NASBHC: 2011 Financial Survey of State Funding and “Out of the Box “ Financial Strategies for SBHCs Laura Brey NCSCHA Conference, December 3, 2012.

NASBHC: 2011 Financial Survey of State Funding and “Out of the Box “ Financial

Strategies for SBHCs

Laura BreyNCSCHA 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

Adopted by Board of Directors, January 2009

NASBHC Membership

Individual $75 ($25 student)

• A national voice advocating for SBHCs at the Federal level

• Quarterly newsletter • Events calendar • Online renewal • Free access to NASBHC publications • Access to members-only space on

NASBHC.org – Searchable member directory – Archived issues of the newsletter – Special member updates – Archived NASBHC Web conferences

• Free access to NASBHC toolkits

Organizational $500

• All of the benefits of an individual membership, AND

• Two individual memberships   • Access to  job board with ability to

post positions • 50 customizable postcards

promoting the SBHC model • E-mail updates and action alerts for

the entire staff (requires submission of a staff e-mail roster)

3

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

1990 1992 1994 1996 1998 2001 2004 20080

200

400

600

800

1000

1200

1400

1600

1800

2000

Map

: Dist

ribut

ion

of S

BHCs

, 200

8

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

DC

States that Fund SBHCs, 2011

FL’s SBHC earmark is specific to a legislative district and is not a statewide program. It is not included in the analysis.

State-directed funds for SBHCs (18)

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 FundsFY2011

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 SourceTotal for FY2011: $89.6M

$59.9M $9.3M

$5.6M $14.8MState General Revenue

Tobacco Settlement

Title V MCH Block Grant

Other

n = 18 states

State SBHCs Funded Total State General

FundTobacco

SettlementTitle V MCH Block Grant Other

AR 11 $ 2,000,000 $ 2,000,000 - - - CO 41 $ 1,205,118 $ 947,177 - $ 226,122 $ 31,819

CT 81 $ 10,728,342 $ 10,440,246 Unknown $ 288,096 -

DC 4 $ 2,675,000 - $ 2,000,000 $ 675,000 -DE 28 $ 5,200,000 $ 5,200,000 - - -

IL 39 $ 4,244,600 $ 159,800 $ 1,958,500 $ 1,339,100 $ 787,200 IN 3 $ 271,000 - - $ 271,000 - LA 62 $ 7,606,790 $ 2,586,308 $ 4,792,277 $ 228,204 -MA 36 $ 2,868,998 $ 2,868,998 - - - MD 68 $ 2,700,000 $ 2,700,000 - - - ME 20 $ 719,500 $ 219,745 $ 499,555 $ 200 - MI 72 $ 16,557,000 $ 3,557,000 - - $13,000,000

NC 21 $ 1,429,812 $ 1,429,812 - - -

NM 56 $ 5,175,000 $ 5,067,000 - $ 80,000 $ 28,000

NY 223 $ 21,765,126 $19,699,140 - $ 2,065,986

OR 54 $ 2,973,497 $ 2,033,497 - - $ 940,000

TX 6 $ 462,500 - - $ 462,500 -

WV 50 $ 1,027,100 $ 1,027,100 - - - Total 875 $ 89,609,383 $ 59,935,823 $ 9,250,332 $ 5,636,208 $ 14,787,019

State-Directed Funding for SBHCsBy State, FY 2011

DE CT NM WV NY MD OR LA ME CO MA MI DC AR IL NC IN TX FL0%

2%

4%

6%

8%

10%

12%

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

Percent of All Public Schoolswith State-Directed $ for SBHCs

Total State-Directed Funding, 1996-2011

Data sources: Center for Health and Health Care and Schools (1996-2002); NASBHC (2005-2011)

Mill

ions

FY1996 FY1998 FY2000 FY2002 FY2005 FY2008 FY20110

10

20

30

40

50

60

70

80

90

Title V MCH Block Grant State General RevenueTobacco Other

Data sources: Center for Health and Health Care and Schools (1996-2002); NASBHC (2005-2011)

Number of State Programs Declines; Total State-Directed Funds Increase

FY1996 FY1998 FY2000 FY2005 FY2008 FY200110

10

20

30

40

50

60

70

80

90

Total State Dedicated Funds ($Ms)Total # State SBHC Programs

Data sources: Center for Health and Health Care and Schools (1996-2002); NASBHC (2005-2011)

% of SBHCs Funded by State-Directed $1996-2011

FY1996 FY1998 FY2000 FY2005 FY2008 FY200110

500

1000

1500

2000

2500

OtherState-funded

?

54% 56% 51% 45% 45%

*

* 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)

-50% 0% 50% 100% 150% 200%

Colorado

Maine

New York

Oregon

Connecticut

Louisiana

West Virginia

Illinois

Delaware

North Carolina

Massachusetts

Maryland

State-Directed SBHC Funds, % Change, 2000-2011

Off the ChartsNew Mexico 1,194%Michigan 472%

50% 100% 150% 200%-50% 0%

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 IndicatorsMost Frequently Tracked by States

Top 5 of 28 choices

Annual Risk Assessment

Mental Health

Weight Assessment & Counseling

Immunization Status

BMI Assessment

0 3 6 9 12 15

Number of States

States that fund SBHCs (n=17)

Most Common SBHC Data Collected by States

Physical Space

Special Projects/Initiatives

Policies

Risk Assessment

Finance

Staffing

Quality Improvement

Client/Visit

0 3 6 9 12 15 18

Number of States

States that fund SBHCs (n=18)

How States Value SBHC Contributionsto Public Health Mission

Tobacco Prevention

Mental Health

Preventive Care

Obesity Prevention

Immunizations

Access to Care

0 3 6 9 12 15

States

States that fund SBHCs (n=18)

Creating sustainable financial model for SBHCs

Demonstrating value/ efficacy to payers

Ensuring continued public sector funding

Maximizing patient revenue streams

Demonstrating value/efficacyto education sector

Demonstrating SBHCs do not duplicate services

Lack of clarity of SBHC rolere: medical home

Providing adolescents withfamily planning services

Concerns re: parental authority

0 2 4 6 8 10 12 14

Top Challenges to SBHCs: State Agency Perspective

States that fund SBHCs (n=18)

State MedicaidPolicies and SBHCs

State Medicaid Policies

Define SBHCs as Provider Type

Waive Preauthorization

for SBHCs

Waive Preauthorization

for Specific SBHC Services

Managed Care Organizations Required to Reimburse

SBHCs

Require Billing Uninsured

(sliding scale)

DelawareIllinois

LouisianaMaine

New MexicoNorth CarolinaWest Virginia

IllinoisLouisiana

North CarolinaWest Virginia

ConnecticutDelaware

MaineMaryland

MarylandMichigan

New Mexico

IllinoisMarylandNew York

West Virginia

NOTE: New York SBHCs are carved out from New York’s Medicaid policies.

Conditions Required to Bill Medicaid

Of the 19 states that fund SBHCs, 13 responded

  CO CT DC IL LA MD NC NM NY WV

Licensure of SBHC

Certification Maintain Comms

w/PCP      

Licensure of Sponsor Agency      

MCO Credentialing          

State Medicaid’s View of SBHC Role

Of the 19 states that fund SBHCs, 12 responded

AR CO CT IL LA MD ME NC NM NY OR WV

Prevention

Reproductive

EPSDT Provider

Outreach/Enrollment

Acute Care

Primary Care

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