A commissioned administrative review of health services at Brandeis University released by the Office of Students and Enrollment on Nov. 4 criticized aspects of the Health Center and Psychological Counseling Center and recommended organizational adjustments and insurance billing changes, among other modifications to University health services.

According to Senior Vice President for Students and Enrollment Andrew Flagel, the University selected Hodgkins Beckley Consulting, a consulting firm specializing in higher education health care management, after a Request for Proposals to "review administrative systems for our Health and Psychological Counseling Centers."

Hodgkins Beckley Consulting staff conducted the review by making several visits to campus and conducting follow-up interviews with leadership and staff over the summer. The final draft of the report is dated Oct. 14.

The report issued five major recommendations that involve changing the organizational structure of the University's health systems, hiring a new executive director to oversee a more comprehensive health system, conducting an RFP process for the Health Center contract, expanding access and eligibility for graduate students at the Health Center and PCC and implementing an insurance billing structure.

The University announced yesterday to staff under the Division of Students and Enrollment that it is making some structural changes recommended by the report. Director of Athletics Sheryl Sousa '90 has been promoted to assistant vice president for health and wellness and a new division of Health and Wellness has been created under her supervision. (See accompanying article for more.) There is also a search for an executive director underway.

When asked about the impetus behind soliciting HBC's review and making the recent changes, Flagel connected it to the strategic plan and the University's image. In feedback sessions and surveys surrounding the plan, he said, "a strong concern about the University's image," or "how well known we were, especially in other areas of the country," came up repeatedly.

"There [were] ... concerns that were raised at different points about our health apparatus, lots of concerns expressed ... in the student feedback sessions," he said. "The talent of the individuals involved wasn't a question; it was really structural questions."

In the strategic plan, the mention of health and wellness services is listed under Strategic Goal 4 ("Build the Engaged Lifelong Community") Objective B ("Make sustainability an integral part of the Brandeis experience") and Action 3: "Facilitate healthy living through a community health approach that integrates health and recreation services and organizations across campus."

Health Center Assessment
The assessment by Hodgkins Beckley provides sobering criticisms of the Health Center and PCC. A recurring analysis in the report is that there is poor communication and a lack of adherence to best practices in terms of technology and community outreach across the Health Center and PCC. Both also lack mission statements and clear, accessible policies delineated on their websites.

The Health Center, which is operated by Beth Israel Deaconess Medical Center, "has favorable relationships with the key departments within the Students and Enrollment Division," according to the report. However, the report states that the Health Center does not use an electronic management system, nor does it produce annual reports or utilization reports for the University.

There is also a difference in graduate students' ability to access the Health Center. While the student health fee, which supports the University's health services, is mandatory for undergraduates, it is optional for graduate students.

In terms of staffing and the cost of running the Health Center, the report states: "Compared to ACHA [American College Health Association] medians for private universities, the [Health Center] clinical staffing is high and productivity is low. ... Costs are also higher than would be expected for a health center that is outsourced to a local health care provider."

In an interview with the Justice, Medical Director of the Health Center Debra Poaster said that she is excited about working with Sousa, but that in her view, the report is not perfect.
"I don't want to speak for the whole organization I work for, BIDMC, but I think that we felt that there were some things that were very positive ... [but] that there were some distortions and some misinformation in the report," said Poaster.

PCC Assessment
The report also notes key flaws in the PCC. Similar to the Health Center, the report noted that the PCC does not produce regular administrative or utilization reports.

The report states there are barriers to access for students, and students are not necessarily seen within one week of requesting an appointment: "In HBC's opinion, the PCC [Psychological Counseling Center] data showing that 80 percent of students are seen within one week of requesting an intake appointment are not credible."

The assessment also states that "wait times for intake appointments can be a serious concern."

The PCC also does not provide training to other University departments, conduct outreach efforts, nor is it involved with student support groups. In comparison, the report states that most peer institutions have dedicated staff to oversee outreach coordination.

Another major criticism from the report is the PCC's policy of providing 12 free visits to the counseling center for undergraduate students.

While the student health fee covers a student's first 12 counseling visits, "there is no mention of the 12 visit maximum on the PCC website." Moreover, the PCC's Psychotherapist-Patient Services Agreement is inconsistent with the official policy, "by stating that after two consecutive years, the student can continue with the therapist on a private basis or be referred out," according to the report.

Access to the PCC for graduate students is also a concern, according to the report.

"There may also be substantial number of graduate students who are underserved for counseling services. ... All ... peer institutions automatically provide eligibility for counseling services to graduate students," the report said.

Currently, the health fee is optional; however, if graduate students do not ay the fee, then they will be charged for the first 12 counseling visits, but graduate students not paying the fee are often not charged for the visits, according to the report's analysis: "The eligibility and fee policies are inconsistent, confusing, and may be arbitrarily applied."

The report also criticizes the staffing model of the PCC. Currently, "the PCC is staffed by over 20 part-time psychologists and social workers, three half-time psychiatrists, and six unpaid interns."

The use of a large number of part-time staff has significant drawbacks, including a lack of coordination and integration, and more difficulty with quality assurance, according to the report.

"The administrative burden and cost is high. There is no justifiable reason the [sic] keep this system. Counseling positions in a university setting are very desirable, especially at a university as prestigious as Brandeis. Brandeis would have no problem in recruiting excellent full-time staff for the PCC."

The report also states that the PCC has "insufficient administrative staff" and its physical facility is "lacking in a number of ways," including a lack of handicap access and a generally unwelcoming and outdated facility.

Senior Director of the PCC Robert Berlin declined to comment and referred all questions to Flagel. When asked to comment on the assessment by phone, Berlin said he had been instructed not to respond to questions from the Justice.

Recommendations
The report's major recommendations include the creation of a "comprehensive health system" with several new staff positions, including an executive director, a student health insurance plan coordinator, a case manager and an additional administrator for the counseling center.

The comprehensive system would "consolidate all health-related services and benefits under a single department."
The report also recommends that the University transition the PCC away from long-term care, referring to students who are visiting the PCC more than 10 or 12 times. For example, the report recommends that the University "limit availability of PCC services to eight to twelve visits per year and refer students to community resources for care."

"[S]urveys report that the average number of visits per student user is between five and six. The average number of visits per student at the PCC is over nine, or 49 to 82 percent greater than benchmark," the report reads. "All of the UAA peer institutions and the selected Boston area colleges and universities, with the possible exception of Harvard University, are providing short-term counseling services."

While the report notes that "there could be strong resistance to this change among current PCC staff, students, and Students and Enrollment Division stakeholders," it argues that the recommendation "appropriately emphasizes key organizational objectives and facilitates compliance with best practices for the operation of college counseling centers."

The report also recommends that the University conduct an RFP process for the Health Center contract. "Concomitant with this RFP process should be consideration of returning the [Health Center] to an internal department of the University."

Regarding graduate students, the report notes differences in the treatment of graduates and undergraduates.

The report recommends that the same services be available to graduates as are available to undergraduates.

Currently, the health fee, which funds health services on campus, is mandatory for undergraduates and optional for graduate students. "This would mean discontinuing the optional health fee and could include assessing a health fee to all students and/or initiating charges to graduate students and their insurers for services."

According to the Health Center website, "All undergraduate students have unlimited access to the on-campus resources at Brandeis Health Center." Graduate students, however, only have access to immunization services unless they purchase access to the Health Center.

Insurance Billing
The final aspect of the proposal recommends implementing an insurance billing structure. Currently, students' health insurance plans are not billed when they go to the Health Center. All undergraduates pay a mandatory health services fee, which covers visits to the Health Center and some counseling services.

According to its website, "The Health Center does not offer fee-for-service medical care nor does it bill insurers for services.  Access to the Health Center is not to be confused with the Qualifying Student Health Insurance Plan (QSHIP). This is the student health insurance plan offered by the University to meet state regulations mandating insurance coverage for all full and 3/4 time students."

The report recommends two new models for insurance billing: a "secondary [payer] system" and the other is a "longer term three tier system."

"Both offer significant revenue and/or savings potential, potentially as soon as the next fiscal year," according to the report.

Under the secondary payer system, the Health Center would bill students' insurance, but the University would use Health Center fees to cover students' out-of-pocket costs such as copays and deductibles.

"Following the passage of the ACA [Affordable Care Act], the question is increasingly asked as to why health fees and other institutional funding allocations should continue to pay for or subsidize services and supplies that are covered at 100 percent, regardless of the deductible, under the new preventive care benefits," the report states.

The report also recommends considering a "Triple Option Program." The three options would be insurance through personal platinum, gold or silver plans or Medicaid, insurance through a Bronze plan with purchase of a health fee or enrollment in the Comprehensive Student Health Insurance Program.

"The key difference between a Triple Option Program and the strategic option for secondary payer status is that the health fee at Brandeis would be reduced to funding health education and wellness programs, which cannot be effectively funded from insurance reimbursements, and an overall subsidy for the availability of services when there are almost no students on the campus and the facilities have to remain open," according to the report.

Implementation
"The first order of business will be getting an executive director on board," Sousa said in an interview.
The first steps of consolidating health services and hiring an executive director are already underway. The other recommendations will be evaluated once a director is in place, according to Sousa.

"You don't immediately leap into changes that could put what's best about our structures at risk," said Flagel in an interview with the Justice.

-Tate Herbert, Marissa Ditkowsky and Sam Mintz contributed reporting