The College Health Opportunity

Universities are re-opening, some in-person, some fully virtual, some hybrid. As with anything else during this pandemic, instead of usable standards and guidelines colleges had to figure it out themselves. I cannot believe the CDC is once again making the exact same mistake it made with masks in regards to regular testing for colleges planning .

This is one of those things we don’t need a systematic study on, it’s common sense. And in a similar vein as masks, if the messaging was about shortages then say it’s about temporary shortages but it’s still IDEAL to move towards continuous testing on campuses.

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So, in a completely predictable series of events, here’s the summary of the last few weeks.

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I just can’t believe how bad university students coming back to campus have it. NYU students being forced to stay in their dorms with the school providing lunch to their room and getting hilariously bad meals once a day. Imagine paying $60K+ to get this.

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Or how laughably bad the communications to students are. I can’t believe administrations are trying to convince people to adhere to quarantine guidelines with…this.

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I feel bad for these students, they’re getting robbed of the true college experience. Hopefully NYU fixes the situation by including Four Lokos and a random freshman you’ve never seen before vomiting in the shared bathroom as part of the next meal delivery.

Student Health Plans

You may have noticed that a running theme of this newsletter is that the US is secretly a bunch of small, independent healthcare systems with their own rules. Student health is one of them.

Interestingly enough, student health seems to be in a reverse trend from the rest of healthcare. This paper form 1988 surveyed universities and found that most had a fee dedicated to health services or included it as part of general tuition. Very little was based on insurance or fee-for-service revenue, so this model actually kind of looked like…capitation?

When taken together, the average public campus in the Table derives 45.5% of its operating expenses from university general fund sources, 34.4% from an identified health fee charged to students, 14.3% from fee-for-service revenue, 3.4% from insurance revenues, and 2.4% from miscellaneous sources

That all changed when utilization started increasing (especially for mental health issues) and healthcare services started getting expensive. Now it’s not uncommon to see campus health get funded 60%+ by fee-for-service billing for student health services.

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When you go to college, most schools require you to have some sort of health insurance plan, and many provide their own student health plan (that’s usually contracted with some third-party health insurance carrier). These plans are actually pretty decent, but the thing is:

• Most people are now under their parents health insurance until they’re 26 so you theoretically would already have coverage. However if you go to a school in a different state, it’s likely that none of the providers at your school (including your campus health service) are in-network.
• It’s an opt-out process and the fees are usually buried in the rest of your tuition bills, so many times families don’t realize they’re paying an extra $1000-$4000 a year for health insurance that might be duplicative.
• To opt-out, you need to prove that the insurance you have is equal or better to the health insurance the school provides. Most times this actually isn’t difficult, but if you’re in an HMO plan like Kaiser or Medicaid for your state then this won’t work. Also most times you can’t be on a catastrophic plan, even though the catastrophic plan will likely have lower premiums. For example, I pay about $2400/year for catastrophic health insurance in New York. Columbia University’s plan is $4600+ if you include summer.

It was pretty hard to find any data on how many students enroll in student health plans in total. These surveys suggest about 18% of students have a student health plan as a primary source of coverage, but I would guess a very very large % are enrolled in their schools health plan as secondary insurance (potentially without realizing you need to opt-out).

But here’s a really interesting quirk. While the student health plans are actually not a great deal for students already under their parent’s health insurance, they’re fantastic for adults because the risk pool of students is great. This post walks through some of the reasons why (including some fun actuarial math where risk is actually mispriced relative to age). But the main takeaway is that it’s actually way better to be in a university plan than the individual marketplace plans because of how the risk pool works.

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In fact…this is such an insane loophole that someone actually built out a site that shows how many credits you have to take at a school to qualify for their health insurance plan. In many states, the cost of taking the class + health insurance costs is actually lower than monthly premiums for a plan within the state.

How dumb of a system do you have to have for this to be a viable workaround.

COVID + School healthcare

One of the things I’ve always wondered is why healthcare startups don’t really target college students with their offerings. Lots of other tech companies realized that if you target students at the point which they become independent people, you can be one of their first purchases into adulthood and keep them sticky within your product. This is why Spotify and Amazon offer discount student plans, and why there are like a billion banks that set up booths all over campus so you’ll open a student account with them.

Several reasons why it hasn’t been a good idea for health companies

• Who’s going to use your service if the university provides said service?
• Contracting with universities is a nightmare
• Students will automatically churn when they leave campus/graduate (and many don’t stay in that same geography).
• Most young, healthy people aren’t actively seeking out health services other than contraception and Pedialyte.

But I actually think we’re starting to see the first wave of companies potentially cracking this market, starting in cash pay. For example, some companies are offering faster UTI detection or cheaper birth control. If you look at some of the conditions that seem to affect college students, I would think there’s more opportunities especially in areas like allergy management, musculoskeletal issues, migraine management, etc.

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But by far the most glaring gap seems to be in the mental health space. It was shocking to me to see in this survey that 45% of students surveyed “felt so depressed that it was difficult to function” and more than 10% had seriously contemplated suicide (with 2% actually attempting it). A large number also have body dysmorphia issues, an area Lantern (previously ThriveOn) was tackling on college campuses.

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Having on campus services to actually support these needs is extremely difficult, with many students complaining either about lack of access to such services on their campus or extremely long wait times. One issue could be that universities are redirecting their limited resources to more serious students, which are taking away from more regular, routine visits.

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Plus, all of these surveys were done pre-COVID. As students come back to campus without the same social support, increased isolation, and general sad state of the world I can only imagine these issues become more acute.

Another Front Door?

I think a new opportunity has opened for healthcare companies to better reach college students thanks to COVID.

For one, universities in many cases are acknowledging that they don’t have the ability to serve students and are putting out RFPs to work with third parties. Here’s an example of one for telehealth and tele-psychiatry services from Central Washington University that’s pretty thoughtful. This could be a great way for companies to work in tandem with campus health to get distribution for their product and help college students.

Second, removing state-by-state telemedicine licensing means being able to provide services to lots of colleges simultaneously whether or not students are on campus or at home. Care isn’t localized to your college anymore.

Third, as colleges try to limit the number of students coming to their campus health centers they might be more open to pushing more remote-diagnostic/monitoring tools to their students.

Finally, I think health has become top of mind. For many students, testing is now a regular part of their activities and will be a regular part of their lives for a while. It’s true that most people in the college age range don’t have as many acute issues, but COVID could potentially open the door for mental health services or testing to be the front door for these young people that could evolve into a longer standing health relationship.

Either way, I sympathize with the students going to college today because this experience sucks. The least we can do is try to figure out how to keep people safe and address their health needs.

Thinkboi out,

Nikhil

P.S. did you know that there are college specific EMRs??? (Medicat, Titanium Schedule, ADSC)

Twitter: @nikillinit

IG: @outofpockethealth

Thanks to Matt Kennedy from Mantra Health for helping me to understand the landscape, and Malay Gandhi for sound boarding

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