities.
Source of data: Student, parent and primary care provider surveys

Expected outcomes: The Project assumes that students and parents from the two samples will be significantly more satisfied with overall primary care availability and quality of service in the SBHC communities. As above, we will look for 10% differences in these ratings and perceptions between our samples. The impact of SBHCs on community provider attitudes and perceptions has not been studied and the health plans are very interested in exploring this issue within their provider networks.

Outcome area # 5: Test to see if availability of school-based health services leads to increased utilization of behavioral and psychiatric services.

Data elements: Total outpatient mental health office visits, psychiatric and substance abuse services, psychiatric inpatient admissions and lengths of stay, and psychoactive medication prescriptions for 13-18 year olds
Sources of data: Maine Health Claims Data Bank

Expected outcomes: While the health plans in the study are not making any changes in their policy with regard to coverage of behavioral services at SBHCs, studies suggest that the existence of SBHC services increases access and utilization of such services. One SBHC study found that students with access to SBHC services accessed outpatient mental health services at a rate of 25% of the outpatient health services visit rate, or estimated here at 0.40 visits per student per year, which was 30 times the rate for students without SBHC access. The same study found a rate of 0.165 outpatient substance abuse service visits (about 10% of the outpatient health services visit rate for those with SBHC access) compared to a rate of 0.0 for those without SBHC services. Therefore we expect 50% or greater differences in rates of behavioral services when comparing the SBHC communities with the non-SBHC communities.

Outcome area # 6: Test to determine if availability of school-based health services results in reductions in unnecessary utilization of specialty services thus lowering overall medical costs.

Data elements: Costs in claims data, by category: primary care services, other outpatient services, emergency department costs, medical hospitalization costs, medication costs, and behavioral health services and psychiatric hospitalization costs.

Source of data: Maine Health Care Claims Data Bank
Expected outcomes: A 1996 - 1998 pilot study found that total Medicaid per member per month costs were about 10% lower for the SBHC community compared to statewide figures. This project will first compare the average total medical costs of students in the SBHC communities and comparison communities and than compare total costs, including behavioral and psychiatric costs. As with the utilization data, we will perform quarterly runs of the data, each three months after the last date of claim in the previous quarter. This will allow us at least 6 quarters of data for analysis during the final three years of this project. We expect to see a 10% reduction in total medical costs and no difference in total cost when behavioral costs are included. (more ...)

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