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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
