Roy Wade, Jr., MD, PhD, MPH

Roy Wade, Jr., MD, PhD, MPH

2010-2011

Clinical Instructor, Department of General Pediatrics, Children's Hospital of Philadelphia, Philadelphia, PA

Dr. Roy Wade, Jr. most recently completed his residency in Pediatrics at the University of Virginia, Charlottesville, VA. He has been a volunteer physician at the University of Virginia Health System, the Charlotesville-Albermarle Health Department, the Charlottesville Free Clinic, and at the Boys & Girls Club. Among his honors and awards, Dr. Wade received the Dean of the College Award for Service, the Merck Manual Award, and an Albert Schweitzer Fellowship while at Dartmouth. Most recently, he received the Janet Jeffries Award from the University of Virginia Health System. Dr. Wade’s combined interest and training in research and pediatrics has provided him with the skills to analyze data, to develop and oversee research projects, and to understand the fundamental healthcare needs of Americans. Dr. Wade believes that effective policy can only be attained through the acquisition and interpretation of accurate data elucidating the true mechanisms leading to poor health outcomes. His interests focus on health policy and preventive health. Dr. Wade received his medical degree from Dartmouth Medical School, Hanover, NH in 2007, and earned a Ph.D. in Molecular Microbiology from Georgia Institute of Technology, Atlanta, GA in 2002.

School-Based Health Center Medicaid Reimbursement: Implications of State Policies

Objective:      

The project will analyze current state Medicaid policies and practices to identify state-level policies targeted at improving Medicaid reimbursement for School-Based Health Centers (SBHCs), as well as the efficacy and degree to which each of these policies has been implemented.  This information will be used as the basis to develop a comprehensive SBHC state survey instrument designed to better understand state SBHC Medicaid billing policies and practices.

Background:   

SBHCs are health centers located inside or near schools providing access to primary care and prevention services for children of all grade levels in urban, rural, and suburban areas throughout the country.  First developed in the 1970’s, these centers provide medical services for nearly 2 million children each year.  Many of the children receiving these services are low-income, Medicaid recipients with limited access to primary care services.  Thus SBHCs, represent a primary mechanism to address health disparities in these vulnerable populations.  Primarily financed through tenuous state and federal sources, funding for SBHCs represents a continual concern limiting the long-term viability of these centers.  Medicaid billing represents one source of long-term fiscal stability.  Nearly 75% of SBHCs bill Medicaid for services provided to Medicaid enrolled children.  Unfortunately, a variety of state policies limit Medicaid reimbursement to these centers.  Several states have established policies to improve SBHC Medicaid reimbursement but the degree to which these policies have been implemented and their overall efficacy remains unclear.

Methods:

A structured review of the current literature on SBHCs, including a published report of the most recent survey of SBHCs performed by the National Assembly on School-Based Health Care, was performed allowing for identification of the current state Medicaid SBHC policies.  A concept analysis of federal and state Medicaid polices was performed.  Key informant interviews were completed with several officials from select states in order to correlate implementation of these policies with SBHC practice.  The information obtained using these qualitative methods was used to guide the development of a state SBHC survey.

Results:

Preliminary results from the concept analysis and literature review indicate barriers to Medicaid reimbursement due to the use of Managed Care Organizations to administer Medicaid reimbursement.  Several states have circumvented these barriers by implementing policies requiring Medicaid carve outs for SBHCs as well as waiving prior authorization requirements.  Results from key informant interviews suggest that the efficacy of these policies is still limited by the capacity of SBHCs to bill for services.  Many states have focused their efforts around Medicaid billing instruction and improving billing office infrastructure at SBHCs.

Future Direction:

Additional work needs to be performed at the clinic level analyzing Medicaid billing data and clinic organization to better understand how effective these policies are at improving Medicaid billing as well as what services are highly utilized by Medicaid patients.

Preceptor and Sponsoring Agency:

Linda Juszcak, Executive Director of the National Assembly on School-Based Health Care