Smart Health
Sep 20 2003 18:40
School-based medical clinics across maine get a chance to prove their worth
It's just after lunch at Foxcroft Academy, in Dover-Foxcroft and the tiled halls ring with the clamor and din of teenagers making their noisy way back to class.
In the school health clinic's closet-sized examination room, 16-year-old Shannon Long of Charleston hops up on the shiny metal table, grimacing slightly. Turning back the right leg of her boot-cut jeans and gingerly prying off her sneaker, she exposes a swollen ankle swathed in layers of elastic bandage.
Physician Assistant Bill Bisbee, an orthopedic specialist, delicately unwraps the puffy appendage, pokes at it gently, and notes that the swelling has gone down some. "How did you do this, again?" he asks.
"I fell off my boot," Shannon answers cheerfully. "Ouch!"
Shannon's badly sprained ankle - turned hard a few days ago while wearing a high-heeled dress boot - isn't being assessed at her doctor's office. She hasn't taken the afternoon off from classes, and her busy parents haven't had to draw straws to decide who'll get her to her appointment.
"It's a lot better than having to wait a week or two to see a doctor," Shannon says, as Bisbee rewraps her foot. "I get hurt all the time. These people are my friends."
With a list of instructions and a follow-up appointment scheduled for next week, Shannon's off to class, expertly navigating the crowded hallway on her crutches.
School-based health centers like the one at Foxcroft Academy - a private school that gets a healthy dose of public tuition funding from surrounding towns - have been providing on-site primary care and mental health services to Maine schoolchildren for 15 years, an invaluable convenience for captive students and their busy parents.
The clinics provide care to all students at little or no charge, regardless of insurance coverage. They treat children whose families can't or won't get them to a doctor, and, in some cases, children who are reluctant to involve their parents in the more personal aspects of their lives.
Despite filling this critical niche on the margins of the health care system, school-based health centers struggle year to year to stay afloat financially, and their credibility suffers from a lack of data that supports the value of the work they do.
A first-in-the-nation study that begins this month in Maine could be the financial turning point for school-based health centers everywhere. The pilot program seeks to measure the impact of the clinics on student health and the overall cost of providing health care, while allowing the clinics to tap into a steady source of reimbursement for the services they provide.
Once again, Maine is in the national health care spotlight. A history of caring for kids
School-based clinics tailor their services to reflect the needs and values of the communities and families they serve. While most clinical staff would prefer to provide a soup-to-nuts menu of adolescent care, all acknowledge the need to be responsive to parental and community concerns. For example, some clinics don't offer birth control services at all. Others require parental permission either at the beginning of the school year for access to all clinical offerings or on a visit-by-visit basis for specific services.
Unlike the school nurse, medically trained staff at clinics - doctors, nurse practitioners and physician assistants - can perform a sports physical, stitch up a cut, determine neurological status after a fall, prescribe medications, and diagnose a sexually transmitted disease.
They can refer a child for specialized services like physical therapy or nutritional guidance. They can monitor the healing of a painful sprained ankle like Shannon Long's , or help a young athlete like Dustin Colbry, Shannon's classmate, identify, manage and come to emotional terms with a rare and potentially lethal cardiac condition.
School clinicians routinely help kids stay ahead of chronic disorders, such as diabetes and asthma, and provide friendly, professional, confidential and on-the-spot information on hot-button teen issues like sex, drugs, family interactions, peer pressure and safety.
Some centers include diagnostic labs for testing blood, urine and other substances. A few offer prenatal care to pregnant teens.
Many clinics contract with mental health providers for on-site treatment, and some offer dental care as well.
Best of all, most school-based health clinics serve all students at little or no cost. Some request a small annual enrollment fee ($10 is typical) that is waived for low-income families. Patching it together
Like most of the 1,500 school-based health centers in the nation, the 26 in Maine lead precarious financial lives, their threadbare budgets patched together each season from a ragtag assemblage of grants, gifts and occasional public reimbursements.
The state's Bureau of Health distributes about $620,000 annually to school clinics. According to Nancy Berkheimer, director of the teen and young-adult health program at the Bureau of Health, state funding to existing clinics ranges between $22,000 and $28,000 per year and rarely covers more than 25 percent of a clinic's costs.
A few clinics file for Medicaid reimbursement, if they have enough students enrolled in the public program to justify mastering the arcane billing system.
Some rely heavily on sponsorship by area hospitals or medical offices. In Dover-Foxcroft, for example, Mayo Regional Hospital provides physician assistants and registered nurses, supplies and administrative support to the clinic at Foxcroft Academy.
Most, if not all, clinics depend on "in-kind" support from the school: physical space for the clinic, utilities, clerical support or a school nurse incorporated into the clinic staff.
Most charge a nominal, one-time access fee for each student, apply for grants and accept donations from appreciative parents.
Although about 40 percent of Maine youngsters have private health insurance, many still use the school clinics as well as their family physicians. But most student visits to school clinics aren't billed out at all, because the considerable hassles of third-party billing are simply not offset by capturing the infrequent insurance payment.
Up until now, insurance companies, if they've recognized school clinics at all, have treated them the way they do specialty physicians, requiring a referral from the primary care provider and prior authorization for the visit. This policy defeats the purpose of the on-site clinics, which function largely on a walk-in basis.
But this fall marks the beginning of the nation's first formal study of the clinical and financial impacts of school-based clinics in Maine. For the first time - ever, anywhere - private insurers have agreed to pay clinics directly for the services they provide, just as if they were the student's primary care provider. No referral, no prior authorization, no hassles.
Along with Maine's four private health insurance companies - Anthem, Cigna, Aetna and Harvard Pilgrim - 14 of Maine's school-based health centers, providing services to roughly 11,000 youngsters from 12 to 18 years of age, will take part in the three-year study.
For clinic administrators and boosters, this is a golden opportunity to prove what they've said all along: School-based health centers keep kids healthy and productive, reduce pressure on families, create health-conscious communities, and - importantly, in these dollar-conscious days - help hold down the overall cost of health care in Maine.
"It seems to work," said Elinor Goldberg, director of the Maine Children's Alliance, a nonprofit children's advocacy organization. "But if you're an insurance company - or a legislator or a taxpayer - you want to know that it actually works." As Maine goes
If it does actually work here, says Lisa Belanger, co-chair of the Maine chapter of the National Assembly on School-Based Health Care, there are far-reaching implications for the relationship between insurers and school clinics in other states. "This study is definitely being watched at the national level," she said.
Belanger, who works for the city of Portland as a school-clinic nurse practitioner, said that though the pressure is on for health centers to make their case, she expects clinics will go about their business as usual.
She warns that the study seeks to analyze information that can be hard to track accurately and that the impact of reimbursement may itself present conflicts in the delivery of services.
"There are still so many variables and unknowns," Belanger said. "It behooves us to structure the evaluation carefully so that at the end of the three years we are truly showing the impact a school-based health center can have."
At the national level, NASBHC Executive Director John Schlitt confirms his organization's interest in Maine's pilot program. "We are eagerly watching what's happening in Maine," he said.
While school-based clinics have benefited in some ways from their marginalized status, Schlitt said there's a near-total lack of data relating to their performance.
"What percentage of kids have health insurance? How much do they use the clinics compared to kids with Medicaid or no insurance? Do they use them for different services? These are some of the questions we have, and we don't have any answers. You can understand how critical this study [in Maine] is," he said.
Like Belanger, Schlitt said insurance reimbursements may be something of a mixed blessing, potentially requiring a new layer of administrative expertise and threatening confidentiality with student users. Many players
Maine Children's Alliance is the recipient of a $204,382 Maine Health Access Foundation grant, which, along with about $40,000 from the state Bureau of Health, will be used to fund the study. MCA will act as mediator, bringing together insurers, state officials, clinic administrators, school boards and other interested parties. MCA has helped with the design of the study and evaluation and will assist in ironing out any problems as the pilot program goes forward.
"This is a just huge step forward for kids," MCA director Goldberg said. Direct, reliable reimbursement of school-based clinics is just what's needed to legitimize clinics and provide them with the funding they need to stay viable, she said.
Although she embraces the idea of a "rigorous, replicable" study and is quick to praise the insurance companies for their participation, Goldberg admits it took some prodding to get them to the table.
Legislation presented to Maine lawmakers in 1999 sought to mandate insurers to include school clinics in their lists of participating providers, Goldberg said. In seeking to sidestep the pricey mandate, she said, "insurers knew they had to not look 'evil'."
Rather than wage an all-out effort to defeat the measure, insurers took another tack.
"We said, 'Wait a minute... let's develop a pilot, create a hypothesis," said Victoria Kuhn, program manager at Anthem Blue Cross and Blue Shield of Maine, the state's largest insurer. "If it works, we can look at expanding it. If not, we'll see if it's a concept that can work or if we absolutely want it to go away."
Kuhn said Maine insurers didn't want to get railroaded into supporting a system without understanding how well it works. But the companies' "show me" stance in no way means they're looking for negative outcomes, she said.
"We are building the study on the idea that positive things will happen," she said. As evidence of the industry's commitment to the study, Kuhn pointed to its investment in training school-clinic staff to bill correctly for services as well as its campaign to get participating clinics signed on as primary care providers in time for the start of school this year. Students with insurance can see either their regular doctor or school clinic staff, depending on what's most convenient. Information is shared between provider offices as appropriate.
Kuhn said Anthem and other insurers are investing in the probability that making it easier for teens to get the services they need will result in better health for the kids and a reduction in pricey emergency room visits, hospitalizations and referrals to specialists. Proof of the pudding
The information generated for the study will be collected, interpreted and reported by physician Dan Meyer, a medical sociologist and director of research at the Maine-Dartmouth family planning residency program at Maine General Hospital in Augusta.
The study will identify "comparison communities" for each area served by a school-based clinic matching population, age distribution, median incomes, education levels, numbers of Medicaid enrollments, employment status and other demographics as closely as possible.
Then, using data reported routinely to the Maine Health Data Organization and analyzed by the Maine Health Information Center, Meyer will compare the number of primary care visits, the number of hospitalizations and emergency room visits, and the total cost of insurance claims for the 12-18 age group. He will also compare school days lost due to illness and develop a satisfaction survey for students, community physicians and schools. The full details of the evaluation have not yet been fleshed out, he said.
Meyer was selected by a committee made up of representatives from the insurance companies, Maine Children's Alliance, clinic administrators and other groups. He's quick to point out that he's not entirely neutral on the subject of school-based centers; his children attend Maranacook High in nearby Readfield, home to the first such clinic in Maine. He's a big fan, he admits, but says it would be hard for him to misinterpret the reporting data.
Meyer said he expects the study will demonstrate to insurance companies that their dollars are well spent in bringing health care to students at school, and that more schools will be encouraged to establish their own clinics knowing they can count on the support of commercial insurers.
School nurse Cathryn Sherman at Brewer High School needs no such encouragement. The school recently developed a handsome, 2,000-square-foot student services complex, complete with roomy clinic space. "The vision was to have a health center," Sherman said last week, but for now she's working alone. Although new clinics came on line this fall in Augusta and Calais, Sherman's application for a $50,000 start-up grant from the state was turned down because, she said, her projected budget figures were fuzzy.
She'll reapply in January with more concrete numbers, and hopes that at this time next year Brewer High will be offering "the full gamut of health services."
Pointing out that, statistically, adolescents receive the least amount of medical care of any age group, Sherman said the teens at BHS have many unmet health needs.
Could she identify the most pressing need? Physicals? Acute care? Mental health services? Asthma control? Smoking cessation? Nutritional counseling? Reproductive services?
Sherman shook her head firmly. "I can't pinpoint it," she said. "I think they should have it all."
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