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Special Report:
Policy Report: School-Based
Mental Health Services
Under Medicaid Managed Care
Methodology
The development of SBHCs and the delivery of mental health
services within the centers has been a community-driven
process, with each center striving to meet the unique needs
of its students and community. Centers must be responsive to the expectations
of school boards, school administrations, and health care and
community leaders. This history creates variety in school-based health
center designs and operations. The evaluation team was challenged to
account for SBHC variation in the study design and produce a report
useful to a majority of programs. The study explored policy options at
the national and State levels and addressed practical questions for
schools and operating SBHCs. The study focus included the following:
- Collecting information about changes
in school-based mental health services,
client mix, and service utilization following
implementation of Medicaid
managed care.
- Observing how school-based mental
health services fit within the overall
health care system.
- Questioning study participants about
the impact of Medicaid and MCO
policies and procedures.
- Gathering suggestions about feasible
options for including school-based
mental health services in Medicaid
managed care contracts.
Major components of the study methodology
are described in the balance of this
chapter.
Literature Review
The search for relevant literature drew
upon recent studies from the fields of health,
mental health, education, and health care
financing. Making the Grade, an SBHC
national technical assistance center, funded
by the Robert Wood Johnson Foundation;
the National Assembly on School-Based
Health Care; and the Centers for School
Mental Health Assistance, funded by the
Bureau of Maternal and Child Health,
Health Resources and Services Administration,
DHHS, were rich sources of historical
and current information. A 1998 survey
of SBHCs released by Making the Grade
provided State SBHC comparison information
on service utilization, providers, and
funding sources. Additionally, several health
and social science databases were searched,
among them Dialog, Medline, and
Healthstar. In the initial summary of reviewed literature, information was presented
on access to and utilization of school-based
mental health services, SBHC experiences
with managed care contracts, and
financing of SBHC. This information was
then used to refine the research questions
and shape site visit protocols. Specific findings
from the literature review include the
following:
- The range of mental health services
offered at SBHCs varies considerably
from center to center. However, the
majority of SBHCs offer crisis intervention
(80 percent), case management
(71 percent), comprehensive individual
evaluation (70 percent), preventive mental
health programs (62 percent), and
comprehensive individual treatment
(57 percent).
- Adolescents enrolled in a managed care
plan with access to an SBHC were more
likely to make a mental health or substance
abuse-related visit to the SBHC
than those without access to an SBHC.
Currently, 28 percent of SBHCs have
formed relationships with managed care
entities. The roles SBHCs adopt vary
considerably, but generally can be categorized
into one of three types of arrangement:
full primary care provider, specialty
care provider, and co-manager of primary
care.
There are considerable communications
and legal obstacles to overcome before
SBHCs and managed care entities can
work together successfully. Since few free-standing
SBHCs have the experience or
authority to negotiate with health plans,
they may be reluctant to pursue relationships
with managed care entities.
Several themes drawn from the literature
had particular implications for study
design:
- Mental health services are among the
most frequently used services in SBHCs;
SBHCs provide important points of access
to mental health services, since they are
perceived by students as presenting fewer
barriers to care than traditional mental
health settings. Such characteristics as
immediate availability of care, confidentiality
of services, and student-centered
providers are important service aspects
that are different from other service sites.
The current study was careful to assess
how managed care plans understand
and accommodate these unique aspects
of care.
- State Medicaid policy ranges from
mandating that Medicaid MCOs contract
with SBHCs, to requiring coordination
between Medicaid MCOs and
SBHC, to simply encouraging coordination.
SBHC contract arrangements
seem to group into three categories:
SBHCs are contracted with as primary
care providers, ancillary or specialty
providers, or primary care co-managers
in partnership with a network provider.
When selecting sites for the study,
the diversity of requirements and
contracting practices was taken into
consideration.
- Information about other approaches
to financing SBHC and mental health
services in schools is very limited in
the literature. Site visit protocols therefore
were designed to elicit information
about innovative financing and managed
care strategies that may be developing
in the field.
Advisory Panel
An advisory panel to the project was established
to help guide the scope of research,
critique the study design, and advise about
appropriate sites for data collection. The
panel included nationally recognized leaders
in the fields of mental health, adolescent
health care, education, Medicaid, public
health, and several advocacy or technical
assistance groups experienced in school-based
health care. The group convened in
February 1999, after the release of the project
literature review. Criteria for selecting
the study sites were discussed, and practical
advice about the scope of the study was
elicited. The advisory panel strongly suggested
that the study be designed to provide
practical information to programs and State
agencies to begin or enhance the process connecting managed care and school-based
mental health services. Advisors also encouraged
developing the report as a tool to help
educate State officials and MCOs about value of mental health services in schools.
Site Visit Protocol and Study Site Selection
Site visit protocols were designed to gather
data from a wide array of informants and
vantage points across the health system.
Preliminary telephone interviews included
State Medicaid and public health officials
and representatives from Medicaid managed
care plans. On-site interviews included
school administrators, school nurses, SBHC
coordinators and providers, representatives
from managed care plans, staff or providers
from SBHC-sponsoring agencies, and, in
some cases, other school staff such as
school psychologists and counselors. At
some sites, perspectives from teachers,
students, and parents were also gathered.
The protocols were designed to gather descriptive data about the structure of
school-based services, the arrangements
with MCOs, and qualitative data about the
experiences of respondents at different
points in the service system.
Study site selection was based on four
criteria:
- Sites with different types of managed
care programs, such as fully capitated
integrated health and behavioral health
plans, partially carved-out behavioral
health plans, and plans that subcontract
with behavioral health care networks.
- Sites with formal agreements in place
between SBHCs and managed care organizations
with at least 1 year’s experience
with managed care.
- At least one site in which the State
Medicaid agency requires plans to
contract with SBHC.
- At least one site in which the school or
educational system is heavily involved
in and funds the SBHC.
Possible candidate sites included California,
Colorado, Connecticut, Maryland,
Massachusetts, North Carolina, and New
Mexico. Final site selection was based partially
on practical considerations such as
the availability and willingness of the State
and local SBHC to participate in the study.
The selected sites were the following:
- Albuquerque, New Mexico
This site was selected because of its
collaborative pilot program, involving
Medicaid, the State health department,
and school districts, to develop and
demonstrate the delivery of mental health
services in schools within managed care
arrangements. The educational system
was also strongly committed to school-based
health care. Medicaid managed care arrangements in this State were such
that schools had to work with several
competing plans, which helped explore
the complexities of implementing multiple
contracts for each SBHC.
- Baltimore, Maryland
This site was selected because of Baltimore’s
historic commitment to school-based
health care, the role that the State
mental health administration played in
organizing managed care mental health
services, and the inclusion of the administrative
services organization (ASO) in the
system. An ASO is a third party that carries
out certain administrative functions
under contract with the health insurance
purchaser or State agency; for example,
in Baltimore, the ASO handles claims
processing and requests for prior authorization
of services.
- New London/Groton, Connecticut
This site was selected because the State
Medicaid agency and the State health
department both required SBHCs and
managed care plans to contract with
each other. These State entities were
actively involved in monitoring the
progress of the contracts and facilitating
solutions to implementation problems.
The specific site was sponsored by a
community agency with a long history
as a provider of community-based
mental health services, different from
other sites that were sponsored by
medical or public health agencies.
Several types of respondents at the respective
sites were interviewed. Table 1
summarizes both the number and types of
interviewees who provided information
detailed in the case studies.
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