Managed Care and School-Based Health Centers: Title and subTitle BreakUse of Health Services FREE

PROVIDING EFFECTIVE and comprehensive physical, mental, and preventive health care for adolescents has been a complicated issue for health care providers and delivery systems, parents, school systems, and adolescents. During the last 2 decades, as the array of adolescent health problems has increased, the barriers adolescents face in accessing physical and mental health services have emerged in sharp focus.^{1 - 7} Prominent obstacles include the availability and accessibility of physical and mental health services, confidentiality, and insurance coverage. Indeed, 9.8 million children and adolescents younger than 18 years had no health insurance at any time in 1995. During a 28-month period in 1992, 1993, and 1994, 30% of all children and adolescents younger than 18 years lacked health insurance for at least 1 of the 28 months (20.4 million).⁸ Many more adolescents are underinsured, with health insurance that does not include preventive care, counseling, substance abuse treatment, or other needed services.⁹

In response to the troubling physical and mental health status of many adolescents in the United States, and because of the desire to establish effective prevention and early intervention programs, there has been a resurgence of interest in the school as a focal point for integrating comprehensive health education with the provision of basic primary and preventive health and mental health services. Many of the most significant and costly national health problems are in large part caused by behaviors established during youth, including lifestyles, activities, and behaviors that cause unintentional and intentional injuries; drug and alcohol abuse; sexual behaviors that cause sexually transmitted diseases (STDs), including infection with the human immunodeficiency virus (HIV) and unintended pregnancy; tobacco use; inadequate physical activity; and dietary patterns that cause disease.¹⁰ Focusing on preventing these behaviors has become increasingly important.

An emerging approach to these issues has been the development of school-based health centers (SBHCs) structured to provide basic physical and mental health services in the school. This model has several compelling features as a delivery system for adolescents: it reduces physical barriers to access,¹¹ improves compliance and follow-up,¹² offers self-initiated confidential care,¹³ focuses on early identification of high-risk problems,¹⁴ provides an array of services that can be customized for the adolescent population,¹¹ integrates health promotion into the school environment,¹⁵ and uses midlevel practitioners to reduce health care costs.

The number of SBHCs has increased substantially during the last decade, from 40 in 1985 to 900 in 1995.¹⁶ These health centers, most often supported by mixtures of grant money and local agency in-kind resources, have the potential for addressing the major issues facing health care of adolescents by having health and mental health care services available at a location where most teens spend substantial amounts of time.

However, the most important issue facing SBHCs is that of sustainable funding. The prospect of long-term funding from school district budgets is poor; health care is not a core business function of public schools, and our tax-averse environment seems unlikely to support expansion into this area. Foundation grants are not intended as long-term funding streams, and local youth-serving agencies have difficulty sustaining these expanded services on existing budgets. This gap leaves health insurance entities and public health funds as the most logical and perhaps only viable funding sources for these programs. Given the competitive health economic environment, insurance payers are not looking for additional areas in which to spend purchasers' dollars; yet, an increasing number of adolescents served by SBHCs are insured through managed care. The proliferation of SBHCs has coincided with the growth in managed care. An estimated 149 million Americans received their health care through health maintenance organizations (HMOs) and preferred provider organizations in 1995.¹⁷ Thus, to encourage reimbursement of SBHCs, the value of these programs must be documented for insurers, managed care organizations, and health care consumers.

To explore the potential value of SBHC services in the current health care environment, Kaiser Permanente of Colorado, Denver (KPC) and the University of Colorado Health Sciences Center Department of Pediatrics, Denver, undertook a collaborative study of the use and utility of SBHCs. The study was designed to compare the use of primary and subspecialty physical and mental health services for adolescents who were enrolled in managed care and had access to an SBHC with that of adolescents enrolled in managed care without access to an SBHC. Specifically, patterns of use were analyzed for physical health, mental health, and substance abuse services; preventive health services; and after hours (emergent or urgent) care services.

The Denver SBHCs began providing health services in April 1988. The 3 high school SBHCs included in the study have a combined student body size of 3900 and serve an urban, inner-city student population in grades 9 through 12. By academic year 1990-1991, medical and mental health services were stable and fully operational. Primary health and mental health services are provided at each clinic by a pediatric nurse practitioner or physician assistant, clinical social worker, and substance abuse counselor, all with additional training in working with adolescents. Supervision of the nurse practitioners is provided by physicians who spend some time on-site and are available on-call. After-hours coverage is shared by the pediatric nurse practitioners and physician assistants by pager.

The SBHCs offer a broad array of basic primary physical and mental health services. Physical health services include health supervision examinations, including health screening, psychosocial histories, immunizations, and health guidance; diagnosis and treatment of acute illnesses and injuries; acute management of chronic conditions, such as asthma, diabetes, and epilepsy (the management of chronic conditions is usually coordinated with the student's medical home); treatment of common adolescent concerns, such as acne and weight management; gynecological examinations; pregnancy testing; and diagnosis and treatment of STDs, including HIV testing and counseling. Basic mental health services include mental health assessment and consultation; individual, group and family counseling; and crisis intervention. Substance abuse services include assessment and intervention for use of illicit drugs, mainly alcohol and marijuana. A few students were found to be abusing hallucinogens and other illegal drugs, and a small number were found to be abusing licit drugs. Tobacco use was not identified by substance abuse providers as warranting referral for their services. Student referrals to the substance abuse treatment provider originated from the medical and mental health providers, who, during an examination, identified substance abuse as a problem. Referrals also were made by school disciplinary staff when a student violated the school's substance abuse policy, which required a referral for counseling.

Health promotion services include one-on-one patient education, as well as classroom and community health education on a broad range of age-appropriate topics, such as the prevention of HIV infection and acquired immunodeficiency syndrome, other STDs, substance abuse, pregnancy, interpersonal violence, unintentional injury, and treatment of chronic diseases. Social services include identification of basic needs and referrals for food, shelter, clothing, legal and employment services, and public assistance.

All students attending a school with an SBHC are eligible to enroll and use services. Enrollment requires signed parental consent. No fees are charged to students, parents, or health care insurers for care delivered through the SBHC. During the study, SBHC and KPC had no fiscal or administrative relationship. The SBHCs are closed during winter and spring breaks and for 6 weeks during the summer.

Kaiser Permanente is a national group model, closed-panel, nonprofit HMO. Providing care since 1969, KPC currently has approximately 320000 members in the Denver metropolitan area, representing about 15% of the population and is the third largest health plan in the state. In 1993, KPC had approximately 20000 members between the ages of 14 and 18 years. A KPC outpatient facility is located within 1 mile of each of the 3 SBHCs. The range of benefits provided by the health plan includes all medically necessary outpatient, physician, diagnostic, treatment, home health, preventive, and short-term rehabilitation services; medical detoxification and assessment of the need for chemical dependency treatment or referral; and up to 20 outpatient mental health care visits and 45 days of inpatient mental health per calendar year. Data about the average household income of families insured with KPC are not collected; however, the subscribers are uniformly employed. Office visit copayments range from $0 to $15, although the provider may waive the copayment for special situations, for example, when a teenager who is unable to pay requests a confidential service. The KPC pediatricians, family physicians, and nurse practitioners have demonstrated a special interest in adolescent health by establishing an adolescent task force that meets monthly to address issues related to the provision of adolescent health care. The members of the task force support coordination of care with the SBHCs.

Screening for health risks in adolescent members at KPC occurs within the context of health supervision visits (eg, well-teen visits, camp and sports physicals, immunization visits, routine gynecological visits for sexually active teens). Medical forms for these office visits include brief checklists of health behaviors to be assessed and documented by the health care provider.

Adolescents are encouraged to make routine visits during regular office hours. After-hours calls are triaged by trained nursing staff and referred for emergency care, urgent after-hours care, next-day routine care, or telephone advice.

A retrospective cohort design with matching of age, sex, and socioeconomic status was used to compare the use of health services of adolescent members of KPC who had access to SBHCs with those with no such access. Adolescents enrolled in KPC were selected as the study population for the following reasons: (1) KPC is a closed-panel HMO. Covered visits must be made to a KPC facility, allowing identification of all outpatient, emergency department, mental health, and substance abuse visits in the KPC system. (2) KPC has had a special interest in serving adolescents and reducing barriers to providing comprehensive and confidential services to this age group. As an HMO system of care, KPC had the least number of barriers to providing adolescent services. The SBHCs have successfully served adolescents who had no health insurance or who faced barriers such as distance, cost, lack of confidentiality, or restrictive mental health and substance abuse benefits. We believed this design would provide the greatest insight into the use of SBHC services for insured adolescents enrolled in an HMO.

All adolescents registered in the Denver SBHCs from August 1, 1990, through June 7, 1993, were matched to the KPC enrollment database. Matching was based on birth date, name, and sex. Race was not used to match because race is not part of the KPC enrollment database. To be included in the study, adolescents had to be enrolled and eligible to receive services from KPC continuously during the study. A control group of adolescents who did not match enrollment in an SBHC was selected from the KPC enrollment database. The control group was limited to adolescents who were at least 14 years old at the beginning of each academic year and not older than age 18 years at the end of each academic year. Family income data were not collected by the SBHC or KPC. Because of the influence of socioeconomic status on patterns of health care use, a control group was selected by zip code from a geographic area in the city without access to an SBHC and with the same census tract median family income as the census tracts for the adolescents with access to an SBHC. To assure that adolescents were accurately classified as attending a school with an SBHC or not having access to an SBHC, the combined data set of study adolescents and control adolescents was matched to the Denver Public Schools pupil database. The school in which the student was enrolled, if any, was entered into the data set for each of the 3 academic years in the study period as follows: year 1, August 1, 1990, through June 7, 1991; year 2, August 1, 1991, through June 7, 1992; and year 3, August 1, 1992, through June 7, 1993. Adolescents who made at least 1 visit during the study period to the SBHC or KPC were included in the study. A total of 342 adolescents were enrolled in the study, accounting for 3394 visits.

Because students' use of health services and school of enrollment could change from one academic year to the next, most of the analyses were performed and reported for the individual academic year. For example, an adolescent attending an SBHC school could transfer to a school without access to a SBHC the following academic year or could drop out of school. Analysis on a yearly academic basis was used as a safeguard to avoid misclassification.

Use of services at the SBHC was obtained from audits of the SBHC medical records. The visit encounter forms are highly structured with checklists for the assessment of risk factors. The most common outpatient International Classification of Diseases, Ninth Revision (ICD-9)¹⁸ diagnoses are printed on the back of the encounter form to facilitate diagnostic coding. The forms are used at each SBHC visit. For visits at KPC, the medical records for each subject were reviewed. These records use a structured encounter form for health supervision visits but not for other types of visits. The assessment of health risks at KPC is not as formalized as that conducted at the SBHC sites. In addition, ICD-9 diagnoses are not printed on the encounter form as they are in the SBHCs. Mental health and chemical dependency records at KPC and the SBHCs are kept separate from the medical record. These also were audited for the study participants.

Visit rates were compared for the KPC members with and without access to an SBHC. Visit type (ie, routine ambulatory, emergent or urgent care, mental health, or chemical dependency), diagnosis, and risk factor assessment were also examined. Fisher exact and χ³ tests were used for categorical data comparisons, and the Student t test (2-tailed) was used to compare continuous data. Direct age standardization to the Colorado population was used to examine any effect of the differential age distribution that arose after confirmation of the study participants through school records.

A total of 342 adolescents were included in the study, resulting in 3394 visits occurring during the 3 academic years when the SBHCs were open. Of the adolescents, 194 (56.7%) were female and 148 (43.3%) were male. Of the visits, 63% were by females and 37% by males. Table 1 gives the age and sex distribution for adolescents using KPC and an SBHC and adolescents using KPC without access to an SBHC. In each of the 3 academic years, there was no significant difference in the composition of the population by sex or age for adolescents using an SBHC and KPC compared with adolescents using KPC without access to an SBHC. During at least 1 of the 3 academic years, 240 adolescents attended a school with an SBHC, resulting in 2599 visits. The mean number of combined KPC and SBHC visits per adolescent during each of the academic years for adolescents who attended a school with an SBHC was 5.3 during year 1990-1991, 5.3 during year 1991-1992, and 5.7 during year 1992-1993. For adolescents not attending a school with an SBHC, the mean number of KPC visits per adolescent was 3.9 during year 1990-1991, 3.8 during year 1991-1992, and 3.4 during year 1992-1993. For the adolescents who attended a school with an SBHC and used the SBHC, the mean number of visits per individual was 7.6 during year 1990-1991, 6.7 during year 1991-1992, and 8.2 during year 1992-1993. For the adolescents attending a school with an SBHC who did not use the SBHC, the mean number of visits per adolescent was 2.8 during year 1990-1991, 4.1 during year 1991-1992, and 3.7 during year 1992-1993.

Table 2 gives data about the health, mental health, and substance abuse visits for adolescents using an SBHC and KPC compared with adolescents making KPC visits without access to an SBHC. The difference in utilization of mental health and substance abuse visits was significant for the adolescents with access to an SBHC: 96.5% of the 314 mental health visits occurred in the group with access to the SBHC (P<.001), and all of the 120 substance abuse visits occurred in the SBHC (P<.001).

The differential use of the SBHCs for mental health and substance abuse treatment is striking. Of the adolescents actually using the SBHC, 31% used mental health services. Eight percent used substance abuse services, and 36% used mental health or substance abuse services. These figures compare with only 3% of adolescents without access to an SBHC who visited KPC for mental health or substance abuse treatment (P<.001). Table 3 lists the frequency of mental health and substance abuse primary diagnoses for adolescents using the SBHC mental health and substance abuse services.

Because of the large difference in the number of mental health and substance abuse visits between the SBHC and KPC, the mean annual visit rate for adolescents using the SBHC for medical, mental health, and substance abuse treatment services is greater than that for adolescents using KPC. If all the mental health and substance abuse visits are ignored, the use for adolescents using KPC and the SBHC for medical care only is much closer to the rate of use for adolescents using KPC without access to an SBHC (Table 4). In each of the 3 academic years, the rates of use range from 4.4 to 4.7 medical visits per adolescent using the SBHCs and KPC and from 3.4 to 3.7 visits per adolescent using KPC without access to an SBHC. The difference in the rate of use of medical services was statistically significant only during the academic year 1992-1993.

Figure 1 shows the frequency of primary medical diagnoses for SBHC visits and visits to KPC for the adolescents who used an SBHC. Table 5 gives further analysis of the primary medical diagnoses seen in higher frequency at KPC than at the SBHCs, grouping the diagnosis by the site of care. The grouping of diagnosis by site of care within KPC offers some insight into how adolescents used the 2 systems of care. For example, there was greater use of KPC for musculoskeletal problems, but 26.0% of the visits were to occupational and physical therapy and 48.0% to after hours (emergent or urgent) care, services not available at the SBHC. Similarly, 80.2% of visits for injuries and poisonings occurred after hours.

As shown in Figure 1, there was higher use of the SBHC for health supervision visits. During the 3-year study period, 80.2% of adolescents using the SBHC and KPC had at least 1 comprehensive health supervision visit compared with 68.8% of adolescents without access to an SBHC (P=.04). The rate of documentation of screening was much higher for high-risk health behaviors and anticipatory guidance during the comprehensive health supervision visits in the SBHCs compared with visits to KPC (Table 6).

Table 7 compares the use of after-hours (emergent or urgent) services for adolescents using KPC and an SBHC with adolescents using KPC without access to an SBHC. In each of the 3 academic years, the rate of use by adolescents with access to an SBHC (0.42-0.55 visits per adolescent) was significantly lower compared with the rate of use by adolescents without access (0.88-0.94 visits per adolescent). In 2 of the 3 academic years, the percentage of adolescents making after-hours visits if they had access to an SBHC (29.2%-41.6%) was also significantly lower compared with those who did not (52.8%-60.0%).

This study provides a first look at the patterns of use of health, mental health, and substance abuse treatment services for an insured population of adolescents with and without access to an SBHC. Overall, adolescents with access to SBHCs made nearly 1 additional medical visit, but fewer after-hours visits, than did adolescents without access to an SBHC. The annual rate of medical visits for adolescents using an SBHC compares favorably with the rates reported in other studies of the use of other SBHCs.¹⁹

The study provides some insight into whether provision of a similar array of basic primary health services in an SBHC for a population of insured adolescents is additive to or duplicative of services available through KPC. Figure 1 and Table 5 display statistically different primary medical diagnoses for the SBHC and KPC for adolescents using an SBHC. The greater proportion of health supervision visits in SBHCs could reflect easier access, program emphasis, or a means of circumventing the KPC copayment for a physical examination. It may be that the availability of an SBHC attracts a harder-to-reach segment of the population into preventive health care. Whatever the factor(s), the combination of KPC with an SBHC results in a higher health supervision rate for adolescents with access to an SBHC (80.2%) than for those without access (68.8%; P=.04). Further research is necessary to better understand the difference in use of preventive health care.

Other differences in use by diagnosis were found. A much greater proportion of gynecological care occurred at the SBHCs. This may be attributed to easier access, an understanding by the users that the SBHC provided confidential services, a programmatic emphasis on early detection of STDs and pregnancy testing, or staff visiting the classrooms to encourage students to visit the health center if they thought they might be pregnant or have an STD. The higher rate of primary diagnosis at KPC related to pregnancy and contraception is because these services are not provided at the SBHC.

A greater proportion of diagnoses for injury and poisonings occurred at KPC. Because 80.2% of the visits for injury and poisonings occurred in the after-hours (emergent or urgent) clinics, these visits may reflect appropriate use for acute injuries. Similarly, KPC had a greater proportion of musculoskeletal primary diagnoses. Three quarters of these visits occurred in the after-hours clinics or to occupational or physical therapy. These services are not available in the SBHC.

Clearly, one of the most important findings of the study is the differential use of mental health and substance abuse services. Adolescents with access to an SBHC were 10 times more likely to make a mental health or substance abuse visit, with 96.5% of the mental health and all of the substance abuse visits occurring at the SBHC. Of the adolescents using the SBHC, 31.4% were seen by a mental health provider and 8.3% received substance abuse counseling. Emotional problems accounted for 29% of all diagnoses made in the Denver SBHCs.¹¹ The frequency of emotional problems treated is similar to that found in a study of the use by high school seniors of an SBHC in Los Angeles, Calif, where 26% of students who used the clinic had counseling about mental health and psychosocial problems.²⁰ Estimates of the prevalence of mental health disorders among adolescents living in the United States range from 12% to 22%.^{3 ,21 - 22} Although rough estimates suggest that one fourth to one third of adolescents who need mental health services actually receive them,³ few national data exist on the use of mental health services by adolescents.

The difference in use of mental health services could be due to a number of factors: differences in mental health "screening," identification, and referral by primary care providers; differences in availability of or access to mental health services; differences in the manner in which mental health services are delivered or the style or personality of the providers; or availability of other referral sources, such as teachers, administrators, school counselors, nurses, and social workers. A combination of factors may explain the stark contrast in use. Providers in the SBHCs received specific training in the identification of common emotional problems in the age group. Many of the adolescents seeking care because of physical symptoms that could have an underlying emotional basis were introduced to the on-site clinical social worker (mental health provider). This on-site multidisciplinary team approach resulted in effective mental health referrals and helped reduce perceived stigma attached to "going to counseling." No outcome data were collected for the adolescents receiving mental health treatment. However, because continued participation was usually voluntary and the mean number of mental health visits was between 5.4 and 6.4 per adolescent per year, the continuation in treatment seems to be perceived as beneficial by the students.

The difference in use for substance abuse treatment was similarly striking. Adolescent use of substance abuse treatment services in the SBHCs is consistent with epidemiologic studies of substance abuse: about 8% of students using the SBHCs made at least 1 visit, and 6% made at least 2 visits to substance abuse counselors.¹¹ Of the students who had initial visits to substance abuse counselors, 76% continued in counseling, and 84% of students who made at least 2 visits continued. Slightly more than half (51%) of students having any contact with substance abuse counselors also had contact with mental health counselors.¹¹ Engaging adolescents with substance abuse disorders into treatment is important, not only because this age group is difficult to draw into treatment, but also because of the high national prevalence of substance use. The most recent national data document that 51.3% of seniors and 38.8% of sophomores drank alcohol during the preceding month. Almost 21.9% of high school seniors and 20.4% of sophomores have used marijuana during the past month. Of high school seniors, 39% report having used an illicit drug during the preceding 12 months.²³

In addition to the aforementioned possible factors for increasing use of mental health services in the SBHC, an important factor contributing to the use of substance abuse treatment was the institution of a school policy that gave students caught drinking alcohol or using other illegal drugs at school a choice between suspension or compulsory substance abuse treatment through the SBHC. For students selecting treatment, the treatment process began with an assessment of the extent, duration, and type of abuse, as well as contributing and enabling factors, such as family and peer relationships. Treatment modalities included small closed-ended groups, which met weekly for about 12 weeks, and adolescent counseling. Aftercare groups were available for students needing a longer period of support to remain substance free. Telephone contacts were made with parents as appropriate and necessary.

The success of the SBHCs in engaging adolescents into mental health and substance abuse services may be the program's coordination between physical and mental health providers, which has been a long-standing challenge in traditional health care settings.²⁴ Almost one fourth of adolescents in the Denver SBHCs had contact with more than 1 category of service provider. The increased access to mental health and substance abuse services seems to meet an important need in this population.

The higher rate of documented screening for high-risk health behaviors and anticipatory guidance during the comprehensive health supervision visits in the SBHCs (Table 6) may be a result of 3 factors. First, the SBHC used an encounter form for the provider to comment on each risk behavior that was raised and addressed during any preventive health visit. Except for preventive visits, a more limited form was used in KPC. The documented difference thus may be related primarily to a recording artifact. Protocols and forms have been found to improve provider behavior.²⁵ Second, SBHC providers spend more time during each preventive health visit, with a mean visit time of 45 minutes compared with 20 minutes at KPC. Thus, there was more time available to cover a broader array of subjects. Third, providing comprehensive and prevention-oriented care was a major objective of the SBHC program.

This study confirms the findings of the study by Santelli et al²⁶ that documented a self-reported reduction in emergency department use by students who had attended a school with an SBHC for more than 1 year compared with students in comparable schools without SBHCs. Both of these studies contrast an evaluation of the SHBCs funded by the Robert Wood Johnson Foundation, Princeton, NJ. The evaluation found a nonsignificant increase in emergency department use among adolescents relative to a comparison group of urban adolescents interviewed by telephone.¹⁵ However, that study had a number of methodological limitations, including the choice of comparison group. Our finding that in each of the academic years there was a significantly lower rate of visits to the after-hours (emergent or urgent) services by adolescents with access to an SBHC compared with adolescents without access is strengthened by the study design to identify all emergent and urgent care. Adolescents enrolled in KPC must use a KPC facility for all routine and emergency care for the care to be compensated. If the study population were not limited to a KPC facility, documenting all emergency department and after-hours care in a large metropolitan area with various sources of care would have been extremely complicated.

We believe that the availability of acute care services at the school has decreased the rate of after-hours (emergent or urgent) visits at KPC. In addition, this may improve continuity of care because after-hours care is seldom provided by the patient's primary care provider and, provision is more expensive. This is a potential opportunity for managed care to improve the comprehensiveness and quality of care provided to adolescents while reducing costs, and it may prompt discussion of formal relationships with SBHC programs.

The study was limited by restriction to adolescents insured by KPC only, and the results may not be generalizable to uninsured teens or to those insured through other types of plans.

This comparison of the use of health services by adolescents enrolled in a closed-panel nonprofit HMO (KPC) who had access to an SBHC with adolescents without access to an SBHC found that adolescents with access to an SBHC were more than 10 times more likely to make a mental health or substance abuse visit, with 98% of these visits occurring at the SBHC. Adolescents with access to an SBHC had between 38% and 55% fewer after-hours (emergent or urgent) visits than did adolescents without access to an SBHC, and a significantly lower percentage of adolescents used after-hours (emergent or urgent) services if they had access to an SBHC compared with those who did not. A greater percentage, 80.2%, of adolescents with access to SBHCs had at least 1 comprehensive health supervision visit compared with 68.8% of adolescents without access. Furthermore, there was a much higher rate of documentation of screening for high-risk health behaviors in the SBHC.

School-based health centers providing comprehensive primary physical and mental health services seem to have a synergistic effect for adolescents enrolled in KPC. Adolescents seem to use both systems of care appropriately, and the significant improvement in access to mental health and substance abuse treatment may be an important finding in improving adolescent health services. A decrease in the number of after-hours (emergent or urgent) visits may be an area of potential savings for insurers.

Accepted for publication August 28, 1997.

This study was supported by a grant from Kaiser Permanente of Colorado. Dr Kaplan's time was supported by The Robert Wood Johnson Foundation, Princeton, NJ, and the Carnegie Corporation of New York, New York City.

We gratefully acknowledge the contributions of John Santelli, MD, and Paul Melinkovich, MD, for their analytic advice; Wayne D. Eckerling, PhD, and David W. Lowry, MS, Denver Public Schools, Office of Planning, Research, and Program Evaluation, for assistance in matching the KPC data set; and Marilyn Langello for data collection.

Editor's Note: Providing school-based health care services for the managed care–enrolled adolescents in this study seems to be a win-win situation for everyone. Should we add a fourth R to the school basics, Routine health care?—Catherine D. DeAngelis, MD, MPH

Reprints: David W. Kaplan, MD, MPH, The Children's Hospital, 1056 E 19th Ave, B025, Denver, CO 80218.