Student Health's Uncertain Future

Campus health centers are being hammered by unusual circumstances as they struggle to stay afloat financially. A way forward, while unclear, is imminent, health officials said at a conference last week.

June 7, 2012

CHICAGO -- College health centers are living in a brave new world, and if they want to survive, they’ll have to adapt.

That was the takeaway of a presentation here last week at the annual convention of the American College Health Association. It was a sign of the times that the topic, “Funding College Health Programs: Current Options and Future Trends,” drew a packed crowd.

“We’re obviously facing difficult times, but there’s a lot of opportunity,” said Jim Mitchell, director of health services at Montana State University. “If you approach it right I think you can remain optimistic and excited about where we’re headed, rather than get too depressed about it.”

Health centers in recent years have, like the rest of higher education, seen their funding dwindle as demand increases. But several other issues have also emerged or intensified to compound the difficulty of staying afloat.

Student demand has been steadily rising -- not only in the form of more patients, but also more serious problems that in turn mean higher expectations for care. Concerns about campus safety have peaked, placing new burdens on mental health divisions. And as the U.S. Supreme Court reviews the legality of President Obama’s health care reform, the legislation’s full effect on student plans still is not completely clear. That’s all happening as the cost of running a college health program is going up, driven by new technology, deferred maintenance for half-century-old and sometimes deficient facilities, and employee salaries, which must be high enough to compete with the (larger) paychecks received in (high demand) professional medical positions.

“For the most part, our predecessors have not had to deal with all of these things at the same time,” said Dana Mills, director of the University of Oregon health center. “It’s quite interesting, to say the least, and in some ways unprecedented, given the dynamics of our environment.”

When Mills and Mitchell asked who was rethinking the way their health centers are funded, a sizable majority of hands went up. But many also said they’d had a hard time raising fees, underscoring one of the problems centers have to work around.

Fees for service are one of several ways centers are funded. They can also receive money from tuition dollars or a university’s general fund in the form of a student activity fee or designated health service fee (57 percent of centers have designated fees, ACHA surveys show); earn grants or research money; or seek donations (a tip from the session: try putting a button on the center website to bring in contributions from appreciative parents). Centers that outsource services can reduce their operating budgets.

In practice, ACHA attendees agreed, it’s best to have some combination of sources.

The bigger the campus, most likely, the more resources its health center needs to function. Of course, campuses aren’t exactly flush with cash. So as the cost-cutting continues, health centers need to be ready at any moment to make a case for sufficient funding. (Having an institutional mission-based focus, and allies in academics and other campus departments, can prove helpful, too.)

“College health programs, because they’re a high-dollar and visible program, are just inevitably going to be reviewed,” Mitchell said. “We better be ready with our arguments and we better have data to support [them].”

How effective those arguments are may be determined to some degree by the future of President Obama’s Affordable Care Act, which extended to 26 the age through which young adults can be covered by their parents’ health plans.

“It’s kind of one of those good-news, bad-news things that students will all have some form of health insurance coverage by 2014,” Mitchell said. “Some of you have justified your health fees and even your existence on the grounds that a lot of your students are uninsured…. If that justification is taken away, then you’re going to need a new justification for why you should exist.”

That’s not to say health officials should sit around twiddling their thumbs until a clearer picture of the future landscape emerges, the presenters said. So, while acknowledging that “at this point, everybody’s crystal ball is on equal footing,” they did some speculating as to what the future could hold.

First and foremost: “fee-for-service is dead.” As some counseling centers have already discovered, fees for service can literally be more trouble than they’re worth because of infrastructure costs. Mills and Mitchell predicted a push to move back to capitation for their institutional student health plans, meaning that the health care provider would receive a set amount to take care of everyone, because it’s more cost-efficient.

ACHA surveys show that about one in 10 students is enrolled in a student health insurance plan, or SHIP. Under the Affordable Care Act, those plans are subject to tighter restrictions that give better coverage to students, including no caps on spending and no dropping coverage when an enrollee gets sick.

Community partnerships with other providers or organizations that offer additional resources for students are always desirable. And new technology doesn’t have to just be a money-sucking nuisance; when used right, it can create new, easier avenues for gathering data. Montana State created a “vision statement” on how to use technology to support health care there.

But the idea that proved most contentious -- one that, while not new, is getting more attention than ever as health centers struggle with these issues -- was to consolidate different units. That doesn’t mean just putting all of health services under one roof or even intermingling by floor: it means complete record and service integration and collaboration between primary care, mental health, counseling, pharmacy, etc.

“The truth of the matter is, even when many of those units are, quote, integrated, they’re not really integrated, they’re just put under the same manager,” Mitchell said. “Actually, many of the smaller health services already do that. They could probably teach the bigger services a thing or two about how that can be done.”

Such a system is in theory more efficient in terms of cost and manpower, but some hesitate to share records. And there was a wide range of interpretations on display at the convention, where the idea came up in multiple sessions.

One health official in this room suggested there’s no evidence that having teams of counselors and medical providers improves patient outcomes or reduces cost.

“While I’m all for, ‘Can’t we all just get along?’ I think we ought to look carefully when we’re thinking about some of these opportunities,” he said. “When you’re really trying to look at the bottom line, we probably have to pay attention to outcome measures, too.”

One official from Cornell University pointed out that his institution has been researching integrated care, and there are data out there -- just not published data.

“Unfortunately the places that are being the most innovative,” he said, “also aren’t staffed or funded well enough to publish.”

Perhaps illustrating why some officials might get “depressed” when dealing with these issues, as Mitchell half-joked at the session, one attendee summed it up.

“This discussion kind of leads me to the same conclusion every time,” she said, “which is there is no silver bullet, and we should be doing all of these things.”

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