Transcript Title

NASBHC: 2011 Financial
Survey of State Funding and
“Out of the Box “ Financial
Strategies for SBHCs
Laura Brey
NCSCHA Conference, December 3, 2012
Our Vision
All children and adolescents are healthy and
achieving at their fullest potential.
Our Mission
To improve the health status of children and youth
by advancing and advocating for school-based
health care
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Objectives
• Review results of nationwide survey of states’
financial support of school-based health centers
• Discuss innovative ideas of financial
support/strategies for school-based health services
Total SBHCs in US, 1990-2008
2000
1800
1600
1400
Map: Distribution of SBHCs, 2008
1200
1000
800
600
400
200
0
1990
1992
1994
1996
1998
2001
2004
2008
Why State Funds Matter
Nearly one in two school-based health
centers rely on state-directed public
funds to help sustain their services.
Data Sets
• Department of Public Health State Policy Survey
– Target: State public health agencies (inc. DC, PR)
– Objective: assess types and amount of state SBHC
funding, technical support and data collection.
– Response = 52 agencies (inc. DC, PR)
• Medicaid State Policy Survey
– Target: State Medicaid agencies (inc. DC, PR)
– Objective: assess state Medicaid SBHC policies
– Reponse Rate = 41 agencies (inc. DC)
Department of Public Health
State Policy Survey
States that Fund SBHCs, 2011
DC
State-directed funds for SBHCs (18)
FL’s SBHC earmark is specific to a legislative district and is
not a statewide program. It is not included in the analysis.
18 States Fund SBHCs
•
•
•
•
17 collect data from SBHCs
15 convene a statewide network
14 staff a state program office
14 set and monitor SBHC standards
Summary of State-Directed Funds
FY2011
State
Investment
# SBHCs
funded
Grant size/
SBHC
Total
$89.6M
875
--
Average
$5M
49
$102,000
High
$21.7M
223
$660,000
Low
$271,000
3
$20,000
n = 18 states
Total State-Directed Funds by Source
Total for FY2011: $89.6M
$14.8M
$5.6M
$9.3M
State General Revenue
$59.9M
Tobacco Settlement
Title V MCH Block Grant
Other
n = 18 states
State-Directed Funding for SBHCs
By State, FY 2011
State
AR
CO
CT
DC
DE
IL
IN
LA
MA
MD
ME
MI
NC
NM
NY
OR
TX
WV
Total
SBHCs
Funded
Total
State General
Fund
Tobacco
Settlement
Title V MCH
Block Grant
Other
11
41
81
4
28
39
3
62
36
68
20
72
21
$ 2,000,000
$ 1,205,118
$ 10,728,342
$ 2,675,000
$ 5,200,000
$ 4,244,600
$ 271,000
$ 7,606,790
$ 2,868,998
$ 2,700,000
$ 719,500
$ 16,557,000
$ 1,429,812
$ 2,000,000
$ 947,177
$ 10,440,246
$ 5,200,000
$ 159,800
$ 2,586,308
$ 2,868,998
$ 2,700,000
$ 219,745
$ 3,557,000
$ 1,429,812
Unknown
$ 2,000,000
$ 1,958,500
$ 4,792,277
$ 499,555
-
$ 226,122
$ 288,096
$ 675,000
$ 1,339,100
$ 271,000
$ 228,204
$ 200
-
$ 31,819
$ 787,200
$13,000,000
-
56
223
54
6
50
875
$ 5,175,000
$ 21,765,126
$ 2,973,497
$ 462,500
$ 1,027,100
$ 89,609,383
$ 5,067,000
$19,699,140
$ 2,033,497
$ 1,027,100
$ 59,935,823
$ 9,250,332
$ 80,000
$ 2,065,986
$ 462,500
$ 5,636,208
$ 28,000
$ 940,000
$ 14,787,019
Percent of All Public Schools
with State-Directed $ for SBHCs
12%
10%
8%
6%
4%
2%
0%
DE
CT
NM
WV
NY
MD
OR
LA
ME
Note: Total number of school is from 2008-09; SBHC count is from FY2011.
Data source: National Center for Education Statistics:
http://nces.ed.gov/programs/digest/d10/tables/dt10_102.asp
CO
MA
MI
DC
AR
IL
NC
IN
TX
FL
Total State-Directed Funding, 1996-2011
90
80
70
Millions
60
50
40
30
20
10
0
FY1996
FY1998
FY2000
Title V MCH Block Grant
FY2002
FY2005
State General Revenue
FY2008
Tobacco
Data sources: Center for Health and Health Care and Schools (1996-2002); NASBHC (2005-2011)
FY2011
Other
Number of State Programs Declines;
Total State-Directed Funds Increase
90
80
70
60
Total State Dedicated
Funds ($Ms)
Total # State SBHC
Programs
50
40
30
20
10
0
FY1996
FY1998
FY2000
FY2005
Data sources: Center for Health and Health Care and Schools (1996-2002); NASBHC (2005-2011)
FY2008
FY20011
% of SBHCs Funded by State-Directed $
1996-2011
2500
?*
2000
Other
State-funded
1500
1000
500
54%
56%
51%
45%
45%
FY1996
FY1998
FY2000
FY2005
FY2008
0
* NASBHC’s national census of SBHCs for FY2011 is still underway.
Data sources: Center for Health and Health Care and Schools (1996-2002); NASBHC (2005-2011)
FY20011
State-Directed
SBHC
% Change,150%2000-2011
0%
50% Funds, 100%
200%
-50%
Colorado
Maine
New York
Oregon
Connecticut
Louisiana
Off the Charts
New Mexico 1,194%
Michigan
472%
West Virginia
Illinois
Delaware
North Carolina
Massachusetts
Maryland
-50%
0%
50%
100%
Data sources: Center for Health and Health Care and Schools (1996-2002); NASBHC (2005-2011)
150%
200%
States’ Accountability for SBHC Funds
• 14 of 18 States set SBHC operating standards as condition
of grant funds
– States monitor adherence to SBHC standards through
combination of paper review and/or in-person site visit
• All 18 States track SBHC performance indicators
• All 18 States collect a range of program data
• 7 of 18 States monitor Medicaid billing practices
SBHC Performance Indicators
Most Frequently Tracked by States
Top 5 of 28 choices
BMI Assessment
Immunization Status
Weight Assessment & Counseling
Mental Health
Annual Risk Assessment
0
3
6
9
Number of States
States that fund SBHCs (n=17)
12
15
Most Common SBHC Data
Collected by States
Client/Visit
Quality Improvement
Staffing
Finance
Risk Assessment
Policies
Special Projects/Initiatives
Physical Space
0
3
6
9
Number of States
States that fund SBHCs (n=18)
12
15
18
How States Value SBHC Contributions
to Public Health Mission
Access to Care
Immunizations
Obesity Prevention
Preventive Care
Mental Health
Tobacco Prevention
0
3
6
9
States
States that fund SBHCs (n=18)
12
15
Top Challenges to SBHCs: State Agency Perspective
Concerns re:
parental authority
Providing adolescents with
family planning services
Lack of clarity of SBHC role
re: medical home
Demonstrating SBHCs do not
duplicate services
Demonstrating value/efficacy
to education sector
Maximizing patient
revenue streams
Ensuring continued
public sector funding
Demonstrating value/
efficacy to payers
Creating sustainable
financial model for SBHCs
0
States that fund SBHCs (n=18)
2
4
6
8
10
12
14
State Medicaid
Policies and SBHCs
State Medicaid Policies
Managed Care
Organizations
Required to
Reimburse
SBHCs
Require Billing
Uninsured
(sliding scale)
Define SBHCs as
Provider Type
Waive
Preauthorization
for SBHCs
Waive
Preauthorization
for Specific
SBHC Services
Delaware
Illinois
Connecticut
Maryland
Illinois
Illinois
Louisiana
Delaware
Michigan
Maryland
Louisiana
North Carolina
Maine
New Mexico
New York
Maine
West Virginia
Maryland
New Mexico
North Carolina
West Virginia
NOTE: New York SBHCs are carved out from New York’s Medicaid policies.
West Virginia
Conditions Required to Bill Medicaid
Licensure of SBHC
CO
CT
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
DC
IL
LA
MD
NC
NM
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
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
NY

Certification



Maintain Comms
w/PCP
Licensure of Sponsor
Agency
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MCO Credentialing
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Of the 19 states that fund SBHCs, 13 responded
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WV
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
State Medicaid’s View of SBHC Role
AR CO CT IL
LA MD ME NC NM NY OR WV
Prevention            
Reproductive       
   
EPSDT Provider
    
 
 
Outreach/Enrollment
    
 
 
Acute Care

  
 
 
Primary Care

 

 
Of the 19 states that fund SBHCs, 12 responded
Summary
• Number of states with investments has stabilized over
decade
• 15 states with decade-old program
– Only AR, DC, IN and TX joined ranks in last 10 years
• Funding remains stable – in spite of state revenue woes
• More work to be done in Medicaid/CHIP to assure
payment, role for SBHCs as medical home
• Future: aligning SBHC strengths with health care reform
goals
“Out of the Box”
Finance Strategies
Community Benefit Plans
Affordable Care Act requires tax-exempt hospitals and health care
organizations to conduct periodic community health needs assessments
every three years and adopt plans to meet assessed needs .
• Include input from persons representative of broad community interests
including those with special knowledge or public health expertise.
• Adopt implementation strategies to meet the community health needs
identified through the assessment.
• Report annually how it is addressing the needs identified in the
community health needs assessment and IRS reporting
• Describe needs not being addressed including reasons why such needs
are not being addressed.
Many states require tax-exempt hospitals to conduct community needs
assessments and develop community benefit plans, in varying degrees of
specifications.
Community Benefit
• Assists with maintaining tax exempt status
• Value of what a tax exempt health care organization is giving
back to the community compared to revenue it is collecting
• Includes programs or activities that provide treatment and/or
promote health and healing as a response to identified
community needs
• And meets at least one of the following criteria
– Improves access to health care services
– Enhances health of the community
– Advances medical or health knowledge
– Relieves or reduces the burden of government or other
community efforts
Community Benefit
• Programs or activities that provide treatment and/or promote
health and healing as a response to identified community
needs
• And meets at least one of the following criteria
– Improves access to health care services
– Enhances health of the community
– Advances medical or health knowledge
– Relieves or reduces the burden of government or other
community efforts
• Marketing must not be the primary purpose
Hospital OPD Facility Fees /Charges
• Fact: Out Patient Departments (OPDs) of hospitals are reimbursed
80% more for a 15 minute Evaluation and Management Visit than a
private physician’s practice
• Reason: Hospital OPDs are allowed to add facility fees or charges to
the rate billed for each visit. This policy is meant to cover the
increased costs of delivering these services in a hospital related
setting.
• Result:: Hospitals are purchasing physician practices and converting
them to hospital OPDs without changing their location or patient mix.
• Question: Can hospital sponsored SBHCs add facility charges to
their Medicaid bills? Yes, for now
• CMS 2012 Recommendation: Realign allowed payment rates over a
three year period: lowering OPD rates and increasing free standing
physician practice rates
Federal Qualified Health Center (FQHC)
Program Fundamentals
• Located in or serve a high need community
• Governed by a community board
• Provide comprehensive primary care services and
supportive services (education, translation, transportation)
that promote health care access
• Provide services available to all based on ability to pay
• Meet performance and accountability requirements
(administrative, clinical, and financial operations0
Federal Qualified Health Center (FQHC)
Types of Health Centers
• Grant-supported FQHCs – public and private non-profit health
care organizations which meet health center definition and
receive funding under Section 330 of the PHS Act
• Non-grant supported health centers identified by HRSA and
certified by CMS as meeting the health center definition under
330 of PHS Act, referred to as “look-alikes”
• Outpatient health programs/ facilities operated by tribal
organizations (Indian Self-Determination Act) or urban Indian
organization (under the Indian Health Care Improvement Act)
Federal Qualified Health Center (FQHC)
330 grant supported
Benefits
• New starts can request up to $650,000
• Access to medical malpractice coverage under Federal Tort Claims Act (FTCA)
• Prospective Payment System (PPS) or other state-approved Alternative
Payment Methodology (APM) for services to Medicaid patients
• Cost-based reimbursement for services to Medicare patients
• Drug Pricing Discounts for pharmaceutical products under the 340B Program
• Access to on-site eligibility workers to provide Medicaid and CHIP enrollment
services
• Access to Vaccines for Children Program for uninsured children
• Access to National Health Service Corps (NHSC) medical, dental, and mental
health providers
• Eligible for other federal grants and programs
Federal Qualified Health Center (FQHC)
Non-330 grant funded
Benefits
• Reimbursement under the Prospective Payment System (PPS) or other
state- approved Alternative Payment Methodology (APM) for Medicaid
services
• Cost-based reimbursement for services to Medicare patients
• Drug Pricing Discounts for pharmaceutical products under the 340B
Program
• Access to on-site eligibility workers to provide Medicaid and CHIP enrollment
services
• Health Professional Shortage Area (HPSA ) designation and eligible to apply
to receive National Health Service Corps (NHSC) medical, dental, and
mental health providers placements