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SPECTRUM A P U B L I CAT I O N OF T H E C H I C K E R I N G G RO U P student health MAY 2003 STUDENT HEALTH AND THE BUDGET CRISIS Relevance, Measurement and Value JAMES E. MORLEY, JR. PRESIDENT, NACUBO Special Interview: Working Smarter With Less MARGARET BRIDWELL, MD UNIVERSITY OF MARYLAND, COLLEGE PARK Special Interview: Plan, Assess, Communicate and Celebrate SAUNDRA L. TAYLOR, PHD U NIVERSITY OF A RIZONA Budget Cuts: A California Perspective STEVE LUSTIG UNIVERSITY OF CALIFORNIA AT BERKELEY Campus Health Services: Surviving the Academy's Budget Crisis J. ROBERT WIRAG, HSD THE UNIVERSITY OF NORTH CAROLINA AT CHAPEL HILL Columbia University's Volunteer Ambulance Corps MARGO AMGOTT AND HANNAH KRIMINS Prescription Costs: Does Your Student Health Insurance Plan Measure Up? PAUL A. CRONIN, FSA THE CHICKERING GROUP Editorial O ur special edition of Spectrum on the uninsured student, Maggi Bridwell, one of the "deans" of college health, describes how she has worked with her financial and program officers to be fiscally published in March 2003, introduced a new look, responsible and yet preserve the resources necessary the addition of outside editors, and greater reliance for an adequate student health service. Steve Lustig on contributed articles. Since we heard from many at Berkeley describes how he has maintained Student of you that you were pleased with these changes, we Health Services in the face of a 20% reduction in plan to continue to publish in this new format. University funds. Finally, Saundra Taylor, Vice When Spectrum was launched six years ago, President for Campus Life at the University of our mission was to provide a newsletter of opinion, Arizona, discusses the Solomon-like choices in ideas, and information on current issues in student managing budget reductions across an array of health. That mission remains unchanged, but six important programs. years have helped us to be clearer about how Rounding out each issue will be an article on Spectrum can be more useful. a topic related to student health insurance. In this For example, we have published a number of issue, Chickering's Chief Actuary, Paul Cronin, contributed articles on how things are done at focuses on the patterns of utilization and cost various campuses, called "In the Spotlight." We observed in prescription drug coverage. have received favorable comments on these real-life, We will also include abstracts of articles from real-time descriptions of current practices. Therefore, other journals and the popular press on items of each issue will now include that kind of article interest to student health. This section will continue in a section called "How We Do It." In this issue, to be called "Briefly Noted." Margo Amgott and Hannah Krimins at Columbia With this issue we also are introducing an describe Columbia's student-run ambulance service, independent editorial board. Although Spectrum is a story of involvement, quality, service, efficiency, not a refereed journal, we felt that an editorial board and cost savings. would provide valuable suggestions for both We have also heard that Spectrum has been content and authors and would help ensure the a useful instrument for informing and educating ongoing relevance of the publication. This editorial colleagues. The lead piece this winter on the core board will grow over the next few issues to become competencies for Student Health Services Directors a group that will represent both the leadership and has gone to several search committees and to many diverse constituencies of college health. Student Affairs Offices with route slips saying, As always, your suggestions and comments "This is what I actually do!" are valued. We hope that Spectrum will continue to To meet that need, we will have an integrating be an important forum for the field. theme for each issue, focusing on topics of high and current interest. This issue focuses on how student Best regards, health programs are coping with the budget constraints facing all of higher education, but most acutely, public institutions, which rely on tax dollars. Bob Wirag's article, "Surviving the Academy's Fredrick H. Chicos Stephen C. Caulfield Budget Crisis," lays out several strategies for President and CEO Chairman achieving independence from university funds. The Chickering Group The Chickering Group 2 SPECTRUM May 2003 Relevance, Measurement,Value I am pleased to be asked to introduce this issue of Spectrum, which, in a very timely way, discusses the difficult financial challenges all of us in higher education are now facing. A few words of introduction may be in order.The National Association of Colleges and University Business Officers (NACUBO) has over 2,100 institutional members. Our primary constituents are chief administrative and financial officers. I came to this position in 1995, after a succession of business officer positions, including Senior Vice President of Cornell University. I am not sure whether this is the most difficult period I have experienced, but it is certainly among the most challenging. My colleagues who are directly responsible for the financial health (and sometimes survival) of institutions are facing a sharp erosion in endowments, constraints on tuition and fees to keep higher education affordable, precipitous declines in annual giving (including unfulfilled pledges) and increasing enrollments that tend to run counter to a faltering economy. Our public institutions that rely on tax-levy support at the state level are particularly hard hit. As someone suggested, this year the signs on my colleagues' desks now read, "The Buck Shrinks Here." What are the three or four key messages from the business officers at times like these? First and foremost, each program competing for university funds has to be both clear and credible about how that program relates to the central missions of the institution. Those most closely aligned with both the core missions and core values will receive more favorable treatment. As Dr. Bridwell points out, it is too late to make this case at a time of crisis. It must be an ongoing process, and each program's story must be heard, understood and believed at the highest level. It is important for student health leaders to make your case in this context, and, for the CFO to have the institutional perspective to listen. Second, although we are sometimes viewed as "Doctor No," our proper function is as a business consultant and facilitator of information and best practices to all internal units. Third, we in NACUBO are, by nature, quantitative people. If a program does not collect and use data to make prudent business decisions, we will work with them to help identify appropriate analysis and metrics to assist in the resource allocation process. Dr. Taylor's strong emphasis on assessment comes close to qualifying her as an honorary NACUBO member. Finally, our role in some ways is to be the value police. Our job is less difficult when programs have been tough-minded about their value proposition. This requires both benchmarking against best practices in other higher education institutions and comparable programs in other settings. The authors writing in this issue of Spectrum capture the issues and support these four themes.Those of us who have to guide the budget to a balanced bottom line appreciate this kind of informed dialogue. James E. Morley, Jr. President, NACUBO 3 May 2003 SPECTRUM I n t e r v i ew Working Smarter With Less: An Interview with Margaret Bridwell, Editor's note: At Chickering's Leadership Forum last October, While there is talk of furloughs on other campuses of Dr. Bridwell asked her colleagues for advice on how to manage the University, we haven't been asked to do this. There is no her program in the face of significant reductions in the state of plan that I know of for early retirement packages, but there Maryland's funding for higher education. Five months later, is now talk of layoffs, and we have been told to expect we checked back with Dr. Bridwell to see how the process another round of cuts next year. Nothing specific has had unfolded. been suggested, although another 5% is anticipated. Since the governor's plan for slot machines has been voted Stephen Caulfield: Dr. Bridwell, last fall the University down, we can definitely expect more cuts next year. directed all programs to respond to the state's budget What else have we done? We are looking very crisis by across-the-board budget reductions. Can you carefully at salary savings and our operating expenses. At give us the broad outline of what you were asked to do this point, we are still delivering the same services. We have and what mechanisms, such as hiring freezes, were about 65,000 visits each year, but we are looking at services imposed on you? and positions that we can outsource, for better service and, hopefully, at less cost. The services we're looking at Dr. Maggi Bridwell: Let me start by setting the context include housekeeping and IT. I think we can make the for our program. We are the main campus of the State requested cuts this year, but we need to look at the long University. We have about 34,000 students whose tuition term and decide what we want to be then — continue as and fees at the start of this year were $5,600 for Maryland is, downsize or add services which could be self-sustaining residents. The Student Health Services (SHS) began this on a fee-for-service basis. For example, physical therapy academic year with a budget of $5.4 million, of which (PT) is a service we are moving back to the Health Center, $3.126 million came from the state (University funds). We and it should be busier now that it is not on the other side do not have an identified Student Health fee. The approx- of campus. PT is fee-based and should be self-supporting. imately $2.3 million that is added to the state funds to Another example is our dental service, but here our make up our total budget comes from fees we charge for budget crisis requires that we be very careful. Our new pharmacy, dentistry, physical therapy and other services. facility (which was under construction prior to the budget Our whole budget of $5.4 million was considered crisis) is planned to have six dental operatories, an addition our "base budget."* From this we have had to cut 5%, or of two over the four currently in the clinic. This is a gamble, about $270,000. To achieve this, we have given up five but I think we might reduce our risk by contracting with positions out of a full-time equivalent staff of 80. local dentists to provide the care. We are now evaluating In addition to these five positions, there was a University- the current dental clinic operation to document whether it wide hiring freeze, which has recently been lifted. Under can become self-sufficient. Another complication is that the freeze, vacant positions could not be filled without the latest review of our budget puts in question whether high-level University approval. Some months ago, that we can equip and furnish the dental clinic as planned. was tightened further, with appeals going directly to the State Capitol. Under the freeze, we had been given Caulfield: Do you think those responsible for the budget permission to fill two of several vacancies — a nurse and now understand the unique missions of the SHS, and has a medical records technician — but we still have other that understanding allowed some flexibility with regard openings, including three in Medical Records. to the across-the-board program? *Budget is for direct compensation, supplies, travel, and minor equipment. Fringe benefits, space, utilities and major capital expenses are excluded. 4 SP E C T R U M May 2003 "When the budget crisis hits, it's too late to make friends and sell your pro g ram up the organization because eve ryo n e MD else is doing the same thing for their own pro g ra m s ." Dr. Bridwell: The University and, specifically, the Student still function. My preferred way to do this is to get Affairs Division, do understand our mission. We are together in small functional groups, when we have hurting no more than the rest of the University, and I something to talk about. I do send the occasional all-staff might even say we have been treated well, or at least very email, and we have a monthly newsletter. I am sometimes fairly. With our current state budget deficit, the University asked to hold meetings every two weeks on the budget. I has limited options. This semester, tuition was raised $200 have two problems with this: First, I don't have something for in-state and $300 for out-of-state residents. Because of to talk about every two weeks, and, more importantly, the uproar these increases caused among students and our primary job is to provide health care. The best way to parents, another increase in tuition will be tough, so there keep morale up is to stay busy and focus on our primary has to be a rigorous effort to cut costs. These decisions (to job — taking care of students. The staff is working hard require both a 5% cut and a hiring freeze) were made at and remain dedicated to their jobs. However, it is difficult a higher level, by the Provost and the President, but I don't for them — rumors spread when we do not have any know what else could have been done. specific information to pass on to them. When they hear there are layoffs in other departments, they are concerned Caulfield: Can you talk about the moral and ethical for themselves. With the budget crunch, we can't afford dilemma of wanting to help the state resolve its budget meetings, and we don't have ways to reward staff. crisis and, as a physician, wanting to provide necessary and appropriate care? Caulfield: If the University budget process gave you the degree of freedom you think is necessary to run the Dr. Bridwell: We still feel responsible for delivering Student Health Service, what are the two or three necessary and appropriate care and will do so. I am not alternatives you'd like to pursue to stabilize your sure I feel responsible for resolving budget problems at the program financially, without increasing your reliance on state level. Ethically, we must help the staff understand University funds? what the situation is and enlist their ideas and support as we make the necessary cuts. Dr. Bridwell: Obviously we have to work on both the What makes this particularly challenging is there is expense side and the income side of our ledger. On no fat. Ten years ago, during the last big budget crisis, we the expense side, I am looking at outsourcing what services eliminated a number of positions. Now we either have to we can, but not losing control of our core clinical be more productive with what we have, or we have to cut services, health education, wellness health promotion, services. I hope this year we can do more with productivity and healthy lifestyle programs, which are integral to the — working smarter and using the improvements in work delivery of health care in a higher education setting and flows that our new facility will allow. But another 5% which should be maintained. Outsourcing some non- next year? I don't know. central services may have two advantages, it may save us money, and it will free up personnel lines. In our system, Caulfield: How have you kept your staff informed, while you need both. Even if you have a revenue stream, you can't maintaining morale and focus on the primary job of taking hire without an approved personnel line. Looking down care of students? the road, I want to be sure to have personnel lines available. Also on the expense side, we are looking at ways of Dr. Bridwell: As information becomes available, the staff working smarter. Our clinicians (MDs, NPs, and PAs) now is informed. All units are looking at ways we can cut and do tasks that nurses could do. Our nurses do work that 5 May 2003 SPECTRUM " These are uniquely challenging times. able to make one-time cuts to solve the c u r rent services with any further budget Caulfield: From what you've described, you will get through the next academic year with constrained resources. What is the realistic outlook for the next few years and what are your strategies for the next round University of Maryland, College Park Campus Health Center (pre-construction). of budgets? nursing assistants can do, and nursing assistants do what Dr. Bridwell: Strategies for the next few years will include clerks could be doing. Changing will take time, but we must continuing to consider outsourcing, as we have talked do it. This also illustrates the need for personnel lines. We about before; the restructuring of our staffing model; and will need more support positions to fix this problem. looking at income generation. Regarding income, two On the income side of what we do, the most pressing points are worth noting. I had mentioned our fees earlier. need is to bring our fees up to something close to the Virtually all of our fees and charges are way below those current market rates in our community. I would also like charged in the surrounding community. We need to to go back to a specific student health fee, rather than to bring those up, but I still want them to be somewhat be part of the undifferentiated tuition and state supplement below "market" rates to ensure students use our program. pool, but I don't think that will happen. A second point is that, because of our state employee status, our physicians and other clinicians are covered Caulfield: During this process, you have been in the under Maryland's tort claim limits. This is not considered midst of a very significant construction and renovation adequate malpractice coverage by the insurance or managed project which will more than double the size of your care programs, so we cannot bill for clinicians' care SHS. I assume the construction budget is untouchable, because we are not considered participating providers. but what about the program budget to adequately staff your new facility? Caulfield: You have not mentioned moving your Student Health Insurance Program from a voluntary to a hard Dr. Bridwell: The construction goes on and is funded up waiver or mandatory program. With everyone insured, to a point. For example, there has been a commitment by you might improve your fee recovery and perhaps get us of $1 million from our budget to finish the project, some capitation payments to address your credentialing but we have not been able to put the full amount in the and malpractice problem. construction account. We also have already had to use some of the budgeted furniture and equipment money to Dr. Bridwell: I have not mentioned it because I think it cover construction contingencies. wouldn't be acceptable at a time when tuition is rising. At this point, it means that we will have less new I'm torn on this, because it's the right thing to do and it furniture and will have to put old furniture into a nice- should, with increased numbers, make the insurance less looking new facility. We will put the new furniture in the costly for everyone. On the other hand, as Rick Kronick common areas to start. pointed out in your special issue of Spectrum, at some But, as you suggest, the real concern is staffing. point you make higher education unaffordable. It's also Moving existing staff into the new facilities will not a good time to take on that issue, with the budget improve productivity by creating two exam rooms for crisis hitting every part of the University. each clinician and better work flow. But we had planned on some new hires. I worry that, due to loss of Caulfield: You have directed this program for many years, position lines, we will have a beautiful new Health Center you are a national leader in accreditation of SHS programs, with not enough staff to deliver services. and you have been active in ACHA for years. Combining 6 SP E C T R U M May 2003 We have had cuts before, but we always had a cushion and we re budget dilemma. This time, there is no way to maintain all our c u t s ." your Maryland experience and your national experience, next five years. Nothing is sacred. Look at everything are these uniquely challenging times for Student Health? you do. Can you do it differently? Can you do without? If you have always done things a certain way, re-evaluate. Dr. Bridwell: Yes, these are uniquely challenging times. Try to involve everyone. That is not easy. None of it We have had cuts before, but we always had a cushion is easy!!! For example, I commented earlier that we don't and were able to make one-time cuts to solve the budget have the right mix of junior people. In a more comfortable dilemma. This time, there is no way to maintain all our time, we could live with these inefficiencies. Today current services with any further budget cuts. And this we can't. will raise the very difficult question of what gets sacrificed. Fourth, I always ask the people who do the various College health has had the extraordinary opportunity to jobs how they could do them better. They know because provide primary care, to manage specialty and subspecialty they are the ones in the trenches; they just need permission care, to practice public health and prevention with a captive to tell you that it isn't perfect and could be improved. population and to address questions of lifestyle and risk Fifth, it's true that you have to spend money to save behaviors. My fear is that with further cuts, public health money, but that's virtually impossible with tight budgets. and prevention will be compromised. Thank goodness we had our new facility going up when this hit. Could we save money going to an electronic Caulfield: From your budget travails of the last six medical record? Probably. But can we afford to do that months, have you developed at least the broad outline now? Probably not. So, if you get a little bit of breathing of a "survival guide" that might be useful to your room, build your efficiencies then, improve your systems colleagues elsewhere? and invest in what is required to make those changes. Finally, you asked about the morale. Let me add Dr. Bridwell: First, you have to know your budget inside that to the lessons. If you've done your staffing right, a and out. As a physician and director, I had focused on budget crisis will strain morale, but it won't break it. Our care delivery issues and program planning, particularly staff likes what they do. Sure they complain, but they with our new facility. It took me a while to get up to speed pitch in and manage. The crisis will expose the weak links with all of the detail and nuances of what makes up our in your staffing. As director, you've got to fix those quickly, budget. For example, I had always assumed our pharmacy but if taking care of ill, injured, or worried students was "made" money, but found that the salary lines and other rewarding before the budget crisis, it should be just as expenses associated with the pharmacy were not included rewarding during and after budget cuts. in the expense side. I still think the pharmacy is a net income producer, but we're looking at it in a different and Margaret W. Bridwell, MD, has been Director of the University Health Center at the University of Maryland, College Park since much more detailed way. 1975. She received her BS fromTulane University and her MD from Second, when the budget crisis hits, it's too late to . Louisiana State University Medical Center Dr. Bridwell is past make friends and "sell" your program up the organization president of the American College Health Association, past president because everyone else is doing the same thing for their and a current board member of the Accreditation Association for Ambulatory Health Care, and a surveyor for AccreditationAssociation own programs. I mentioned that our Vice President for r for Ambulatory Health Car e, Inc. and Faculty for T aining. Student Affairs and others in the University hierarchy 's Dr. Bridwell was the recipient of ACHA Edward Hitchcock Awar d have treated us fairly and appropriately, that is because in 2000. She can be reached at firstname.lastname@example.com. they knew and understood our value long before the G Stephen C. Caulfield, MSW, is Chairman of The Chickering roup. budget crisis hit. Prior to joining Chickering he was a worldwide partner at Mercer Third, always look for ways to work "smarter." Human Resource Consulting. He can be reached at scaulfield@ Look ahead and plan, not on a yearly basis, but for the chickering.com. 7 May 2003 SPECTRUM I n t e r v i ew Plan, Assess, Communicate and Cele An Interview with Saundra L. Taylor, Editor's note: The budget crises on college and university this program, an outreach effort for K-12 students. Human campuses are felt and responded to at many levels, from the Resources has all of the traditional units, including a work/ Trustees right down to the student. Dr. Saundra L. Taylor, the life unit. It is a full-service resource for the entire campus. University of Arizona's Vice President for Campus Life, is close All of this is on a fairly large scale. We have a small to the top of that process. She reports directly to the President city here — 37,000 students and 20,000 faculty and staff. and has some 1,200 people working in programs she oversees. Twelve hundred people work in Campus Life, including Dr. Taylor talked with Spectrum for over an hour about the 300 student workers. Campus Life's operating budget is difficult decisions she and her colleagues are making. just under $100 million, with $14 million in state funds and $85 million in auxiliaries. Over the past three years, Stephen Caulfield: In your role as Vice President for there has been a slight growth in enrollment, perhaps 2% Campus Life, you are responsible for everything from each year. But the state budget has been in decline during residence life, to judicial affairs, to student health. Can you that three year period. give us an overview of the scope of your responsibilities — how many departments, how many people, total budget, Caulfield: Since you mentioned the decline in the state serving how many students? budget, it is no secret that virtually every state is facing particularly significant budget cuts this year, and in Dr. Saundra Taylor: Let me start with a word about the virtually every state, those cuts have been felt in public title, Campus Life. The President and I take that quite higher education. In most jurisdictions, there is some literally to mean we have the responsibility to make all political process whereby some programs do somewhat campus experiences as fulfilling and productive as possible better and some fare less well, but even during that — for students, faculty, staff and visitors — from the process the "writing on the wall" is pretty clear. What is the community, parents, or others. One specific department Arizona story, and what has your University had to absorb? that I have that you would not find in Student Affairs is Human Resources, which serves both faculty and staff, Dr. Taylor: The state allocation for the University is to be including faculty recruitment. reduced by 13%, or about $45 million. In Campus Life, How does this get done? I have one Associate Vice we will absorb about 10%, and in academics, only about President and three executive directors, as well as staff, 7%. The auxiliaries don't take the same hit, but I can find who report directly to me. We are organized into four ways that the auxiliary programs can help me. For example, broad areas: Student Life, Health and Wellness, Human the bookstore will pay for part of commencement, and Resources and Cultural Affairs. In each of these you will Residence Life pays for a program called the Faculty find the usual suspects — for example, in Student Affairs Fellows. Residence Life also pays for a person who does we have Residence Life, Multicultural Services, the assessment for the whole division. This is always very Student Government, the Student Union/Bookstore, delicate, since I have to keep fund balances in the auxiliaries Greek life, etc. A few programs are somewhat unique. so they can weather future storms. With the exception of Under Health and Wellness, for example, we have our the bookstore, those balances are pretty thin. programs for students with learning disabilities. Under Cultural Affairs, we have a program called UApresents, Caulfield: How has the University decided to deal with which brings performing artists to the campus, and through these budget cuts? Have you imposed hiring freezes, early 8 SP E C T R U M May 2003 brate: PhD retirement packages, across-the-board cuts, and how much develop a strategic plan three years ago, before these really is at your discretion programmatically? tough budget decisions came down. That was extremely helpful because we identified our core values — things Dr. Taylor: We have what I would call a "soft" hiring like diversity as an issue for Campus Life and collaboration freeze. Every new hire has to be prior approved by a Vice outside of our division to promote retention, things like President. We discussed furloughs and ruled them out that. The plan expresses what it is we value about the because we felt they would send the wrong message — work we do, how those values get represented in the goals that people were not necessary for some periods of time. we have set, and what our tactics are to get to those Regarding early retirement, the University of Arizona is goals. The plan has become our "moral compass." What highly tenured. When our HR people looked at this, they is also very important is that we have added how we are told us it would cost us more than we would save, so no. going to assess how effective we are in doing what the So what do we do? We first looked for marginal plan says we will do. We have been working on the programs. If we found one, we eliminated it. If it had assessment program full throttle for two years now, and I some good people in it, we tried to get them well placed think, after this year, we are really going to have the kind elsewhere, hopefully within the UA campus. Second, we of feedback we need to adjust the compass, but also to looked for marginal parts of programs. This is tougher, demonstrate to the President and the budget process that both to identify and cut, because most program parts are most of what we are doing is working. somehow linked to the whole. Third, we looked for people The Campus Health Center has been following a who were not contributing, sometimes through no fault planning and evaluation process for a long time. They of their own. These people have to be moved into fully belong to ACHA, and the Health Center is committed to productive roles. Sometimes we are able to do that within an accreditation process. It was their model that we said the University. we should use across the whole division. At the University level everything is being examined. Of course to do this, you need to commit to it, and We have been able to refinance some of the buildings at we have, with a director of assessment, who has helped us more favorable rates, and we recognized $4 million there, a great deal. We have had workshops and retreats and which has enabled us to protect some academic functions. everybody now has their assessment plan. These assessment plans must measure contributions to the division's goals, Caulfield: In the normal conduct of your responsibilities, such as diversity and retention, as well as each individual you indicated you rely on a management group, which program's goals. consists of your Associate Vice President/Dean of Student One example of how the assessment program helps Life and your three executive directors. How has this with the difficult budget decisions is the orientation worked to help you with these difficult budget decisions? program (Wildcat Welcome) for all of the students at the beginning of the year. Our assessment showed us what Dr. Taylor: These four have certainly been my "go to" students valued and what they did not. We had a lot of group, and we have had many sessions looking at what fluff in that program. We now know we can reduce that were going to be our priorities. I also have a budget director program and focus on what is working. [Editor's note: for the division who works very closely with this group. Dr. Taylor's emphasis on assessment ties nicely into Jay Morley's Perhaps the most important thing we have done was to letter on page 3 of this issue.] 9 May 2003 SPECTRUM " When you are new to a position...it l ack of knowl edge...but also because participate in NASPA and ACPA. Now, informally, the VPs for Student Affairs on the three state campuses Student Union Memorial Center/Bookstore, University of Arizona. communicate all the time. There is also a Regent's Board staff that keeps us connected on financial aid issues, Having a plan and solid assessment program is international students, and other areas of common interest. critical, but I must tell you, reporting directly to the In addition, I belong to a group of vice presidents President is also very helpful. The President is very clear from across the country, which has been meeting for that a number of areas should be treated like the academic about 30 years. They are known simply as the National side of the University. An example is all of the multi- Vice Presidents' Group, and I've been a member of that cultural programs and services that are really invested in the group for about eight years. It truly is my reference group. recruitment and retention of underrepresented students. I use them all the time for opinions and for what they can tell me about what is going on on other campuses. We Caulfield: You have discussed your own reporting channel meet as a group twice a year, and we work hard to make to the President and how valuable that has been. Let me these meetings places where you share in great detail ask you about colleagues. Have they been helpful and how things are done. That has been a great support group supportive during these difficult budget decisions? for me. Dr. Taylor: Yes. Our Athletic Director has been particularly Caulfield: At the end of the day, I suspect you have faced supportive, agreeing to transfer $500,000 from his budget some very difficult, Solomon-like decisions. Tell us about to help fund our new Student Union. This very generous how you make those decisions. reallocation was made possible when the debt on the stadium was retired early, freeing up these funds. The Dr. Taylor: You know, the irony for me is that the toughest Athletic Director, the President and I all discussed the value decisions I have had to make at the University of Arizona that a really terrific Student Union would have in recruiting were made the first year I was here. As I look back on that for athletics and for all of campus life, and we talked him time, I've never had to handle anything as difficult since. into contributing these funds for the debt service on our When I came, I had to make a million dollar cut. I did new $60 million Student Union. not know the programs, I did not know the people, and I did not know the culture, and, because so much had Caulfield: Tell me about your consultation with already been cut, I was left trying to figure out how to colleagues on other campuses. What have you found to streamline my administration. My principle was going to be particularly helpful? be that I would cut the administrative level, but protect the service level. Once I made that decision, I had to Dr. Taylor: Sadly, our state association has failed. When implement it. Just to give you some detail, one decision I I arrived here eleven years ago, it was very strong, but like made was to eliminate two direct reports to me. One was so many voluntary organizations, it was overly dependent an Assistant Vice President for Minority Affairs and the on the energy and hard work of a few individuals. When other a director for a student service center (focused on they burned out or left, we just couldn't keep it going. retention). I won't go into all of the details, but the one For myself personally, I am very committed and thing I found out immediately was that every minority involved in NASPA, and my colleagues at NAU and ASU group on campus and every minority group in the 10 SP E C T R U M May 2003 is ve ry tough to make these decisions, both because of the you lack t he 're lationship c ollatera l' ." community was heavily vested in keeping the minority process, gives us both the objectivity and the data to affairs position. It seemed like the world came after me. make the required tough decisions. The toughest decisions A minority woman with a PhD was in the position and was for me are always what to do with good people in positions very talented, but much of her program had previously where they are not fully contributing. You have to work been stripped away. Because of her great strengths, I especially hard to get them into a position where their worked with the Provost to find her a faculty position, contribution is greater than their compensation. That's which we did. It has worked out very well — she's now tough for me and tough for them too. tenured, but it took three years for some people to calm down. Politically, it was a bold decision, and the President Caulfield: Under the "clouds have silver linings" heading, backed me on it, but it was a big firestorm for quite some are there two or three positive things that the process time. I guess if there are lessons here, one is that you have has facilitated? to make some tough political decisions, but it's awfully good to have the President on your side and you have to Dr. Taylor: I was talking yesterday with an international have the fortitude to ride out the storm that may take a student for whom I am the dissertation advisor. She made year or three! a very interesting observation that students from overseas One other interesting irony. When you are new to admire American universities precisely because they go a position, particularly in an institution, it is very tough through this kind of budgetary discipline. They feel it to make these decisions, both because of the lack of results in better teaching, better programs, and better knowledge I already mentioned, but also because you lack campus life. I must admit, it's hard to see that when you the "relationship collateral" that these decisions seem are in the middle of it. When I step outside of the process, to require. I do think the hard decisions we've made truly add value On the other hand, now that I have a fair amount to the core of what we are doing. In large institutions, this of relationship capital, I don't know whether I could can be particularly hard to do because it is easy not to make those decisions today, because I am so vested in address modest inefficiencies. If you have the resources, these programs. those inefficiencies will proliferate. When you don't have I still stand by my original decision. We have put the resources, you have to zero in on those services that back in place an excellent multicultural program that students really need. has much more than the cultural centers in it. It is a very legitimate enterprise. Caulfield: If Arizona is like most other states, budgets don't look like they are going to improve next year. How Caulfield: You make a very interesting point. A leader do you help your people and programs plan for a difficult, who is committed and passionate about their programs near-term, future? may not have the ability to really evaluate them objectively. This ties back to your earlier comments on the importance Dr. Taylor: We forecast that we will have to make another of assessment. 4-5% cut next year. This will be a moment of truth for me. We have realigned, reorganized and gotten rid of every- Dr. Taylor: There is no question in my mind that the thing that we could possibly say was peripheral. When we assessment work we are doing is absolutely critical. That, get to this next cut, it's going to be core, because there is combined with a fairly rigorous planning and goal-setting just not anything left. It is going to mean cutting some 11 May 2003 SPECTRUM "Un i versities w ill be loo king t o pr iva t i ze or outsource their heal th Can someone ou tside the center do it bet ter or cheap er, or both?" really basic services. I know those programs are needed, "How nearly free as possible is it?" because the Arizona and they are excellent and we have the data to support constitution has a clause in it that says that. that they are really being effective, but I am still probably going to have to cut some of those things. Caulfield: A related question: How do you manage peer competition, rivalry, or perhaps open warfare, as each Caulfield: Physicians have an advantage over other department head fights for their particular program? department heads, in that they can draw lines in the budgetary sand and say, "Without these resources, student Dr. Taylor: Happily, the planning and goal setting process health and safety will be jeopardized." I doubt Harry we began three years ago, disciplined by a fairly rigorous [McDermott] has done that, but does student health have assessment process, has resulted in all programs knowing a somewhat unique position in the budgeting process? and respecting where their colleagues fit in. So it really has not been a problem. Also, the fact that 85% of our budget Dr. Taylor: I think they do, although one of the is from auxiliary functions means that programs "own" challenges is that Universities will be looking to privatize or their own revenue streams. outsource their health centers. That is always the challenge of downsizing. Can someone outside the center do it better Caulfield: Have you evolved two or three rules or or cheaper, or both? It is my job to demonstrate to my guidelines for making these tough budget decisions? administration that we are running this Health Center in a very cost-effective way. It's very lean administratively and Dr. Taylor: My first rule is always try to reduce "over- we put the resources in the service delivery. They need to head" or administration, before attacking the program. know that we are poised to deal with mass immunizations, Having worked on that strategy for a number of years, containment of infectious disease, that we know how we you'll see my organizational structure is now pretty flat. I will deal with meningitis on campus — all things that will only have four direct reports. We may have gone too far, get a President's attention. I think I've got our President's and I am now talking about breaking out some programs attention, and he's very supportive of our maintaining the and adding a fifth direct report. base for our Student Health Center out of our retained This illustrates a kind of corollary to the first rule, fee pool. We switched the Health Center from the state which is, "Don't overdo it." When we have administration allocation to a retained fee basis about eight years ago. The as lean as it can be, when we have no fat in programs and state budget is the most vulnerable, so this shift to a measurable results, the next step is to do less — reduce the designated student health fee reduced that exposure. scope of what you are doing. This, of course, raises the question of the overall Going back to a point I made at the beginning, if affordability of higher education in Arizona, which adds you can possibly take out an entire program rather than up all costs to the student, including retained fees. Thus starving everyone, you should do it. We have just gotten far, this is not an issue because the University of Arizona out of our occupational health activities, where we is in the bottom third of all state universities for tuition contracted with the city and did some internal contracts and fees. Actually, we were second from the bottom, and with risk management. It just wasn't cost-effective for us, we've just raised tuition by 40% ($1,000) for the fall, so so we got out of that business. we will see where that brings us. We are going from about So I guess I'm saying as a second rule that if $2,500 to $3,400, but we still will be in the bottom third. something is not serving our core missions, going back to We are so far off the chart compared to our peer institutions our planning and goal setting process, let's get rid of that that the affordability question really does not get framed program rather than handicap those activities which do in the same way in Arizona. In Arizona the question is, support the core mission. 12 SP E C T R U M May 2003 centers. T hat is always t he challenge of dow n s i z i n g . This, of course, highlights what really may be my almost always remarks on the opening of these facilities strongest message. Take the time always, before, during and how proud he is. So, in spite of the negative things and after difficult times, to know what your core missions that are happening to us, we all feel very fortunate that we are, how you are going to achieve them and how were lucky enough to find the window of opportunity to you are going to measure success. If there is one do these projects. I guess the lesson is, don't let these kinds thing more than anything else that has helped us in this of opportunities pass you by. time of limited resources it has been our planning and If my first rule on maintaining morale is celebrate, assessment work. my second is communicate. As you probably know, capital projects are continuing, interest rates are low and the Caulfield: Someone recently commented that budget cuts state's bonding authority is sound, but people don't can wound programs, but bad morale can kill them. How understand how we can keep building while cutting have you maintained morale, collegiality and focus on the programs and raising tuition. Our President has a whole tasks at hand? communication campaign called "The Color of Money" where he explains the different sources of funding. You Dr. Taylor: One of the morale boosters for Campus Life have to keep your communications going continuously, is that we were able to get a number of building projects because there is always the next group of applicants, the through when the University was not in crisis — a next class of students who need to understand. student union and bookstore, a building for our learning Finally, I think morale is closely tied to management's disabilities program, several residence halls and the ability to identify and reward people who are ready to campus health building (which will open next spring). take on new responsibilities. Even in this difficult time, we All those projects are heralded on campus as can promote people and give them promotion increases. improving campus and student life. What we have done Of course, we have to find that money elsewhere, but it is concentrated on celebrating that we've upgraded our is critical to morale for the entire organization to see good campus. We had a whole week celebration in opening people being moved up. the Student Union/Bookstore, with different people sponsoring each day. The whole campus was invited. Yes, Saundra Lawson Taylor, PhD, isVice President for Campus Life at the University of Arizona. She is a tenured faculty member in the the Student Union and Bookstore have had to take cuts, Department of Higher Education. P . reviously, Dr Taylor served at but their mindset is, "How fortunate we are to have this Western Washington University as Vice President for Student Affairs, terrific facility." Interim Vice President for University Advancement, and tenured Another thing we are planning is to open a very y faculty member in Psycholog. She received her BA in Psycholog y from DePauw University (1963), an MA in Clinical Psychology from upscale dining room in the Student Union — which is Bowling Green State University (1965), and a PhD in Clinical only now used for lunch — in the afternoon and evening . Psychology from Ohio University (1969). DrTaylor is active in for a social hour for faculty and staff. Faculty morale is A the National Association of Student Personnel dministrators A's (NASPA). Locally, she chaired the U United Way Campaign also suffering, but when they announced this in the for 2001-02, and she is a past board member of the Sahuaro Girl Faculty Senate, they all applauded. Scout Council of Southern Arizona. She can be reached at sltaylor@ Celebrating what we have, which is truly impressive, u.arizona.edu. is a way to distract people from the other realities, like the G Stephen C. Caulfield, MSW, is Chairman of The Chickering roup. fact that there will be no pay increases next year.* It is also Prior to joining Chickering he was a worldwide partner at Mercer a way for me to say "thank you" to everyone who worked Human Resource Consulting. He can be reached at scaulfield@ so hard to make the facilities possible. The President chickering.com. * This applies to all faculty and staff without regard to the source of their compensation. It does not apply to promotions. 13 May 2003 SPECTRUM Budget Cuts: A California Perspective St e ve Lustig, Assistant Vice Chancellor, UC Be rk e l e y Editor's note: No state in the union faces a more daunting health care. Prior to this decision, health services on UC fiscal challenge than California. And few states have been campuses varied — some campuses, including Berkeley, as focused as California on the importance of student health had mandatory health insurance for graduate and under- to higher education. Across the nine-campus system of the graduate students and strong on-campus services, others University of California (UC), registration and other non- did not. waivable fees provide an average of about 54% of the Now, across the UC campuses, about 120,000 funding for on-campus services, including student health. By undergraduate and graduate students are enrolled in mandating student health insurance three years ago, the UC campus-sponsored major medical plans. On the Berkeley system now has most graduate students and a majority of campus, all students depend on campus health services undergraduates enrolled in campus-sponsored plans. Although for counseling and primary health care, and 25,000 of this model approaches Dr. Wirag's "Gold Standard," (see page these students (91% of the graduate and 73% of the 18 in this issue) it is not "budget proof." This article describes undergraduate students) purchase the Student Health the extreme challenges Steve Lustig is facing at UC Berkeley. Insurance Plan (SHIP) and rely on the health services as gatekeeper to their major medical plan. Cuts to on- I n California, we have a great irony on our hands. A task force organized by the University of California Office of the President has just completed a multiyear campus services are inextricably linked to the strength of the student major medical plan. On the Berkeley campus, 20% translates to a process during which mandatory health insurance was $1.6 million reduction in campus funding for health implemented for all students on UC campuses. The same and counseling services. We currently project a loss task force also articulated guidelines to meet "…the of 26 positions in our medical, counseling, and health responsibility of each campus to continue to fund on- promotion programs. For the 34,000 students who use campus health and counseling services…to provide a these services, there will be additional fees, reduced continuum of services…" and to help keep the health services, longer waits and increased referrals to the insurance premiums low. community — which already are costing students 20% Within one year of implementation came the state more next year because of local market forces. At a budget crisis and proposed cutbacks for 2003. For most time in California when educational fees are being raised campuses in the UC system, proposed cuts to the to support academic programs, students will experience a University translate into 20% cuts to student services. reduction in those services which are designed to support Will the budget crisis of the next few years pull the their engagement in those programs. rug out from under the University's vision? If we cut back And yet, the Berkeley health services staff is on campus-based services, will it increase costs to drawing upon creative ideas to keep services effective. students? Place a burden on the insurance benefits? Other departments, both academic and service, are Reduce responsive care? receptive to new partnerships. These include the teaching The impetus for the September 2000 Board of of our academic classes in the School of Public Health, Regents' decision to require health insurance as a condition and teaming up to improve outreach, prevention and of enrollment was pure and simple: the University did education efforts. Our after-hours advice service most not want to become part of the national picture, causing likely will merge with other after-hours departments on students to fail or withdraw due to a lack of access to campus, e.g. campus police, or with community after- 14 SP E C T R U M May 2003 " The Un i versity did not want to become part of the national picture, causing students to fail or w i t h d raw due to a lack of access to health care ." ON-CAMPUS STUDENT HEALTH AND COUNSELING SERVICES MAJOR MEDICAL PLANS Prevention/Education Intervention and Treatment Off-Campus Treatment Peer education, academic classes, Medical, counseling, mental health Medical and mental health workshops, community campaigns for individuals and campus for individuals for individuals and groups • Education • Crisis response and mitigation • Pharmacy • Major medical care Clinical education • Urgent consultations • Clinical lab/x-ray • Emergency care and Consumer education • Psychological assessment • Selected specialties (e.g. psychiatry, transportation Health education • Emergency and disaster response orthopedics, musculoskeletal, • Long-term treatment of • Campus community outreach • Communicable disease clinical gynecology, dermatology, physical chronic or complex Public health information response therapy) medical and mental Media and Web information • Urgent educational response • Social services health conditions Resources referrals (e.g. food-borne pathogens, • Case management for chronic • Specialty care • Consultation and advice bio-terrorism, TB, hep B) needs • Long-term therapy Aberrant behavior • Primary care, urgent care and • Nutrition (e.g. physical therapy, Risk management women's health • Medication management vocational rehab, • Disaster and emergency planning • Counseling and assessments • Academic program screening counseling, etc.) • Immunizations • Triage (e.g. physicals, travel screening) • Out-of-area coverage • Training • Referrals and insurance advising ü General and insurance administration ü Quality assurance, accreditation, program management ü Needs assessments and service evaluations ü Health policy and regulatory compliance Registration and other non-waivable fees* Insurance premiums *Most campus medical services charge some fee s for service. PRIMARY FUNDING SOURCE Source: Recommendation and Guidelines, Campus Health and Counseling Services Workgroup, University of California Office of the President, June 2002 hours emergency lines. Some of our counseling personnel be happening, the process for decisions, and what criteria will move to contracts with specific departments, and we are being used. will fund other staff through grants. Planning is in various stages at other UC campuses; Since much of our student population lives in the some student health services have been asked to develop surrounding community, we are meeting with City of scenarios for cuts greater than 20%. At UCLA, Deputy Berkeley Health and Human Services staff to explore Assistant Vice Chancellor Al Setton has been asked to collaborative options. In-house, we are moving certain plan for up to a 25% permanent cut, but to avoid reducing functions on-line, e.g., student health insurance waivers, student services. "This means we reduce the administrative immunization requirements and health histories. And, staff," he says, "but that won't be enough. So we will be we are reorganizing our practice plan to manage clinical introducing new fees ... And keeping our fingers crossed." patients with a reduced staff. Steve Lustig is Assistant Vice Chancellor, University Health and For our staff, the emphasis during this period has Counseling Services, and E xecutive Director of University Health been on communication and on viewing cuts within a n a Services at the U iversity of C lifornia, Berkeley. He recently chaired the long-range planning perspective. The goal is to be as UC Office of the P resident Advisory Committee on Student Health, as well as the statewide task force that established the guidelines for forthcoming as possible and to share information with all mandatory student health insurance and on-campus health services for staff — including the larger state picture and what may all nine UC campuses. He can be reached at email@example.com y.edu. 15 May 2003 SPECTRUM Campus Health Services: Surviving the Academy's Budget Crisis J. Ro b e rt Wi rag, HSD T ough times…war, terrorism, layoffs, shrinking economy, state governments in financial crisis, less support for higher education, salary compression, travel receives the same dollar amount from one year to the next, it is effectively a budget reduction because of increasing operating and personnel costs. The risk is a year-by-year restrictions…tough times, indeed….especially for campus erosion of services, including staff reductions. Clearly, this health service programs dependent on institutional funds method of financing the campus health service program is for financial support. Many in student health anticipate not appropriate for many, especially for those mid-sized to another year on their knees, begging for an infusion of large campuses that have student populations large enough cash to keep their programs afloat. to warrant an alternative financing arrangement, which If you are one of those, don't feel like the Lone can provide for a student health service that fully meets Ranger. Each year many student health care administrators the needs of students and is stable over time. face the challenge of financing their programs with enough Another shortcoming of the allocation method is the money to, at the least, maintain essential services. illusion it creates…leading students to believe the health services are "free." It may also lead them to believe the SHS The University Giveth, The University Taketh Away is of lower quality. "What you don't pay for can't be worth The most vulnerable are programs financed very much." It is a deceptive practice and should be avoided. exclusively by an allocation from university funds — one of the two extreme financing systems that can threaten Piecework: What Pieces At What Price? student health programs' ability to maintain access to care The other extreme is the exclusive fee-for-service and at least a basic range of services. (The other extreme method of financing…no health fee and no allocation of is pure fee-for-service, which is discussed below.) The institutional funds. The risks to the program financed vulnerability of the allocation method rests with the solely with fee-for-service differ from those noted above. ability and willingness of the institution to continue to While historical data related to students' demand for support the scope of the health services provided. In this chargeable services and good data on the services actually model, all on-site services are expected to be covered by provided in the previous year are a relative gauge of the annual allocation. The argument in favor of this potential patient revenue, there is no guarantee from one financing model is the cost-savings to students (no out-of- year to the next that patient demand will remain stable. pocket costs), to the program (no personnel costs for As the environment changes and the cohort of eligible, cashiering or billing activity), and to the institution (no potential patients/customers changes, a decrease in demand staff necessary to handle collections since no charges are could have a dramatic and adverse impact on the financial transferred to the student's institutional account). viability of the program. Similarly, an increase in demand A significant problem with the allocation method is could overwhelm existing resources, leading to long waiting that it forces the Student Health Services (SHS) director times, briefer visits, and highly stressed staff. Another to "plan to the budget" rather than "plan to the need." downside is the financial barrier to access for some students, That is, the allocation method determines the scope of especially for those who are uninsured or underinsured services of the program and may not adequately address and have little or no means of reimbursement for out-of- students' primary care needs, much less the needs for pocket medical care costs. prevention and health education. Even if the program To be successful, the fee-for-service model is 16 SP E C T R U M May 2003 "College health is at the nexus of two worlds, both of which a re feeling great financial pre s s u re — higher education and the greater health care community." dependent on a combination of the number of students financial barrier to access of campus-based health services who walk through the door and the chargeable (and is eliminated or lowered as well. collectable) services they receive. The mix of undergraduate, A further complication with the exclusive "fee-for- graduate students, and dependents is also a key variable. service" operation is staffing. In addition to clinical staff, In addition, the services provided under this model tend a well-organized "back office" business operation is essential to be limited to those that generate revenue…mostly to manage billing and collections. Finding the right clinical in nature, to the exclusion of primary prevention balance between clinical staff and demand is no small (health promotion and disease prevention) that generate challenge. If demand drops for any reason, the resultant little, if any, revenue. Other variables include students' over-staffing may be very appealing to the consumer, personal finances, perception of the quality of the because patient care needs can be expedited, and also to program, willingness to have a health service charge the staff, because work loads become lighter. However, an appear on a bursar bill or insurance claim, and the type excess of personnel will very quickly increase expenses of insurance coverage (if any). If "the pain in the relative to revenue. Under-staffing may also prove to be a wallet exceeds the pain in the belly," they will bypass the program detriment. Too few staff to adequately meet program and either ignore the problem, resort to self- demand may result in customer dissatisfaction, loss of remedy or wait until they go home to see the family confidence in the program, and deterioration of image to doctor. If they belong to an HMO and are "out-of- the point that future decreases in patient volume threaten network" and "functionally uninsured" when on campus, the delicate balance of expenses and revenue required to they are also more likely to bypass the campus health maintain a fiscally sound program. (A dynamic eloquently service program. 1 described by Yogi Berra, who observed "That place is so The prospect for success using the fee-for-service crowded nobody goes there anymore.") Furthermore, if only model (no allocation, no health fee), as well as for automated systems are not in place to support and expedite the "Gold Standard" model discussed below, can be business functions, the "back office" personnel costs may enhanced if the institution adopts a mandatory with further erode the financial strength of the program. right-of-waiver (hard waiver) health insurance policy. In between these two extremes there exist a variety Students who are required to purchase the campus- of financing combinations that have to be considered: endorsed medical insurance plan — because they either allocation and fee-for-service; health fee, allocation and do not participate in another plan or their plan does not fee-for-service; health fee and fee-for-service. In an ideal meet established minimum coverage benefit thresholds world, any combination can work. Unfortunately, we are — help ensure financial stability of the student health a far cry from an ideal world. College health is, in fact, at program. Furthermore, if the plan provides hassle-free the nexus of two worlds, both of which are feeling great reimbursement for chargeable (insurance-reimbursable) financial pressure — higher education and the greater services, or, if the health service is able to assist students health care community. Like the postdocs who are neither with filing claims and accepts assignment of claims, the "faculty" nor "student," college health workers tend to health service and students alike are the beneficiaries. have a similarly diffused identity (neither "faculty" in the The health service captures the revenue, the student's out- context of the Academy, nor real doctors/nurses when of-pocket costs are either eliminated or reduced, and the compared to their counterparts elsewhere). If the allocation 17 SP E C T R U M May 2003 " The Gold St a n d a rd is the student health service which functions as the university and is financed by a combination of an adequate and method treats the campus health service as a stepchild of community, accessible to all students for the express the Academy and the exclusive fee-for-service method purpose of helping them maintain a level of wellness concentrates only on those services that maximize revenue, and functioning to achieve academic success. It is separate what model has the greatest prospect for success? from all other tuition-related benefits of the institution Consider a model that insulates, but does not and is recognized as such. And, the health fee is a relatively isolate the student health service program from other parts easy sell, especially to parents who know how expensive of the Academy, one that projects independence and self- health care is, or can be, if minor problems are exacerbated determination, promotes accountability, is more proactive by delays in receiving care. Having ready access right on than reactive, and applies sound business principles. campus is also a clear and well-understood benefit. The health fee makes it possible to dedicate resources The Gold Standard to campus-wide, primary-prevention initiatives, including The Gold Standard is the student health service promotion of healthy behaviors. Since these services which functions as an auxiliary operation of the university do not generate fee-for-service revenue, the use of a and is financed by a combination of an adequate and portion of the health fee as a principal funding source clearly identified health fee and fee-for-service. Auxiliary is justifiable. Even for that student who does not have a programs in universities are designed to pay their own way. need for clinical care, the health promotion and disease They function as a business. They employ staff sufficient prevention programs and services are available and have to meet consumers' demands, have well-defined policies been demonstrated to reach most students at some time and procedures, adhere to rigorous standards and best during their academic career. The health fee is akin to the practices, and adapt to the fluctuating demands and premium paid for a basic insurance policy that provides sensitivities of customers. certain benefits. By spreading the risk over the entire Migrating to the Gold Standard for those not already student population, the health fee may obviate, or at least there does not have to be an onerous undertaking. It will, reduce, the need to institute a visit charge to help cover however, require a shift in the institution's philosophy. the program's expenses — a cogent argument over the Anticipate resistance. Nonetheless, in today's difficult previously discussed fee-for-service model, which tends economic times, the timing could not be better. The notion to financially penalize the user for getting sick or for of redirecting university funds currently allocated in support seeking care. of the campus health service program to other areas of critical institutional needs can be extraordinarily persuasive. Setting the Health Fee. Setting the health fee is no small Some may suggest a designated health fee or a hard- challenge. If one subscribes to the concept of "budget to waiver student health insurance policy will add to the total the plan," the first task is to clarify the student health costs of the education, raising the question of "affordability." service's plan to ensure the program is the driving force in There is a strong counter-argument when one considers determining what the health fee should be. The challenge the higher charges students pay for services when they is greater than the financing by allocation method (which bypass the student health service. These hidden, but very real, forces one to "plan to the budget," limiting the scope of costs should be considered when measuring affordability. services to the funds available). Many factors come into play. • What does the historical experience regarding patient The Health Fee. The separate, identifiable health fee demand suggest? makes an important statement — that the health service • Are there unmet primary prevention and clinical needs program is a value-added resource to the academic identified from survey research? 18 SP E C T R U M May 2003 an auxiliary operation of clearly identified health fee and fee-for-ser v i c e ." • What is the extent of other health-related resources number by two to arrive at the semester health fee. (Some on- and off-campus? campuses weight the semesters differently, and most • What is the age, gender, nationality of the population to have a separate fee for the summer session.) The clearly be served? identifiable health fee spreads the risk among all students • What is the residential/commuter mix? and is set at a level which provides assurance that specified • What are your options regarding staffing ratios, the services will be available when needed and that number and type of staff necessary to provide your any associated charges will be kept to a minimum required scope of services (include or exclude mental compared to prevailing rates in the local community — health and health education services)? a real competitive advantage for any campus health service • What are the operating costs (historical and projected)? program. [Editor's note: Many institutions have systemwide • What is the appropriate funding for depreciation of the limits on fee increases, including designated health service fees.] physical plant and equipment and/or funding of capital project reserves? Setting Charges for Services. Times, they are a-changing. Regarding this last question of funding capital The practice of "giving away medicine" is history for many, projects, do not underestimate the value of the facility if not most, campus health service programs today. This is where health services are provided. Is it accessible (can not new. For example, in the mid-60s, by an act of the students get to it), not just location, but transportation North Carolina legislature, student health service programs and parking as well? Is it available (at times when students were required to function as self-supporting auxiliaries, need it)…hours of operation? What does it look/feel ineligible for tax dollar or tuition support. Colleges and like (welcoming, aesthetic)? Is it configured to promote universities in North Carolina were permitted to assess a confidentiality/privacy, patient flow (intake and egress)? mandatory health fee to make such services available. In the Since students (like most health care consumers) make 70s and 80s, as tax dollars in support of higher education decisions about quality of care with their eyes, if the facility began to dwindle, many schools, such as the University of doesn't look like it provides quality care, opinions Arkansas, shifted from an allocation to a health fee plus are quickly formed and these initial impressions are fee-for-service to continue providing health services to hard to reverse — even if all other invisible measures of their students. quality are considered (accredited, staff credentials, latest If the decision is made to assess fees for those technology, etc.). services/procedures typically reimbursed by health insurance One approach to setting the semester health fee plans, setting charges for those services can be difficult. is to determine the funds that will be required to cover Most universities want to price their services close to, but all or most of the fixed costs of the program, namely below, the prevailing rates in the surrounding community. salaries, fringe benefits, liability insurance and institutional Trying to gain access to "charge masters" from area clinics overhead charges (if any). The balance of the budget and hospitals, however, can be a frustrating experience. — operating costs — can be made up by charges for Another option is available from the Healthcare Financial services paid for by cash or through health insurance Management Association, which publishes a Customized reimbursement. To simplify, take the total annual fixed Fee Analyzer called MEDICODE, which enables an costs (using historical budget data plus any substantive organization to compare its fees against national bench- reductions or enhancements to the scope of services) and marks. (The address is Ingenix, Inc., 2525 Lake Park Blvd., divide it by the projected annual student enrollment to Salt Lake City, UT 84120.) determine the student health fee per year. Divide that Perhaps finding the median charge for various 19 May 2003 SP E C T R U M " If 'the pain in the wallet exceeds the pain in the belly,' students will bypass the pro g ram and either ignore the p roblem, re s o rt to s elf-remedy or wait until they go home to see the family doctor." services (50% charge more, 50% charge less) in your area • Subjects itself to the rigors of accreditation to demonstrate will serve as a gauge to set your own charges. You may that standards of quality are being addressed. find it advisable to set the fees at or below the median The Gold Standard method of financing sees its charge as an additional benefit of the health fee — having finest hour in times of economic distress. It helps insulate access to services at charges lower than prevailing rates in the campus health service from the financial stressors the surrounding community. of state and tuition support. Health service programs independent of tax dollars and functioning as a self- Sowing the Seeds for Success.It's all about leadership. It's supporting, auxiliary operation are surviving, and even about knowing what to do and how to do it. An excellent thriving, if the following conditions are met: the program source of guidance is the chapter on "Administration and is well managed; is fiscally sound; is meeting the needs of Financing College Health" written by Ericson, Mills and those served; receives high marks for customer satisfaction; Ledlow in the newly-published text The History and has the confidence of constituent groups, especially those Practice of College Health, edited by Turner and Hurley.2 who manage the annual fee-review process; and has In the same text, Stephen C. Caulfield's chapter on the endorsement of any faculty member, administrator Student Health Insurance discusses the insurer's role in or staff member who would say "If I was sick or hurt helping finance student health centers (pp. 345-346). A and needed medical attention, I would use the student well-crafted student medical insurance plan that reimburses health service for my primary care needs…as my first the student health program for chargeable services choice, if I were eligible to do so." Now, that's a makes a significant contribution to the financial health "Gold Standard" outcome! of the program and provides a return on the premium students pay.3 J. Robert Wirag, HSD, has served as the Director of the Student n o Health Service program at The U iversity of N rth Carolina at Chapel In summary, the Gold Standard of financing: Hill since January 1999. This is his third directorship, following • Provides dependable revenue from the health fee; The University of Texas at Austin, 1987-95, and The University • Makes a statement of value…spreads the risk…helps of Arkansas, 1983-87. His professional career spans a period of the institution protect its investment in its students by over 30 years and includes faculty appointments at The University of e Notre Dame, DePaul University and The P nnsylvania S tate promoting retention; v University, where he ser ed as the Director of Health Education for • Promotes the college health model: health promotion, University Health Services. Dr. Wirag is past president of the disease prevention, clinical services; American College Health Association, a board member of • Includes direct reimbursement to the student health the American College Health Foundation, and an active participant in ACHA's Consultative Services Program. He can be r ached e service program from the institution-sponsored medical at email@example.com. insurance plan for chargeable services covered by the plan; Notes: • Facilitates access; 1. See the special issue of Spectrum, March 2003, "The Uninsured • Reduces costs associated with the higher education Student: a Failing Grade." experience; 2. Ericson, Mills and Ledlow, "Administration and Financing College Health," The History and Practice of College Health, ed. Turner, Hurley • Makes "budget to the plan" more viable; 2002: 42-78. • Provides a well-established referral network to specialists, 3. Caulfield, "Student Health Insurance," The History and Practice of hospitals and rehabilitation services; and, College Health, ed. Turner, Hurley 2002: 345-6. 20 SP E C T R U M May 2003 H ow We Do It Columbia University: Columbia Area Volunteer Ambulance Margo Amgott and Hannah Krimins N ow in its 41st year, Columbia University's Emergency Medical Services — CAVA (the Columbia Area Volunteer Ambulance), as it is known on campus — is critical since other New York City emergency medical services can take as long as 30 minutes to reach an emergency site. one of the oldest collegiate EMS programs in the country. CAVA is known not only for its longevity, but also Staffed by student volunteers, known as the Corps, who for innovative programming. Strong member initiative are New York State emergency medical technicians, CAVA is encouraged to continuously improve the program, operates in accordance with the rules and regulations of the making it more professional and responsive. Training Regional Emergency Medical Services Council. CAVA is and leadership development are key in defining available to respond to emergency calls on campus and membership, and the Corps has worked diligently over from the surrounding community. the past few years to ensure that an effective system is Begun in 1962, after students and staff transported a in place. faculty member to the local hospital, the idea grew for an New student volunteers begin as probationary on-campus EMS service. In 1974, the University bought members, taking an EMT class run by CAVA that is its first vehicle, a van outfitted as an ambulance. In 1980, offered both to students and other members of the the program was named CAVA and became state-certified, community. Each probationary member then goes with service available 24 hours a day, seven days a week through an individualized training program before throughout the academic year. becoming part of the Corps. The program is designed so As a division of Health Services at Columbia (HSC) that new members with no previous experience become and Columbia's Security Department, CAVA is a key part Drivers, then Crew Chiefs, within five semesters. Crew of campus emergency response services. It works as a Chiefs are responsible for all aspects of a call, including bridge between the campus community and health care logistics, patient care, and safety. options: HSC, the local emergency department (or other Volunteers are then introduced to practical examples facilities as required), or self care. Health Services provides and experiences. After every shift, a trainee goes through medical direction and manages the finances, while Security an evaluation and self-appraisal process. Trainees who manages the vehicle and dispatch. It is the student pass the probationary period and are confirmed as volunteers who run the day-to-day operations and lead members then take a defensive driving course. initiatives to enhance CAVA. CAVA made the driving course mandatory in 2000, The Corps consists of 50 members, from all areas while New York State added it as a requirement the of the campus, who manage 600-700 calls per academic following year. year. This number grows annually, primarily due to more The leadership of CAVA is carefully structured, widespread awareness of CAVA's services and an increased with both an Executive Board and a Medical Board. comfort with the confidential nature of CAVA's work. The Executive Board consists of the Director, Response time is 4-5 minutes, well below the standard Captain, Operations Officer, and Personnel Officer. industry response time of 8-10 minutes. This is particularly The Medical Board is comprised of Crew Chiefs. 21 May 2003 SP E C T R U M " C AVA has become better integrated into the Un i versity infra s t ru c t u re. a role in determining Security and Un i versity policy on calls related to CAVA has elections on the calendar year, which allows secure a new ambulance. The process began with the new board members to overlap at least one semester CAVA facilitating discussion between HSC and Security, with the previous board members. This overlap allows detailing how each service defined its role and how they for a seamless transition between outgoing and were interconnected. They demonstrated that the incoming leadership and fosters collaboration within current ambulance needed immediate replacing. After the CAVA hierarchy. investigating what type of vehicle and specifications Health Services provides medical oversight. As part were needed and then selecting a vendor, CAVA senior of the program's quality assurance, a physician reviews leadership worked with University administrators to every chart and follows up with patients as needed. identify resources to fund the new ambulance. HSC Particular attention is paid to "repeat customers," linking and Security shared the cost of the vehicle, along with a them to other health or counseling services as appropriate. contribution from Chickering. Delivery is anticipated in The CAVA leadership updates protocols and offers May 2003. expanded services as State regulations permit. In November Transport or medical support by Columbia's EMS 2001, when it became legal for EMS to administer two is provided without a fee to the patient; no bill is received emergency medications — epinephrine and albuterol, by the recipient of care. Support of CAVA's operations used to treat severe cases of allergic reactions and comes from Health Services, Columbia's Security asthma attacks, respectively — the Corps updated their Department, fees earned from services provided for protocols and developed training sessions to ensure athletic events on and off campus and student transport proper use. fees paid by the student medical insurance program CAVA has become better integrated into the administered by Chickering. The program occasionally University infrastructure. Members have worked receives donations from grateful patients, and is high on assiduously to have a role in determining Security and the list of fundraising priorities for Health Services. University policy on calls related to alcohol and psycho- This program is a model for the establishment of logical emergencies. They have also become more new collegiate EMS programs and for the improvement involved in contingency planning for campus events of existing programs. At the National Collegiate EMS and are called on more frequently to be available for Foundation (NCEMSF) Conference in February 2003, high-profile campus functions and activities. CAVA is CAVA was awarded the Striving for Excellence Award, present at University athletic events on- and off-campus, which recognizes the program as a leader in collegiate providing first response medical care to athletes and EMS. At the same conference, CAVA members lectured on bystanders. And on September 11, 2001, as well as its training program and on the purchase of an emergency September 11, 2002, the Corps was out in uniform in an vehicle. Joshua Marks, director of CAVA through effort to provide the community with a sense of comfort December 2002, was honored with the 2002-2003 and safety. NCEMSF Collegiate EMS Provider of the Year Award. CAVA has also been actively engaged in finding Joshua also was awarded the Lewis Barbato Award by the resources to fund its program. One of a handful of American College Health Association (ACHA), which collegiate programs that drive a University-owned vehicle, will be presented to him in May 2003 at the ACHA CAVA worked with the University over three years to Annual Meeting. 22 SP E C T R U M May 2003 Members have worked assiduously to have alcohol and psychological emergencies." Staffed by student volunteers, known as the Corps, who are New York State emergency medical technicians, CAVA operates in accordance with the rules and regulations of the Regional Emergency Medical Services Council. CAVA is available to respond to emergency calls on campus and from the surrounding community. o executive director of administrative planning. Before joining Clumbia In the coming years, CAVA plans to work towards in 1991, she spent seven years in senior administrative positions in becoming an even more integral part of the public health New York City and NewYork State go vernment, serving as budget and community. With a grant from Columbia Community support services director for New York City's Department of Juvenile 's Justice and director of special projects at the CityHealth Department. Service, CAVA has been able to begin the initial stages of Prior to that she managed health services for women in North a CPR program for the greater community in the v o Brooklyn and ser ed on the staff of the pr vost of the SUNYD ownstate Morningside area. Under direction of Jordan Brafman, Medical Center in Brooklyn. She has a BA from Barnard College and Director for 2003, CAVA has proposed extending services an MPA in health policy and management from New . York University She can be reached at email@example.com. throughout summers and breaks in the academic calendar, further positioning CAVA within the reliable infrastructure e Hannah Krimins is program coordinator at Health Srvices at Columbia. She manages a range of special projects, including immunization of University services. compliance and researching and writing new policy initiatives for the v y service. Previously, she ser ed as marketing associate for The Advisor e Margo Amgott is currently xecutive director of Health Services for Board Company, a health care strategic research consortium. Hannah el Columbia University, directing student health, counseling and w lness holds a BA from Barnard College and is a post-baccalaureate student ' programs on Columbias Morningside campus. P reviously, she was at Columbia University. 23 May 2003 SPECTRUM Prescription Costs: Does Your Student Health Insurance Plan Measure Up? Paul A. Cronin, FSA T he consensus, as reported by major benefit consulting firms' survey research, is that prescription drug costs are increasing at an annual rate of between 16-22% for an increase in the number of people in treatment for a particular disease. group employer plans in the current year. Student health New drugs may have programs have not only felt the same pricing pressures, major benefits, such as but are often more sensitive to them because outpatient reduced side effects or prescription drugs usually represent a higher proportion greater clinical effective- of the health premium dollar under student health ness, but may also lead to plans (this is because employer plans typically have greater utilization [e.g., higher medical, surgical and hospitalization costs than "diagnosis rates for student plans). depression doubled after The components, or drivers, of these predicted high the SSRIs (Prozac-like drug trends are: drugs) became available"].1 • Price inflation — prescription drugs are a major In addition, the influence Figure 2: The top individual drugs contributor to the Medical Consumer Price Index (CPI). of new drugs on drug used by the student population • Product shift (also known as the "treatment substitution utilization is further (ranked by amount paid). effect")1 — newly approved drugs replace older drugs in compounded by the more recent phenomena of direct- the therapy of established patients, but are often more to-consumer marketing of drugs. expensive than the drugs they replace. • Leverage — the cost impact to a drug benefit • Utilization (also known as the "treatment expansion plan will be greater because of the leveraging effect a effect")1 — the introduction of a new drug often leads to co-pay has on the benefit paid. An increase of, say, 10% in the retail price of a drug will have an 11-20% increase in the benefit paid, depending on the applicable co-pay (the greater the co-pay, the greater the leveraging effect). For example: Your prescription benefit plan has a $20 brand co-pay and is then paid at 100%. A drug which costs $50 costs your benefit plan $30 ($50 Rx - $20 co-pay = $30 claim). A 10% increase in the retail price of this $50 drug now costs $55. If you choose to maintain the same prescription benefit design for the next year, then this drug will cost your plan $35 ($55 Rx - $20 co-pay = $35), or an increase of 17%. Since high prescription drug cost trend is a reality that is projected to continue, it may be helpful to share some general observations about student health Figure 1: Drugs utilized by the student population (grouped by class and prescription drug programs, as well as a breakdown of the ranked by amount paid). various benefit plan design features currently in place. 24 SP E C T R U M May 2003 " The use and price of prescription drugs will continue to grow for college students. St rategies to make these drugs affordable thro u g h i n s u rance must include appropriate utilization, prudent purc h a s i n g , generic substitution, and reasonable consumer cost-sharing." was 5.7, when the claimant wasn't restricted by benefit plan maximums and oral contraceptives were excluded.* In terms of what drugs are utilized by the student population, the drugs were grouped by therapeutic class and then ranked by amount paid (Figure 1).* The top individual drugs, ranked by amount paid, are listed in Figure 2.* Psychotropic drugs have a very high utilization among the student population and account for 20-22% of the total cost of a student health outpatient prescription drug program. Benefit Design Features The next year, 2002- 2003, we underwrote 76 outpatient prescription drug programs. Figure 3 Figure 3: A review of 76 outpatient prescription drug programs provides provides the distribution the distribution by benefit maximum (2002-2003) and projects the by benefit maximum. number of claimants that will reach each maximum in 2003-2004. Using the number of claimants who reached General Observations their respective benefit For the academic year 2001-2002, The Chickering maximums in the 2001- Group underwrote 71 student health outpatient prescrip- 2002 academic year, we tion drug programs. An analysis of these programs projected the percentage provided the following observations: of claimants that would • Prescription drugs, as a percentage of the total cost of a reach each maximum in student health insurance program, ranged from 6-15%, 2003-2004 for a drug depending on the prescription drug benefit maximum. program with $10/20 • Brand drugs accounted for 60% of the prescriptions co-pays. filled, but 88% of the cost of drug programs. Figure 4 provides • The average retail cost of a brand drug was $72, for the distribution based on generics, it was $20. generic/brand co-pays that Figure 4: Distribution by generic/ • The average number of prescriptions filled per claimant are currently in place. brand co-pays already in place. * A majority of drug programs do not cover oral contraceptives except where there is prior authorization. This is now changing as state mandates and other pressures for inclusion of oral contraceptives are felt. 25 May 2003 SPECTRUM Points to Consider Prescription Benefit Managers Accused of Steering Based on these observations and data, we suggest Physicians and Patients to Higher Cost Drugs you consider these plan design features: • The co-pay for brand prescriptions should be at least Recently, the American Foundation of State, County $20. We base this recommendation on the assumption and Municipal Employees and the Prescription Access that the average retail cost of a brand drug will be $85- Litigation Project (PAL) have sued four Prescription 100 for 2003-2004 and that 20% cost-sharing on the part Benefits Managers (the PBMs), which together control of the student is reasonable. 80% of the market, alleging that these PBMs have • The benefit maximum should be at least $1,000, an entered agreements with drug companies to encourage amount that should provide sufficient coverage for 90% customers to use the most expensive drugs. One of the of the claimants. named PBMs, Express Scripts, Inc., announced on • Mail-order drug programs should not be considered March 17, 2003 that it will phase out its practice of because of the high potential for theft on campus. accepting payment from drug makers in exchange • Finally, strong incentives should be given to the use for promoting certain products through letters and of generics. In addition, student health centers should telephone calls to doctors and patients. educate student consumers about brand name prescrip- tions that are coming off patent, and, if possible, work other practice pattern review programs. Both the research with students to migrate to the newly available generic literature and anecdotal evidence from student health alternatives (Figure 5). service directors suggest that both strategies have merit, but We have limited our observations and recommenda- to some degree these interventions go to issues of physician tions to plan design features. We have not mentioned the decision making, which we believe are outside of the use of formularies, or the use of drug utilization review or purview of the insurance program. Finally, we have not discussed the utility of campus- based pharmacies in managing costs, again because we believe it is separate from the insurance program. But, unlike formularies and drug utilization review, campus- based pharmacies do not impinge on physicians' decisions. The reported experiences with campus pharmacies is almost universally favorable among student health service directors, who cite the lower drug costs, higher point- of-prescribing drug interaction checks, superior patient education and improved compliance. Given recent concerns about prescription benefits managers (see sidebar), campus- based pharmacy programs should be considered. The bottom line is this: the use and price of pre- scription drugs will continue to grow for college students. Strategies to make these drugs affordable through insurance must include appropriate utilization, prudent purchasing, generic substitution, and reasonable consumer cost-sharing. Paul A. Cronin is Senior Vice President of Actuarial Services at The Chickering G roup. He is a Fellow of the Society of Actuaries and o a member of the American Academy of Actuaries. He hasver thirty years of corporate and consulting actuarial experience in the group life, health and disability arenas. Paul can be reached at pcronin@ chickering.com. Note: 1. Carter, David M. and Mark McClellan. "Is Technological Change in Figure 5: Prescription drugs that will come off of patent protection in the Medicine Worth It?" Health Affairs (Sept/Oct 2001): 11-29. Volume 20, near future. Number 5. 26 SP E C T R U M May 2003 BRIEFLY NOTED... Editor's note: On March 25, 2003, The Wall Street Journal I am a board-certified family physician with seven ran an article on the front page of their second section years' experience. I suppose I could be on the fast track entitled, "Why You Shouldn't Get Sick at College—Strapped and driving a Porsche, but I drive an old Honda with more Colleges Cut Medical Staff, Close Infirmaries: The Best (and than 150,000 miles, live in a rented house and pack my Worst) Health Services." One of the introductory lines was, lunch for work. I make $30,000 a year less than my least- "Faced with shrinking budgets and the same runaway costs paid colleague and I won't get a raise ever. I take calls 24 that are squeezing the overall US health care system, schools hours a day, 365 days a year so that a student with stomach are being forced to lay off doctors and pare back everything pain won't have to go without care, a rape victim won't from weekend hours to around-the-clock advice lines staffed have to go to the ER alone and a distraught undergrad won't by nurses." Several days later, The WSJ published these two commit suicide because his girlfriend broke up with him. letters. With permission from the authors, we reprint them Thank you again for choosing to write about this here in their entirety. little-understood, but essential, area of medicine. I hope your words will help all of us to understand each other In regard to Anne Marie Chaker's March 25 story in better. It might just make the case for me with the admin- The Wall Street Journal, "Why You Shouldn't Get Sick at istration for a raise in health fees. College—Strapped Schools Cut Medical Staff, Close Thomasina H. Sharpe, MD Infirmaries: the Best (and Worst) Health Services": University of South Alabama Thanks for bringing to light many of the problems in Mobile, Alabama college health care. A USC senior summed it up very well in the last paragraph, "You're not prepared, when you go As the medical director of a university health service, to college, to be in charge of your own health. It's actually I'm all too familiar with the financial constraints facing a big deal." That's why I love practicing college health: many colleges and universities as they try to provide quality educating the students, parents and administration about health care. At MIT, we work hard to provide high-quality what a big deal it is. care at a reasonable cost and to help our students and their College health is more than a walk-in clinic — you can families make the difficult transition from home- to get that at any "doc-in-a-box." We cannot be compared to school-based health care as smooth as possible. your regular family doctor either, since we provide specialty As your article pointed out, it can be difficult to care to a distinct population of patients. We are a full-service make health care available when it's needed. While most center that offers medical, psychiatric and educational of us in Cambridge run on Eastern Time, I often say our counseling, testing, laboratory results, X-ray, and pharmacy students tend to keep schedules more suited to a location services, all for $15 a semester. I challenge you to find several time zones to our west — waking later in the clinicians anywhere who will evaluate you, test you, perform morning and hitting their stride in the late afternoon and a pelvic exam, and treat your sexually-transmitted disease evening. To address this issue, MIT Medical offers a walk- for less than $15 and then spend an hour counseling you on in service until 7 pm on weeknights, an on-site physician what to do now, how to talk to your partner, how not to get overnight and on weekends for urgent care, and specialists it again, how to protect yourself, give you condoms and/or who are on-call outside of regular office hours. birth control, provide emergency contraception if needed I applaud you for encouraging parents and students and hold you while you cry. Usually all the same day you call. to think about the breadth and depth of health care services That's what I do every day, in between diagnosing available when they shop for colleges. new onset diabetes, ankylosing spendylitis, counseling William M. Kettyle, MD on weight loss, treating malaria, doing administrative Medical Director, MIT Medical Department duties and caring for students with the flu. And I love it. Cambridge, Massachusetts 27 May 2003 SPECTRUM PUB LI SHED BY THE CHICKERING GRO U P The Chickering Group, established in 1955, is an insurance product and services company which has provided student health insurance to colleges and universities as its exclusive business since 1980. In partnership with Aetna, one of the country's largest health insurance companies, Chickering offers students access to more than 500,000 physicians, hospitals and other health care providers throughout the United States. The Chickering Group now serves 250,000 students at approximately one hundred colleges and u n i ve r s i t i e s in twenty-two states and the District of Columbia. Editorial Board Managing Editor William A. Christmas, MD, FACP Frederick H. Chicos Gillian C. Buckley Duke University President, The Chickering Group Shonda Craft, MS Stephen C. Caulfield Art Director The Ohio State University Chairman, The Chickering Group Feroza Unvala Margo Post Marshak, JD Linda M. Ragosta, EdD California Institute of Technology Vice President for Institutional Affairs, Marketing Communications William A. Payton The Chickering Group Manager University of Missouri Christine Murray Evelyn Wiener, MD University of Pennsylvania Student Health Spectrum is published by The Chickering Group. Back issues of Student Health Spectrum are available at www.chickering.com. If you would like to see a topic covered or would like to be a contributing writer, please contact Marketing Communications Manager, Christine Murray, at firstname.lastname@example.com. Chickering congratulates Ralph Manchester of the University of Rochester on the completion of his highly- successful term as the President of ACHA, and offers Reginal Fennell of Miami University of Ohio every good wish as he assumes the presidency. We also congratulate Spence Turner from the University of Kentucky on his well-deserved Lifetime Achievement Award, and all of the other ACHA awardees and newly-elected Fellows. THE CHICKERING GROUP 1010 Commonwealth Ave nu e B o s t o n , Massachusetts 02215 (617) 582-5000 (617) 582-5001 fa x www.chickering.com
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