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Congressional Testimony
April 5, 2000, Wednesday
SECTION: CAPITOL HILL HEARING TESTIMONY
LENGTH: 4200 words
HEADLINE:
TESTIMONY April 05, 2000 SUSAN SCLAFANI CHIEF OF STAFF EDUCATIONAL SERVICES
SENATE FINANCE MEDICAL PAYMENTS TO SCHOOLS
BODY:
SUSAN SCLAFANI CHIEF OF STAFF - EDUCATIONAL
SERVICES HOUSTON INDEPENDENT SCHOOL DISTRICT APRIL 5, 2000 Mr. Chairman, Senator
Moynihan, and members of the Senate Finance Committee: I am here today to speak
with you on behalf of Larry Marshall, President of the Board of Trustees and Dr.
Rod Paige, Superintendent of Schools of the Houston Independent School District
(HISD), and the Council of Great City Schools, a coalition of the 57 largest
city and urban school systems in the nation. We appreciate the opportunity to
come before you today to provide testimony about a subject that we have very
strong convictions about, the delivery of health and medical services to our
children. The Houston Independent School District is the largest district in
Texas and the seventh largest in the United States. It serves 211,000 students
who are predominantly minority-53% Hispanic, 35% African American and 12% White
and Asian. Seventy-one percent qualify for the Free and Reduced Price Meal
Program, and 11% are served in special education programs. The district has
participated in the School Health and Related Services (SHARS) Medicaid program
since 1992, and the Medicaid Administrative Case Management (MACM) Medicaid
program since 1 994. These two Medicaid programs have contributed significantly
to the delivery of health and related services to our students and particularly
to our students with special needs. With the additional Medicaid reimbursement
funding, the HISD has been able to enhance, improve, and expand the level and
quality of health and related services being delivered to our students. Our
school district serves a vital role in providing outreach services,
coordination, medical referral services, and the actual delivery of basic health
and medical services to students in general, and more specifically to our
students with disabilities and special needs. Our federally mandated and
non-mandated school- based health services costs annually exceed $38 million.
Our annual expenditures for services to disabled students are approximately $100
million annually or $4,545 per disabled student, while our federal IDEA
allocation is only $8 million or $363 per disabled student. On a daily basis,
our school district encounters a significant number of at-risk children in need
of health, medical and mental care. The district provides outreach and
case-finding services that subsequently initiate the coordination and referral
process toward the delivery of clinical or medical intervention. The district
understands the Medicaid System's objective of making the Medicaid System more
effective and efficient by ensuring Medicaid patients receive covered medical,
mental and health care service at the appropriate level of intervention with
early illness detection, primary care or wellness care. HISD shares in this
vision by providing outreach services and direct Medicaid- covered services.
Healthier children are able to achieve greater academic success, because their
basic and most fundamental health care needs are met while concurrently
receiving a free and unencumbered education. HISD ESTABLISHES THE MEDICAID
FINANCE DEPARTMENT In October 1992, the Houston Independent School District
established the Medicaid Finance Department (MFD) to plan, implement, and manage
the district's Medicaid programs and initiatives. The MFD's mission is to
pursue, implement and manage the district's Medicaid Programs to enhance,
improve and expand the level and quality of health-related services being
delivered to our students. The MEDICAID pr )gram has reimbursed HISD for
approximately 240 health and related clinicians that directly serve students
district wide. The HISD has generated approximately $47,982,585 in Medicaid
reimbursement revenue between January 1993 and Feb. 2000. MACM Revenue: $
25,265,345 (May-1 994 to Feb. 2000) SHARS Revenue: $ 22,717,241 (Jan.-1 993 to
Feb. 2000) Total Medicaid Revenue: $47,982,586 Medicaid reimbursement funds
generated from the SHARS and MACM programs have been designated to help enhance
health-related services for all students with disabilities by providing the HISD
funds for additional staff and services. The HISD has been able to fund the
following types of positions and services with SHARS and MACM reimbursement
revenue: Associate School Psychologists School-Based Health Clinics In- home
Clinical Training Speech Therapist (Pathologist) School Nurses Educational
Diagnosticians Audiologist Life Skills Coordinators our program to meet all of
the Medicaid requirements. The HISD has also assisted the state and federal
Medicaid agencies with developing SHARS rate studies and clinical cost analyses
to establish reimbursement rates that eventually affect all Texas school
districts. HISD is currently petitioning the Texas Department of Human Service
(TDHS) for adaptive equipment and additional health or medical services to be
covered with Medicaid reimbursement. Currently, students who qualify for
adaptive devices must bring those devices with them each day on the school bus
and return home with them each evening. Having the devices at home and school
would make it far easier for their families and their teachers. MEDICAID
ADMINISTRATIVE CASE MANAGEMENT (MACM) The HISD has participated in the MACM
program since May 1994. Under this program, the district can be reimbursed for
administrative case management activities that are rendered to all students
within the district. MACM differs from the SHARS program, because SHARS will
reimburse school districts for direct services delivered to students with IEP's,
and MACM only reimburses districts for medical case management and Medicaid
covered outreach activities. On a quarterly basis for a period of three days,
over 300 clinicians who provide services participate in a comprehensive time
study which includes notations of activities for every 1 5 minutes of their
daily work schedule. These clinicians have been trained to complete these tasks,
and they understand their value in providing the necessary resources to serve
their students. The MACM program has been designed to comply with the state
Medicaid plan with established regulations and guidelines. In annual state
Medicaid audits and in the two Health Care Financing Administration (HCFA)
audits, the district was found to be in full compliance. The HISD generates
between $4.5 to $5.5 million in MACM reimbursement annually. Between May 1994
and Feb. 2000, HISD generated approximately $25,265,345 in MACM Medicaid
reimbursement revenue for allowable MACM activities. MACM Revenue: $ 25,265,345
(May-1 994 to Feb. 2000) The MACM program is currently being implemented by the
Texas Department of Human Services. In August, 1995 the Health Care Finance
Administration (HCFA), approved the MACM program for Texas. HISD shares in the
Health Care Finance Administration's (HCFA) programmatic objective that these
Medicaid programs will eventually reduce the cost of delivering Medicaid-covered
health care, if children receive care at the appropriate level of intervention
with primary health care or wellness care through outreach and improved
interagency coordination of delivered services. The HISD has been through annual
Medicaid audits by both state and federal Medicaid agencies, and it has
successfully met compliance with all regulatory and audit standards required by
Medicaid and HCFA. FISCAL IMPLICATIONS FOR SCHOOL DISTRICTS In 1975, the United
States Congress passed the Individuals with Disabilities Education
Act (IDEA) that requires school districts to provide education related
health and medical services to students with disabilities and to develop
individual education plans OEP) for service delivery. Congress passed IDEA
without providing adequate special education funding, this consequently left
school districts ill- equipped to meet the clinical demands of IDEA
requirements. Even the major expansions of IDEA funding in the 105th and 106th
Congress have yet to reach 20% of the original congressional funding promise for
this special group of schoolchildren. To meet the regulatory requirements of
IDEA, school districts find that they have to employ or contract for speech
therapists, speech pathologists, nurses, audiologists, diagnosticians,
psychologists, physical therapists, occupational therapists, and other
clinicians as required for students enrolled with special needs. In many cases,
parents have taken school districts to court and sued under the provisions of
IDEA and the Americans with Disabilities Act (ADA) to provide additional or more
comprehensive clinical services to their disabled children. Medicaid
reimbursement funding is increasingly becoming a significant funding source for
the costs of providing health and medical services to students. Once received,
these funds have been utilized to improve and expand the level and quality of
health and medical services being delivered to students. With increased
enforcement of court decrees to comply with IDEA criteria via the recent Supreme
Court decision of Garret F. Vs. Cedar Rapids School District, school districts
are required to accommodate the extensive and costly health and medical services
needed by profoundly disabled students. The fiscal impact of providing such
services places school districts on a critical funding path. Districts have
great difficulty in absorbing the extra costs of providing mandated IDEA health
and medical services to disabled students without assistance from the federal
government. Unfortunately, the existing public health system has been unable to
provide adequate health services to Houston's at- risk populations, particularly
our low-income and disabled children. In view of IDEA regulations, it is HISD's
recommendation that federal guidelines and requirements for state Medicaid
programs be revised to include specific mandates that include school districts
in state Medicaid programs for reimbursement of health and Medicaid services
delivered. This would guarantee that sufficient levels of funding would be
available to address the direct needs of students with disabilities per IDEA
compliance. Without this alternative funding mechanism, school districts may not
be in a position to maintain high levels of quality health and medical care for
their students. The main reason for this quality assurance concern is that
health care professionals who must be clinically competent to provide health and
medical services are very costly to recruit and employ within a school district.
IMPLICATIONS AND RECOMMENDATIONS School districts serve a vital role in
providing outreach, coordinating, referral services, and, in some cases, the
delivery of basic health and medical services to students with disabilities and
other special needs. On a daily basis, school districts, especially large urban
districts, encounter large numbers of at-risk children in need of health,
medical and mental care. For many of our students, the school nurse is the only
health professional the child sees. School districts can be utilized as an
outreach and case finding agent to initiate the referral process toward medical
intervention. State and federal health and human services agencies should
partner with school districts to provide early illness detection, preventative
and wellness care to at-risk children. With sufficient funding, school districts
could enhance their efforts to establish either school-based or school-linked
clinics available at the campus to provide basic medical screenings and care.
HCFA has always taken the position of trying to contain rising costs of health
care by engaging in dialogue with the health care sector; it would be
advantageous for more efforts to be taken to incorporate school districts in
acculturating children and families as to the importance of becoming their own
health care advocates and wiser health care consumers. These grassroots efforts
will equate to reducing the fundamental cost of delivering health care to not
only Medicaid recipients, but for 'insured" recipients as well. School districts
can make a significant difference in the delivery of health, medical and mental
care, and they should be given the opportunity to be a part of the Medicaid
system to acculturate children and families in being better health care
consumers. School districts currently participate in the health care advocacy of
children. Such efforts will lead to the effective and efficient utilization of
our Medicaid system with the appropriate level of medical intervention, which
leads to healthier children with our society. PROGRAM RECOMMENDATIONS TO
STABILIZE SCHOOL-BASED MEDICAID PROGRAMS AND INITIATIVES While states and school
districts implement school-based MEDICAID services in a variety of different
approaches, HISD suggests that the SHARS AND MACM programs may serve as a useful
example for other states and school districts. The Texas implementation of SHARS
and MACM has been audited by the HCFA and meets the regulatory requirements of
the Code of Federal Regulations (CFR). As it is designed in Texas, the SHARS
program is a traditional fee-for-service Medicaid program that is self-adjusting
based from a reimbursement perspective that is tied into direct utilization of
services delivered to students. School districts will only be reimbursed for the
SHARS services that they deliver based on the health and medical needs of IDEA
students. This means that Medicaid reimbursement to school districts will
automatically increase or decrease based on SHARS services delivered. It is this
fee-for-service model with its self- adjusting utilization component that will
meet the regulatory and fiscal requirements of HCFA and the program expectations
of the U.S. Congress. The Texas version of the MACM program has been reviewed,
audited and approved by the HCFA Dallas (Region VI) office with coordinated
approval of HCFA Baltimore, the headquarters for HCFA. This MACM program is also
self-adjusting from a Medicaid reimbursement perspective that is tied into
direct utilization of services delivered to the Medicaid population for Medicaid
covered administrative case management services. CONCLUSION Participation in the
school-based Medicaid program is a complex undertaking for a school district.
The Houston program has evolved from eight years of intense effort and
attention, and the resources to match. Other school districts have not had the
expertise or the opportunity to develop their school-based Medicaid programs in
an analogous manner. Federal technical assistance to school districts to
implement Medicaid has generally not been available, forcing many schools to
rely on expensive external contractors to meet the complex requirements of the
Medicaid program. HISD recommends that the comments of the Council Of The Great
City Schools regarding improvements in school based Medicaid services be
seriously reviewed by The Department Of Health And Human Services. HISD further
suggests that the dialogue and process begun at the March 21st meeting between
the national education groups, and the Departments Of Health And Human Services
and Education serve as the collaborative basis for correcting any improper
school-based claiming practices and for improving Medicaid services to eligible
children through the very realistic opportunities presented in school settings.
We must put children first, and we must collectively participate in their health
care advocacy with more outreach, which will lead to the effective and efficient
utilization of our Medicaid System with the appropriate level of medical
intervention which leads to healthier educated children within our society.
LOAD-DATE: April 10, 2000, Monday
