School nursing programs in danger as state and managed care organizations fight over Medicaid reimbursements
By Jennifer Wohlleb
For the first time since 1990, Johnson County Schools is having to pay for school nurses. The district has become one of the first casualties in the ongoing battle between the state and the managed care organizations that run Kentucky’s Medicaid program.
“We were very blessed that we had that relationship with the local health department (for the last few years) and prior to that, our youth services centers had paid for the nurses through grants,” said Superintendent Steve Trimble. “It worked really well, then these Medicaid reimbursements started not coming in.”
PHOTO: School nurse Terri Burford walks from Johnson County High School, where she saw 23 students in an hour and a half, to Johnson County Middle School where five sick children and a student with diabetes await her. The phone call she is taking was about a child’s carb count. The district had to find money to pay for its school nurses beginning Jan. 1. The number of nurses was cut from eight to six.
Local health departments around the state say they are owed hundreds of thousands of dollars by Kentucky Spirit, one of three managed care companies that took over management of Kentucky’s Medicaid program in November 2011. Kentucky Spirit has since claimed Kentucky’s Medicaid model is unsustainable and that the state allegedly misled the company on the true costs of the program. It plans to end its three-year contract early and both it and the state have threatened litigation, although none had been filed as of this print deadline.
The Cabinet for Finance and Administration issued a decision in January that said these groups must pay Medicaid reimbursements to local health departments for the services its nurses provide in schools.
While it is unclear when or if the reimbursements will begin to flow, both school district and health department bottom lines are taking a hit.
Johnson County’s school board began spending $108,000 out of its general fund on Jan. 1 to make sure the services of six of the eight school nurses in the district – initially one for each school – would continue for the rest of the school year.
“We felt it was important to do because here we are mid school year and there actually was not a good Plan B out there to satisfy the immediate needs of the children,” said board Chairman Bob Hutchison. “By having it all come down so quick, this was the best answer to the situation for the children this school year … I’m not sure what we’ll be able to do next year or what the answer or solution will be.”
Trimble said he understands the position of local health departments.
“They were going in the hole, moneywise, trying to do a service that is outside their realm,” he said. “I think as long as they were breaking even, they would have been fine with that and we would have been fine with it, but they were not getting the money to pay the salary for their nurses.”
Green County Schools still has the four nurses it contracts for through the Lake Cumberland District Health Department, but Superintendent James Frank said he knows that could change.
“We’ve been in some conversations with them (the health department), as well as our local legislators, trying to figure out if there’s any way to head this off at the pass,” he said. “We have heard from the health department and they have definite concerns with their funding source in essence being cut. It’s going to cause our nursing costs to increase considerably. They haven’t given us an amount that I recall, but it could make it cost prohibitive the way that they’re talking.”
Green County and other school districts interviewed for this article currently pay about $12,500 for each health department nurse, a bargain, school leaders say, for the services students receive, which range from distribution of medication and to monitoring of chronic conditions like diabetes, to physical exams and vision and hearing screenings.
Shawn Crabtree, executive director of the Lake Cumberland District Health Department, said his agency is still providing nurses at more than 50 sites in the 14 school districts it serves, but it’s getting tough.
“In our department, we have enough reserves that we can very likely make it through this fiscal year, but we can’t make it through another fiscal year if Kentucky Spirit isn’t paying us for what we’re doing,” he said. “It has to get worked out this school year. The school boards know that. We can’t afford to stay in an optional program when we’re not getting enough money to cover our costs. It’s either we get out or pass a tremendous increased expense onto the schools.”
Hickman County Schools Superintendent Kenny Wilson credited his district’s high attendance rate last year, which was fourth in the state, to the full-time nurse it had. He said that number is slipping this year since the district began sharing a nurse with Carlisle County Schools, contracted through the Purchase Area District Health Department.
“We have had part-time services and our attendance is down compared to last year, which is going to end up costing us money,” he said. “Our attendance will be good this year, but our kids are not getting the quality of care that they got last year. And the word from the Purchase Area Health Department is that next year they’re going to look and see if they’re even going to do the school nurse program, due to them not being able to get the funding.”
For Robertson County Schools, being small may actually be working in its favor, at least for now.
“We only have one school, so we have one nurse from our local health department, so if we lose one, we lose all,” said Superintendent Chuck Brown. “They haven’t said anything about raising our contract for next year, yet. If we have to pay more it’s going to be hard, as small as our budget is anyway, but we would really have to look at coming up with a way to keep her here because we really need something.”
School districts around the state are going to have difficult decisions to make if this situation is not resolved soon.
“Do we educate or do we provide health care if it comes right down to it,” asked Hutchison, the Johnson County board chairman. “That’s a decision that the state’s going to have to make for us or the board will have to make for our district.”