Sharon Garber does plenty of physicals at the Mount Pleasant High School health clinic, and she treats asthmatic kids, gives immunizations, and even worked with two students in recent weeks who appeared to have heart problems.
To the extent that the students have health insurance – and more than 20 percent don’t – Garber bills the carriers for anything for which she has a billing code.
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But Garber spends much longer with students than the typical 15-minute consultations for which insurers will pay. And much of Garber’s work, and mental health counselor Phyllis Renzi’s, isn’t covered at all: tracking obese students’ weight, and providing nutrition counseling; connecting families with social services; even placing homeless students.
Rhode Island’s seven school-based health centers, including the Mount Pleasant clinic, had more than 12,000 patient “encounters” in the 2003-04 school year, according to the state Department of Health. For all this, they got $264,452 from insurers, an average of $22 per visit.
The centers’ combined budgets, however, are three to four times that much. For the last several years, their main source of revenue has been $75,000 provided for each by the state.
Gov. Donald L. Carcieri’s proposed budget for fiscal 2006, however, would cut those grants to $41,000 per center – even though a special Senate commission actually recommended providing much more than is currently given, $125,000 per center.
Interviews with Dr. William Hollinshead, medical director of the Division of Family Health, and with state Rep. Steven A. Costantino (D-Providence), chair of the House Finance Committee, suggest there’s a good chance that the cut will be reversed.
Hollinshead said the budget was only reduced because health officials believed that federal money would be available to offset it, and Costantino said the centers provide “a valuable service” and should continue to get substantial state support.
But at a hearing on the health budget, Costantino and other legislators also made it clear that they’re not pleased with how little the centers are collecting from insurers – both from private plans, and from the RIte Care plans that cover about half the students served.
“I have no problem with the state money going for those things that insurance doesn’t cover,” Costantino said in an interview. “My issue is the services that insurance companies traditionally do cover; the health centers should be able to receive reimbursement for (them). But I want to know if they’re even billing. I’m suspicious that not even that is happening.”
The school clinics are all run by community health centers: Mount Pleasant by the Providence Community Health Centers; Central Falls High School, Shea High School and Slater Junior High by Blackstone Valley Community Health Care; and Woonsocket Middle School, Woonsocket High School, Coleman Elementary School, and West Warwick Middle and High School by Thundermist Health Center.
Interviews with the directors of the three agencies, two of their nurses, and others familiar with the school clinics suggest that there may really be differences in how aggressively each center bills for its services. Figures for 2002-03 also show big discrepancies in the share of students labeled as “uninsured” – over half the enrollment at Slater and Shea, for example, while Woonsocket Middle and High Schools have 19 percent and 22 percent, respectively.
Thundermist’s three Woonsocket centers have dramatically improved their collection rates in recent years, according to a Health Department analysis, going from 20 percent in 2000-01 to 42 percent to 54 percent in 2003-04. Cynthia Buckley, who runs the center at Woonsocket Middle School, said her secretary underwent training to be able to bill better, and when asked how hard it was to get reimbursed, Buckley’s immediate response was, “I can always find a code.”
That said, Buckley added that only about 60 percent of the services her center provides are “traditional medical” services – the same as Garber estimated at Mount Pleasant.
“A lot of the counseling and stuff like that that we do, you can’t bill for, or you can’t bill as much as it’s worth,” Buckley said.
At Mount Pleasant, Garber said one of the things she does is try to get students insured. “We’ve gotten whole families on (RIte Care) that didn’t even know they were eligible,” she said. “But we can’t bill them for that, because when we saw them they weren’t insured.”
Maria Montanaro, president and CEO of Thundermist, said the lower reimbursement rate for nurse practitioners is a big part of why the centers can’t recover more of their costs. Insurers’ credentialing restrictions also get in the way, she said – much of the nutrition counseling her centers offer, for example, isn’t done by registered dietitians, so it can’t be reimbursed.
Montanaro said she doesn’t begrudge the insurers; to fully reimburse the school-based centers, they’d have to “create a whole new billing system, which I don’t think is realistic.”
Neither UnitedHealthcare of New England nor Blue Cross & Blue Shield of Rhode Island replied to requests for comment. PBN was also unsuccessful seeking comment from Neighborhood Health Plan of Rhode Island, which once provided grants to the centers, but now pays limited fees for each service (still the best deal, according to Montanaro).
The leaders of all three centers agreed, however, that expecting substantially higher collection rates is unrealistic, no matter how much the school clinics try.
