When students receive health services while at school, they miss fewer classes and are more likely to graduate from high school. They can receive pain medication and antibiotics as well as diabetes and asthma maintenance during the day, according to Dr. Michele St. Louis, a primary-care physician at Montefiore's Columbus campus school center.
According to a study published in the Journal of School Health in August 2010, school-based health centers directly affect educational outcomes. Students with access to care at school are less likely to get sent home and miss school time.
Providing comprehensive services isn't cheap. While New York City may assist interested clinic sponsors with grant money for their capital investment, it's up to the health systems and foundations to fund the day-to-day operations.
In 1993, Montefiore and others lobbied Congress for Medicaid reimbursement equal to their outpatient rate for school-based health center services. That regulatory change beefed up payments from $20 to $93 per visit, which led Montefiore and other health systems to expand their programs, according to Dr. David Appel, director of Montefiore's school health department.
The program has mushroomed from five paid staff in 1993 to 180 full-time workers, and the health system plans to open another two to four new clinics in the next school year.
School-based health centers have also received support from the Affordable Care Act, though that has generated controversy. HHS established 200 grants totaling $100 million for school-based health center construction and renovation in fiscal 2011. House Republicans have tried to defund the program.
Even with Medicaid reimbursements, running a school-based health clinic can be difficult. Providers often have to outfit the space with equipment and staff the facilities with a physician, nurse practitioner, social worker and other health workers.
“Insurance covers about 75% of our budget,” Appel said. The system has renewable public grants on the city, state and federal level that cover the rest, he said.
When the program exceeds its budget—which Appel says happens some years—the health system picks up the difference. They have never once had to lay off staff. “The school-based health program aligns very well with Montefiore's mission of doing more in the community and seeing that everybody, and all children, have great access to all the services that Montefiore affords,” he said.
Montefiore tries to integrate school clinic services with its overall health system by using the same electronic health record system and referring students within the system for treatment they can't get in the school setting. “The idea is that we are looking to be part of an integrated healthcare system,” Appel said.
But some other providers may not have convenient and widespread ambulatory networks such as Montefiore's. At Northwell, their school-based health centers harness community resources to augment their care.
It's possible New York's move to fund managed care and value-based payments over the traditional fee-for-service model will hurt school-based health providers. New payment models could threaten current reimbursement rates and hurt the centers' bottom lines.
It's led to some health systems and foundations that are interested in sponsoring the centers to hold back from opening new facilities. “The whole system is in flux,” Platt from the city's health department said. “We'll have to see as the whole healthcare system evolves if more people get closer to the Montefiore population health model, which the state certainly is encouraging with the Medicaid redesign.”
Some sponsors are looking to partner with federally qualified health centers to open new school-based health clinics and take advantage of their guaranteed higher Medicaid reimbursements, Platt said.
While the state would like the clinics to start billing private insurance when students come from families with coverage, health privacy concerns have stymied that since some teenagers seek reproductive health services at school without their parents' knowledge. High school clinics have been a factor in lowering teen birth rates in New York.
Private insurers would send information about reproductive health visits to students' homes, according to Carmine. That could discourage teens from accessing birth control or STD tests.
At the Columbus campus in the Bronx, St. Louis says they're continuing to gain traction with kids and their families as more sign up to use the clinic's services and learn to trust the providers.
“The challenges are making sure people know who we are,” she says. “It requires continuing those conversations.”