SCHOOL-BASED HEALTH CENTERS:
HEALTH CARE REFORM
AND MEDICAL HOME
NORTH CAROLINA SCHOOL COMMUNITY
HEALTH ALLIANCE
2012 ANNUAL CONFERENCE
OBJECTIVES
Review health care reform initiatives that are
relevant to school health
 Discuss background information concerning
Medicaid and CHIP
 Examine medical home options for school-based
health centers

REFLECTIONS
Shortage/maldistribution of primary care
physicians
 Shortage of pediatricians who choose to enter
community pediatrics
 The growth of ACO (Accountable Care
Organization)-type entities
 Failure of school-based health centers to generate
sufficient revenue to justify their existence

PEDIATRICS 2020 AND BEYOND

Sick children sicker

Mental health issues

Families more isolated

Increased diversity

Transitional care
HEALTH EQUITY
 17%
of children live in poverty
 Poverty
affects sequential generations of the
same families
 Poverty
status
is a key contributor to poor health
 Generational
violence robs lives
 Incarcerated
youth share a common history
 Cabinet-level
attention is needed
What insurance reforms are
included in the new law?

Requires that private insurance include the
following consumer protections:

No annual caps on coverage

No rescissions (if a child or adult gets sick, coverage can’t
be lost)

Children may stay covered on their parents’ policy until
age 26

Children may not be denied
care because of a pre-existing
condition

Minimum medical loss ratios

Cap on out of pocket costs
for families
PREVENTABLE CAUSES OF DEATH IN N.C.
Preventable Causes of Death
in North Carolina (2007)
Tobacco Use
13,720
Diet/Physical Inactivity
12,583
2,653
Alcohol Consumption
2,350
Microbial Agents
Toxic Agents
1,743
Medical Error
1,516
Motor Vehicles
1,364
Firearms
910
Uninsurance
758
Unsafe Sex
606
Illicit Drug Use
531
0
2,000
4,000
6,000
8,000
10,000 12,000 14,000 16,000
Estimated Number of deaths
State Center for Health Statistics, North Carolina Department of Health and
Human Services, (2007).
WHAT IS A MEDICAL HOME?
An approach to providing health care services in a
high-quality, comprehensive, and cost-effective manner
 Provision of care through a primary care physician
through partnership with other allied health care
professionals and the family
 Acts in best interest of children and youth to achieve
maximum family potential
 Many notions tested among children and youth with
special health care needs – but principles and
characteristics apply broadly to all children/families

MEDICAL HOME DEFINITION
 Primary
care
 Family-centered partnership
 Community-based, interdisciplinary
approach to care
 Care that is: accessible, family-centered,
coordinated, compassionate, continuous,
and culturally effective.
 Preventive, acute and chronic care
 Quality improvement
ATTRIBUTES OF THE MEDICAL
HOME
 Accessible
 Family
Centered
 Continuous
 Comprehensive
 Coordinated
 Compassionate
 Culturally Competent
NCQA: PATIENT CENTERED
MEDICAL HOME MEASUREMENT









Access and Communication
Patient tracking and registries
Care management
Patient self management
Electronic prescribing
Test tracking
Referral tracking
Performance reporting and improving
Enhanced electronic communications
MEDICAL HOME
Pediatric Medical Home under CCNC
(Community Care of NC)
 Typical adult medicine medical home
 Information technology and the NC Health
Information Exchange
 School-based health centers and medical home

Health Care Reform

CHIPRA (Children’s Health Insurance Program
Reauthorization Act)

ARRA (American Recovery and Reinvestment Act)

HITECH Act

Affordable Care Act (ACA)
MEDICAID AND SCHIP
200
6 to 19 Years
100
200
1 to 6 Years
133
200
Birth to 1 Year
185
0
50
SCHIP
100
150
Medicaid
200
250
MEDICAID EXPANSION (2014)
For patients younger than 65 who are not
pregnant and have family incomes up to 133% of
poverty
 2014-2016: 100% federal funding
 After 2020: 90% federal funding
 Essential Health Benefits Package
 Eligible adults required to enroll their children in
Medicaid/CHIP

CHIPRA COMPONENTS

$32.8 billion over 4.5 years

300% FPL eligibility for CHIP match

$225m for quality and health IT

$100m for outreach and enrollment


8 enrollment improvements – if state chooses 5, boosts
federal funding
Public/private partnership on premium subsidy –
eliminates crowd out
CHIPRA




Strengthens AAP Access, Quality and Finance
Pillars
Establishes Medicaid and CHIP Payment and
Access Commission
Calls for development of a core set of health care
quality measures for children enrolled in Medicaid
or CHIP
Directs implementation of a GAO study and report
on access to primary and specialty services.
CHIPRA COMPONENTS

Immigrant Children's Health Improvement Act (ICHIA) –
states can remove 5-year wait for legal immigrants

Translation Services now at 75% FMAP

Coverage of pregnant women up to 200%

Dental benefits required

Mental health parity, if provide mental health
DAVID T. TAYLOE, JR., MD, FAAP
2706 Medical Office Place
 Goldsboro, NC 27534
 919-734-4736
 919-580-1017 (fax)
 dtayloe@aap.org
 December 4, 2012

FIRST DOLLAR COVERAGE FOR
PREVENTIVE SERVICES
September 23, 2010
 Bright Futures: Guidelines for Health
Supervision of Infants, Children, and Adolescents
(AAP, MCHB)
 Does not apply to “grandfathered” plans
 Does not apply to Medicaid plans

HEALTH CARE HOMES
Grants available to state Medicaid programs as
of January 1, 2011
 Enrollees must have:
2 chronic conditions
1 chronic condition and at-risk for second
1 serious mental health condition

CENTER FOR MEDICARE AND
MEDICAID INNOVATION (CMI)
Fiscal Year 2011-2019
 $5 million available to organizations for design of
projects
 $10 billion available for implementation of projects
 Project design/regulations pending

GRANDFATHERED PLANS
 Existing
group health plans or health
insurance coverage in which a person was
enrolled as of March 23, 2010
 Prohibition on Pre-existing Conditions for
Children, September 23, 2010
 Prohibition on Pre-existing Conditions for
Adults, January 1, 2014
 Coverage of and Prohibition on Copayments and Deductibles for Preventive
Care, September 23, 2010
PREVENTION AND PUBLIC HEALTH
FUND
$15 billion: FY 2010-2020
 The fund will support programs authorized by
the Public Health Service Act for prevention,
wellness, and public health activities, including
prevention research and health screenings and
initiatives.
 www.hhs.gov/news/press/2010pres/06/20100618g.
html

PREVENTION AND PUBLIC HEALTH
FUND
$250 million: community-based health settings;
obesity prevention and fitness; tobacco cessation;
infectious disease outbreaks; CDC’s Clinical
Preventive Services Task Force
recommendations; public health workforce and
training centers
 $250 million: US primary care workforce projects
(residency slots; PA’s; NP’s;nurses)

SCHOOL-BASED HEALTH CENTERS
(SBHC’S)
$200 million for FY 2010-2013
 Target SBHC’s that serve large numbers of
children eligible for Medicaid and CHIP
 Infrastructure only (not for paying for personnel
or services)

IMMUNIZATION COVERAGE
IMPROVEMENT PROGRAM
FY 2010-2014
 Grants to states to improve the provision of
recommended immunizations to children,
adolescents, and adults
 Permanently reauthorizes the state
immunization grant program in section 317(j) of
the Public Health Service Act

COMMUNITY TRANSFORMATION
GRANTS
FY 2010-2014
 Funds for the implementation, evaluation, and
dissemination of evidence-based community
preventive health activities to reduce chronic
disease rates, prevent the development of
secondary conditions, address health disparities,
and develop a stronger evidence base of effective
prevention programming.

PERSONAL RESPONSIBILITY
EDUCATION
FY 2010-2014
 Grants to states for programs to educate adolescents
on both abstinence and contraception and sexually
transmitted infections, including HIV/AIDS

AMERICAN RECOVERY AND
REINVESTMENT ACT (ARRA)


$87b in FMAP increase

Hold enrollment at 7-1-08 levels

Prompt payment

6.2% minimum increase
$19b in Health IT infrastructure (2011) (HITECH Act,
Title IV)

20% Medicaid patient threshold

State planning and implementation grants
ARRA

$10.4 billion to NIH

$1 billion for Prevention and Wellness Fund

$500 million to HRSA workforce development

$200 million for Title VII and VIII programs

$300 million for the National Health Service Corps

$2 billion for Child Care Development Block Grant
PEDIATRIC ACCOUNTABLE CARE
ORGANIZATION (ACO)
Incentive payments to stimulate improvements in
quality and cost-effectiveness
 Fee-for-service to providers who contract directly with
payers
 Quality improvement payments to the ACO
 January 1, 2012 – December 31, 2016

AAP RESOURCE


State Implementation of the Patient Protection
and Affordable Care Act (ACA)
www.aap.org/moc and go to “Advocacy” (lower left
hand corner), and then “State Government
Affairs,” then look for the document “State
Health – State Implementation of the Patient
Protection and Affordable Care Act (ACA)”
FEDERAL ACA WEB PORTAL
www.hhs.gov/ociio/regulations/webportal/index/ht
ml
 www.healthcare.gov
