The Future Is Here: Demonstrating Value through Data

By Suzanne Mackey, Senior Policy Analyst, School-Based Health Alliance

School-based health centers (SBHCs) provide care to a medically underserved, hard-to-reach population of children and adolescents. However, our voice is often absent from state and local decision-making around health care financing and delivery system reform. It’s easy to feel overlooked by a larger reform movement that’s primarily focused on adults, but SBHCs bring tremendous value to the new health care landscape. There is a critical window of opportunity created by health care reform, and it may not stay open forever. Now is the time for the SBHC field to demonstrate our value to the health care system, and doing so may not be as daunting as we think.

Last year we launched a public private multi-state policy collaborative to advance this work. Groups of states are now working in “learning labs” comprised of public and private SBHC funders and other key stakeholders to strategically identify opportunities to integrate SBHCs into reform efforts. While each state team is pursuing unique goals, a unifying theme is to demonstrate value to payers, either state Medicaid or managed care organizations (MCOs). The first place for SBHCs to start is to show how they perform against national benchmarks such as HEDIS and EPSDT:

  • HEDIS (Healthcare Effectiveness Data and Information Set) is a tool used by nearly all health plans to measure performance. Medicaid MCOs must meet HEDIS measures, which are often tied to financial incentives or disincentives. Included in the numerous HEDIS measures for children and adolescents are the core services that SBHCs excel at providing, such as well-child visits, immunizations, and asthma management. MCOs are competing to hit these targets, and SBHCs are uniquely poised to help them.
  • EPSDT (Early and Periodic Screening, Diagnostic and Treatment)—another important benchmark—is a comprehensive health benefit for children and adolescents covered under Medicaid that encompasses preventive, dental, mental, and developmental health and specialty services. A 2010 report by the HHS Office of the Inspector General found that 76% of eligible children did not receive one or more of the required EPSDT medical, vision, or hearing screenings in nine surveyed states. Although these numbers have slightly improved in the past few years, states are still falling below CMS national target goals.

How does your state measure up?

The CMS-416 form is the state report card for EPSDT participation that SBHCs can use as an advocacy tool to help remove barriers to reimbursement for these services. Too often, Medicaid managed care plans aren’t familiar with their obligations under EPSDT. This causes SBHCs to face barriers to reimbursement for EPSDT services, such as prior authorization when they aren’t the child’s primary care provider (PCP). Soon-to-be-released data from our 2013-14 national census of SBHCs indicate that 55% of SBHCs are not recognized as the preferred provider by the child’s MCO and are only reimbursed for some services delivered in the SBHC. Anecdotal evidence further suggests that some SBHCs don’t even attempt to bill Medicaid for services if they are not the child’s assigned PCP, due to the cumbersome process and uncertainty of reimbursement. Not only does this threaten financial sustainability, it also denies the SBHC credit for the service. As we all know—if it doesn’t get counted, it might as well not have happened.

In addition to our policy collaborative, our School Health Services National Quality Initiative (NQI) is pushing the SBHC field to collect and monitor key standardized performance measures that align with Medicaid benchmarks. This is a groundbreaking first step to bring this work to scale on a national level. Our long-term goal is for all SBHCs to voluntarily report on these measures to ultimately demonstrate our collective value as a field through standardized data.

Now is the time to claim our seat at the reform table. We can demonstrate a compelling picture of our value through data. Early results from the NQI suggest it’s not as difficult as we thought. And honestly, we can’t afford not to try.

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