Well-Visit Screenings Identifying Kids' Mental Health Issues

Larry Hand

December 02, 2013

Court-mandated screening of Massachusetts children and teenagers for behavioral health (BH) issues during well-child visits may be leading to identification of "large numbers" of children with problems not previously recognized, according to an article published online December 2 in Pediatrics.

As of January 2008, healthcare providers in Massachusetts were required to integrate BH screenings into well-child visits for children up to 21 years old who were covered by the state's Medicaid program, MassHealth.

The requirement arose from a 2006 court decision (Rosie D v Romney, now Rosie D v Patrick) calling for enforcement of the Early and Periodic Screening, Diagnosis, and Treatment (EPSDT) mandate for all states to screen and provide treatment for Medicaid-insured children for mental health disorders and substance abuse.

Karen A. Hacker, MD, MPH, director of the Allegheny County Health Department in Pittsburgh, Pennsylvania, and colleagues analyzed MassHealth claims data on Medicaid-eligible children in fiscal year (FY) 2009 plus BH history for FY 2008 and 2009. The data included a code for screening, as well as a modifier for needing BH services and a modifier for not needing BH services.

Dr. Hacker was executive director of the Institute for Community Health in Cambridge, Massachusetts, when the research took place. She became director of the Allegheny County Health Department in September 2013.

Newly Identified

Of 355,490 children younger than age 16 years eligible for the analysis, almost half (46%) had evidence of BH screening. Of those who were screened, 131,116 (12%) had records coded "positive" for needing BH services.

Among screened children and youth coded positive for needing BH services, 43% had no history of receiving such services. Almost a third (29.3%) of those coded positive had claim information documented for previous BH services or diagnoses before screening.

Compared with screened children with prior BH services history, the "newly identified children "were less likely to be male, were on average younger, more likely to be Asian, less likely to be white, and less likely to be in foster care," the researchers write.

"The key finding is the newly identified and who they are," Dr. Hacker told Medscape Medical News. "Those are all often the cases that go unidentified."

Also, identifying children with previous histories of care is "actually an opportunity," she added, "because one of the things we are struggling with is how do we integrate mental health into pediatrics. A screening opportunity, even if a child has had mental health issues in the past, can really be used as a check-in and a time to figure out whether or not those problems are still going on."

Overall, through multivariate logistic regression analyses of screened children coded for needing or not needing BH services (n = 103,413), the researchers found that being male, age 5 to 7 years, Hispanic, from an urban zip code, and in foster care and having a BH history predicted being coded positive for needing services. They also found that being age 13 to 16 years and Asian reduced the odds of being coded positive.

Multiple Studies

In a related study published online November 11 in Clinical Pediatrics, researchers at the MGH Chelsea HealthCare Center in Chelsea, Massachusetts, found that physicians at 2 primary care practices in Massachusetts had significantly increased their inclusion of BH screenings during well-child visits during 2008 and 2009. Those researchers reviewed billing data and electronic medical records (EMRs).

In another study by Dr. Hacker and colleagues, published in the November-December issue of the Journal of Developmental & Behavioral Pediatrics, researchers talked with pediatricians about how they were using screening BH tools and found that providers accepted and valued the screening tools but based their clinical decisions on a variety of evidence.

"To really understand this whole piece, we've got to triangulate our results," Dr. Hacker told Medscape Medical News. "The EMR data, actually talking to people to find out what they're doing, and looking at the claims data, I think all of those together help us begin to paint this picture."

In summary, she said, "Screening is hopefully identifying children that we wouldn't likely identify otherwise. Now the next question is what happens when they are identified."

Other States?

"At this point in time, this is the only state we know of that mandated screening and also gave us the modifiers to actually be able to look at children who are identified in claims data versus having to go into the charts to identify them," Dr. Hacker said, although she pointed out that Washington State recently experienced activity in this regard and that she has been contacted by interested officials in Connecticut.

In Washington, officials announced in August 2013 that a court settlement had been reached regarding the Medicaid EPSDT mandate and that the state would begin developing a screening and treatment program.

The American Academy of Pediatrics has been recommending BH screening for a long time, Dr. Hacker added, so the availability of the new data and modifiers may prompt other states to follow.

"We know that behavioral health issues are at the top of chronic diseases that pediatricians are dealing with, so to me, it only makes sense that we would do this."

A challenge for physicians is whether they will get paid for doing the screening, she said, and in Massachusetts, physicians are reimbursed through MassHealth.

This research was funded by the National Institutes of Health and supported by the Bennett Foundation, the National Institute of Mental Health, the Institute for Community Health, and the Massachusetts Department of Mental Health. None of the authors have disclosed any relevant financial relationships.

Pediatrics. Published online December 2, 2013. Abstract

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