Brandeis University Administrative Review of the Health Center the Psychological Counseling Center

Brandeis University

Administrative Review of the Health Center

and

the Psychological Counseling Center

Volume One: Report Sections I Through V

October 14, 2013

I

Section

II

III-A

III-B

IV-A

IV-B

TABLE OF CONTENTS

Page

Executive Summary

A.

B.

Assessment ................................................................................................... 1

Recommendations ........................................................................................... 2

Consultation Objectives, Approach and Process, and Limitations

A.

Key Abbreviations and Defined Terms .................................................................. 3

B.

C.

Objectives .................................................................................................. 3-4

Approach and Process .................................................................................... 4-5

D.

Limitations ................................................................................................... 5

Internal Environmental Assessment

A.

Overview of HC ............................................................................................ 6

B.

C.

HC Outsourcing .......................................................................................... 6-7

Overview for the PCC ................................................................................... 7-8

D.

Funding ....................................................................................................... 8

E.

Need for Health and Counseling Services ............................................................ 8-9

F.

Access for Services .......................................................................................... 9

G.

H.

Communication ............................................................................................. 9

Facilities ..................................................................................................... 10

I.

Insurance Status ............................................................................................ 10

External Environmental Assessment

A.

Short- and Long-Term Impact of Health Care Reform on College Health Programs ..... 11-12

B.

C.

Boston Area Community-Based Health Care Providers ......................................... 12-14

Employer-Sponsored Health Plans ................................................................. 14-15

D.

Peer Institutions ........................................................................................ 15-18

E.

College Health Programs ................................................................................. 18

Administrative Review of Heath Center

A.

Overview ................................................................................................... 19

B.

Mission and Assessment .................................................................................. 19

C.

Services .................................................................................................. 20-21

D.

Communication ............................................................................................ 21

E.

Funding ...................................................................................................... 21

F.

G.

Eligibility and Access .................................................................................. 21-22

Staffing ....................................................................................................... 22

H.

Utilization ............................................................................................... 23-24

I.

Productivity ............................................................................................. 24-25

J.

K.

Costs ..................................................................................................... 25-27

Summary ................................................................................................ 27-28

Administrative Review of Psychological Counseling Center

A.

B.

Overview ................................................................................................... 29

Mission and Assessment .................................................................................. 30

C.

Services .................................................................................................. 30-31

D.

Communication ........................................................................................ 31-32

E.

Funding ...................................................................................................... 32

F.

G.

Eligibility and Access .................................................................................. 32-33

Staffing ................................................................................................... 33-35

H.

Utilization ............................................................................................... 35-38

I.

J.

Productivity ................................................................................................. 38

Costs ......................................................................................................... 39

Section

IV-C

V-A

V-B

VI


Page

K.

Summary ................................................................................................ 39-41

Psychologist Consultation

A.

B.

Overview ................................................................................................... 42

Review of Mission and Clinical Model ............................................................ 42-43

C.

Evaluation and Assessment Comments ............................................................ 43-46

Status Quo with Minor Repairs, Step One

A.

B.

Overview .................................................................................................... 47

Summary Rationale ........................................................................................ 47

C.

Proposed Actions ...................................................................................... 47-50

D.

Expected Advantages ...................................................................................... 50

E.

Expected or Possible Disadvantages .................................................................... 51

Comprehensive Health System, Step Two

A.

Overview .................................................................................................... 51

B.

Summary Rationale .................................................................................... 51-52

C.

D.

Proposed Actions .......................................................................................... 52


E.

Expected or Possible Disadvantages ................................................................ 52-53

Aligning PCC Practices and Model with Student Need and Services,

Step Three

A.

Overview .................................................................................................... 53

B.


C.

D.



E.

F.


Permutation ................................................................................................. 55

Secondary Payor System

A.

B.

Overview ................................................................................................ 56-58


C.

Proposed Actions .......................................................................................... 61

D.


E.

Expected or Possible Disadvantages ................................................................ 61-62

F.

Permutation ................................................................................................. 62

Triple Insurance Option Program

A.

B.

Overview ................................................................................................ 63-64

Summary Rationale ........................................................................................ 64

C.


D.


E.


F.

Permutations ............................................................................................... 65

Volume Two – Report Attachments

A.

B.

C.

Medicaid Advocacy Primer, ACHA

Email from Kay Petersen to HBC, August 9, 2013

HBC References for Integration of Primary Care and Counseling Services

D.

Trend for High Deductible Health Plans

1.

Berkshire Hospital Review , September 25, 2013

2.

3.

Dallas Morning News , October 4, 2013

Kaiser Health News , September 17, 2013

Section


E.

F.

G.

H.

I.

J.

Page

Trend for On-Site Employer Health Clinics, Wall Street Journal , December 14, 2011

2011-12 Annual Report for Emory University Student Health and Counseling Services

Informed Consent for Assessment and Treatment, University of Rochester

Patient Rights and Responsibilities, BIDMC

PCC Psychotherapist-Patient Services Agreement

HBC’s Position Paper on Insurance Billing for College Health Programs

Hodgkins Beckley Consulting, LLC

Doreen Hodgkins

Toll-Free: 877-653-7300

Cell: 360-280-2440

Email: Hodgkins@HBC-SLBA.com

Stephen L. Beckley

Toll-Free: 877-559-9800

Cell: 970-222-0124

Email: Beckley@HBC-SLBA.com

HBC’s Secure Messaging Program https://hbc-slba.wordsecure.com/

Website: www.HBC-SLBA.COM

Executive Summary

A.

Assessment

Section I

The staffs of the HC and the PCC are composed of dedicated and skilled professionals. This is a key basis for HBC’s recommendation in Section V-A, Status Quo with Minor Repairs. That being said, there are major changes recommended in this review. Among challenges that were identified, neither the Health Center (HC) nor the Psychological Counseling Center (PCC) produces monthly usage or annual reports, and both lack policy documents, mission statements, and typical management structures. Likewise, these organizations suffer from little or no use of electronic practice management systems. The offices also appear to have above average staffing levels based on national studies, and in comparison to peer institutions. In addition, the PCC utilizes significant numbers of part-time staff members, in contrast to peers and national norms.

In the HC, it appears that there could be significant savings in organizational structure without reduction in services, or that graduate students could be served on the same basis as undergraduates with close to current staffing levels.

The concerns for the PCC are complex. The PCC service model appears to be inconsistent with national models and with peer institutions. Staffing levels are directed at longer term approaches to patient care and, as a result, fewer patients are being seen than would be typically expected for current staffing levels. At the same time, little outreach, training, and prevention are being conducted on campus. Staff members are very dedicated to the current model, but there is little or no assessment on which to base support for the model; and significant evidence exists that portions of the student population are not being served to levels consistent with peer institutions. Consistent with peer and national norms, PCC resources could be redirected and/or cost savings realized with greater use of outside referrals and a shorter term approach to client/patient care.

Issues to Resolve

 Policy and procedure manuals are needed for both the HC and the PCC.

 Monthly utilization and annual reports should be produced for both the PCC and the HC consistent with national standards for student health and counseling programs.

 Regularly scheduled health status assessments (e.g., CORE, NCHA) should be implemented.

 Electronic records management systems should be fully implemented for both the HC and

PCC.

 Health and counseling services should be integrated. At minimum, a counselor should be located within the HC as part of the care team, and health records shared appropriately.

 The HC should, consistent will all other UAA schools, provide allergy injection services.

 The PCC should be structured to provide desk coverage at all times.

 An audit should be conducted of all PCC and HC communications, especially pertaining to services and privacy standards. Websites for the PCC and graduate students need to be consistent with regard to the level of service available to graduate students.

 Oversight/collaboration should be significantly increased for student health peer groups, especially the Brandeis Counseling and Rape Crisis Hotline (6TALK).

Report for Brandeis University October 14, 2013 Page 1 of 65

Executive Summary

B.

Recommendations

Section I

1.

Changes to Organizational Structure, Comprehensive Health System

The effective administration of college health programs (refer to Section II, subpoint A, Key Abbreviations and Defined Terms) requires specialized expertise in the operation of primary care services, counseling services, public health and health promotion services, and the oversight of student health insurance/benefit programs. Ongoing supervision, monitoring, and strategic planning are also required. Brandeis should adopt the recommendation for implementing a Comprehensive Health System, as detailed in the recommendations that follow.

2.

Executive Director

The short-term success of a new Comprehensive Health System for Brandeis University will require the engagement of senior institutional leadership as well as obtaining the specific skill set and expertise described for the proposed new executive director position. HBC cautions that there are stakeholders who are highly resistant to change and must be educated to recognize and understand the deficiencies of current operations and the opportunities associated with new strategic options. While resistance to change is both normal and often healthy within all organizations, HBC is concerned that some stakeholders will work to undermine the success of any new ventures or modifications to current operations. In addition to raising the service level of campus health and wellness, a position with this level of experience will be critical to conducting a successful request for proposals (RFP) process, realizing potential savings of shifting organizational and practice structures, and for implementing an insurance billing system to create significant savings/revenue.

3.

Conduct an RFP for the Health Center Contract

There are opportunities to reduce the cost of the operation of the HC and expand services if a

RFP process, as specified in Section V-A, Status Quo with Minor Repairs, sub-point C-

8 , is conducted. Brandeis University should seek proposals for a broad spectrum of services and potential contracted health care purchasing arrangements for the future operation of its college health program. Concomitant with this RFP process should be consideration of returning the HC to an internal department of the University.

4.

Graduate Student Services

Eligibility for graduate students should be provided on the same basis for all HC and PCC services as it is presently provided to undergraduate students. This would mean discontinuing the optional health fee and could include assessing a health fee to all students and/or initiating charges to graduate students and their insurers for services. All students should be eligible to use the HC and the PCC during the summer months regardless of whether they are enrolled in classes.

5.

Implement Insurance Billing Structure

Implement a system of billing insurance for services in the HC to undergraduate students, explore expanding this to graduate students, and explore possibly extending this model to the

PCC. Models are provided for a secondary payer system, and for a longer term three tier system. Both offer significant revenue and/or savings potential, potentially as soon as the next fiscal year. HBC conservatively estimates this initial savings/revenue in the range of $300,000 to

500,000.


Consultation Objectives, Approach and Process, and Limitations Section II

A.

Key Abbreviations and Defined Terms

ACA : The Patient Protection and Affordable Care Act

ACHA : American College Health Association

BIDMC : Beth Israel Deaconess Health Center

HBC : Hodgkins Beckley Consulting, LLC

HC : The Health Center at Brandeis University

PCC : The Psychological Counseling Center at Brandeis University

SHP : Student Health Program (previously called QSHIP); Commonwealth of Massachusetts requirement for health insurance and regulation of student health insurance/benefit programs.

SHIP(s) : Student Health Insurance Program(s), either graduate or undergraduate, provided by

Brandeis University

UAA : University Athletic Association

College Health Programs(s) : As defined by the Lookout Mountain Group :

A college health program describes the constellation of services, strategies, policies, and facilities an institution of higher education assembles to advance the health of its students and the academic community. On many campuses, college health programs move well beyond health care and refer to a variety of services, possibly including student health services, disability services, counseling services, crisis intervention and public safety services, health promotion and wellness services, alcohol tobacco and other drug programming, student health insurance/benefit programs, sexual assault advocacy services, sports medicine services for intercollegiate athletes, and intramural recreation sports and fitness programs.

B.

Objectives

Brandeis University retained HBC to provide an administrative review of its Health Center (HC) and its Psychological Counseling Center (PCC). The specific deliverables for the consultation are:

1.

Internal Environmental Assessment

 Garner the perspectives of leaders for other major student service departments and other

Brandeis University entities that routinely interface with the Health and Counseling Centers (e.g., police department, intercollegiate athletics, human resources/benefits, housing, etc.).

 Interview senior Students and Enrollment Division and institutional leadership.

2.

External Environmental Assessment

 Assess general availability of care and services and the organizational capability of local area health care providers and health care organizations in providing services, partnerships, and outsourcing alternatives to Brandeis University.

 Identify the trends for employer-sponsored health plans and insurance exchange coverage for individual health insurance.



 Benchmark the mission/scope of services, funding, and methods of operation for six peer institutions for Brandeis University.

3.

Administrative Review

Assess Mission, Structure, Access, Funding, Scope of Services, Utilization, Internal Processes,

Systems and Operations, Productivity, and Fiscal Effectiveness.

 Assess current scope and delivery of services, capacity, patient utilization, and access of services.

 Review service mix, resources, confidentiality, and patient flow; and workflow, administrative, and support department processes.

 Review data capture, reporting, and management decision-making tools.

 Evaluate provider and support staff productivity, staffing mix, staff efficiency, and costs.

Identify process, system, and structural inefficiencies and strengths; and opportunities for improvement.

 Evaluate financial performance of health and counseling service.

 Review funding model, including health fee support, general fund allocations, fee-forservice, and other options.

4.

Psychologist Consultation

Review clinical model/mission, operations, scope of services, accessibility (including afterhours care), referrals and follow-up, consultation and outreach; and conduct interviews with leadership and staff.

C.

Approach and Process

Dr. Andrew Flagel, Senior Vice President for Students and Enrollment, announced the consultation in a memo to staff on June 4, 2013, providing credentials for the HBC consulting team.

An introductory meeting with Dr. Flagel was conducted by Stephen Beckley at Brandeis on May

30, 2013. Campus and community health care organizations visits were held on June 13, July 16-

17, and August 28, 2013. Follow-up telephone interviews were conducted with individuals who were not available for in-person meetings.

A recent limited report from Michelle Bowdler (a Brandeis alumna), Senior Director of Health and

Wellness Services for Tufts University, was provided to HBC for review. A list of requested documents for the consultation was submitted on June 21, 2013, and a supplemental document request was submitted on August 8, 2013. Extensive communications and data requests were also initiated directly by HBC with BIDMC.

HBC’s recommendations for the renewal of services with BIDMC for the 2013-14 academic year were provided to Dr. Flagel in a letter dated August 8, 2013. Any risk management or compliance concerns were submitted by HBC to Brandeis University’s General Counsel in the draft report phase as privileged and confidential communication. This is a standard practice for HBC consultations.



HBC will issue report corrections or additions as needed following delivery of this final report.

HBC will also be available for telephone consultations, without additional charge, for one year following the delivery of this report.

D.

Limitations

1.

Only limited data for utilization of health and counseling services were available. Data were not available by standard service codes, services by provider, or by insurance status of students.

Visit and utilization data and reports were inconsistent. Data that was provided to HBC were compiled just for HBC’s use as they were not part of standard management reports.

2.

HBC conducted a limited administrative programmatic review that did not include physician or psychologist clinical assessments. This review also excluded student health insurance, health promotion, public health, disability services, and sports medicine for intercollegiate sports.

3.

HBC does not provide legal advice to its clients. Legal issues must be reviewed by the client’s legal counsel.

4.

HBC’s consultation is not intended to support program marketing claims about the quality of services delivered by health care providers relative to the technical delivery of medical or mental health care services. The scope of such evaluations may generally be found within the parameters of accreditation services performed by organizations such as The Joint Commission , the Accreditation Association for Ambulatory Health Care ( AAAHC ), or the International Association of Counseling Services ( IACS ).


III-A

This Section of HBC’s report is derived primarily from interviews conducted with Brandeis administrators, external to the PCC and the HC, and students. Comments of stakeholders are reported only if there was

(1) no apparent personal experience bias that could inappropriately influence perceptions and (2) there was confirmation from comments from other stakeholders and/or HBC’s operational assessments. As is expected, stakeholders have conflicting views on key points relative to the HC and the PCC.

A.

Overview of the HC

The HC has favorable relationships with the key departments within the Students and Enrollment

Division and with other academic departments with which the HC routinely needs to work with collaboratively. Stakeholders expressed that the relationship with Dr. Poaster and all of the HC staff is collegial in every respect, and there is a high level of confidence that the interests of students and Brandeis University are of the utmost concern to the HC. There was a strong consensus among all stakeholders that the HC is not perceived as being operated by an externally contracted organization. In other words, the HC is not viewed any differently than other departments with the Students and Enrollment Division, even though it is not directly operated by Brandeis.

Since the contract was first established with BIDMC in 1998, the HC has consistently supported campus safety efforts, effectively responded to public health concerns (garnering praise from the

Waltham Public Health Department), provided health promotion and wellness programs, worked well with the Brandeis nutritionist, initiated numerous outreach programs with the Department of

Community Living, and provided medical supervision for the Brandeis Emergency Medical Corps.

These were all sited as common examples of outstanding collaboration, most of which are not specifically enumerated as contractual obligations for BIDMC.

Although only the senior survey has questions pertaining to students’ use of the HC, stakeholders are generally confident that most students are satisfied with their care experience at the HC. A survey of students four years ago was purported to show high user satisfaction. Some stakeholders are aware of students who will not use the HC and prefer to go directly to nearby urgent care clinics. In some cases, this is because the HC does not bill insurance and students believe services may actually cost less and/or be of higher quality at other health care providers. Lack of radiology services at the HC was also noted as reason that many students with injuries obtain care elsewhere.

Almost all of the undergraduate students HBC met with had used the HC. Concern was expressed by students that the care experience at the HC can vary depending upon whether treatment is provided by a physician or nurse practitioner versus evening or weekend hours when care is provided by a nurse. The lack of on-line reference data was also noted, and comment was made that referencing hard copy medical journals or research documents seemed antiquated. Students generally had positive or neutral comments about the appearance of the facility and its campus location.

B.

HC Outsourcing

Since most stakeholders do not perceive the HC as being outsourced, there has not been much thought given to the rationale for outsourcing or common advantages and disadvantages. Stakeholders also had difficulty expressing why the HC is outsourced and the PCC remains an internal operation, although it could be argued that the part-time counselors who are compensated on a feefor-service basis reflect a form of outsourcing.


Internal Environmental Assessment Section III-A and pre-dates the 2008 economic downturn, and that the financial constraints only reinforced a predisposition not to provide these services.

 Lack of annual reports for the PCC makes formal assessment difficult. Concern was also expressed for the PCC not having any supervisory or support role for the numerous student support groups that provide varying levels of peer counseling.

 The credibility of the PCC is seriously jeopardized in the view of many stakeholders, as they view both leadership and staff, and many of its ardent external supporters, as being highly defensive and change resistant. For example, suggestions (sometimes perceived as demands) that endowments for the PCC are highly prescriptive as to mission and methods of operation are not well-received.

D.

Funding

As a result of the economic downturn that began in 2008, substantial budget reductions were implemented for most student service departments. Reductions in overall institutional costs were also significant (e.g., Brandeis contributions for retirement accounts were temporarily suspended).

Stakeholders could not explain why the HC and the PCC were exempted from these budget reductions or asked if there were opportunities to operate differently to reduce costs and/or enhance services. One stakeholder speculated that the exceptionally high need for services among Brandeis students, which could increase with reductions in other service areas, may have precluded considering changes to the HC or the PCC.

When HBC noted that the PCC is already engaged in insurance billing for psychiatry and long-term counseling, no stakeholder could explain why insurance billing was not considered for short-term counseling and for services provided by the HC. Stakeholders were not aware of any discussion with BIDMC regarding the potential for insurance billing from 2008 to present. Likewise, stakeholders seemed largely unaware of common changes in the operation for other college health and counseling services over the past decade, and particularly since the economic downturn of 2008, among private colleges and universities nationally, among University Athletic Association (UAA) peer institutions, or for programs in the Boston area.

Apparently, there was discussion for the 2012-13 renewal with the BIDMC about reducing the hours of operation for evening and weekend services. During HBC’s meeting with BIDMC, it was announced that the hours would be changed on weekdays for the HC to close at 6:00 PM rather than 8:00PM and that the HC would be closed on Saturdays. No stakeholder made reference to these changes during the course of HBC’s campus visits.

E.

Need for Health and Counseling Services

Many stakeholders commented that Brandeis attracts undergraduate students (and parents) who have high needs and expectations for services. This is particularly true for health and counseling services. Stakeholders could not point to any student or parent survey data (e.g., the National College Health Assessment ) to support this contention, but it has clearly become conventional wisdom


Internal Environmental Assessment for both students and many administrators.

Section III-A

F.

Access for Services

Stakeholders could not explain why the health fee is optional for graduate students or the basis for the academic year cost of $694 for 2012-13 and $725 for 2013-14. HC staff inaccurately reported that graduate students only purchase the optional health fee during the summer when the cost decreases to $100. Many stakeholders did not seem concerned that graduate students do not have access to the HC and the PCC on the same basis as undergraduate students, nor of how unique this situation is in comparison to peer institutions. Several stakeholders expressed strong concerns that graduate students should have the same eligibility for services at the HC and PCC and have the same fee schedule as undergraduate students. Although they perceive that graduate students can obtain 12 sessions for counseling each year without charge, stakeholders expressed concern that the lack of effective communication to graduate students and misinformation for the health fee combine to create significant access barriers.

No concerns for access were noted by stakeholders for undergraduate students receiving services at the HC. Stakeholders were not, however, aware of the changes for hours of service being implemented for the HC for the 2013-14 academic year. Several stakeholders expressed disappointment that the change of hours had not been communicated to either returning students or faculty and staff.

There is a substantial difference of opinion among certain stakeholders as to whether significant wait times routinely occur for intake appointments at the PCC. Some stakeholders also expressed concern that the PCC’s intake process is cumbersome, requiring students to go to the PCC to complete and submit paperwork before an appointment can be scheduled. Some stakeholders do not find data from the PCC that most students are seen within one week of requesting an appointment to be credible. Other stakeholders find these data to be consistent with their personal experience in referring students to the PCC. Two stakeholders challenged HBC to make telephone calls to the PCC in October to see how many times phone calls will go to voice mail and how long it takes for return calls. Combined with the perceived cumbersome intake process, there is a sense among many stakeholders that access to the PCC is not sufficient after the beginning of each semester, and that the following cautionary statement on the PCC website under Hours and Appointments is valid:

It is best to contact the Center as early as possible in the semester if you anticipate that you will want a course of counseling.

G.

Communication

Effective communication is recognized as a major challenge for both the HC and the PCC by many stakeholders, including students. Some stakeholders are highly aware of the inconsistent and incomplete communications, as well as the lack of graphically attractive, well-organized websites for the PCC and the HC, use of social media, streaming video, and other best practice communication methodologies.


Internal Environmental Assessment

H.

Facilities

Section III-A

Stakeholders view the HC and the PCC as not having optimal locations, particularly for disabled student access to the PCC. The second floor location of the receptionist office not being at the entrance to the PCC was identified as an unwelcoming organizational feature for students. Most stakeholders felt both facilities were in need of refurbishment. Several stakeholders expressed need for facility planning, including consideration of joint location of the HC and the PCC. One stakeholder expressed interest in the trend for co-location of health and counseling services with student recreation centers and wellness programs.

I.

Insurance Status

None of the stakeholders expressed concerns about the adequacy of coverage for either the undergraduate or graduate SHIPs.

Many stakeholders believe the insurance requirements for Brandies are not effectively enforced for either undergraduate or graduate students. These stakeholders have had extensive experiences in recent years whereby students had severely limited coverage (e.g., no benefits for outpatient mental health care services), have health insurance plans that do not include participating providers in the Boston area, have pre-existing condition exclusions, inadequate prescription drug benefits, or other serious limitations. Some of these problems are undoubtedly due to the trend for increasing use of high deductible health plans.


External Environmental Assessment Section III-B

A.

Short- and Long-Term Impact of Health Care Reform on College Health Programs

The passage of the Patient Protection and Affordable Care Act (ACA) is beginning to have substantial impact on college health programs. Many observers are, however, surprised to find that informal surveying of college health professionals at four-year degree granting institutions shows only nominal reduction in the large number of uninsured students resulting from the expansion of eligibility to age 26 for dependent coverage under parental health insurance. The Lookout Mountain

Group’s estimate (refer to page three and Appendix A of their 2009 report ) that four million uninsured college students appear to largely remain uninsured. Uninsured students are primarily enrolled at the approximately two-thirds of public institutions that do not require health insurance as a condition of enrollment. The large uninsured college student population was not caused by students aging out of dependent coverage on parental health insurance. Rather, it was caused by almost all job growth occurring among small employers over the past three decades. Small employers are least likely to provide health insurance or subsidized coverage for children, and both large and small employers that do provide health insurance have substantially shifted the premium cost to employees. Internal Revenue Service regulations issued late in 2012 confirm that employers do not have to provide coverage for the spouse of employees under the ACA and that there is no mandate that coverage for children be affordable.

The main impact of the ACA on college health programs is three-fold. First, college health professionals have seen a substantial increase since 2010 in the number of students who are covered by high deductible health plans (HDHPs). This experience is borne out by the employer surveying data provided by the Kaiser Health Foundation showing that one in five workers is covered by a high deductible health plan in 2013, up from eight percent in 2009 (refer to sub-point C below).

Due to unfunded or under-funded Health Reimbursement Accounts (HRAs) and Health Savings

Accounts (HSAs), many students covered by these plans are reluctant to obtain high cost prescription drugs, diagnostic imaging and scans, long-term mental health care counseling, emergency room treatment, and other perceived discretionary high cost services. From a national perspective, the good news is that HDHPs are having a major favorable impact on the cost trend for health insurance for both employers and employees. The bad news is that there is great uncertainty as to the impact on long-term health, either positive or negative, by less utilization of health care services. For college health professionals, there are major concerns for access to care for students and how to communicate the importance of the insurance decision, particularly waiving enrollment in a

SHIP that provides extensive, traditional first dollar benefits rather than an HDHP. Most colleges and universities are unprepared to deal with this situation and are only beginning to become aware of the impact on budgets (e.g., significantly increasing expenditures for intercollegiate athletes for care that was previously funded by students’ health insurance).

The second major impact of the ACA is that the adoption of 100 percent coverage (i.e., benefits are provided without deductibles, copayments, or coinsurance) for a broad spectrum of medical and mental health care services is creating major questions and communication challenges for explaining the rationale for designated mandatory health fees and why health and counseling services do not participate with students’ personal health insurance. As explained in HBC’s recent position paper on insurance billing for college health programs , there are complex regulatory environmental questions and revenue/return on investment projection challenges associated with insurance billing.



The third major impact of the ACA is that it has effectively ended the debate about whether fouryear degree granting colleges should provide SHIPs with comprehensive coverage (fully comply with the insurance standards endorsed by the American College Health Association) or whether

SHIPs should provide nominal coverage and be low cost programs that students and parents are encouraged to rely on as a course of last resort.

Fortunately, final market rules ( CMS-9972-F ) were adopted in late February affirming that fully insured student health insurance programs were not subject to the guaranteed issue and guaranteed renewability provisions (i.e., eligibility SHIPs could be limited to currently enrolled students) and that the cost of the coverage could be based on the expected paid claims for a specific group of covered students. The end result is that SHIPS will have a substantial cost advantage over individual coverage available through the insurance exchanges, in large part because young adults will not be expected to subsidize coverage for older insured persons.

The cost subsidies for low income individuals will not have significant impact for many students because they will still be a dependent on a parent’s/guardian’s tax returns and the family income calculation will preclude subsidies, and/or the student will have access to an employer-sponsored health plan. In states where Medicaid expansion is not adopted, there will be no insurance exchange cost subsidization for individuals with income at less than 133 percent of the federal poverty level.

In states that do adopt expansion of eligibility for Medicaid, it is possible that administrative rules or specific legislation may be adopted to allow Medicaid funds to be used to pay for the cost of SHIPs.

The American College Health Association ( ACHA ) recently published a position paper on this subject (refer to Section VI, Attachment A).

B.

Boston Area Community-Based Health Care Providers

There are at least three major health care providers in the Boston area that would be likely to respond to respond to the recommended request for proposals for the 2014-15 academic year.

 BIDMC/Harvard Medical Faculty Physicians (HMFP)

As the current vendor, Beth Israel Deaconess Medical Center has expressed interest in continuing to operate Brandeis University’s HC. At a meeting at the HC on Wednesday, July

17, 2013, representatives of BIDMC noted that BIDMC or HMFP operates other college health services in the Boston area. The capability to operate college health services is not being marketed by BIDMC, nor is this expected to become a significant service area in the future. BIDMC views this as a service it can provide to certain colleges and universities versus a major strategic opportunity. This is not to say that BIDMC is not fully committed to the relationship with Brandeis University or its other college clients. It is also possible that BIDMC’s representatives are not aware of the importance of the Brandeis contract to

BIDMC senior’s leadership.

BIDMC’s representatives are generally satisfied with the current practices and methods of operation for the HC. Provided in Section VI, Attachment B, is an email of August 9,

2013, from Dr. Kay Petersen to HBC identifying recommended actions or items for con-


External Environmental Assessment Section III-B sideration for the operation of the HC. This email message affirms the availability of an electronic health records system (EHR), insurance billing capability (including credentialing providers and having participating provider agreements), and a fully functioning practice management system, if the contract could be provided through BIDMC’s affiliated physician organization, Harvard Medical Faculty Physicians (HMFP) . HMFP is operating the Health Services at Emmanuel College, although the website continues to show that the program is operated by BIDMC. Representatives of BIDMC explained that HMFP is billing students’ personal health insurance, and Emmanuel College is funding the remaining balances for insurance deductibles, copayments, coinsurance charges, and other services not covered by insurance (also referenced on page two of the email from Dr. Petersen).

The representatives of BIDMC affirmed HMFP’s community practices feature state-of-theart services relative to use of an EHR, evidence-based medicine, delivery of services consistent with a Patient-Centered Medical Home , and integration of behavioral health counseling into primary care services (refer to an HHS video for Health Resources and Services

Administration and Section VI, Attachment C, for HBC’s reference documents).

 Newton-Wellesley Hospital (NWH)

Newton-Wellesley Hospital provides the closest emergency department and has a strong working relationship with the PCC for psychiatric evaluations. NWH owns and operates both family practice clinics and urgent care clinics. Approximately one-third of the primary care clinics affiliated with NWH are owned by physicians. NWH provides practice management and EHR systems, billing services, provider credentialing and managed care contracting for these privately owned practices. In 2016, they will transition to EPIC for their EHR through their affiliation with Partners Healthcare .

NWH has a strong interest in providing services for college health programs. They appreciate the existing relationship with Brandeis and are working to expand college health program relationships with other area colleges and universities. They could provide outsourcing services as is presently structured with BIDMC, or they could provide a management services only program as they are providing to numerous privately owned physician practices.

NWH is committed to integrating behavioral health into primary care, fully developing the

Patient-Centered Medical Home concept. They could provide both counseling and primary care services, combined with a fully integrated EHR that would include Brandeis University’s on-campus care, urgent care, emergency room, and hospital care through the

Partners Hospital and network of specialty physicians.

Most important, NHW could provide a direct contracting relationship with self-funded student health benefit plans that could significantly lower both cost of care and administrative cost for Brandeis University’s SHIPs.


External Environmental Assessment

 Harvard Vanguard Medical Associates (HVMA)

Section III-B

Harvard Vanguard Medical Associates has more than 20 clinic locations across eastern Massachusetts, including a family practice/urgent care location in Wellesley. They operate the

Student Health Services clinic at the Massachusetts College of Art and Design, which also serves students from Wentworth Institute of Technology and the Massachusetts College of

Pharmacy and Health Sciences. This arrangement began in 2007. They also provide student health services for Wheelock College.

HVMA is one of the nation’s leading healthcare organizations, serving nationally as one of the 19 pioneer accountable care organizations. There is a high level of interest among

HVMA’s leadership in contracting to operate other college health programs in Massachusetts. They routinely provide an electronic health record system, billing capability with secondary payor funding system, 24-hour call services, access to urgent care services, surveys of student patients, and are not opposed to having their college health clinics be licensed by the Commonwealth of Massachusetts.

C.

Employer-Sponsored Health Plans

Following the passage of the ACA in 2010, employers aggressively moved to increase the availability of high deductible health plans. The following bar chart from the Kaiser Family Foundation’s

2013 survey shows that one in five workers is now covered by a high deductible health plan

(HDHP) with a savings option (SO).



The trend for adoption of high deductible health plans is expected to continue, but the consequences for access to care are uncertain. Many health care economists and other observers are confident that the adoption of HDHPs is the single largest factor in the favorable trend for health care costs over the past four years (refer to Section VI, Attachments D-1, D-2, and D-3).

While employers are adopting HDHPs, many are also investing heavily in on-site employee health clinics. More than 40 percent of employers with more than 1,000 workers are reported to have such clinics (refer to Section VI, Attachment E, and to OnSite Clinics.org

). These clinics often feature integrated primary care and mental health care services and biometric-based health coaching and wellness programs. These trends suggest major changes for the long-term operation of college health programs as it is likely that the effectiveness of these approaches can be translated to the college health field.

The other major change for employer-sponsored health plans since the passage of the ACA is to discontinue subsidizing dependent coverage and transition to unbundled cost contributions from employees for dependent coverage. Many employers are adopting per-dependent cost contributions rather than simply having single employee and family rate structures. This means that increasing numbers of parents are seeing a specific health insurance cost for their college student. As shown in the video produced this summer by Northeastern University, this situation creates an opportunity for highly effective college health programs to become a student recruitment asset.

D.

Peer Institutions

In conducting an evaluation of peer institutions, HBC agreed to focus on the University Athletic Association member institutions:

Carnegie Mellon University

Student Health Services

University Health Services

Student Counseling

Services

Counseling and Psychological

Services

Case Western Reserve

University

University Health Services University Counseling Services

Emory University

Student Health and Counseling Services

Student Health Services

Counseling and Psychological

Services

Safety, Health, and Wellness

New York University

Student Health Center Counseling and Wellness Services

University of Chicago

University of Rochester

Student Health and Counseling Services

Student Health Service Student Counseling Service

University Health Service University Counseling Center

Washington University

Habif Health and Wellness Center

Student Medical Services Mental Health Services



Because New York University has more than 44,000 students, it was evaluated only for graduate students’ eligibility for health and services and for the delivery of counseling services. These same limited comparisons were completed for following Boston area colleges and universities: Boston

College, Boston University, Harvard University, Massachusetts Institute of Technology, Northeastern University, and Tufts University.

The following are key observations for Brandeis University peer institutions and selected Boston area colleges and universities:

 Emory University, New York University, University of Chicago, and Washington University are either working toward or have fully developed a comprehensive college health programs (refer to Section V-A, Comprehensive Health System, Step Two). HBC was particularly impressed by the program at Emory University, which features coordinated primary and specialty medical care, counseling services, research-based health promotion, and student health insurance benefits. Some of the programs at other institutions, including Boston area colleges and universities, such as Northeastern University’s University Health and

Counseling Service, include sexual assault prevention, disability services, sports medicine, and other health-related services. The 2011-12 annual report for Emory University’s Student Health and Counseling is included in Section VI, Attachment F. An impressive introductory video for the program is also available at Emory’s website for their Student Health and Counseling Services.

 Neither the UAA peer institutions nor the selected Boston area colleges and universities have outsourced their health or counseling services to community health care providers.

While there is a significant trend toward outsourcing for college health and counseling services, most of it is occurring at colleges and universities serving less than 10,000 students

(particularly small liberal arts colleges) with limited internal capabilities to obtain participating provider status and engage in insurance billing. HBC anticipates several elite private colleges and universities in Massachusetts will consider outsourcing as part of a strategic review to evaluate a secondary payor funding system and/or other responses to the full implementation of the ACA.

 All of the UAA peer institutions and the selected Boston area colleges and universities provide eligibility for health and counseling services automatically to graduate students on the same basis as undergraduate students. From a national perspective, HBC is only aware of health and counseling services being limited for graduate students at colleges and universities that have evening, weekend, or distance learning programs where graduate students would not be on campus when health and counseling services are open. There are also academic health centers that allow graduate students involved in medical education to waive participation in certain health and counseling service components based on their eligibility to use hospital-based clinics for faculty and staff care.



 All of the UAA peer institutions and the selected Boston area colleges and universities, with the possible exception of Harvard University, are providing short-term counseling services. While there are varying definitions and some noted exceptions for training programs, none have declared that they provide long-term counseling services. While longterm counseling (and/or no statement of session limits) may be provided at a few Ivy

League institutions, AUCCCD data show that session limits did not significantly change the average number of sessions per student (5.07 for schools with 5,001 to 7,500 students).

The AUCCCD reported that 50.5% of survey participants had session limits.

 None of the UAA peer institutions are charging students for psychiatry services and billing insurance plans. Similarly, none of the UAA peer institutions have large part-time staffs that are integral to a funding system for counseling.

 With only a few possible exceptions, the counseling centers at UAA peer institutions and the selected Boston area colleges and universities have extensive outreach and wellness programs. Most of the websites are well organized, graphically attractive, and feature links to social media, on-line appointment portals, and other advanced marketing and communications strategies. There is a strong emphasis in messaging for diversity and cultural competency. In addition to the video previously referenced for Emory University, other peer institutions with high quality welcoming counseling videos include:

University of Rochester: http://www.youtube.com/watch?v=ieTTnRXgFys

Case Western Reserve University http://www.youtube.com/watch?feature=player_embedded&v=Qn3rWmmF1bE

The videos and text describing counseling services is based on language that would reduce the stigma and intimidation associated with counseling for young adults. The informed consent document provided by the University of Rochester (refer to Section VI, Attachment G) is an example of a document that meets risk-managed care requirements, but is also designed to be communicative and minimize anxiety for beginning counseling.

 Four UAA peer institutions have accredited health services through the Accreditation Association of Ambulatory Health Care ( AAAHC ): Carnegie Mellon University, University of

Rochester, Emory University, and Washington University. None of the UAA peer institutions have accreditation through the International Association of Counseling Centers

( IACS ). Prominent Boston area colleges and universities with IACS accredited counseling centers include: Bentley College, Emerson University, Harvard University, and Suffolk

University. Institutions that do not have accreditation often have formal, periodic external reviews.

Case Western Reserve University has a long history of operating a self-funded student health benefits plan. MIT, Harvard, Northeastern, and UMass-Amherst operate self-funded student health benefit plans, providing coverage to more than one in four students insured by college student health insurance plans domiciled in Massachusetts. Northeastern University recently introduced two videos, one for domestic students and one for international students, featuring their NUSHP


External Environmental Assessment program: http://www.northeastern.edu/nushp/ .

Section III-B

E.

College Health Programs

Numerous colleges and universities are reconsidering the mission, scope of services, funding systems, and methods of operation for their college health programs . Finding opportunities to improve fiscal effectiveness, increase productivity, reduce costs, improve campus safety, and increasing monitoring capability are key drivers, often within the context of student recruitment, retention, or enhancing the educational experience. These overarching objectives are being achieved by elite private universities relative to the operation of their college health programs. For example, the Northeastern University Student Health Plan (NUSHP), referenced above, is becoming a student recruitment asset because it promotes campus safety and is proven to be a cost savings program for many parents.


Administrative Review of Health Center Section IV-A

Recommendations for the Health Center (HC) are provided in the in Section V-A, Status Quo with Minor

Repairs, Step One. Any risk management or compliance concerns were communicated via privileged and confidential communication to Brandeis University’s legal counsel.

A.

Overview

From 1998 to present, the HC was operated through a contract with Beth Israel Deaconess Medical

Center (BIDMC). The staff members were welcoming and enthusiastic about working at Brandeis.

Almost all services are pre-funded through health fees, without dollar amount designation for undergraduates, included in students’ tuition and fee billing.

In at least one regard, outsourcing has been exceptionally successful at Brandeis as neither students nor staff view the HC as operating any differently than other student service departments. HC leadership and staff are seen as highly dedicated and trusted colleagues by almost all of the staff that

HBC interviewed.

The HC facility is dated and has an inefficient layout for patient care. Patient medical records are on paper, and there is no use of an electronic practice management system. As a result, BIDMC was not able to provide HBC with detailed or consistent utilization data. Since there is no electronic transmission of protected health information, the HC is not a HIPAA covered entity. There is no mention on the HC website’s home page that the HC is operated by BIDMC. One has to go to the

“Health Services” link under the subheading “Hospitalization” to find mention that the HC is managed by BIDMC. Any patient or student will likely not know that the staff members are not

Brandeis employees.

The HC is not accredited by the Accreditation Association for Ambulatory Health Care , is not a licensed clinic by the Massachusetts Department of Public Health, nor are there routine external assessments.

A Patient Rights and Responsibilities statement is not posted at the HC nor is this statement published on the HC’s website. BIDMC’s Patient Rights and Responsibilities statement is provided in the Section VI, Attachment H.

B.

Mission and Assessment

There is no mission, vision, or values statement for the HC, nor is there a link to BIDMC’s mission statement . The home page for the HC website states the following:

The Brandeis HC has a long history of providing comprehensive health care, health education, and wellness promotion to the Brandeis community. Our services are respectful, inclusive, accessible, and confidential.

The HC does not produce annual reports, and utilization reporting is not routinely provided to

Brandeis. There are no recent patient satisfaction and non-user surveys for the HC and no health assessment surveys (e.g., the American College Health Association’s National College Health Assessment ) were reported to HBC.



C.

Services

BIDMC staff is responsible for rendering health services at the HC for Brandeis students, participants of summer programs, Brandeis employees, and visitors to campus. Available medical services include visits to registered nurses, nurse practitioners, and physicians by walk-in or appointment.

Alcohol and other drug counseling is also provided. A nutritionist, who is a Brandeis Dining Services employee, is located in the HC and provides nutrition services to students. Immunizations are administered by registered nurses. HC staff dispenses starter prescriptions for antibiotics, and students can pick up prescriptions delivered to the HC through arrangements with two local pharmacies.

In addition to providing on-campus medical services, BIDMC provides Brandeis with a Medical Director; patient access to 24-hour telephone triage, including emergency triage; and administering compliance with the Brandeis insurance requirement. The scope of on-campus medical services is consistent with university health services of Brandeis’ size where they are run by the university or college. Brandeis provides significantly less health promotion services than many of its peer institutions, particularly in regard to having a research-based program that would assess short- and longterm outcomes.

The HC hours for the 2012-13 academic year were Monday through Friday, 8:00 am to 8:00 pm and 10:00 am to 4:00 pm on Saturdays, Sundays, and holidays. During HBC’s site visit, HC staff informed HBC that the hours had been changed starting fall of 2013; and hours would be Monday through Friday 8:00 am to 6:00 pm and Sundays from 10:00 am to 4:00 pm. Staff indicated that low utilization was the reason for discontinuing Saturday service. There was no mention that any reduction in staff was anticipated as a result of the reduction in hours, but contract negotiations for the 2013-14 had not yet commenced. At the time of HBC’s last site visit, the HC website reflected the new hours. Per the website, the HC may be closed for hour-long meetings during regular hours, at which time the closure will be posted on the door, and students with emergencies can

“ring doorbell” for service (an awkward policy for a center that normally has walk-in service at these times of day). Prior to the recent change in hours, the HC was staffed by a registered nurse working under protocol with no physician on-site on weekends and evenings. BIDMC expected to initially staff the HC for the first few Sundays with both a nurse practitioner and registered nurse

(RN) until they have a better idea of the Sunday patient volume, in light of the Saturday closure.

BIDMC expected that the patient volume will result in a single nurse working on Sundays under protocol.

On weekdays, the RNs see walk-in patients, and the physician and nurse practitioners see appointments. The nurses work under standing orders and protocols and, if they have any concerns, they can consult a nurse practitioner (NP) or physician. If a patient sees an RN and has to return, the patient is scheduled with a physician or NP. Nurses also administer injections and dispense starter doses of medications. The HC charges for immunizations and flu shots. Expenses and revenues for these injections flow through BIDMC. In 2012-13, BIDMC reported that they received about

$44,000 in revenues for vaccines.

The HC staff receives and reviews pre-matriculation health history forms required of new students.



They also review health screens for athletes and participate in new student orientation. They work with the Department of Community Living and Disability Services and Support by screening medical applications for accommodations. Staff indicates that they attend regular meetings with personnel from the Department of Community Living, Public Safety, the PCC, and Dean of Students offices to discuss persons of interest/concern. The contract indicates that Brandeis and BIDMC will establish a Joint Oversight Advisory Committee. There were intermittent attempts to maintain a student health advisory committee but attempts/outcomes seemed minimal based on 2011 and

2012 meeting minutes provided to HBC.

Regarding counseling services, HC staff will call the PCC or walk a student to the PCC if a counseling referral is needed. HC staff indicated that they confer with the PCC psychiatrist with regard to medication management. The PCC will send a student to the HC if the psychiatrist is not available.

BIDMC staff felt that it would be optimal to have counseling integrated within the health center.

D.

Communication

The HC website’s is not optimally organized and does not have a personalized, welcoming message.

There are no pictures of staff or other images to give students and parents an overall feel for the facility or the approach to providing care. The links to emergency resources on the home page are excellent. Some of the content needs updating and editing (e.g., not all links work and some of the dates are obsolete, prices are in format “20$”). Most individuals would not know that HC is run by, or the staff members are employees of, BIDMC.

E.

Funding

For fiscal year 2012-13, Brandeis paid BIDMC $1,130,627. The contract specifies the monthly payment amounts, which achieve an annual amount of $1,128,957. The actual monthly payments by Brandeis were lower than the contracted amount as the increased charges did not go into effect until September. In addition to the flat contracted amount, Brandeis paid BIDMC an additional

$2,700 for other services. For the 12-month contract period (September through August), the total payments to BIDMC from Brandeis will be $1,131,657. In addition to the contracted amount,

BIDMC received about $44,000 in revenues for immunizations, for a total of $1,175,657. The current contract was initiated in 2003 and included an initial investment by BIDMC for improvements to the facility that was repaid by Brandeis to BIDMC over ten years. The contracts have been renewed each year with adjustments in amount of compensation.

F.

Eligibility and Access

Undergraduate student enrollment fees include support for the HC entitling undergraduates to access most services at no additional charge. The HC website states the following under the Health

Services Access page:

All undergraduate students have unlimited access to the on-campus resources at Brandeis

Health Center. Graduate students have access for immunization services and have the option of purchasing access to the health center for other medical care needs. This access fee covers unlimited visits to Brandeis Health Center and up to twelve (12) visits at the Psychological Counseling Center.



It is noteworthy that the PCC website does not state that there is a twelve visit limit or that graduate students who have not paid the optional health fee are not eligible for services. Graduate student purchases of the annual health fee were reported to HBC as follows.

Term

Fall 2010

Fall 2011

Academic Year

Cost of Fee

$636

$662

Total Optional

Fee Enrollees

247

246

Fall 2012

Fall 2013

$694

$726

205

192

The summer only cost for the optional health fee was $100 for four reporting periods. HBC has no information on these students’ utilization of health and counseling services, though it seems doubtful that the graduate students who are paying the health fee are receiving a fair value. Sixty-five graduate students had three or more visits at the HC, but it is unknown if these were covered office visits or were immunizations for which they had to pay (and gained no advantage from having paid the optional fee). It is also unknown whether these graduate students paid the optional fee to access the PCC, thinking that this payment was required to receive PCC services. HC staff members inaccurately reported to HBC that most graduate students only purchase the summer optional health fee. HC staff reported to HBC that they spend a lot of time helping these students get access to care off campus.

G.

Staffing

The table below shows the HC staffing:

Physician Director

Primary Care Physician

Ortho

Nurse Practitioners

Total Providers

Registered Nurses

Nursing Director

Total RNs

Alcohol & Substance Abuse

Admin Staff

Total

FTE

0.6

0.45

0.05

2.4

3.5

2.0

0.9

2.9

0.9

2.2

3.1

9.5

9 months 3 months Annual Clinical

0.45 0.08 0.53 0.26

0.34 0.34 0.34

0.04

1.80

2.63

0.25

0.33

0.04

2.05

2.95

0.04

2.05

2.69

1.5

0.68

2.2

0.675

1.65

2.3

0.23

0.2

0.55

0.6

1.50

0.90

2.4

0.68

2.20

2.9

7.1 1.1 8.2



H.

Utilization

HBC’s analysis includes comparing utilization and staffing of the HC to health services at private universities of similar size. Graduate students are not eligible for care at the HC unless they pay the optional health fee. This leaves only undergraduates and the relatively small number of graduates who have paid the fee as the basis for making eligible population comparisons to other universities.

Other universities provide equal access to their graduate student populations.

The HC provided the following data with regard to the number of patients seen at the Student HC

(labeled SHC Pts in the table) and the number of total visits and visits by insurance status. The visits, however, include office visits with providers (physicians and NPs) as well as visits for only immunizations and other services (provided by RNs). If a student saw a physician or NP and also an

RN on the same visit, it is unclear whether these encounters are counted as more than one visit.

There are no details on the complexity of any of the visits (e.g., a blood pressure check vs. a complex new patient office visit). The HC reported that 402 graduate students were seen for 688 visits. There were 213 graduate students who paid the health fee in 2012-13, leaving 189 graduate students who likely received only fee-for-service immunizations. Some of the students paying the health fee may also have received only immunization (charged for) services or no HC services at all.

The penetration rate (percent of student population using the HC) for undergraduate students is 65 percent. This includes immunizations, so it is likely that the primary care penetration rate is about

50 to 55 percent. This is about what would be expected for primary care services at an elite private university. The penetration rate for graduate students in settings where they have equal access to on-campus resources is generally higher than for undergraduates because of age and the higher likelihood that they are from out of the local area. Assuming all of the graduate students who paid the health fee received primary care services at the HC, the primary care penetration rate for Brandeis would be about 9.6%.

SHC Pts Enrolled % Enrolled % of Pts

Graduate Students 402 2,220 18% 15%

Undergraduate Students 2,341 3,588 65% 85%

Total 2,743 5,808 47% 100%

All Visits, Including Immunizations

Graduate Students

Undergraduate Students

Total

Students

402

2,341

2,743

Visits

688

5,909

6,597

All Visits, Including Immunizations

SHIP

Visits

Total

Average per

Student

1.7

2.5

2.4

% Total


Administrative Review of Health Center

Graduate Students 361

Undergraduate Students 1,495

Total 1,856

688

5,909

6,597

52%

25%

28%

Section IV-A

The effective population eligible for the HC is 3,801 (3,588 undergraduates + 213 graduates). A survey conducted by the American College Health Association

(

ACHA

) reported that there was an average of 1,939 students per FTE provider for private colleges/universities. At 2.6 FTE clinical providers and an eligible population of 3,801, Brandeis has 1,462 students per FTE, or 25 percent lower than the ACHA average. Another way to look at it is that for an eligible population of 3,801, there would be expected to be 2.0 FTE providers based on the ACHA average, rather than 2.6

(Brandeis is 30 percent higher than the ACHA average). If all Brandeis graduate students were to be eligible on the same basis as undergraduate students, the current staffing would be fairly close to the ACHA average. In this case, Brandeis’ 3.0 FTE providers would be consistent with the ACHA average for private colleges/universities.

The ACHA average number of students per FTE RN for private colleges/universities is 2,135. The

Brandeis ratio for its effective eligible population is 1,584 students per RN. If Brandeis was at the

ACHA staffing average, it would have 1.8 FTE registered nurses. At 2.4 FTEs, Brandeis RN staffing is 33 percent higher than the ACHA average. Again, if all Brandeis graduate students were to be eligible on the same basis as undergraduate students, the current staffing would be fairly close to the ACHA average.

HBC received several reports with data aggregated differently, and all had varying totals, as the list below illustrates. There is a 17 percent difference between the lowest and highest reported number of visits.

By Unique Patient Visits

By Insurance Status

6,597

7,018

By Patient Volume Summer/Academic Year 7,661

By Provider Type 7,707

I.

Productivity

The following table shows visits by provider type for 2012-13 and shows that of the 7,649 nonnutrition visits reported, 3,681 were by MD or NP providers. At 2.6 FTE clinical providers, the average visits per year per FTE provider is 1,416 per provider. The ACHA median annual visits per FTE provider is 2,356. The average HC visits per FTE provider is 40 percent lower than the

ACHA median. BIDMC indicated that approximately 1,500 immunizations are done annually. If

1,500 visits are subtracted from the total visits of 7,649, this leaves 6,149 total non-immunization visits and 2,468 non-immunization visits provided by registered nurses. Some of the RN nonimmunization visits are for other nursing services, such as blood pressure checks, while others are for office visits performed under protocol. Assuming 2,000 of these non-immunization visits are office visits under protocol that might be provided in other settings by NPs, the total office visits to be covered by NPs and MDs would be 5,681 (3,681 + 2,000).

At the ACHA mean of 2,356 visits per FTE, Brandeis would need 2.4 FTE providers to cover the office visits provided currently by both providers and RNs. Another way to look at this is that



BIDMC could provide all office visits using MDs and NPs at current provider staffing levels rather than utilizing RNs, if productivity were improved to ACHA median levels. Alternately, provider staffing could be reduced. It should be noted that ACHA productivity levels are below community levels, even compared to community practices where physicians are compensated at 100 percent salary (i.e., no productivity component in the compensation). Compared to the community, factors affecting college health productivity also include inefficient facilities (many college health facilities are inefficient), support staff levels, the varying student population, and other campus-related, non-patient care duties. The duties performed by the HC staff are consistent with those provided by the ACHA comparison groups in terms of facilities, immunization compliance, and support staff levels. One advantage of outsourcing is that the inefficiency caused by the varying student population can be significantly reduced, if not eliminated, with the flexibility in staffing that is possible with an outsourcing arrangement.

Sept

Oct

MD NP

2012-13 Visits by Provider Type

Flu vac-

RN cine/TST only,

Total without provider type not specified

Nutrition

106 315 445

124 326 455

0

319

866

1224

Nutrition

13

10

Total with

Nutrition

879

1234

Nov

Dec

Jan

Feb

138 274 344

81 195 421

87 211 269

100 224 260

March 92 218 233

April 98 285 345

May 48 189 198

June

July

Aug

Total

3 116 0

11 225 0

40 175 175

928 2753 3145

12% 36% 41%

61

26

246

3

167

1

0

0

0

0

823

11%

817

723

813

587

710

729

435

119

236

390

7649

100%

6

10

2

7

4

4

2

0

0

0

58

821

725

820

591

716

739

437

119

236

390

7707

J.

Costs

The table below shows the cost per visit based on the various figures for number of visits provided to HBC. The final figure (7,649) is the total that BIDMC indicated was most accurate (and referred to as the “gold standard”). Depending on the visit assumption, the cost per visit to the HC ranges from $153.46 to $178.21. Included in this cost are immunizations, urinalysis, and pregnancy tests.

The average ranges from $147.72 to $171.54 if immunizations are removed from the cost. The average cost per visit for other comparable outsourced health centers in the Boston area (which does not include other clinics operated by BIDMC) ranges from $113 to $142 per visit. The services included in these per visit costs are extended hours during the week and weekends at contractors’ local facilities; health center staffing by MDs, PA, and NPs; a number of laboratory tests; and access


Administrative Review of Health Center Section IV-A to contractors’ electronic EHR and practice management systems. At the midpoint of $125 per visit, the total cost would be $825,000 to $958,000 (depending on the visit assumption), which includes expanded services. The cost for 7,649 visits would be $956,000 at $125 per visit. Generally, compliance with immunization requirements is included but compliance with the institutional insurance requirement is not. BIDMC performs the latter plus also provides alcohol and other drug

(AOD) counseling services. BIDMC also dedicates resources to reviewing pre-matriculation health histories and physicals which other outsourced entities consider not to be a worthwhile or cost effective use of resources.

A more accurate methodology would be to factor into the calculation the impact of the proportion of lower cost services. The HC has a high number of immunizations relative to the comparison health centers, and BIDMC receives fees for these immunizations. BIDMC received $44,000 for immunizations in 2012-13, and they reported doing about 1,500 immunizations; a cost of $29.33 per immunization. HC immunizations account for 19.6% of visits; immunizations at the comparison health centers were 9.0% to 10.0% of visits. If the HC had 10.0% of visits for immunizations instead of 19.6%, there would be 771 lower cost visits for comparison. The table below prices out the 771 immunizations at $29.33 and the remainder of visits at the mid-level comparison cost of

$125 per visit, for a total of $882,392.

Immunization Revenues

# Immunizations

Charge per Immunization

$ 44,000

1,500

$ 29.33

Total Visits

Immunizations @ 10%

Comparative Visits

Total Comparative Cost

Cost

Total Comparative Cost

Difference

Contract Amount 2012-13


Total for 2012-13

7,649

771

6,878

Cost/Visit Total Cost

$ 29.33

$ 125.00

$ 22,605

$ 859,788

$ 882,392

W/O

Immunizations

$ 249,265

With

Immunizations

$ 1,131,657 $ 1,175,657

$ (882,392) $ (956,125)

$ 219,532

Cost per Visit

$ 1,131,657

6,597 7,018

Visits @

7,661

$171.54 161.25 $147.72

$ 44,000

$ 1,175,657 $178.21 167.52 $153.46

7,649

$147.95

$153.70



If all graduate students were eligible for care on the same basis as undergraduate students, they would be expected to generate 1,900 to 2,300 additional provider visits, based on ACHA utilization medians. Assuming that RNs see about 600 visits on weekends, there would be 1,400 RN visits on weekdays. If RNs continue to see about 24 percent of primary care office visits under protocol, the table below shows the impact of graduate student utilization for MDs and NPs. If the

Brandeis providers’ productivity was at ACHA median, there would need to be 2.4 to 2.6 total provider FTEs to meet demand. There are currently 2.7 FTE clinical providers staffing the HC.

Total

Current

+/- Sundays

Primary Care Visits

Grads @ 1,900

Provider

Adjusted

Total

1,400

+ Grads

460

Total

1,860

4,281 1,440 5,721

Grads @ 2,300

+ Grads Total

RN 2,000 (600)

MD/NP 3,681 600

550

1,750

1,950

6,031

TOTAL 5,681 - 5,681 1,900 7,581 2,300 7,981

FTE Providers @ 2,356 Visits per FTE 0.61 2.43 0.74 2.56

If graduate student visits were increase by these amounts to 9,549 to 9,900 total, including immunizations, the current cost per visit would be in line with the comparison health centers (not adjusting for the high number of lower cost immunizations at Brandeis).

Cost per Visit, Including Projected Graduate Student Visits

Visits @

Contract Amount 2011/12


9,549 9,900

$ 1,131,657 $ 118.51 $ 114.31

$ 44,000

Total for 2012-13 $ 1,175,657 $ 123.12 $ 118.75

Assuming 7,649 total visits, it would be reasonable to expect that a contractor could provide expanded services, including commonly ordered lab tests (e.g., PAP, CBC, STD testing, urinalysis, rapid strep, pregnancy, and several others), after-hours urgent care visits at its facilities, TB testing, and after-hours telephone access to the currently eligible population for about $930,000 to

$1,000,000. It could expand the covered level of services to graduate students without an increase in provider staffing and without an increase in cost. In both cases, there would be no additional cost for bringing in and utilizing an electronic practice management system and electronic health record (EHR).

K.

Summary

The HC staff is enthusiastic about serving Brandeis students and providing a caring environment.

BIDMC’s leadership understands that best practices include working in an integrated model of medical and behavioral health care (refer to Section VI, Attachment C). There seems to be a perception that many of the policies implemented and the constraints to operations (e.g., outdated fa-


Administrative Review of Health Center Section IV-A cility, lack of EHR, lack of practice management system) is either because Brandies wanted specific processes/procedures or that there were budget or other constraints prohibiting implementation.

BIDMC did not feel compelled, possibly due to informal communications from Brandeis over a protracted period, to provide leadership for Brandeis with information or perspective on the operation of other college health centers, either facilities BIDMC operates or health centers operated in the Boston area or nationally.

Compared to ACHA medians for private universities, the HC clinical staffing is high and productivity is low. Resources that are being utilized for immunization review and compliance, student insurance compliance, and review of health histories should be evaluated for their appropriateness and cost effectiveness. Costs are also higher than would be expected for a health center that is outsourced to a local health care provider. The advantages of outsourcing include flexible staffing to adjust to the variation in student population over the year, allowing for reduced expenses compared to in-house staffing. Additional advantages include the use of the contractor’s EHR and practice management system, and the ability for the contract to bill students’ insurance for services. Contractors already have participating provider relationships with insurance companies and have the infrastructure to do compliance, credentialing, billing, and collecting functions. Brandeis could also take advantage of its HC funding being secondary to students’ private insurance, as BIDMC is doing for at least one of its other clients. BIDMC has not been proactive in proposing to Brandeis leadership changes to HC operations that would bring the HC in line with current best practices or would assist in improving the overall cost to the University.

There are no annual reports and there is a lack of data on utilization, which should include utilization by student demographics, insurance status, provider, standard procedure and diagnosis codes, day of week, time of day, and other metrics for appropriate program management.


Administrative Review of Psychological Counseling Center Section IV-B

Recommendations for the Psychological Counseling Center (PCC) are provided in the in Section V-A, Status Quo with Minor Repairs, Step One. Please also refer to Section IV-C, Psychologist Consultation. Any risk management or compliance concerns were communicated via privileged and confidential communication to Brandeis University’s legal counsel.

A.

Overview

The PCC is staffed by over 20 part-time psychologists and social workers, three half-time psychiatrists, and six unpaid interns. The Senior Director indicates that the PCC “part-time model” allows for diversity of therapists to meet students’ needs. He describes the PCC as being a developmental counseling model, though in the last three years psychiatric demands and major mental illness have outpaced developmental concerns. The PCC website states that both long- and short-term counseling is available and that the duration of an individual's course of counseling will be determined by the therapist and the student. Services are largely pre-funded through health fees charged to undergraduate students, with augmented funding from insurance billing for psychiatry and long-term counseling.

In some respects, the PCC resembles an outsourced center in that approximately half of the 18 part-time counselors’ compensation is covered by fees-for-services. Part of the rationale for having the part-time counselors is that fee-for-service charges will cover expenses for sessions that exceed

12 per year, and that there are insufficient community resources to refer students for long-term therapy. All of psychiatry services are billed on a fee-for-service basis. None of the seven University Athletic Association ( UAA ) peer institutions for Brandeis use so many part-time staff. Similarly, billing students’ personal health insurance for psychiatry services is unusual for elite private colleges and universities, as almost all institutions would regard psychiatry access as an essential service that must be pre-funded for all students, regardless of insurance status. Lastly, while counseling centers at many private universities don’t have published session limits, AUCCCD survey data show that the number of sessions per client averages about the same for counseling centers with and without session limits. While the Senior Director states that the PCC does not have a long-term model, the average number of sessions suggests otherwise.

The PCC has Titanium, which has both a scheduling and an electronic health record (EHR) capacity, but the EHR portion of the application has not been implemented. The number of part-time staff is one possible barrier that has prevented implementation of the EHR function of Titanium.

There are no annual reports or management/utilization reports generated on a regular basis. There was no policy and procedure manual.

The PCC is not accredited by the International Association of Counseling Centers ( IACS ) and the training program is not accredited by the American Psychological Association. There are also no routine external assessments.

The facility is not in an optimal campus location, is not handicap accessible, and there is no open receptionist area. The Administrator’s office serves as the reception point and it is located on the second floor of the facility rather than near the building entrance.



B.

Mission and Assessment

The PCC does not have a formal mission, vision, and values statement. The Overview page of the

PCC website states the following:

The Psychological Counseling Center was founded in 1952 to provide counseling to

Brandeis undergraduates and graduate students. Staffed by psychologists, social workers, supervised doctoral interns and psychiatrists, the center aims to facilitate the developmental transition from late adolescence to young adulthood while providing diagnostic and treatment services.

The Senior Director indicated that research is an area of emphasis, and HBC was given copies of survey results and summaries of intake/treatment data. These examples of “research” were actually primarily descriptive statistics about PCC clients and rudimentary outcome studies involving only clinicians’ subjective ratings of progress. There is no substantive evidence that research was a significant part of the PCC mission. The Senior Director also summarized the basic mission of the

PCC as being to keep students safe, emotionally healthy, and able to cope with the pressures of young adulthood, student life, interpersonal growth, and mental illness.

The PCC provides nominal outreach programming to the Brandeis community, and there is no involvement of the PCC with numerous student support groups. The Senior Director and several stakeholders suggested that the PCC provides extensive training to the Department of Community

Living and other Brandeis departments. HBC found no record of such training activities, and almost all stakeholders reported that the PCC had not provided any training in recent years. Only two part-time staff positions have dedicated outreach responsibilities, amounting to less than one half-time position devoted to outreach programming and external training. Most peer institutions have outreach coordinators or assistant directors for outreach services who devote a significant portion of their time to overseeing these functions.

As was the case for the HC, the PCC does not produce annual reports, and utilization reporting is not routinely provided to Brandeis. There are no recent client satisfaction or non-user surveys for the PCC, and no health assessment surveys (e.g., the American College Health Association’s National College Health Assessment ) were reported to HBC.

C.

Services

The PCC provides short- and long-term counseling and psychiatry services. The Overview page of the PCC website provides the following description of services.

Approximately 20 percent of Brandeis students make use of Counseling Center services each academic year. They present a wide range of concerns, including academic problems, relationship and roommate problems, family problems, substance use/abuse, sexuality, depression, anxiety and psychosis. The majority of students are seen in individual counseling, with a focus on collaboration between student and counselor on how counseling might be most helpful. The Counseling Center also offers couples counseling and issue-specific counseling groups that vary yearly according to the needs of the student body. Both shortterm and long-term counseling are available.

A Counseling Center staff member is availa-


Administrative Review of Psychological Counseling Center Section IV-B ble for urgent situations throughout the year. After normal hours and on weekends, the oncall clinician can be reached through the answering service (617-431-4814) for consultation in emergency situations.

The PCC website states that that the duration of an individual's course of counseling will be determined by the therapist and the student. In response to HBC’s inquiries about integration of medical and counseling services and a strategy of billing for counseling services under an always secondary payor funding system, the Senior Director was very clear that he objected to both. He objected because he opposed the “medicalization” of students’ concerns.

There appear to be almost no group counseling services provided. Only an eating disorders group was mentioned during the facility tour and in staff interviews.

The PCC is open Monday through Friday, 9:00 am to 6:00 pm. The Senior Director is on call

24/7. No other counselors cover after hours call. The PCC does not offer walk-in/urgent care services in the summer, and students are instructed to receive care at home if they are not in the

Boston area. Some accommodations are made for a few students to be seen during the summer.

D. Communications

Concerns regarding communications were also addressed in Section IV-C, Psychologist Consultation, sub-point C-12.

The HC and Graduate Student Affairs websites state that graduate students who have paid the health fee ($694 for 2012-13 and $726 for 2013-14) are eligible to use the PCC and that the health fee funds the first 12 counseling visits. Visits in excess of 12 and all psychiatry visits are billed to insurance and/or charged on a fee-for-service basis. While this is the policy, there is no mention of the 12 visit maximum on the PCC website. The website only provides the following statements under the Services and Confidentiality page in regard to fees.

All students, undergraduate and graduate, may request counseling during the academic year. The duration of an individual's course of counseling will be determined by the therapist and the student. Faculty and staff members can also use the service for consultation and referral purposes.

The fee structure changes from year to year. Please contact the department administrator for details.

The PCC’s Psychotherapist-Patient Services Agreement (refer to Section VI, Attachment I), excepted below, explains that there are 12 visits in each year of their attendance but then contradicts this statement by stating that after two consecutive years, the student can continue with the therapist on a private basis or be referred out.

TREATMENT POLICIES AT THE COUNSELING CENTER

All students who have paid the Student Health Fee arc entitled to 12 sessions of counseling


Administrative Review of Psychological Counseling Center Section IV-B or psychotherapy in each year of their attendance at Brandeis. This will ensure that care will be possible throughout the time you are attending Brandeis

If you choose to engage in longer-term counseling, the Counseling Center now provides the option of using your health insurance to defray the cost of continuing beyond 12 sessions.

After two consecutive years, you may choose to continue with me on a private basis or be referred to another therapist or treatment modality. All of these options will be considered on a case-by case bas is, with primary importance placed on your well-being.

Psychiatric consultations, aftercare, continuing medication consultations, and emergency consultations will be billed. It is the Counseling Center's expectation that you will utilize your health insurance for these costs, and you should not incur any substantial out-of-pocket expense.

This agreement is also problematic in that it suggests the PCC has the capability to provide ability- to-pay allowances for students with limited financial resources, uses incorrect language regarding billing of insurance companies, and inappropriately suggests that claims data submitted to insurance companies and health plans is not kept confidential.

A Patient Rights and Responsibilities statement is not posted at the PCC nor is one published on the

PCC’s website.

E.

Funding

The following summarizes the PCC annual budget. Of the $172,500 received for fee-for-services,

$22,800 was from student cash payments (including copayments, coinsurance, etc.). The largest portion, $91,000 (52.7%), is probably payments by the undergraduate student health insurance plan. The billing company charges 15 percent of collections for their services.

Expenses

Billing Exp

$ 1,305,436

25,818

Total Expenses $ 1,331,254

Receipts (172,492)

Net Expenses $ 1,158,762

F.

Eligibility and Access

Based on the preponderance of comments from stakeholders, the limited resources for administrative support at the PCC, and the lack of a practice management system, HBC has concluded that there are valid access issues for intake appointments for counseling services. In HBC’s opinion, the

PCC data showing that 80 percent of students are seen within one week of requesting an intake appointment are not credible. In many instances, staff cannot see the barriers to access counseling services and only observe the perceived time required to schedule an intake appointment from the time they receive the request from the PCC Administrator. Wait times for intake appointments can be a serious concern, especially when resources are not focused on short-term care, and longterm care is not facilitated through strong community relationships and effective insurance re-


Administrative Review of Psychological Counseling Center Section IV-B quirements (including favorable copayment costs for long-term counseling in SHIP coverage).

As noted in sub-point B, Mission and Assessment, the website states that the PCC was founded in

1952 to provide counseling to Brandeis undergraduates and graduate students. The website also states that all students, undergraduate and graduate, may request counseling during the academic year. This message is consistent with stakeholder comments as to what many graduate students understand their eligibility to be for the PCC, and what the actual eligibility policy appears to be for graduate students. There were, however, over 200 graduate students who paid the optional health fee and may have done so with the understanding that paying the fee was necessary to receive PCC services. This being said, there is a low level of utilization of the PCC by graduate students which suggests that there are substantial perceived or structural access barriers, possibly due in part to contradictory language on various Brandeis websites regarding graduate student eligibility for the

PCC.

Several stakeholders and PCC staff strongly asserted that counseling is not readily available in the community. However, other stakeholder referrals to community counselors and the low $15 copayment in the graduate SHIP for visit charges suggests that many graduate students may be obtaining counseling services at locations other than the PCC. There may also be substantial number of graduate students who are underserved for counseling services. As noted in the sub-point D, Peer

Institutions, Section III-B, External Environmental Assessment, all AUU peer institutions automatically provide eligibility for counseling services to graduate students.

The explanation of eligibility by the Senior Director for graduate students changed several times during the course of HBC’s consultation. The last written exchange on this subject with the Senior

Director included his assertion that insurance is billed to graduate students for all counseling visits.

Again, stakeholder comments do not support this contention, including comments from graduate students who used the PCC during the 2012-13 academic year, and HBC’s analysis of insurance revenue.

Numerous stakeholder comments regarding access to the PCC, and HBC analysis of non-free revenue, suggests graduate students are neither paying the optional health fee to obtain services at the

PCC nor are they being charged for the first 12 visits. The eligibility and fee policies are inconsistent, confusing, and may be arbitrarily applied.

G.

Staffing

The professional staff is composed of nine FTE counselors and 1.4 FTE psychiatrists. The total number of counselors is 20, 18 of whom have part-time positions (ranging from .13 to .51 FTE).

There are four to six unpaid pre- and post-doctoral trainees per year. Trainees typically work 16 or more hours per week. Most part-time staff members are contracted to work during the year.

The following charts show professional and trainee staffing of the PCC and compare the ratio of staff to students with IACS means. Paid professional staffing is based on the two different figures provided to HBC (report and verbal vs. staff roster). Since the Senior Director indicated that most staff members work only during the academic year, HBC assumes that the difference is academic year vs. full year FTEs. Three different assumptions were made as to the effective population to


Administrative Review of Psychological Counseling Center Section IV-B which to compare the PCC staffing. The first is the total Brandeis student population. The next two are based on the premise that the current funding model is a barrier to graduate student utilization, and that if Brandeis didn’t have such a disadvantageous access policy, the graduate student rate would be higher. Based on the current number of graduate students using the PCC, if a typical graduate utilization rate is 15 percent of the population, then 110 students would be representative of an overall graduate population of 733 rather than 2,200 (total of 4,321 students). If the expected utilization rate is 10 percent, the effective graduate population for 110 users would be

1,100 (total of 4,688 students).

The PCC ratios are substantially higher than IACS means (see tables below). This being said, it is not uncommon for elite, private colleges and universities to have a ratio of 500 to 750 students per

FTE professional staff. These institutions, however, are also seeing a greater percent of the student population with this level of staffing, and the comparable eligible population for Brandeis would be

4,321. Compared to the 750 student per FTE, PCC is 1.6 times higher, based on full year FTEs.

Said differently, at 5.8 FTE paid professional staff, the PCC ratio would be 750 students per FTE paid professional staff. The AUCCCD mean number of paid professional staff for four-year, private universities with 5,001 to 7,500 students is 5.0.

Student to Staff Ratio

Paid Professional Staff

# Students

Academic

Year

Full Year

Counselors 9.0 7.6

Psychiatrists 1.5 1.4

Total Paid Professional Staff 10.5 9.0

Students per Paid Professional 5,808 553.1 645.3

Effective Population @ 15% 4,321 411.6 480.1

Effective Population @10% 4,688

IACS, 4-yr private university, 2,501 – 7,500 students

446.5

1,251

520.9

1,250

Student to Staff Ratio

Paid Professional Staff and Trainees

#

Students

Total Paid Professional Staff

Trainees (5 x 16hrs/40hrs)

Academic

Year

10.5

2.0

Total Professional Staff & Trainees

Students per Paid Professional

Effective Population @ 15%

5,808

4,321

12.5

464.6

345.7

Effective Population @10%

IACS, 4-yr private university, 2,501 – 7,500 students

4,688 375.0

1,016

Relative to psychiatric services, the IACS survey reported that for schools with enrollments of

2,500 to 7,500, the range of psychiatric consultation hours per 1,000 students ranged from 0.2 to



14.3. For 5,800 students this range translates to .03 FTE to 2.1 FTEs. The mean for schools of this size was 1.8, or .26 FTE for a university with 5,800 students. Most participants in the surveys indicate that they do not have sufficient psychiatric coverage. The PCC has 1.5 FTE psychiatrists, well above the IACS and the Association for University and College Counseling Center Directors

( AUCCCD ) means. This level of coverage is appropriate and commendable.

H.

Utilization

Penetration Rate

The table below shows that in 2012-13, there were 585 undergraduates and 110 graduate students who received care in the PCC. This represents 16.3% of the undergraduate population and only five percent of the graduate population. Twelve percent of the total population utilized the PCC during the year.

The table also shows the utilization rates reported in the most recent surveys by the IACS and the

AUCCCD. Neither survey breaks down utilization rate by public and private for this metric, or by graduate and undergraduate status. Overall, private residential colleges and universities have higher utilization rates and higher staff to student ratios (lower number of students per FTE staff) than public colleges and universities.

The PCC utilization rate of 12 percent is within the range for the IACS and AUCCD means for schools of Brandeis’ size. However, for private, residential universities and colleges, HBC generally sees an overall counseling utilization rate of 20 percent or higher (more consistent with the high end of the IACS range). This may be somewhat mitigated by Brandeis’ large percent of international students, who typically use fewer counseling services than domestic students. Per the

Brandeis 2012-13 International Students and Scholars Statistics report, there were 501 undergraduate and 693 graduate international students (excludes graduated international students on practical/academic training and visiting scholars), or 20.6% of the student population.

The AUCCCD overall mean utilization rate for international students (not available by institution size) was 6.4%. The AUCCCD report also stated that utilization by diverse groups of students was proportional to the general student body, except for males (who overall were 44 percent of the student body but only 34 percent of clients). There were also a few other groups that were listed who did not proportionally use counseling services. These included gay/lesbian students, athletes, and international students. That the graduate student utilization rate (5.0%) at Brandeis is lower than the mean AUCCCD international student rate (6.4%) and that graduate student use of the

PCC (15.8%) is disproportional to the graduate student population (38.0%) implies an access issue.

If graduate students utilized the PCC at a similar rate as undergraduates, the overall percent utilization would be closer to what HBC would expect to see at similarly situated colleges and universities with adequate counseling center staffing. Since utilization is a function of access and staffing, low utilization rates are usually due to lack of available clinical staffing and not lack of demand.

Population

PCC Utilization by Class Status

Undergrad

3,588

Grad

2,220

Total

5,808



PCC Utilization by Class Status

# PCC Clients

Undergrad

585

Grad

110

Total

695

% of PCC Clients 84.2% 15.8% 100.0%

% Population 16.3% 5.0% 12.0%

IACS (2,500 – 7,500 students) range = 1% - 21.7%; mean = 9.3%

AUCCCD (5,001 – 7,500 students) mean = 8.01%

Number of Visits/Sessions

The IACS and AUCCCD surveys report that the average number of annual visits per student user is between five and six. This average is similar for both counseling centers that have session limits and those that do not. About half of the survey respondents indicated that they did not have session limits. Of those that reported session limits, 81 percent had a limit of 12 or fewer and 37 percent had a limit of 10 or fewer. The average number of sessions at the PCC was 9.2

overall, the average for graduate students was 10.1

, and the average for just psychiatry visits was 6.1

. Compared to the

AUCCCD mean of 5.07, the PCC’s counseling average is 82 percent higher. Compared to the

IACS average of 6.2, the PCC’s average is 49 percent higher. It is hard to reconcile these figures to the notion that the PCC is not a long-term model.

The tables below show the distribution of the number of clients and frequency of visits (i.e., number of clients having one visit, two visits, three visits, etc.) and total visits. Graduate students accounted for 15.8% of the clients and 17.3% of the appointments. The tables can be summarized as follows:

 For All Students o 203 (29%) Clients had 3984 (62%) Visits (>12) o 142 (20%) Clients had 3135 (49%) of visits (>15) o 84 (12%) Clients had 1859 (29%) Visits (>20)

 For Graduate Students o 33 (30%) Clients had 687(62%) Visits (>12) o 26 (24%) Clients had 589 (53%) of visits (>15) o 16 (14.5%) Clients had 354 (32%) Visits (>20)

 For Psychiatry for All Students o 19 (10%) Clients had 311(28%) Visits (>12) o 12 (6%) Clients had 209 (19%) of visits (>15) o 2 (1%) Clients had 42 (4%) Visits (>20)

1

2

3

Counseling

(Grad & Undergrad)

% of

Clients

#

Clients

#

Visits

14.7%

9.2%

8.0%

102

64

56

Graduate Students

% of

Clients

102 13.3%

128 7.5%

167 2.8%

#

Clients

15

8

3

#

Visits

% of

Clients

15 12.7%

17 13.5%

9 13.5%

Psychiatry

#

Clients

23

25

25

#

Visits

23

49

74



Counseling

(Grad & Undergrad)

% of

Clients

#

Clients

#

Visits

Graduate Students

% of

Clients

#

Clients

#

Visits

% of

Clients

Psychiatry

#

Clients

#

Visits

4

5

6

7

8

9

10

11

12

13

14

21+

5.5%

6.4%

4.3%

5.3%

3.0%

3.9%

2.7%

3.9%

3.9%

3.6%

2.7%

15 2.5%

16 - 20 8.3%

12.1%

38

44

30

37

21

27

19

27

27

25

19

17

58

84

153 6.6%

222 3.8%

179 6.6%

258 8.5%

167 5.7%

244 4.7%

188 4.7%

298 0.9%

325 4.8%

325 2.8%

263 2.8%

261 0.9%

1276 9.4%

1859 14.2%

7

4

7

9

6

5

5

1

5

3

3

1

10

16

29 5.8%

21 12.2%

44 6.4%

65 4.5%

50 2.6%

47 6.3%

52 5.8%

11 2.6%

63 3.8%

40 0.0%

43 2.6%

15 1.3%

235 5.1%

354 1.3%

11

22

12

8

5

12

11

5

7

0

5

2

9

2

42

112

70

58

38

104

106

52

83

0

67

36

167

42

100.0% 695 6415 100.0% 110 1109 100.0% 183 1124

Another way to look at the utilization is by number of visits that exceed a certain threshold. In the following table, two thresholds are summarized. The table shows that for counseling sessions

2,615 visits (40.8%) were students’ ninth or greater visit and 1,549 visits (24.1%) were students’

13 th or greater visit.

# of Appts

Psych

Appts

Counseling

Appts

9

10

11

12

13

14

15

Total

7

8

5

6

3

4

1

2

53

41

31

26

19

19

14

1124

100

77

66

57

183

160

135

110

303

276

257

230

203

178

159

6415

435

391

361

324

695

593

529

473



# of Appts

Psych

Appts

Counseling

Appts

> 8 Appts

21.0%

236

40.8%

2615

> 12 Appts

7.6%

86

24.1%

1549

If the PCC average sessions were at AUCCCD or IACS medians of 5.07 to 6.2 sessions per client rather than 9.3, this would result in 2,100 to 2,900 fewer visits that would have to be staffed and funded or could be used to add capacity to improve access, reduce intake appointment wait times, and/or serve graduate students. The argument can be made that since the PCC charges for visits over 12, they choose to retain

PCC Average

Benchmark

Difference

AUCCCD IACS

9.23

5.07

4.16

9.23

6.2

3.03

Total

(696 clients)

2,891 2,106 the students and charge them for services on campus rather than sending them off campus to be charged.

Also unusual is the distribution at the low end of client utilization. Only 14.7% of clients were seen for only one session compared to the norm of about 25 percent. It is also the norm for about

50 percent of students to have four or fewer visits, and at the PCC these visits account for only 37 percent of the visits.

I.

Productivity

Clinical FTEs Academic Year

There were no data provided by the PCC on sessions per professional. The table to the left estimates the clinical time

Senior Director

Training Supervisor

0.4

0.5 for the Senior Director and the training supervisor. Based on this estimate, there were 8.9 total clinical FTEs during

Part-Time

Interns

7.0

1.0 the academic year. Assuming sessions equal hours, for

6,415 sessions, there would be an average of 721 hours per

Total Clinical FTEs 8.9

FTE. At 35 weeks for the academic year, this is an average of 21 sessions per week per FTE. IACS and AUCCCD surveys report an average of about 23 sessions per week. The average sessions per week are somewhat lower than, but consistent with, IACS and AUCCCD means. One of the Senior Director’s arguments for having so many part-time staff was that the staff could expand and contract as the demand varies making this staffing model particularly efficient. If it is true that utilizing this “accordion” staffing model with more than 20 counselors is more efficient than traditional staffing, one would expect the PCC productivity (i.e., average sessions per week) to be higher than AUCCCD and

IACS means. It is not higher. and there is no evidence that it is more effective.

There were 1,124 psychiatry appointments. At 1.5 FTEs, this averages to 749 encounters per year per FTE. The MGMA median for annual encounters for psychiatrists is 2,134. The ACHA mean is

1,380. The PCC annual average is significantly below both the ACHA and MGMA mean/median.



J.

Costs

All psychiatry services and all visits in excess of 12 are supposed to be on a fee-for-service basis, as are services to graduate students who haven’t paid the health fee. There were 1,124 psychiatrist visits and 1,549 non-psych visits in excess of 12, for a minimum of 2,673 visits that should have been charged. In addition, there were 813 graduate student visits that were for the 1 st through 12 th visit. If all of them were counted, the total visits which should have been billed would be 3,486.

However, some of these graduate visits may already be counted in the psychiatry visits.

Received $ 172,492 $ 172,492

Visits 2,673 3,486

Reimbursement/Visit $ 64.53 $ 49.48

Less Billing Expense/Visit $ 9.66 $ 7.41

Net Reimbursement/Visit $ 54.87 $ 42.08

The reimbursement per visit is between $42 and $55. These low figures suggest that charges are not being assessed for all of these visits. After subtracting the direct billing costs, it is questionable whether reimbursements are sufficient to cover the expenses of the counselors brought in to provide the services. If the rationale for having a substantial number of visits in excess of 12 provided in the PCC (vs. in the community) is that the costs can be covered by insurance, it seems unlikely that they are being fully covered by insurance.

A final area to note is inefficiency related to the SHIP. As mentioned, $91,000 appears to have been received from the undergraduate SHIP. Since 15 percent of receipts were assessed for billing services, the PCC realized only $77,350. Because the claims are fully insured and processed by

UHCSR/HPHC, the students would have paid $117,000, at a 78 percent effective target loss ratio, to cover the $91,000 in claims. If these services were carved out of the SHIP premium and capitated directly to the PCC, the PCC would have received the whole $91,000 and the cost to the student for these services would be only $91,000.

K.

Summary

The various communications for the eligibility of graduate students to use the PCC is particularly disconcerting when evaluating their low level of utilization of on-campus counseling. Due to lack of survey data, it is not possible to determine the causes for the low utilization of the PCC and whether there is a significantly number of graduate students who do not have appropriate access to counseling services. There is a possibility that the low utilization of the PCC for graduate students is largely a combination of numerous stakeholders reporting that they periodically refer students directly to community counselors rather than the PCC (most often reported due to wait times for counseling, but also because of unique concerns/needs that would be better served by a community counselor). The low $15 copayment for counseling in the graduate students SHIP (other health insurance plans may also have low copayment features) may be a factor in graduate students not using the PCC.

With regard to staffing, the IACS median is 1,016 students per FTE paid counselors at private, four-year universities. At this level, Brandeis would need only 4.25 FTE counselors. It is not un-


Administrative Review of Psychological Counseling Center Section IV-B common for HBC to see higher staffing levels than this at elite private colleges and universities, and based on 750 students per FTE paid counselor and the effective population served, there would be expected to be 5.8 FTE paid counselors at Brandeis. The PCC has 9.0 FTE paid counselors. If all of Brandeis’ students had equal access to the PCC, if the penetration rate was as high as the comparable institutions, and if there were substantial outreach services and group sessions, the current ratio would be in an acceptable range. For a population of 5,808 (all with equal access), at 750 students per FTE, Brandeis would need 7.7 FTE paid counselors; at 500 per FTE, Brandeis would need 11.6. Most of the current excess staffing is providing long-term visits (40.8% being the ninth or greater visit). Brandeis could choose to have a staffing ratio that looks more like the IACS and have only 5.8 FTEs; or at 750/FTE and have 7.7 FTE counselors; or at 850/FTE and have 6.8 FTE counselors.

The PCC is providing a significant amount of long-term care to their clients, and significant resources are devoted to this care. Not only are many students incurring visits in excess of ten or twelve, but the number of students having five to eight visits is higher than usual for the field. If the

PCC were to average six visits per client (the high end of norm for colleges and universities regardless of whether they report session limits or not), there would be about 4,200 visits for the year for the current 695 clients. PCC FTEs could be reduced and/or capacity could be gained by implementing a short-term model. This increased capacity would allow access for graduate students, reduce waiting lists, and/or allow for outreach.

The use of large numbers of part-time staff is not more efficient than a traditional staffing model. It is, however, problematic in many ways. Continuity of care is compromised, and there are fewer opportunities to consult with colleagues for coordination of care. Training is more difficult, quality assurance is almost impossible, and there are fewer opportunities for staff to be integrated into the campus community or for University leadership to have relationships with the counselors. The staffing model also restricts the opportunities for needed outreach efforts, especially to the large number of international students who may need a different approach to understanding and accepting counseling services. Assuring adherence to University policies and procedures and implementation and use of EHR and practice management systems are hampered. The administrative burden and cost is high. There is no justifiable reason the keep this system. Counseling positions in a university setting are very desirable, especially at a university as prestigious as Brandeis. Brandeis would have no problem in recruiting excellent full-time staff for the PCC.

Regarding integration of counseling and medical services, merged operations can run the gamut of having two physically separated operations with a common Executive Director to the two being totally integrated in the same clinical areas with interdisciplinary clinical teams and shared records.

How far Brandeis would go in integrating health and counseling services will depend upon its philosophy and upon physical constraints (e.g., building design and capacity). Given that there are two separate buildings, there will be some limitations on what integration would mean for Brandeis. Within these physical constraints, electronic systems can be shared (scheduling, accounting, health records, billing, reporting) as can be support staffing for leadership. Since two buildings are the reality at present, having a counselor or two with offices and seeing clients in the HC (imbedding) rather than in the PCC building would be possible. An intake/receptionist could also be shared providing that a counselor was imbedded in the HC. Non-economic advantages include im-


Administrative Review of Psychological Counseling Center Section IV-B proved oversight, coordination of care, communications, process efficiencies, and consistencies in goals and mission.


Psychologist Consultation Section IV-C

This Section of HBC’s report provides a review of the PCC by HBC’s consultant psychologist, Dr. Jeff

Kulley. Please also refer to Section V-B, Administrative Review of Psychological Counseling Center. Any risk management or compliance concerns were communicated via privileged and confidential communication to Brandeis University’s legal counsel.

A.

Overview

The PCC’s counselors and psychiatrists are fully credentialed, highly experienced, and studentcentered. They are dedicated to student care and to the tradition of providing high quality psychotherapy and counseling services to students. The roster of 20 clinicians is large for an institution of

Brandeis’ size, with a mixture of seasoned clinicians and well-trained new professionals. The staffing structure of the PCC is highly unusual in relation to peer institutions, however, in that 18 of the

20 clinicians on staff are part-time (ranging from .13 to .51 FTE). There are also four to six unpaid pre- and post-doctoral trainees working roughly half time. According to the PCC website, the PCC serves approximately 20 percent of Brandeis students each year. HBC’s review of utilization data finds that the PCC actually served 12 percent of the overall Brandeis student body in 2012-13

(16.3% of undergraduates and five percent of graduate students). The Senior Director accurately describes the PCC as a “psychotherapy based service delivery model” in that the center functions primarily as a clinic with the vast majority of its resources devoted to counseling and psychiatric services. This means that very little time is devoted to outreach programming and activities as compared to peer institutions. Only two part-time staff positions have dedicated outreach responsibilities, amounting to less than one half-time position devoted to outreach. Most peer institutions have outreach coordinators or assistant directors for outreach services who devote a significant portion of their time to the administration and delivery of outreach programming on campus. The training program provides ample individual and group clinical supervision and seminar training and affords trainees an opportunity to work with a wide spectrum of clients without session limits.

These are highly desirable features for professionals in training, and the program reliably attracts high quality pre- and post-doctoral trainees. The PCC is not accredited by the International Association of Counseling Centers and the training program is not APA accredited, which can lead to complications for trainees post-graduation when they are seeking professional licensure, but the lack of accreditation does not appear to deter quality applicants and has not diminished the level of training and supervision provided at the center.

B.

Review of Mission and Clinical Model

A designated mission statement does not presently exist for the PCC. According to interviews with the Senior Director and several senior staff clinicians, the clinical model of the PCC was developed to serve the developmental mission, summarized in this excerpt from the website under Overview :

Staffed by psychologists, social workers, supervised doctoral interns and psychiatrists, the center aims to facilitate the developmental transition from late adolescence to young adulthood while providing diagnostic and treatment services.

This is a very limited mission statement, consistent with the view of the PCC as a “clinic” rather than a comprehensive university counseling center including outreach education and prevention programming in its range of services to the campus community. As previously mentioned, this mission statement also conveys a bias toward providing clinical services to undergraduates who are


Psychologist Consultation Section IV-C navigating the transition to young adulthood. It is notable that the mission statement excludes the developmental issues common to graduate students (i.e., transitioning from young adulthood to adulthood, from student to professional, and balancing family and academic/work life).

This historical, developmental mission of the PCC values the ability to serve all students in need in a highly confidential setting that allows for the development of long-term relationships with counselors. Serving long-term, as well as short-term, clinical and developmental needs is viewed as central to this mission. As demands for college mental health services have risen nationally, counseling centers have moved toward brief, or time-limited, therapy models in order to expand access for students seeking initial assessments, crisis services, and brief interventions. Most centers have eliminated or severely restricted long-term psychotherapy services because providing these services encumbers clinical resources, creating waiting lists and restricting access for first visits. While

Brandeis is not alone among counseling centers in adhering to a model that embraces long-term treatment, it is in the small and shrinking minority, even among elite private colleges.

C.

Evaluation and Assessment Comments

1.

According to interviews with the Senior Director and several senior staff clinicians, the clinical model of the PCC was developed to serve the developmental mission described on the PCC website as follows: “…to facilitate the developmental transition from late adolescence to young adulthood while providing diagnostic and treatment services.” This mission values the ability to serve all students in need in a highly confidential setting that allows for the development of long-term relationships with counselors. Serving long-term, as well as short-term, clinical and developmental needs is viewed as central to this mission. At a micro level, clinical staff appear to be devoted to this mission in their dedication to providing high quality clinical services to their individual student clients for as long as their services are needed. Clinical staff appear to be unaware, however, of several macro level problems with access to PCC services. The low utilization rate of graduate students is one of these problems, and it was not mentioned in any interviews with clinical staff. Five percent of graduate students, as compared to 16.3% of undergraduates, utilized PCC clinical services in 2012-2013. This may result from the conflicting messages about graduate student eligibility for PCC services on various websites mentioned previously in this report. It may also result from a perception that PCC services are predominantly geared toward undergraduates. The description of the PCC mission on its website

(“…to facilitate the developmental transition from late adolescence to young adulthood”) may not be perceived by graduate students as speaking to their needs.

2.

The staff seems to be supportive of the Senior Director and the overall current operation of the

PCC. They also expressed genuine admiration for the Senior Director’s abilities to respond to emergency and crisis situations.

3.

A key strength of the current situation for Brandeis University is the Senior Director’s experience in responding to emergency and crisis situations. The Senior Director and Chief Psychiatrist also have strong working relationships with the Chief of Psychiatry at Newton-Wellesley

Hospital. The Senior Director currently handles all after-hours and emergency calls for the center, which is a highly unusual arrangement relative to peer institutions where it is common



practice to rotate emergency and after-hours responsibility among the entire clinical staff. This arrangement has allowed the Senior Director to develop trust and rapport with many senior

Students and Enrollment Division leaders and Department of Community Living staff in his collaborations around mental health emergencies. The arrangement also buffers PCC professional staff from having to respond to emergency and urgent care situations. It is not an optimal system, however, as it relies heavily upon the availability of a single individual. Consequently, PCC professional staff are not cross-trained in responding to emergency care situations outside of the PCC, and they are less likely to develop collaborative, consultative relationships with faculty and administrators.

4.

Psychiatry visits are billed from the initial visit while counseling sessions are billed only after 12 sessions. These billing and insurance submission provisions may serve as a disincentive to students’ acceptance of referral for medication evaluation. The PCC is rooted in a developmental model that places importance on confidentiality and resisting the “medicalization” of students’ normative, developmental concerns. Within this framework, insurance billing is seen as intrusive, as a threat to confidentiality, and a potential barrier to students accessing services; hence the need for 12 “free” sessions. Within this model, it seems philosophically inconsistent to bill insurance for all psychiatric services. Given that students in need of psychiatric services are by nature clinically more severe, it would seem that insurance barriers to accessing psychiatric services would be considered to be at least at problematic as barriers to psychotherapy services.

6.

There is minimal outreach programming provided to the Brandeis community by the PCC, and there is no involvement of the PCC with numerous student support groups. This was true prior to the economic downturn of 2008 so the current lack of emphasis on outreach programming appears to be a reflection of philosophy and mission rather than a cost savings measure.

The Senior Director and several stakeholders suggested that the PCC provides extensive training to the Department of Community Living and other student services departments yet almost all stakeholders reported that the PCC had not provided any training in recent years.

5.

The fee structure for billed clinical services is unclear and inconsistently applied. The following statement appears on the PCC website:

The fee structure changes from year to year. Please contact the department administrator for details.

The fee structure, including participating provider status for insurance and health plans, should be transparent, and there is no reason updates cannot be made to the website each year. Collection of fees for services provided after 12 sessions is dependent upon clinicians initiating billing. This likely leads to inequitable billing as exceptions for billing charges and insurance are based on determinations of financial need or other concerns, without any articulated standards for defining same. Thus, waiving of charges appears to be subjective and likely varies across clinicians.



7.

The PCC has insufficient administrative staff. The PCC Administrator is the receptionist for incoming students and is central to the clinical intake process, as well as providing all other administrative support for the program.

8.

Annual reports for the PCC are not currently produced. Detailed reporting for demographics of clients, common utilization data , and objective outcomes and satisfaction metrics are not systematically gathered. No client satisfaction surveys are routinely collected from PCC clients or from samples of the general student population. No pre-post outcomes assessments other than individualized clinical treatment summaries are gathered. These are based on clinicians’ judgments of progress and cannot be aggregated and averaged like common outcomes measure such as the Counseling Center Assessment of Psychological Symptoms (CCAPS) or Outcomes Questionnaire (OQ-45.2). The CCAPS is available as a feature of the Titanium Schedule, which is already in place at the PCC, but has not been activated and utilized by the center.

For information about the CCAPS, refer to: http://ccmh.squarespace.com/ccaps/

For information about the OQ-45.2, refer to:

 http://www.carepaths.com/assessment-center/outcomes-questionnaire-45-2-oq-45/

 http://www.rchr.com/eas/LinkClick.aspx?fileticket=nYbxd8GNPnI%3D&tabid=2690

9.

The PCC utilizes the Titanium scheduling system for maintaining clinicians’ schedules but does not utilize the integrated electronic health record (EHR) feature that is a part of the program.

10.

The staff of the PCC is culturally somewhat homogenous. There were only two clinicians of color among the 21 interviewed, and none of those interviewed identified themselves as expert in working with Asian American or Asian international students, two important populations with unique cultural needs relative to mental health services. In 2012-13, there were 550 international undergraduate and graduate students from Asian countries and 466 reported domestic undergraduate of Asian descent (for a total of 17.5% of the student body). No data were provided for domestic graduate students’ ethnicity in the Common Data Set. PCC publications and web-based information do not promote cultural sensitivity and diversity as strong values of the center and therefore the PCC may not be viewed as welcoming to racially and culturally diverse students.

11.

The physical facility of the PCC is lacking in a number of ways. While the clinicians’ offices are personalized and inviting, the common spaces are dated, cold, and unwelcoming. The front desk/receptionist office is located on the second floor, and students enter the building on the ground floor into an empty, cavernous space with a sign directing them to the second floor.

There is no handicap access, which requires special accommodations at the Health Center for mobility impaired students.

12.

Internal documents at the PCC (e.g., the Psychotherapist-Patient Services Agreement document, the Student Intake Form) and website communications about the PCC are antiquated in their use of terminology and do not speak in a language that is familiar and welcoming to students. The Psychotherapist-Patient Services Agreement is five pages long and is intended to


Psychologist Consultation Section IV-C serve as an informed consent/consent to treatment agreement to be signed by all PPC clients.

The length of the document, in and of itself, limits its utility, as it would take an inordinate amount of time to read and explain it in its entirety in every intake session. It also contains factually inaccurate information about length of services and when billing occurs (e.g., “After two consecutive years, you may choose to continue with me on a private basis or to be referred to another therapist or treatment modality.”). The current PCC policy is that students receive 12 sessions of counseling services before insurance is billed or fee for service arrangements are made. In interview, the Senior Director stated that staff clinicians “never” transition currently enrolled Brandeis students from the PCC into their private practices. It is possible that this statement represents a past practice and the document simply has not been thoroughly updated.

Other statements in the document suggest that insurance companies share confidential client information with a “national medical information databank.” This is not a practice in the insurance industry and is misleading to student clients. There is also reference to the Health Insurance Portability and Accountability Act of 1996 as being a new federal law.

As discussed elsewhere in this report, website communications contain contradictory information about student eligibility for PCC services, have language that suggests a bias toward serving undergraduates rather than graduate students, and imply to students that they need to seek services early in the semester to ensure availability of services. It appears that the internal and external PCC documents and communications are long overdue for a thorough review and update.


Recommendation One, Improving Services and Structures

Status Quo with Minor Repairs, Step One

Section V-A

A.

Overview

As noted in Section I, Executive Summary, there are highly dedicated and skilled professionals working at the HC and the PCC, and stakeholders are confident of their abilities to effectively serve students in almost all circumstances. Accordingly, the proposed actions in this Section constitute minor repairs rather than a major change in operational direction or methodology.

HBC provided recommendations in a separate report to Brandies for renewal of BIDMC’s contract for the 2013-14 academic year. The sub-point C, Proposed Actions, are consistent with the 2013-

14 recommended renewal modifications.

While HBC has provided detailed recommendations, it is expected that numerous additional changes will be identified through the review and audit recommendations and the recommended request for proposal process. Accordingly, the recommendations in this Section should not be viewed as a definitive and complete list of necessary changes.

B.

Summary Rationale

Taken in its entirety, the HBC consultation found substantive disadvantages with Status Quo operations for the HC and the PCC that warrant immediate change.

As of the date of this report, HBC cannot affirm BIDMC is highly motivated to continue operating college health centers.

C.

Proposed Action

1.

Address Any Risk Management or Compliance Concerns

A standard proposed action would be for HBC’s client to act on any risk management or compliance concerns identified during the course of the consultation.

2.

Assure Graduate Student Eligibility

Except for graduate students who would not be on campus during the hours of operation, all graduate students should have eligibility for use of both the HC and the PCC. This change should be adopted for the 2013-14 academic year, even if it is too late to charge the designated health fee. There is sufficient capacity in both the HC and PCC to serve the graduate student population.

3.

Summer Eligibility

Eligibility for the HC and the PCC should be extended during the summer to any student who is residing in Brandeis housing, attending summer classes, or working on campus in a research or support capacity.

4.

Assure that the Insurance Requirement is Fully Enforced

The insurance requirements for both international students and domestic students should be strengthened to assure that students who waive enrollment in the SHIPs are covered by personal health insurance that includes participating providers in the Boston area. Students who waive


Recommendation One, Improving Services and Structures Section V-A coverage using a high deductible health plan should be required to certify that they have a fully funded medical savings account and/or sufficient financial resources to fund the deductible.

5.

Student Peer Advising/Support Groups

Student peer advising/support groups should be part of the Health Promotion component of the recommendation for (Step Two) for developing a Comprehensive Health System. The HC and the PCC should have an immediate supervisory role for these organizations and be charged with reviewing their operations.

6.

HC and PCC Communications

Brandeis University should conduct an audit of all websites and publications to assure there is consistency for eligibility for the use of the HC and the PCC. Provisions for insurance billing, participating provider status, and fee schedule at the PCC should be fully published. Any ability-to-pay allowance provision should be based on documented financial assessment for the student and periodically updated.

The confidentiality policy should be fully stated on the HC and the PCC websites and prominently displayed in the HC and the PCC facilities. A patient rights and responsibilities statement should be developed for both the HC and the PCC. These documents should also be fully published on the websites and prominently displayed in the HC and the PCC facilities. It would be appropriate to have both confidentiality policies and rights and responsibilities documents translated into foreign languages.

Academic year specific brochures for the HC and the PCC should be available for downloading and printing.

All patient communication documents should be reviewed for accuracy, communicability, and compliance with best practices. Particular attention should be paid to the various PCC communications, particularly the Psychotherapist-Patient Services Agreement. Refer also to subpoint D of Section IV-B, Administrative Review of Psychological Counseling Center and subpoint C-12 of Section IV-C, Psychologist Consultation.

Formal marketing plans should be developed for the HC and the PCC. Consideration should be given to using social media, creating high quality streaming videos, and committing significant resources in both training and communications for enhancing cultural competency for care of Brandeis University’s diverse student population. Several of the websites for UAA peer institutions provide good examples for adoption of this recommendation.

7.

Health Status Assessment

A student survey should be conducting using ACHA’s National College Health Assessment or the University of Minnesota’s College Student Health Survey . Patient/client satisfaction surveys, including surveys of non-users should also be conducted for the HC and the PCC.

8.

Conduct RFP Process for Operation of the HC with an Option to Return to Internal Operation

Conduct a request for proposals process for the operation of the HC for the 2014-15 academic year while also fully developing an option to return the HC to a program internally operated by


Recommendation One, Improving Services and Structures Section V-A

Brandeis. At the conclusion of the RFP process, Brandeis can compare the service and cost capabilities of external contractors with a fully developed proposal for returning the HC to a service operated by Brandeis University.

If outsourcing the HC is continued, an overarching responsibility should be for the contractor to provide state-of-the-art services and methods of operations. Specifically, unless otherwise agreed to by Brandeis University as a special exception or a special service enhancement, services to Brandeis University’s students and other eligible patients should be consistent with the services and methods of operation the contractor provides in its other outpatient and primary care clinic locations in the Boston area. Examples for this state-of-the art operations requirement may include after-hours telephone consultation, use of the contractor’s practice management system and electronic health records system, clinic administrative policies and procedures, medical policies and procedures, HIPAA compliance (regardless of insurance billing), incident reporting, patient surveying, clinic licensing and/or required accreditation, medical peer review and other routine quality assurance program compliance.

The RFP process should also include an option for either hospitals or contractors offering jointventure proposals with hospitals to provide a direct contract arrangement fee schedule for the

SHIPs under a self-funding arrangement. Proposals would be predicated on a highly favorable fee schedule justifying a benefit differential for students insured by the SHIP to obtain services at the Contractor’s hospital, urgent care facility, or other health community health care vendors.

Direct contracting proposals should also be included for ambulance transportation, long-term counseling services, dental and vision care services, and other health care services commonly needed by students. These proposals could be submitted either as joint-ventures with other contractors or as separate proposals from operation of the HC or the PCC.

9.

Health Center Immediate Change Recommendations

 Contract with Waltham Urgent Care Center or Doctors Express or other urgent care provider for after hours and weekend care. Proposals could be evaluated through the RFP process proposed in sub-point C-8. This would enhance consistency and continuity of after-hours care and may result in savings to Brandeis if current on-campus Sunday care is discontinued.

 Assure that the facility is clean and reflective of quality medical care (e.g., no unprofessional signage, clean, equipment and exam tables in good repair).

 Embed counselor(s) from the PCC into the HC. Given the current physical realities, this would mean having one or two FTE counselors with offices located in the HC and part of a multidisciplinary care team. This would be consistent with best practices of integrated health and counseling services (refer to Section VI, Attachment C).

 Reassign a current position to create a new case manager position. This position would assist HC and PCC staff in coordinating care and in facilitating and following up on referrals for students requiring longer term care or care that would better be provided through community resources. This would not represent a new cost to Brandeis; rather it would be a reallocation of resources from long-term care.

 Produce detailed monthly utilization reports.



 Produce an annual report.

Section V-A

 Provide allergy injection services consistent with peers.

 Remove the insurance waiver responsibilities from the contract for operation of the HC to another Brandeis unit. These responsibilities can be funded through fees assessed to the

SHIP. (Administering waivers can be incorporated into responsibilities for a new SHIP position reporting to the Executive Director and covered with administrative fees assessed to

SHIP enrollees – see Section V-A, Comprehensive Health System, Step Two.)

 Do not operate the HC at any time with a single employee in the clinic. For Sunday hours

(if maintained in-house rather than provided at local urgent care center), minimum staffing should include a nurse practitioner and a medical assistant/receptionist.

10.

Psychological Counseling Center Immediate Change Recommendations

 Reallocate staffing resources to allow for the effective operation of the PCC and to address the concerns identified in this report (e.g., assuring that the intake desk is covered at all times, case manager, reporting, policies and procedures). This can also include reallocation of duties for interns.

 Transition to three-quarters of PCC staff serving in full-time positions during the academic year.

 Part-time staff should attend weekly staff meetings and/or weekly case consultation or peer supervision meetings for quality assurance purposes.

 Activate and use the EHR functions of the Titanium system and utilize other features, such as the Counseling Center Assessment of Psychological Symptoms (CCAPS) intake and outcomes assessment measure.

 Produce detailed monthly utilization reports. Full use of the Titanium scheduling system should allow for uniform collection of demographics, health history, and health behaviors data on incoming students; and reporting functionalities should track utilization, client attendance, and other common dashboard metrics.

 Produce an annual report.

 Develop new space plan for the PCC that features an open receptionist area at the entrance to the facility. Alternately, the intake and reception function can be moved to the HC along with at least one full-time counselor. Receptionists would be cross-trained for coverage.

 Share after-hours call by rotating after-hours coverage among a subgroup of experienced clinical staff. Remote access to the EHR function of Titanium can be developed with IT support.

 Install a panic button in the PCC for silent emergency calls to Public Safety and assure that the PCC client waiting area is not left unattended.

D.

Expected Advantages

To the extent existing leadership and staff for the HC and the PCC can support proposed changes, the Status Quo with Minor Repairs strategic option would probably be the least disruptive strategic option.



E.

Expected or Possible Disadvantages

Section V-A

There are no specific expected or possible disadvantages for the changes proposed in this Section.

There will be inconveniences to individuals, including loss of part-time positions, and challenges for making numerous changes, many of which probably cannot be foreseen.

Comprehensive Health System, Step Two

A.

Overview

The Lookout Mountain Group ’s 2009 report regarding health care reform for the college student population provided this definition for college health programs:

A college health program describes the constellation of services, strategies, policies, and facilities an institution of higher education assembles to advance the health of its students and the academic community. On many campuses, college health programs move well beyond health care and refer to a variety of services, possibly including student health services, disability services, counseling services, crisis intervention and public safety services, health promotion and wellness services, alcohol tobacco and other drug programming, student health insurance/benefit programs, sexual assault advocacy services, sports medicine services for intercollegiate athletes, and intramural recreation sports and fitness programs.

Traditionally the components of a college health program have been separately managed across major divisions and departments, often resulting in duplicated services, ineffective management and supervision, and lack of resources to retain expert administrators. The complexity of many college health program components has increased significantly with increased federal and state requirements and mandates, increased use of technology, and the requirement for increased sophistication to achieve optimal program results (e.g., consideration of self-funding for student health insurance programs).

B.


 The expertise required to supervise and manage all college health components is not a skill set that is common for student affairs administrators, risk managers, or individual departmental directors. While outsourcing can be helpful, and use of consultants can augment internal resources, the optimum position for many institutions will be to centralize college health programs in a single department, typically within student affairs and/or risk management.

 The HC and PCC currently operate at a cost to Brandeis of approximately $2.3 million annually. HBC recommends critical staffing roles be filled, including an





Executive Director,

Student Health Insurance Plan Coordinator,





Case Manager, and additional administrative support for the PCC.

The latter two positions/functions do not require additional funding, but rather can be accomplished with reallocation of current PCC resources. The SHIP Coordinator would be funded through administrative fees which would be part of the SHIP costs to students in the plan. This


Recommendation One, Improving Services and Structures Section V-A could be implemented for 2014-15 plan year. HBC estimates that within a year or two, depending on the timing of an RFP, the costs for the Executive Director position can be regained in savings from restructuring of personnel and contracts for the HC and PCC. In addition, a portion of the Executive Director’s position could also be funded through fees to the SHIP, as this position would be responsible for administering the program.

Further, with the implementation of a secondary payer system under this structure, Brandeis should expect to recoup about 50 percent of its HC expenses if productivity and costs were consistent with ACHA and other outsourced health services and if graduate students are included in the model. If PCC is included in the model, Brandeis could expect to recoup a similar level of expenses from PCC services.

 While implementing optimal management practices for the SHIPs may not have a direct monetary impact on Brandeis’ revenues (which is probably not the case for providing health insurance for graduate student teaching assistants and researchers), the connection between creating savings for the cost in the SHIPs and funding new HC and PCC revenue is important. HBC conservatively estimates that total annual saving could exceed $200,00 (five percent savings on more than $3.8 million in premium) for the two student health insurance programs through a combination of favorable vendor contracting, self-funding of a consolidated student health insurance program, and reduced administrative costs.

C.

Proposed Action

1.

Consolidate all health-related services and benefits under a single department at Brandeis University.

2.

Retain an Executive Director with expertise in the operation of all college health program components, including self-funded student health benefit plans.

D.


 The implementation of a Comprehensive Health System should result in significantly improved program design, function, and ongoing supervision.

 The ability to respond to new opportunities and plan effectively for the long-term future should be significantly increased.

 Responsiveness to students, administrators, and other stakeholders should be increased.

 Savings can be used to both decrease costs and significantly improve and expanded services.

 Brandeis can be well-prepared for increased regulatory scrutiny for the operation of college health programs.

 Ultimately, an exceptionally well-designed college health program could be a significant student recruitment and retention asset for Brandeis.

E.


 It may be difficult to fully develop a Comprehensive Health System since some of the services could be provided in divisions other than the Student and Enrollment Division.



 Recruiting for leadership of the new position will be critical, and there is a limited pool nationally of individuals with the specific range of expertise that is needed.

Aligning PCC Practices and Model with Student Needs and Services, Step Three

A.

Overview

Given the long-standing history of operation, discontinuing long-term care at the PCC and referring students to community providers for long-term care represents a significant shift in PCC operations. The Senior Director stated that the PCC does not have a long-term model, but the average number of sessions suggests otherwise. As noted in the Section IV-B, Administrative Review of

Psychological Counseling Center, more than 29 percent of PCC counseling clients had more than

12 sessions. More importantly, 24 percent of all sessions (and resources) were for students’ 13 th and greater appointment, and almost 41 percent of all sessions were students’ 9 th or greater appointment. In other words, significant resources are being utilized for long-term care at the detriment of access, wait times, allocation of resources, outreach, and overall expense.

There is no credible student surveying or other information to support the contention that students would not utilize community health care providers or that community mental health care providers are not readily available or interested in providing services to Brandeis University students. Numerous stakeholders reported that they routinely make direct referrals to community counselors.

This also suggests that it is not essential for Brandeis to provide long-term counseling because students will not otherwise seek services off campus or there is a limited availability of counselors.

HBC also routinely finds that counselors are willing to enter into direct contracts to serve SHIPcovered students if special accommodations can be provided.

There are also no credible data to suggest that students are less at risk with the current model. The

PCC model is an outlier among its peers and among counseling centers participating in IACS and

AUCCCD surveys. Recognition by the JED Foundation for campus-wide suicide prevention measures does not change this conclusion and is not an endorsement of the PCC model, as the recognized universities include those do not look at all like the PCC model.

B.


 The IACS and AUCCCD surveys report that the average number of visits per student user is between five and six. The average number of visits per student at the PCC is over nine, or 49 to 82 percent greater than benchmark. Even though about half of the survey respondents indicated that they did not have session limits (i.e., provided some long-term care), the average number of visits is the same for those that have session limits and those that do not.

 If the PCC average sessions were at AUCCCD or IACS there would be significantly fewer visits that would have to be staffed and funded. These resources could be used to

1.

add capacity to improve access,

2.

reduce intake appointment wait times,

3.

fund critical positions,

4.

improve outreach,

5.

reduce overall Brandeis expenditures, and/or

6.

serve graduate students.



 As stated in the Administrative Review of the PCC, the distribution at the low end of client utilization is also outside of norms. Only 14.7% of clients were seen for only one session compared to about 25 percent at most student counseling centers. Not only are long-term clients seen for a longer period of time at the PCC, but short-term clients are also seen for a longer period of time at the PCC.

 The amount received by the PCC for visits in excess of 12 is not sufficient to cover the costs of providing these services. The argument that long-term care is being fully compensated by revenues for these services (so referrals are not financially warranted) is invalid.

 All of the UAA peer institutions and the selected Boston area colleges and universities, with the possible exception of Harvard University, are providing short-term counseling services. While there are varying definitions and some noted exceptions for training programs, none have declared that they provide long-term counseling services. While long-term counseling (and/or no statement of session limits) may be provided at a few Ivy League institutions, AUCCCD data show that session limits did not significantly change the average number of sessions per student

(5.07 for schools with 5,001 to 7,500 students). The AUCCCD reported that 50.5% of survey participants had session limits.

 None of the UAA peer institutions are charging students for psychiatry services and billing insurance plans. Similarly, none of the UAA peer institutions have large part-time staffs that are integral to a funding system for counseling.

 With only a few possible exceptions, the counseling centers at UAA peer institutions and the selected Boston area colleges and universities have extensive outreach and wellness programs.

Most of the websites are well organized, graphically attractive, and feature links to social media, on-line appointment portals, and other advanced marketing and communications strategies. There is a strong emphasis in messaging for diversity and cultural competency. In addition to the video previously referenced for Emory University, other peer institutions with high quality welcoming counseling videos include:

University of Rochester: http://www.youtube.com/watch?v=ieTTnRXgFys

Case Western Reserve University http://www.youtube.com/watch?feature=player_embedded&v=Qn3rWmmF1bE

The videos and text describing counseling services is based on language that would reduce the stigma and intimidation associated with counseling for young adults. The informed consent document provided by the University of Rochester (refer to Section VI, Attachment G) is an

C.

Proposed Action example of a document that meets risk-managed care requirements but is designed to be communicative and minimize anxiety for beginning counseling.

1.

Limit availability of PCC services to eight to twelve visits per year and refer students to community resources for care. Develop clear criteria for exceptions to this published limitation,



including continuing to provide services (and/or transition to private practice) for returning students who are currently engaged in long-term counseling.

2.

Only provide long-term care to the extent it is required for training purposes or other special exceptions that are included in the PCC’s policy and procedures manual and published on the

PCC website. It is essential that all services provided at PCC are disclosed to students and not discriminatory because of unpublished benefits or services.

3.

To the extent the panel of participating mental health care providers for the SHIPs is not optimal, develop direct contract relationships with community mental health care providers to augment the availability of services. This may require special fee schedules, confidentiality agreements, and removal of managed care prior approval or concurrent care practices.

4.

Provide access to PCC services to graduate students on the same basis as services are provided to undergraduate students.

5.

If revenues were sufficient to fully cover costs, these services could remain in-house providing this doesn’t result in any negative impact on other services, access, wait times, administrative processes, support services, quality assurance, and facility/space demands.

D.


This strategic option appropriately emphasizes key organizational objectives and facilitates compliance with best practices for the operation of college counseling centers. Making this change is also consistent with the trend for elite private colleges and universities to focus on short-term counseling.

E.


There could be strong resistance to this change among current PCC staff, students, and Students and Enrollment Division stakeholders. Effective communication of the necessity of the change and enhancements to other services will be essential.

F.

Permutation

A permutation for this option could be to rent space to counselors at Brandeis (nominal rent only to reinforce independent practice) with no relationship to the PCC that would be any different than referrals from the PCC to a community mental health care provider. The counselors renting space at Brandeis would be solely responsible for their own schedules, billing policies, maintenance of records, malpractice insurance, and other requirements for community mental health care providers. Brandeis would include a credentialing process as part of the rental agreement.

Section V-A


Recommendation Two, Insurance Options

Secondary Payor System

Section V-B

As a precursor to reviewing this strategic option, report recipients may wish to familiarize themselves with the history and trends for insurance billing for college health programs by reviewing HBC’s position paper provided in Section VI, Attachment J.

A.

Overview

A college or university domiciled in Massachusetts (or the contracted operator of its health or counseling service) can (1) contract with health insurance/benefit plans to obtain participating provider status and (2) designate that its health fee and/or institutional funding arrangements would only cover the remaining balances for charges submitted to students’ personal health insurance.

When Massachusetts implemented the original Qualified Student Health Insurance Program

(QSHIP) regulation in the late 1980s, a key provision allowed student health insurance plans to take always secondary payor provisions in coordinating benefits with students’ other personal health insurance. The revised Student Health Program, § 114.6 CMR 3.00 ( SHP ) regulation adopted June 1,

2009, includes this permissible exclusion:

(c) exclude charges reimbursable by any other valid and collectible medical insurance plan, provided that any charges in excess of the limits of such other medical insurance plan must be reimbursed as otherwise provided in the school’s Student Health Program;

This permissible exclusion is commonly referred to as an always secondary payor provision. Almost all other states adopted the National Association of Insurance Commissioners model statute for coordination of benefits (COB) that specifically precludes student health insurance plans that provide both illness and injury benefits from having always secondary payor provisions.

The Commonwealth of Massachusetts has consistently taken the position that student health fees and other institutional allocations for pre-funding college health and counseling services do not constitute a contract of insurance, and the QSHIP/SHP regulations would allow secondary payor status for such funding arrangements even if they fell within the definitions in COB regulations that might otherwise preclude secondary payor status. The position that health fees and other institutional allocations do not constitute health insurance was affirmed by the U.S. Department of Health and

Human Services in regulations ( CMS-9981-F ) issued for fully insured student health insurance plans, adopted March 21, 2012, in determining that college health and counseling service funding arrangements are not a form of insurance and are thereby not subject to regulation under the Patient Protection and Affordable Care Act. The following provision is provided on page 16456 of the regulations.

Student administrative health fees are those that are charged to all students enrolled at a college or university, regardless of whether a student enrolls in student health coverage or utilizes any services offered by the clinic, which gives all students access to a student health clinic’s services and supports a number of services and activities that foster a healthier campus community.

Several public colleges and universities in Massachusetts have successfully adopted always secondary


Recommendation Two, Insurance Options Section V-B payor funding systems for their health and counseling services, most notably the University of Massachusetts-Amherst. When a secondary payor system is adopted, it is most common to see that insurance reimbursements are obtained only for medical services and counseling services continue to be funded by health fees and/or institutional allocations. While the rationale for this approach is questionable, for many institutions it would be a major change in operations to introduce any form of billing to their counseling centers, while there have often been at least nominal charges for numerous services within the health centers.

While several elite private colleges in Massachusetts are considering secondary payor status for college health programs, none have implemented it for the 2013-14 academic year. Two key variables that distinguish the situation for these institutions from the situation at Brandeis University are (1) the institutions have not already outsourced their health services and do not have readily available capability to participate with insurance plans and engage in insurance billing; and (2) their counseling centers are almost entirely funded from health fees and institutional allocations and there is no existing use of insurance billing.

Factors for not adopting a secondary payor funding system include concerns for potential loss of confidentiality, staff resistance for using procedure codes and other administrative requirements for insurance billing, concern that new third party revenue will diminish due to the trend for adoption of high deductible health plans, expected challenges for communication with students and parents, required focus on new facilities or other major changes, lack of institutional emphasis for new approaches to reduce costs and improve operations, and uncertainty for health care reform and the future direction of college health programs. From a national perspective, there is interest among college health and student affairs leadership in several states (e.g., Wisconsin, Oregon, and Virginia) for obtaining enabling legislation or regulatory permission for secondary payor funding systems.

Most notably, the consortium of elite private universities in New York, that recently achieved success in obtaining legislation to allow for self-funding of student health benefit plans, is working to secure a favorable regulatory interpretation for secondary payor status for health fees and institutional funding allocations.

From a general communication perspective, students are informed that the health fee and/or institutional funding allocation will cover charges (with common certain exceptions for employment physicals, travel immunizations, missed appointment charges, etc.) not reimbursed by their personal health insurance. An example communication is provided below for University Health Services at UMass-Amherst (screen shot taken from UHS website , August 1, 2013).


Recommendation Two, Insurance Options Section V-B

B.


 Brandeis University’s expenditures can be significantly decreased without reducing students’ access to care, regardless of the scope of the benefits provided by their personal health insurance coverage or their financial resources. New third party payor revenue could also be used to make important enhancements to the quality of services and/or address any major risk management or compliance concerns.

 Following the passage of the ACA, the question is increasingly asked as to why health fees and other institutional funding allocations should continue to pay for or subsidize services and supplies that are covered at 100 percent, regardless of the deductible, under the new preventive care benefits (refer to https://www.healthcare.gov/what-are-my-preventive-care-benefits/ ).

 Although the national trend for adoption of high deductible health plans (refer to Section VI,

Attachments D-1, D-2, and D-3) is resulting in significant decreases in insurance revenue for many college and university health and counseling services that have adopted secondary payor funding systems, obtaining third party payor revenue is an important bridge to definitive systems for providing health care to students on residential college campuses.

 The HC is already outsourced, and it is likely that the contractor selected through the recommended RFP process for the 2014-15 academic year will not have significant surcharges (possibly none) for participating provider status for the HC under its contracts with insurance/health benefit plans, and for submitting charges, and reconciling remaining balances to be funded by

Brandeis for the HC. The funding system can be designed with reconciliations to assure the contractor does not receive compensation above the proposed annual fee for operating the HC.

 The PCC is already engaged in insurance billing for all psychiatry visit and counseling visits after 12 sessions. Extending a secondary payor funding system to all services could be easily implemented without a significant increase in new costs.


Recommendation Two, Insurance Options Section V-B

 The regulatory environment in Massachusetts is clear as to the permissibility of secondary payor funding systems for college health and counseling services, and the large insurance/benefit plan administrators have supported the position (e.g., they have not required collection of visit copayments even when there is a coordination of benefits situation) that health fees and other institutional funding allocations can be used to pay the remaining balances for deductibles, copayments, and coinsurance for their members.

 Lack of utilization data by type of visit from the HC requires a broader range for estimating the low and high income than would otherwise be applicable, but the savings projection for

Brandeis University for the 2014-15 academic year is significant. The HC budget shown in the following table for undergraduate students is also based on (1) expected contractor cost reductions resulting from the recommended RFP process for the 2014-15 academic year; (2) an assumption that reference lab charges will continue to be submitted directly to students’ personal health insurance; (3) new hours of service for the HC adopted for 2013-14; (4) an assumption that a significant number of nurse visits will transition to physician or nurse practitioner; and

(5) not including cost reductions for eliminating the insurance coordinator position from the contractor’s costs, eliminating the pre-matriculation health history, and increased efficiency from adoption of an electronic health records system.

2014-15 HC Budget – Based only on Undergraduate Students

Projected Total

Visits and

Allowed

Participating

Provider

Reimbursements

Projected

Undergraduate

SHIP

Projected

Other Personal

Health Insurance

Low High Low High Low High

Undergraduate

Student

Enrollment and

HC Visits

Expected Provider/RN Reimbursements

Per Visit (including CLIAwaived lab)

Total Insurance

Reimbursements

Funding Contribution from

Brandeis

Total Projected HC

Budget

3,588

5,900

$295,000

$705,000

$1,000,000

3,588

6,300

$422,000

$478,000

$900,000

1,072

1,825

$50

1,072

1,950

$67

2,516

4,075

$50

2,516

4,350

$67

$91,000 $131,000 $204,000 $291,000

Budget projections are based on both expected results from RFP Process and staffing adjustments.

HBC projects expanding eligibility to automatically include graduate students would not result in a requirement to increase providers or support staff (see Section IV-A, Administrative Re-


Recommendation Two, Insurance Options Section V-B view of Health Center). Graduate students are estimated to generate 2,200 to 2,600 visits.

Accordingly, Brandeis University’s funding contribution required for the HC would decrease from the projected range shown in the above table from $478,000 to $705,000 to $304,000 to

$595,000. The cost increase to the graduate student SHIP would be approximately $60,000 to

$96,000 (assuming SHIP usage of the HC is proportional to the 55 percent of graduate students enrolled in the SHIP). The cost decrease could be less for the graduate student health insurance plan if this change results in a significant portion of visits simply shifting into the HC from community visits.

In summary, by conducting an RFP process for the 2014-15 academic year, and allowing graduate students to have full access to the HC, the current Brandeis University expenditure of

$1.1 million for operation of the HC could be reduced under the best case scenario to

$304,000 and $595,000 under the conservative projection.

 Provisions can be included, with full disclosure, as to the special circumstances when charges may not be submitted to students’ personal health insurance (e.g., discovery of usage of health care services by family members creates risk for the student’s well being and explanation of benefit forms cannot to be redirected to the student’s campus address).

 The several key regulatory and compliance requirements are not cumbersome and can easily be addressed in sub-point C, Proposed Actions.

 The regulatory environment in Massachusetts permits self-funding of student health benefit plans (self-funded programs presently exist at Harvard, MIT, Northeastern and UMass-

Amherst), and ACA regulations ( CMS-9958-F ) issued July 1, 2013, also assure the long-term availability of student health benefit plan self-funding arrangements. Generally, it is important to have the ability to self-fund the health and counseling center claims liability to mitigate some of the impact on the overall cost of the SHIP for charging for medical/counseling visits and other ancillary expenses. The following table illustrates this point in showing a cost comparison for impact on an example SHIP that includes obtaining a highly favorable fee schedule from the HC contractor for care of SHIP-covered students and self-funding the SHIP claims liability for health and counseling services.

3,000 Privately

Insured Students

4,500 HC visits @

1.5 Per Insured

Average Per Visit

HC Reimbursement

For Private Insurance Other than

SHIP

$72.00

$324,000 Total

Third Party Payor

Reimbursements

2,000 SHIP Insured

Students

4,000 HC visits @ 2.0

Per Insured

Average Per Visit HC

Reimbursement

For SHIP

$60.00

$240,000

SHIP Reimbursements

SHIP Cost if Visit is

Fully Insured at 80%

Target Medical Loss

Ratio

$75.00

Under this example, if the SHIP did not have a favorable fee schedule with the health center con-


Recommendation Two, Insurance Options Section V-B tractor and the liability was fully insured, the total cost for SHIP reimbursements would increase from $240,000 to $360,000.

C.

Proposed Actions

1.

The secondary payor status should be included in the recommended RFP for the HC vendor for the 2014-15 plan year. The RFP should also include a requested cost quotation for a preferred fee schedule or capitation for the SHIP.

2.

The PCC would begin billing with secondary payor funding for the first 12 counseling visits.

Given the concerns for access to care, HBC recommends extending the secondary payor funding system to psychiatry visits, which would reduce the amount of savings projected from insurance billing for the first 12 counseling visits.

3.

Many insurance/health plan participating provider contracts require the participating provider to collect payments from members as specified in the schedule of benefits, and charges can only be waived if there is a completed financial assessment that allows for ability-to-pay allowances on the part of the provider. Care should be used to assure students understand the PCC and the HC are not simply waiving deductibles, coinsurance, and, most important, copayments that are the financial responsibility of the covered person. Many college health services engaged in secondary payor funding systems (including those in Massachusetts) make this error. Again, the secondary payor system can assure 100 percent coverage of health and counseling center charges through coordination of benefits with two different health plans/funds.

To demonstrate that students are obtaining 100 percent coverage of HC and PCC charges, it is important to have (1) a formal plan document for the health fee and institutional funds specifying the always secondary payor status and (2) a detailed financial accounting that shows the transfer of funds to the contractor or the PCC via the self-funding arrangement and/or SHIP capitation. The plan document must also specify which services or supplies provided by the

HC are not reimbursed by health fees or institutional allocations.

D.


The key advantages for adopting an always secondary payor system are discussed in sub-point B,

Rationale Summary.

Many colleges and universities find that adopting a secondary payor funding system enhances the importance of the insurance plan choice for students and parents, often resulting in more students participating in the SHIP. Given that SHIP-covered students often have significantly higher access to prescription drugs, long-term counseling, and high cost diagnostic procedures (particularly in comparison to students covered by high deductible health plans), increased SHIP enrollment results in increased campus safety and students’ ability to manage unexpected medical expenses.

E.


 Under the assumed budget modeling provided in sub-point B, the cost of the undergraduate’s

SHIP will have to increase an additional $85.00 ($91,000 ÷ 1,072) for the 2014-15 plan year,


Recommendation Two, Insurance Options Section V-B in addition to any change for the cost for the 2014-15 renewal. This would be an additional 6.1 percent increase to the cost for 2013-14 coverage at $1,389.

 Over the next few years, there may be a steady decline in the revenue generated from insurance reimbursements from plans other than the SHIP. This may be offset somewhat by increased enrollment in the SHIP and increased numbers of non-resident students enrolling in subsidized insurance exchange coverage with primary care and mental health care benefits (certain Silver level plans and all Gold or Platinum coverage).

The Kaiser Family Foundation’s 2013 Employer Benefit Survey shows that 38 percent of all workers are now covered by a deductible of $1,000 or more, up from 22 percent in 2009.

Many health care economists and benefit consultants believe the trend for increasing deductibles is the single most important impact of the ACA prior to the insurance mandate that becomes effective in 2014. Colleges and universities with secondary payor funding systems for student health centers are already seeing decreasing revenue from insurance reimbursements due to high deductible health plans, although there is undoubtedly some offset for this trend due to the ACA requirement for providing 100 percent coverage for preventive care services.

 Some stakeholders and students may raise concerns that the confidentiality of their care is compromised as a result of insurance billing. Brandeis does, however, already have experience with insurance billing for long-term counseling and graduate students are already receiving most of their primary care services through insurance reimbursements.

 Secondary payor systems are often questioned because they can result in students with high quality primary care coverage, particularly students enrolled in the SHIP, inappropriately subsidizing (by increased cost of insurance) other students who are covered by insurance that does not provide first dollar coverage for primary care and counseling services.

F.

Permutation

A possible permutation, which is common for many colleges and universities, is to only have insurance billing apply to medical care services. For many colleges using a secondary payor funding system, psychiatry and counseling services would continue to be pre-funded without any attempt to offset costs with insurance reimbursements.



Triple Insurance Option Program

Section V-B

A.

Overview

One of the long-term impacts of the ACA is the likelihood that compensation for health care services will shift from fee-for-service reimbursements to outcomes-based compensation. In addition, the regulations for the ACA include provisions that highly favor the ability of colleges and universities to provide college health programs that are much more cost effective than coverage provided by employers or individual insurance plans for students who are not eligible for Medicaid or premium subsidies.

Given the advantages for the operation of college health programs, but still having some portion of students covered by employer-sponsored health plans and individual health plans, HBC anticipates that many college health and counseling services will transition their funding from pre-paid health fees and institutional allocations to revenue that is primarily derived from capitation arrangements from their SHIPs and a separate supplemental program for students covered by other personal health insurance. This arrangement will be communicated to students and parents by providing three choices for health insurance and access to on-campus medical care and counseling services.

One name that is being considered for this approach is a “Triple Option” program.

Insurance Option

Cost to Student for On-Campus

Services

OPTION ONE :

Personal Platinum, Gold, Silver, or Medicaid Insurance Coverage

Funding Arrangement

Student is covered by high quality insurance coverage through individual health insurance purchased on insurance exchange or employer- sponsored coverage.

$0 for 100% preventive care services

Cost to Student : There is no

Option Two fee or other institutional cost for students.

Nominal copayments for medical visits, ancillary medical services (e.g., physical therapy) and behavioral health counseling visits

Nominal copayments for prescription drugs



Student is covered by lesser quality

OPTION TWO : insurance, possibly including high deductible health plans.

Bronze Insurance Coverage.*

Cost to Student : Health fee is re-

Purchase of On-Campus Health and Counseling Center health fee is required. quired to provide on-campus health and counseling services. For many colleges, the health fee cost will increase significantly to reflect possible adverse selection, substantial

* The SHP requirements for

Massachusetts would preclude students from using a Catastrophic Plan to meet their insurance requirements. claims volatility margin, and increased scope of services/benefits.

Cost to Student : Supplemental health fee

Section V-B

$0 for 100% preventive care services

Nominal copayments for oncampus medical visits and ancillary services. Nominal copayments for on-campus, shortterm counseling could be included at varying visit number thresholds.

May include or exclude coverage for prescription medications, high cost diagnostic imaging and scans, and long-term counseling.

OPTION THREE:

Comprehensive Student Health

Insurance Program (SHIP)

Student is covered by high quality

SHIP that provides first dollar benefits for on-campus health and counseling services.

Imbedded in cost of Comprehensive

SHIP is Option Two on-campus care

Capitation.

Cost to Student : SHIP annual premium

100% coverage for on-campus services (excluding employment physicals, missed appointments, and other charges that are not covered) and copayment schedule under comprehensive, fully ACA compliant, benefits.

The key difference between a Triple Option Program and the strategic option for secondary payor status is that the health fee at Brandeis would be reduced to funding health education and wellness programs, which cannot be effectively funded from insurance reimbursements, and an overall subsidy for the availability of services when there are almost no students on the campus and the facilities have to remain open.

B.


A Triple Option Program recognizes that students will have highly varied needs for access to health care services, contingent on their personal insurance situation, and that colleges and universities need to offer choices that reflect these circumstances. There is also an opportunity to shift the majority of health and counseling expenses from health fees and institutional allocations to insurance capitations and insurance reimbursements.

C.

Proposed Action

1.

The SHIPs provided by Brandeis would be expanded to include pre-funding of charges at the

HC and the PCC. Brandies would offer in 2014-15 the three health care system choices described in sub-point A, including a self-funded supplemental care program with the following likely cost ranges.



Cost projected based on current fully insured rates requiring a six percent rate increase for

2014-14 with an 80% target medical loss ratio. Reserve funds for self-funding would be provided through savings in health fees

Platinum/Gold/Silver/

Medicaid

Student pays copays to HC and PCC required by personal insurance.

Undergraduate SHIP

Graduate SHIP

Supplemental Care

Fee

Low Cost Estimate

$0

$1,769

Insurance

$1,369

$2,476

HC and PCC

Capitation

$400

Insurance

$1,876

HC and PCC

Capitation

$600

Community

Benefits

$400

$700

HC and PCC

Capitation

$300

Section V-B

High Cost Estimate

$100

Wellness Fee Per Year

$1,975

Insurance

$1,500

HC and PCC

Capitation

$475

$2,750

Insurance

$2,050

HC and PCC

Capitation

$700

Community

Benefits

$500

$850

HC and PCC

Capitation

$350

2.

The Triple Option Program would be incorporated as an alternative cost quotation for the RFP recommended in Section V-A, Status Quo with Minor Repairs, Step One. It could also include capitations for the two SHIPs and the community care liability the Supplemental Care program specialty physician consultation, long-term counseling, emergency room/urgent care, high cost imaging and scans, and possibly other liabilities.

D.


 With effective communication, parents and students will appreciate the well-conceived options that best reflect their needs.

 All of the advantages associated with the Comprehensive Health System could be enhanced with the Triple Option Program.

E.


The main disadvantage for the Triple Option Program will be transition challenges associated with communicating the new program. There will also be increased administrative complexity in having two different fees assessed to students.

F.

Permutations

The most likely permutation for the Triple Option Program is having an additional waiver or feature that allows students and parents with substantial financial resources to waive most of the supplemental care cost if the student is covered by a high deductible health plan.


Brandeis University Administrative Review of the Health Center the Psychological Counseling Center

Brandeis University

Administrative Review of the Health Center

the Psychological Counseling Center

Volume One: Report Sections I Through V

Hodgkins Beckley Consulting, LLC

Consultation Objectives, Approach and Process, and Limitations Section II

III-A

Psychologist Consultation Section IV-C

Status Quo with Minor Repairs, Step One

Comprehensive Health System, Step Two

Aligning PCC Practices and Model with Student Needs and Services, Step Three

Recommendation One, Improving Services and Structures

Section V-A

Secondary Payor System

Triple Insurance Option Program

Related documents

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Brandeis University Administrative Review of the Health Center the Psychological Counseling Center

Brandeis University

Administrative Review of the Health Center

the Psychological Counseling Center

Volume One: Report Sections I Through V

Hodgkins Beckley Consulting, LLC

Consultation Objectives, Approach and Process, and Limitations Section II

III-A

Psychologist Consultation Section IV-C

Status Quo with Minor Repairs, Step One

Comprehensive Health System, Step Two

Aligning PCC Practices and Model with Student Needs and Services, Step Three

Recommendation One, Improving Services and Structures

Section V-A

Secondary Payor System

Triple Insurance Option Program

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