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Special Report:
Policy Report: School-Based
Mental Health Services
Under Medicaid Managed Care
Study Findings
This chapter presents crosscutting findings drawn from the
study sites that suggest options for both national policy and
action to support school-based mental health services.
Appendix B includes detailed site visit case studies containing information
and suggestions from the individual experiences of each site and
its study participants. The case studies will help readers understand
the complexity of day-to-day SBHC and school health operations. They
also may help inform centers and programs about potential solutions
to problems or innovative approaches. A synthesis of study findings
follows:
1. At the study sites, sponsoring agencies
for school-based mental health services
successfully negotiated contracts with
Medicaid managed care plans. However,
these arrangements varied in complexity,
ease of implementation, and results
regarding revenue generation and barrier-free
access to services.
- At all three study sites, contracts with
managed care organizations were undertaken
by the SBHCs’ sponsoring agencies.
The agencies also were employers for the
mental health clinicians who offered primary
mental health services at the
schools.1
This arrangement relieved
school-based staff and school of the burden
of negotiating managed care contracts
directly. Moreover, it meant that SBHC
services were defined in the same terms as
the other clinical services provided by the
sponsoring agency. Sponsoring agencies
did not negotiate for coverage of the full
range of SBHC services, arrange for different
administrative procedures for SBHC
providers, or consider different reimbursement
rates.
- Because the sponsoring agency and the
MCO tended to treat school-based mental
health programs the same as other community-
based mental health providers,
reimbursed services generally were limited
to diagnosis and therapy claims using customary
diagnostic and procedures codes.
None of the study sites used the newly
defined mental health primary care diagnostic
codes of the Diagnostic and Statistical
Manual of Mental Disorders, 4th edition,
primary care version (American
Psychiatric Association, 1995). This
approach did little to ensure that students
would have open access to services, one the hallmarks of the SBHC. The emphasis
on traditional therapy did not permit full exploration of arrangements to cover preventive
mental health services such as
health promotion and risk reduction, early
identification of problems, and early intervention.
Some emerging efforts to cover
preventive mental health services were disclosed
by participating sites. For example,
in Maryland, agencies at the city and State
levels were collaborating to develop
arrangements for preventive mental health
services within managed care. In New
Mexico, one of the behavioral health
MCOs had opened a dialogue with
schools and school-based providers to
consider innovative service arrangements,
expressing the belief that SBHC had great
preventive potential. Contracts had not
yet been expanded, but the plan did allow
self-referral and open access to primary
mental health visits at the school.
- At all three study sites, providers and
school-based mental health program staff
reported that administrative procedures
required by managed care plans were burdensome
and that compliance was time-consuming.
These burdens -- such as
obtaining prior authorization for mental
health visits, submitting mental health
treatment plans, submitting claims, and
meeting provider credentialing requirements --
are the same as those experienced
by community-based mental health
providers. However, SBHCs had fewer
on-site resources and less robust infrastructure
to support the new administrative
requirements. In New Mexico, the
complexity of the system, with three managed
care plans and two behavioral health
plans, created numerous implementation
problems. Maryland and Connecticut also
reported problems learning about and
efficiently carrying out managed care
provider requirements. In Maryland,
SBHCs had only one entity with which to
work -- the statewide management service
organization -- but they still had responsibility
for registering students, requesting
prior authorization for services, and producing
claims for each visit.
- Involvement of SBHC and school-based
mental health clinicians with managed
care, coupled with pressure from funding
agencies to collect third-party revenue,
pushed SBHCs into new roles. Sites
reported that they had to establish new
mechanisms to determine the insurance
status of students and to help enroll students
in Medicaid or CHIP. At several
sites, school staff -- such as the school
nurses -- also were engaged in this "out-reach"
activity. While such outreach is
well within the scope of most SBHCs,
mental health programs were not staffed
for the activity; clinicians found themselves
diverting time formerly available for
clinical services to undertake outreach.
2. School-based mental health clinicians continued
at that site following adoption of a
managed care contract. Providers were not
shifted into other service venues because
of either managed care network pressures
or decisions to end SBHC service. Barriers
to school-based mental health care
emerged from administrative policies, not
from a loss of clinicians within the school.
- School-based providers and administrators
did not report a loss of clinicians working
in schools. In New Mexico, at least one
SBHC obtained a new clinician when one
of the MCOs assigned a provider to practice
in the school. In Maryland, the
administering agency for the Medicaid
mental health managed care plan -- Maryland Mental Health Administration --
opened up Medicaid certification to new
classifications of mental health providers,
including licensed clinical social workers.
This both expanded the provider network
available to Medicaid-eligible children and
enabled SBHCs to recoup revenues for
some of their providers who were previously
excluded from reimbursement.
- Although provider presence in schools
remained relatively steady, all three study
sites reported a decrease in the amount of
time available to see students because of
new administrative demands. The most
frequently reported problem: obtaining
prior authorization for services. With
some plans, the process could take as long
as an hour for each student. In Maryland,
extensively documented treatment plans
were required; in Connecticut, one plan
required the SBHC physician to make the
prior authorization request rather than
support staff. Some plans permitted a limited
number of visits (ranging from 2 to
12 visits in our study sites) without
authorization or with a simplified request.
This eased initial access concerns but did
not eliminate the problem.
- SBHCs and providers reported that
increased pressure to join Medicaid managed
care networks and generate third-party
revenue shifted provider time to
Medicaid-covered children, with less time
for both uninsured and privately insured
children. This tension will exist as long as
service demand in schools exceeds
provider availability. Clear funding
streams for services for uninsured children
can help address this concern.
- For the most part, SBHCs, schools, sponsoring
agencies, and managed care plans
created small, local problem-solving and
coordinating groups to address the administrative
and implementation problems
affecting access to care. New Mexico had
an interagency group as part of its pilot
project. In Maryland, the city health
department and management services
organization worked together to negotiate
new procedures. The degree to which
State agencies encouraged the problem-solving
approach varied. In Connecticut,
both the State Medicaid agency and the
State health department were very active
in helping local groups find ways to
reduce barriers to care.
3. Sponsoring agencies, State Medicaid agencies,
and managed care organizations did
not appreciate fully the scope and value of
school-based mental health services and
the role such services can play within the
overall system of care for children. The
decision to collect third-party dollars
through MCOs was not grounded in carefully
considered strategic plans consistent
with the philosophy and principles of
school-based mental health programs.
- This insufficient understanding was
evidenced by MCOs and by SBHC-sponsoring
agencies, which generally
treated SBHC providers like any other
provider of outpatient mental health
services. On the positive side, these
arrangements with managed care brought
SBHCs into the mainstream of health
care financing, strengthened SBHC
provider credentials, and enhanced service
documentation and accountability.
On the negative side, the emphasis of
managed care arrangements sometimes
conflicted with the philosophy of SBHCs
that emphasizes barrier-free access by students to services, with an emphasis on
prevention and early intervention. Study
respondents reported concern that revenue
generated through managed care might
not offset some of the negative results.
- At study sites, State public health departments
and State Medicaid agencies did
not help SBHCs, sponsoring agencies, or
managed care organizations develop other
approaches to managed care contracting,
such as subcapitation or global fees for
prevention packages. SBHC managed care
contracts did not draw financing from
managed care budget lines other than
provider network budget lines. The use of
managed care community health promotion
or member support budget lines,
instead of provider network contracts,
had not been explored. Development of
such cost alternatives might have reduced
the administrative burden on centers and
eliminated some of the implementation
problems, while accomplishing plan and
center objectives. Study sites each had
some processes in place to help demonstrate
the value and feasibility of some
of these alternative arrangements.
4. Implementation of managed care may
have changed access to community-based
mental health services, including inpatient
care, and also may have changed the mix
of available community-based services.
This, in turn, affected the demand for
mental health services within the school
and the level of care needed by children
attending school.
- Both New Mexico and Connecticut
reported a trend toward keeping students
who are suffering from severe mental
health problems in school. Study respondents
believed this was related to decreased availability of day and residential
treatment services in the community
and/or tight prior authorization requirements
for more extensive treatment services.
In New Mexico, several inpatient
treatment facilities had closed following
implementation of Medicaid managed
care. With fewer deep-end services available
or accessible, school-based providers
reported greater demand for
school-based treatment of serious
mental health problems.
- Extensive efforts by school-based
providers to get managed care authorization
for inpatient or day treatment often
were to no avail. As a result, some
providers felt they had no choice but to
continue to provide care for students in
the school until community-based
arrangements could be made. For example,
one SBHC clinician provided daylong
supervision for a suicidal student since no
other treatment was available. The transfer
of care from community provider to
school caused strain on the entire school
system and shifted services in the school
away from prevention. Although this finding
is preliminary, the potential seriousness
of the problem indicates a need for
further study and confirmation of the
extent of the problem.
5. A number of opportunities have been
missed to enhance coordination between
school-based mental health program agencies
and other school health programs.
- In two study sites, managed care arrangements
for school-based mental health services
and school-based health services were
separate and uncoordinated. In
New Mexico, the sponsoring agency for
the mental health services had arranged contracts for SBHC, but other health care
services were not covered by managed
care plans. This was related to the fact
that different managed care organizations
were involved and also that the sponsoring
agencies for medical services and mental
health services/providers were different.
- In contrast to the inadequate coordination
of contracting with managed care
organizations, individual physical and
mental health care on site at schools more
often than not was integrated. SBHCs
held regular multidisciplinary team meetings
and clinical treatment plan reviews.
Study respondents reported extensive
efforts to coordinate care among center
clinicians and also to coordinate care
between center staff and school staff --
such as teachers, school counselors,
school nurse, and school special education
staff. Providers at schools did report
some instances of disrupted communications
between community providers and
schools. This seemed to be a product of
changes in communication because of
managed care prior authorization requirements
and the need for both entities to
learn how to work with managed care
staff. These concerns were judged by
respondents to be start-up problems that
could be resolved locally.
- In our study sites, several opportunities to
coordinate and integrate other school
health services with the SBHC were not
fully realized. Schools acted as hosts to the
SBHCs and/or school-based mental health
providers and were not actively involved
in negotiating managed care contracts or
processing third-party claims. With the
historic autonomy of local school districts,
each school district and local school board
decides individually how it will participate
in school-based health care, but generally
leaves service delivery management to a
sponsoring health care or behavioral
health agency. In all three study sites,
school arrangements for Medicaid (under
EPSDT) coverage of school nursing services
and health-related special education
services were separate from SBHC. While
the pros and cons of combining these
arrangements are not yet fully understood,
key potential advantages are a reduction
in administrative burden for SBHC programs
and a more comprehensive system
of care for children. While EPSDT school
arrangements are being used by schools to
generate revenue, it is worth considering
how EPSDT might be used to strengthen
the connection between mental health and
other health services in the school and to
integrate both with community-based
health care. Another unrealized opportunity
for coordination is the opening of
SBHC services to teachers and school staff
as an employee benefit. Such an option
could generate a new funding stream for
both mental health and other school-based
health care.
1 In New Mexico the sponsoring agency was a medical
center with outpatient and inpatient mental
health programs; in Maryland the sponsoring
agency was a community mental health center; and
in Connecticut the sponsoring agency was a non-profit,
community-based multiservice organization.
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