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PEDIATRICS Vol. 106 No. 4 October 2000, pp. 860-862
AMERICAN ACADEMY OF PEDIATRICS:
Insurance Coverage of Mental Health and Substance Abuse Services
for Children and Adolescents: A Consensus Statement
Mental health needs of children and
adolescents are increasing while access to behavioral health, mental
health, and substance abuse services is decreasing. Such services
include preventive interventions, early identification, assessment and
diagnosis, case management, outpatient treatment, hospitalization,
home-based treatment, comprehensive drug and alcohol treatment, and
residential and hospital psychiatric treatment. In the past 20 years,
the rate of psychosocial problems identified in children in primary care has increased from 7% to 18%.1 It is currently
estimated that at least 13 million children are in need of mental
health or substance abuse services,2 yet attempts to
restrain health costs have resulted in decreased availability of mental
health and substance abuse services for children and adolescents. This
decrease is attributable to benefits packages that provide limited
mental health services or carve out plans, in which behavioral health
care may be carved out (not included) or contracted for separately,
making mental health services more difficult to obtain. This decrease
is occurring despite increasing evidence of the effectiveness of
specific mental health and substance abuse services.3 In
the general health care sector, primary care clinicians are being
pressured to see more patients in less time and, therefore, have less
time to address psychosocial issues.
Concern regarding the deterioration of clinical mental and behavioral
health and substance abuse services for children and adolescents
resulted in an unprecedented meeting of representatives from
professional organizations who care for the mental health needs
of children. These organizations reached consensus on the issues
outlined in this statement.
To rectify the present shortage of mental health services, a commitment
must be made to increase resources in both the private and public
sectors. Without this increase, current and future needs will not be
met. Although specific long-term economic benefits are difficult to
calculate, children and adolescents who receive early intervention and
care may avoid needing costly treatment in the future. In economic
terms, immediate improvements in the mental health of children and
adolescents are reflected in increased parent work productivity, less
parent absenteeism, and less use of general medical services. More
importantly, in the long-term, preventive efforts and early treatment
of behavioral problems and mental disorders in childhood result not
only in changes in behavior but also in changes in the brain. The
potential impact of early intervention on instances of violence and the
number of incarcerated juveniles and young adults is great. Even a
modest reduction in negative outcomes of youth will more than
compensate for the increased health care costs at this
time.4 Certainly, for children and families, the avoidance
of problems and associated misery is a worthwhile goal in a humane
society.
To improve mental health services, it is important to address 3 issues:
access, coordination, and monitoring. These issues should be
considered from the standpoint of needs for preventive interventions,
direct mental health and substance abuse services, and coordinated
multiservice care.
Traditional mental health care systems, which were limited at
best, have recently been further disrupted by the change to a managed
care system. In the past, primary care clinicians could refer patients
with mental disorders to appropriate mental health clinicians. Parents
and school personnel, when needed, could also obtain direct access to
mental health clinicians. This arrangement increased the chances of the
family obtaining the services needed and increased the likelihood of
communication among professionals.
Many current behavioral health carve out programs make mental health
services much more difficult for families to obtain. In many cases,
clinicians and families must depend on external screening processes in
which decisions for approval are based almost exclusively on preset
guidelines for adults, not children. There is no direct contact between
the referring physician and the professional provider during the
referral process. It is difficult for families to obtain services
because of obstacles, such as an absence of criteria for approving
services that meet the needs of children, copayments that are higher
for behavioral health services than those for other medical services,
more limited yearly and lifetime caps, and limited panels of qualified
mental health care professionals experienced in treating children.
Limiting the ability of primary care clinicians to provide preventive
services further worsens the situation. Primary care clinicians do not
receive adequate reimbursement for preventive efforts, such as
addressing psychosocial problems, and they are pressured to see more
patients in less time. As a result, they have less time to develop
strong, ongoing relationships with families and are less likely to
identify mental health and substance abuse problems.
The low number of qualified child mental health and substance abuse
clinicians contracting with behavioral health management further limits
access.5 Clinicians experience difficulties in
establishing credentials on multiple professional panels. There are
obstacles in obtaining approval for adequate levels and quantity of
services to care appropriately for their patients. In addition, payment
for services to children, adolescents, and their families is
inadequate, and administrative practices are burdensome. These factors
result in a decrease in available facilities and a disincentive for
professionals and those in training to enter or remain in the field.
To address the issues, the following recommendations are proposed:
ACCESS
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COORDINATION |
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Although coordination of care is critical in all types of health care treatment, it is particularly important for mental heath services. Many sectors of a community, including schools, social services, and the justice system, are involved with children and adolescents with mental health and substance abuse problems. For services to be effective and efficient and meet family needs, service professionals must communicate and coordinate with each other. At a time when all sectors are attempting to cut costs, there is a tendency to try to shift responsibilities from one sector to another. As a result, divisions of responsibilities are not always clear. Often, families are caught in the middle and receive no information or conflicting information as to who can best address the child's needs. This lack of organization often results in agencies working inefficiently and sometimes with different purposes. Nowhere is this more evident than with children who have severe and multiple conditions that require coordinated, multiple services.
To address the issues, the following recommendations are proposed:
- Families must be centrally involved in the coordination of care for their children and adolescents. Services provided that address family issues should be reimbursed adequately.6
- A seamless system of care must be established within and across sectors that includes mechanisms to promote communications and referrals among professionals such that children and families receive appropriate services regardless of how and where they seek help and irrespective of the nature of their problems.7
- Clinicians must be compensated for case management and coordination efforts (ie, compensation of counseling Current Procedural Terminology [CPT] codes and consultation CPT codes). Contracts should include compensation for interpretive and indirect services, such as staff conferences, consultation between clinicians, and contacts with professionals in other sectors, such as schools and law enforcement.
- Mechanisms for apportionment of costs and reimbursements must be established for complex cases that involve multiple agencies.
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MONITORING |
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For economic competition to work to improve health services, families and purchasers of health care plans need to be informed about the quality of the services provided. This issue has always been complex, because quality includes the availability of a spectrum of qualified services, the quality and appropriateness of care provided, and the responsiveness of services to concerns raised by professionals or families. As direct recipients of services, families need information about the services provided and guidelines by which to evaluate this information. Families need mechanisms to communicate their comments and experiences to those who purchase health care plans, most commonly their employers. The purchasers also need uniform and accurate information about plans that provide health care services. As programs have multiplied and diversified, it has become difficult for all to determine the quality of services offered and for appropriate regulatory agencies to hold them accountable.
To address the issues, the following recommendations are proposed:
- Clinician professional organizations and provider plans should be encouraged to better define and use evidence-based care in mental and behavioral health and substance abuse services for children, adolescents, and families. Empirically supported assessments and treatments should include level of care criteria, best practices, and monitoring of incremental expectations for progress. Research on quality of care and outcomes effectiveness should also be enhanced by these groups.
- Public and private sectors should develop mechanisms for system accountability in the cost-effectiveness of service calculations, including consideration of administrative costs.
- Mechanisms to provide user-friendly information to families and purchasers regarding the availability, adequacy, and quality of mental and behavioral health and substance abuse services must be developed.
- Simplified and timely internal and independent external appeals processes should be developed by health plans and mental health care management programs. Families should be included on such panels.
The decreasing availability of health care services to meet the mental health needs of children and adolescents is a serious and worsening problem. Action must be taken to curb this decrease. Issues that negatively impact the access, coordination, and monitoring of such services must be addressed. Improvements in these services will have a positive impact not only on the health and well-being of children and adolescents but on society as well.
PARTICIPATING ORGANIZATIONS
Academy for Eating Disorders
American Academy of Child and Adolescent Psychiatry
American Academy of Pediatrics
American Psychiatric Association
American Psychological Association
Family Voices
International Society of Psychiatric-Mental Health Nurses
Society for Developmental and Behavioral Pediatrics
ENDORSING ORGANIZATIONS
Academy for Eating Disorders
American Academy of Child and Adolescent Psychiatry
American Academy of Pediatrics
American Psychiatric Association
American Psychological Association
American Society of Addiction Medicine
Family Voices
International Society of Psychiatric-Mental Health Nurses
National Association of Pediatric Nurse Associates and Practitioners
National Association of Psychiatric Health Systems
National Association of School Psychologists
National Mental Health Association
Society for Developmental and Behavioral Pediatrics
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FOOTNOTES |
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The recommendations in this statement do not indicate an exclusive course of treatment or serve as a standard of medical care. Variations, taking into account individual circumstances, may be appropriate.
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ABBREVIATIONS |
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SCHIP, State Children's Health Insurance Program; CPT, Current Procedural Terminology.
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REFERENCES |
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[Abstract/Free Full Text] - American Psychiatric Association. Issues Affecting Mental Health Coverage for Children. Washington, DC: American Psychiatric Association; 1999
- Kazdin AE, Bass D, Ayers WA, Rodgers A Empirical and clinical focus of child and adolescent psychotherapy research. J Consult Clin Psychol. 1990; 58:729-740 [CrossRef][Medline]
- Durlak JA. Successful Prevention Programs for Children and Adolescents. New York, NY: Plenum Press; 1997
- Roberts MC, Carlson CI, Erickson MT, A model for training psychologists to provide services for children and adolescents. Prof Psychol Res Pract. 1998; 29:293-299 [CrossRef]
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Pediatrics (ISSN 0031 4005). Copyright ©2000 by the American Academy of Pediatrics
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