No Cost or No Care?

To date, most of the debate over how President Obama’s health care overhaul law would affect higher education has dealt strictly with the law's potential effects on the student insurance plans that colleges provide. But now, as many health centers are still trying to come into line with those new rules, they’re bracing for the latest hit from the Affordable Care Act, as a provision takes effect today that could affect far more students.

The provision eliminates cost sharing for women’s preventative services in insurance plans -- meaning that insured women will be able to get things like contraceptives and virus screening and counseling free from their in-network providers, with no co-payment or deductible. These services make up a significant chunk of what student health centers, larger ones in particular, have traditionally provided.

How this will affect health centers depends on whether they are “in network,” meaning that they contract with insurance companies to accept their allowable fee as full payment for services rendered. When providers including health centers are out-of-network, the insurance company covers less of the fee, leaving the provider to cover the costs in other ways. At college health centers, the majority of which are not in-network, that cost is usually covered by a student health fee.

This fall, students won’t have to pay anything for women’s preventive services if their campus health centers are in-network; instead of requiring a copayment or other service fee from the student, the health center can just file a claim to bill the insurance company.

But most campus health providers don’t function that way -- though some say it's becoming increasingly important to change that by moving in-network.

"Times are changing, and I think that more and more universities and colleges are seeing that with declining state funding and the increasing cost of health care not only for the technology but for the staff, you cannot survive on just the student health fee alone,” said Libby Greaney, executive director of university health and recreation at Boise State University. “You can’t keep asking the students to pay more and more and more on the student health fee and at the same time not enhance your efficiencies.”

Health centers that aren’t already in-network with local providers have a few options. They can remain out-of-network and simply let students know they might be able to find cheaper services at a provider that does operate in-network. (Also under the Affordable Care Act, students can now stay on their parents' insurance plans until they turn 26.) They can use the student health fee to cover the preventive services. Or they can stop offering the services altogether, and instead refer students off-campus. 

At Montana State University, officials have no immediate plans to move in-network – instead, they’re just going to stop charging students for the lab work. (The health center can already run contraceptives and other prescriptions, as well as immunizations, through its pharmacy, to give students 100 percent coverage.) The cost for pap smears and other lab testing will be absorbed by the universal student health fee. (Depending on the college, the cost of a pap smear can range from about $15 to more than $100.)

“Every school has got a different set of circumstances they’re facing,” said Jim Mitchell, director of health services at Montana State. The main issue with moving in-network is picking up the tab for outside billing services that coordinate with insurance companies, he said, which typically comes to 8-15 percent of the revenue they generate. Or, a health center can set up its own billing system, which may cost less but which imposes other administrative burdens. “I guess I would say it’s not a huge deal, it’s more whether that’s the direction the health service wants to go.”

Greaney, who also chairs the administration section of the American College Health Association, moved Western Kentucky University to a billing system when she was there more than a decade ago (when it was really controversial), and Boise State uses one, too. But many health centers are too caught up in their old ways to take on stress and expense of moving in-network.

There are initial costs associated with going in-network and setting up the billing system, Greaney says, but the transition ultimately opens up new revenue streams from insurance providers. It also brings campuses into line with the way the rest of American health care functions, thereby helping teach students how to navigate the system.

However, that resemblance of the larger model is precisely the reason some campuses still shy away from being in-network, Greaney said.

“They feel that it mimics the business model, which is a dirty word in health care,” she said. “I think you’re going to continue to see philosophical differences; however, I think the changes are already happening. In order to prepare and better-serve a student and parent; I think they just need to prepare and embrace this.”

Of course, Greaney and others acknowledge that, like everything in campus health, it really depends on the given center and the students it serves. Smaller colleges, for instance, may not even offer women’s preventive services.

But for some, there are bigger factors at issue than logistics.

Colleges are philosophically obligated to go in-network because healthy and engaged students are more likely to be retained, said Glenn Egelman, chief medical officer at Vivature Health, a company that consults and sets up billing systems at health centers.

“The traditional campus health model, which most schools have, is going to create a financial disincentive for the student to get care on campus,” said Egelman, former health center director at Bowling Green State University. “Our mission is to keep students on campus. It’s to ensure that the student is going to be successful in their higher education, and one of the ways that we achieve that mission is by maintaining their health. If we have systems in place that are financially incentivizing people to leave campus for their health care, we are going to be failing in our mission.”

Amid declining state funding and increasing student demand coupled with competition for campus resources, many health centers have found themselves struggling to adapt, and preparing, ultimately, to justify their institutional funding if need be. It’s plausible that not covering women’s preventive services at competitive prices could harm their case. (While Egelman argues that health centers who go in-network can redirect their student fees to fund other things like campus outreach and education efforts -- a key part of what centers do these days – Mitchell suggested that most colleges would just cut the fee altogether.)

However, campus health officials pride themselves on understanding their clientele far better than the average provider. If students do wind up seeking care elsewhere, they could lose that specialization.

“The care in campus health services is excellent because we get students…. Student health care is a heck of a lot more than just treating that infection. It really requires an understanding of the campus lifestyle, the campus community, and the psychosocial needs of the student population,” Egelman said. “My fear is that [students] will say, ‘Why should I go to the campus health center when I can go to Dr. X whose office is three blocks off campus?’ ”