To see how much school-based clinics can improve children's health, go to Denver. There, a loose consortium of hospitals, doctors, a health plan and a medical school has wired a network of school-based health centers that's making real inroads into access to care for adolescents.
Denver Health, the public system in Denver County, is sponsoring school-based health centers in seven of 10 high schools in the county, plus two middle schools and three elementary schools. St. Anthony Central Hospital sponsors two clinics, and Children's Hospital pays for pharmaceuticals and some staff.
"It's an absolutely spectacular way to provide basic physical and mental health services to kids who otherwise have little access to care," said David Kaplan, M.D., chief of adolescent medicine at Children's.
Kaplan isn't sure such clinics will trim healthcare costs, although certain reductions can be documented, such as savings from fewer visits to emergency rooms. But the program contributes substantially to the health and well-being of young people by recognizing and treating serious medical and psychological problems.
Children's also sponsors two school-based health centers just south of Denver in the suburb of Sheridan.
"Adolescents are typically poor users of the health system," said Linda Therrien, a public health nurse from Children's who runs the Sheridan clinic. "Not that they don't need it. They don't access it."
The Sheridan school district comprises 2,170 students. Of those, 42.5% live below the poverty level, and 59% are eligible for a free or reduced-cost lunch. The district has triple the state rate for child abuse and domestic violence.
The closest hospital is four or five miles away, and many residents don't own cars. It takes an hour to get there by bus. Besides, hospitals are not the best place for primary care.
The health center at Sheridan Middle School was started in 1995 and has seen more patients each succeeding year (See chart, p. 54). In the fiscal year ended July 31, 1998, 1,206 users made 3,837 visits. Most, but not all, were pediatric visits.
"We see all people in that community, not only the children in the schools, but their infant siblings and their moms who are pregnant," Therrien said. Students and their families develop relationships with the practitioners and get their school sports physicals, medicines, mental-health care and sick care all at the same place.
Students must enroll in the health center to get care there, and they must obtain permission from their parents. The clinic offers abstinence counseling and dispenses contraceptives, with parental permission. In the high school, 460 of 555 students have registered to receive care at the clinic.
Therrien staffs the clinics with a nurse practitioner, a family-practice physician, a nurse, a pharmacist and a financial counselor. When families come in, the financial counselor finds out whether they're eligible for Medicaid or the Colorado Child Health Plan, the state's version of a new federal program for children. "I thought it was important to get kids insured. I'm trying to help instill a value for health insurance," Therrien explained. About 60% of the students and their families are uninsured.
Most of the staff, including Therrien but not the doctor or the nurse practitioner, are actually employees of Children's Hospital. The doctor belongs to a community health center family practice group. The pediatric nurse practitioner, Bonnie Gance-Cleveland, is employed by the University of Colorado School of Nursing. Children's contracts with the university for her time. But in the bargain, Therrien gets student nurses on site, too.
The financial counselor makes the operating expenses for this center slightly higher than average, she says. In the fiscal year ended July 31, Therrien spent a total of $325,155 on Sheridan Health Services, of which $291,751 went for salary and benefits. Net revenues totaled $260,195. Most of that-$172,356-came from a grant from the Bureau of Primary Health Care, part of the Public Health Service. Maternal Child Health, a state grant program, chipped in $48,401. Patients and third-party payers contributed $78,876, or rather, that is what they were billed. The health center collected only about half that, so there were contractual write-offs of $39,438. The clinic charges children and families on a sliding scale for services, including $5 for prescriptions, up to a maximum of $25.
The difference between revenues and expenses, a gap of $64,960, was made up by Children's, Therrien said.
A lot of the money that greases the skids comes from direct fund-raising by Therrien. She recently hauled in $82,000 to renovate what was the girls' locker room and add it to the clinic. "Actually, I've raised $105,000 so far this year," she said. "It's amazingly easy. Banks have community reinvestment dollars. I've gotten anywhere from $1,000 to $10,000." From a community foundation, she got a grant for $30,000, which she'll put toward mental health.
But what's just as remarkable about this arrangement are the deals Therrien has struck with major managed-care plans.
Sheridan Health Services is a contracted provider to Colorado Access, a Medicaid HMO sponsored by Denver Health, the University of Colorado and Children's. Plus, she's a network provider to Blue Cross and Blue Shield of Colorado. "If a child does have insurance, I can bill Blue Cross," Therrien said.
The icing on the cake comes courtesy of Kaiser Permanente, which actually created an insurance product to serve this specific niche-a product with a premium of $3 a month, no less.
The children receive their primary care at the school clinic, under the supervision of a Permanente medical director. If they need more complex care, they can go to a regular Kaiser Permanente office about five miles away. About 350 of the Sheridan children are enrolled in this program.
Maureen Hanrahan, government programs director at Kaiser's Colorado plan, started the project in January 1997. "We have social mission dollars and want to dedicate them to kids," she said. Kaiser has budgeted $1 million for a two-year pilot program. It subsidizes 95% of the project cost.
Besides developing the new product, Kaiser wanted to see whether it could partner with a school-based health center to reach low-income uninsured children. As far as she knows, it is the only such tight relationship between school-based health centers and a major managed-care plan in the country.
Kaiser capitates the school clinics, giving them a dependable stream of revenue. What Kaiser gets out of the deal is a point of entry for its pediatricians who want to reach and understand school-age children who have poor access to care.
Incredibly, Kaiser is having trouble signing up families for this insurance. About 800 children have enrolled, far fewer than Kaiser expected. The concept of prepaid coverage turns out to be a novelty to people who are used to going to the emergency room when they don't feel well. They need education to understand the benefit. Even so, some enrollees have asked for their $3 back if they didn't use any care the preceding month, Hanrahan says.
Turnover of the patient population is also higher than expected, and considerable effort is needed to make sure enrollees make their premium payments.
As part of this pilot, Kaiser is paying close attention to outcomes and utilization. Kaiser already has documented a decline of half a visit per year in urgent and emergency usage among these enrollees. That could reduce costs significantly if it continues.