Who's Covering College Students?
Parents' Insurance Often Has Restrictions on Out-of-Town Services
By Stuart Auerbach
Washington Post Staff Writer
Page Z07
The Washington Post
Tuesday, April 23 1996
It was almost exactly a year ago, a month before his
graduation from Vassar College, that Adam Sawyer took
the field in a traditional rugby match between college
alumni and students.
"I took some falls in that game, but nothing noticeable at
the time," the 23-year-old Northwest Washington resident
recalls.
The pain came in the next few days, shooting through his
right leg. An orthopedic specialist at Vassar's student
health center diagnosed the injury as a painful and
disabling herniated or slipped disk, caused by falls in that
game.
Sawyer had passed the age of 22 -- the maximum
allowed for dependents on his mother's health insurance
policy, a health maintenance organization (HMO) in the
District. Luckily, he had insurance, part of a plan
purchased from Vassar that is available to all students. It
was scheduled to expire in August, but the college
temporarily extended it because Sawyer's injury occurred
during a college event.
In the past year, Sawyer has lived with his mother,
working part-time, fighting the pain, taking treatment for
his injury. His biggest worry is what will happen when his
health insurance policy runs out next Monday. He is not
covered by his job, and other insurance carriers, including
his mother's, have turned him down because of his injured
back.
The independence that students exuberantly celebrate
when moving off to college is now sometimes haunting
them, their parents and campus health officials. Sawyer is
an example of an increasing number of college students
and recent graduates who have trouble getting health
insurance coverage. Although the majority of students
have no difficulties, campus health officials said the
number of problems in securing coverage is rising.
Some students are not able to extend their parents'
coverage for the years while they are in college, others
have trouble getting treatment while away from their
hometown because the costs are not covered by the
parents' local HMO or insurance network. Others just
don't have insurance.
For instance, Everton Morgan, a 21-year-old sophomore
at Florida International University in Miami, hurt his ankle
in a pickup soccer game. Like Sawyer, he first thought it
was nothing, but then the pain worsened.
"I was really in pain," he relates. "I had to go to a doctor
fast."
It turned out that Morgan, a computer science major,
fractured his ankle. Because the pain became so intense,
he went to a doctor in Miami before getting permission
from the Cambridge, Mass., HMO that covers him under
his mother's policy.
As a result, he paid $400 for care that should have cost
far less under his coverage.
In another case, a young woman complained to student
health officials at Vanderbilt University of a piercing
headache that doctors felt was chronic and severe enough
to require an immediate CAT scan of her brain.
But the California HMO that covered the woman under
her parent's policy refused to pay for the diagnostic test in
Nashville, Tenn. They said it could wait two months for
the Thanksgiving holiday, when the young woman could
come home so the test could be performed in an HMO
facility in California.
The ailing woman wouldn't wait. "She flew home at her
own expense," reports John Greene, chief of health
services at Vanderbilt.
`Over the Phone Medicine'
College health officials across the country say the new
shape of health care in America is changing the way they
work. Although a large proportion of students still come
to school fully insured under their family policy for any
problems, more and more are not insured -- many
because they are too old to fit in a family policy or
because they or their parents cannot get coverage. That
increases the demand for colleges to provide affordable
health policies for these students. Richard Correnti, vice
president for student affairs at Florida International
University, says the average age of his institution's 28,000
students is 26 1/2 -- too old to be covered by parents'
policies.
A recent newsletter of the American College Health
Association cited estimates that at least one-third of
students enrolled in American colleges and universities are
not covered by health insurance.
That is a gamble, but the odds are in the students' favor
since their age group is probably the healthiest segment of
the population. It is generally an accident or sudden acute
illness that can create problems.
College health coverage is complicated further by the
domination of HMOs and other managed care plans that
came into being to curb soaring costs. These operations
make it increasingly difficult to provide proper medical
treatment for students, say campus health officials. The
plans frequently question diagnostic tests and treatments
proposed by college physicians, according to the officials.
Medical care at college "is becoming a significant problem
for students on a traditional residential campus away from
home. They are kind of at the mercy of their parents'
HMO," says James Mitchell, director of student health
services at Montana State University, in Bozeman, Mont.
"It has created a situation in which you have to bargain
over the phone with administrators who can't see the
patient," adds Greene. He says this "over the phone
medicine" can lead to "less than optimal" care.
Finding portable health insurance is yet another burden on
families already under the stress of helping their children
win admission to college and the financial pressure to pay
whopping tuition bills. But student health experts caution
that parents should make sure their children have health
insurance that will cover them when they go to a college
away from home. It could mean buying a separate policy,
often from the college, even though the student is already
covered at home.
Eduard Pfister, director of health care management for the
Prudential Health Care Group, says the issue is "pretty
sensitive" among executives of organized labor and major
corporations that purchase health care plans for workers.
"They are always bringing it up," he said.
Correnti sees little problem in dealing with HMOs or
managed care plans in emergencies or life-threatening
illnesses, where he says they generally provide full
coverage with few questions asked.
"Where we run into big problems is when we have
illnesses that are not life-threatening but chronic, and need
treatment that could be expensive. HMOs want to treat
those illnesses in their own facilities, which generally are
less expensive than ones at college. The university has to
provide primary care for a wide variety of mid-range
ailments that are not life-threatening, but costly to treat,"
he says.
These include flu, food poisoning, broken bones and
sexually transmitted diseases.
Although flu is easily treated at home, Greene says that
"from a college health standpoint we often had to bring
students into the hospital because they were significantly
dehydrated and needed more care than a 19-year-old
roommate could provide. HMOs say that is not a proper
admission."
The question then is who pays? Colleges say they can't
afford it, and many health plans simply refuse, which puts
the burden back on parent and student.
Managed Care Growing Pains
Greene says one solution to the problem is for parents to
challenge their health care plans to provide treatment for
their children at college. "Tell them they are legally
responsible if something happens because of the denial of
treatment or tests. People have to put HMOs and other
managed care plans on notice that what they are doing is
more than a business. They have a legal responsibility, and
you have to err on the side of the patient," he says.
Officials of HMOs and other managed care plans say that
they realize there is a problem, but they see it as part of
the growing pains of a type of medical care that has
exploded in the past few years. All told, about 100 million
Americans are covered by managed care plans, including
43 million enrolled in HMOs.
The growth has been dramatic, with more than 19 percent
of Americans enrolled in HMOs last year compared with
about 11 percent in 1987. Similarly, 69 percent of
employees in companies with more than 200 workers
were covered by some sort of managed care plan
compared with about 42 percent in 1991. The growth of
managed care for all Americans jumped from 29 percent
in 1987 to 40 percent in 1990.
Don White, a spokesman for the American Association of
Health Plans, a Washington-based umbrella organization
of HMOs and managed care providers, defended the care
given in HMOs and by managed care plans as "better or
as good" as that provided under the traditional
fee-for-service system.
There are several options on the drawing board to join
HMOs and managed care plans with college health
programs to provide better treatment for students, but so
far none has been embraced. And some HMOs and
managed care plans have expanded their policies so that
they cover college students.
"Some model for out-of-service area coverage for
students who are on parents' HMOs will have to evolve,"
says Larry Moneta, associate vice provost at the
University of Pennsylvania. "The costs even for primary
care are becoming too high for colleges and universities to
bear, and parents are paying twice for coverage -- once
through their local providers . . . and second through the
school's health fee."
"The major emerging fear among college health folks is
being left out of the loop by the large managed care
networks," adds Donald H. Craig, director of the Norris
Health Center of the University of Wisconsin's Milwaukee
campus.
Many of these problems are lessened if parents' health
care is covered by a plan or an HMO with a national
network of providers.
Prudential's Pfister said his company's managed care plans
offer "portability" that allows college students coverage
under the parents' plan.
If a school is in an area served by a Prudential managed
care plan, a student can get the same coverage at the
same cost that he would have at home, says Pfister. If
there is no network in the region, the student can call an
800 number and get authorization to find his own doctor.
The student will be billed as if that doctor were part of the
network, adds Pfister.
"The aim is to make the policy portable. Portability is
designed to deal with urgent situations . . . not just
emergencies. We get it diagnosed and stabilized, then if
you can go home, you go home," he said.
Blue Cross-Blue Shield, a network of autonomous health
insurance plans that spans the country, will do the same in
July, when it offers a "Blue Card Program" for its 18.5
million members that allows coverage away from the
home area.
For HMO subscribers, the Blues' network offers
HMO-USA, which allows people away from home to get
care at any of its 76 branches in 48 states through a "guest
membership," which is available at no extra charge. This
allows a person away from home to get care at another
Blue Cross-Blue Shield HMO, spokeswoman Laura
Kuratkowski says, that "mirrors what you get at home."
But a guest membership only lasts six months, while the
college year generally is longer.
With the gaps in medical coverage of college students
becoming more apparent, new organizations are being
formed to meet that new health care need. One is
Collegiate Health Care, a company run by Brett Prager, a
30-year-old venture capitalist. It already manages health
facilities on 15 campuses, and Prager would like to
expand CHC from managing college health services to
connecting them in such a way that they can become part
of the networks of existing HMOs and managed care
plans.
Another proposal supported by many college health
service officials is known as the qualified student health
plan, or Q-SHP. It would allow an employer to pay part
of a health insurance premium for a worker to the college
health system instead of to the HMO or managed care
plan that covers the rest of the family.
This, however, would required federal legislation, and
there are no such bills pending, says Montana State's
Mitchell.
He says it would have to be started in states such as
Michigan, where much of the health care is covered under
policies negotiated between the United Auto Workers
union and the Big Three automobile manufacturers, or
Minnesota, where a large number of big managed care
plans cover the state.
(c) Copyright 1996 The Washington Post Company
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