Addressing the Core Issue in Children’s Mental Health: Early Intervention and Prevention
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Research clearly indicates that early intervention (screening, diagnosis and treatment at early stages of a health problem) is the most clinically effective and cost effective intervention. This is well understood in the public health community regarding a wide variety of medical disorders, but unfortunately, this is not the case for mental health disorders. This article addresses the steps necessary for successfully implementing a public health model for children’s mental health in Minnesota.
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The Problem
Research clearly indicates that early intervention (screening, diagnosis and treatment at early stages of a health problem) is the most clinically effective and cost effective intervention. This is well understood in the public health community regarding a wide variety of medical disorders. Unfortunately, this is not the case for mental health disorders. Mental Health advocates have actually been advised to not encourage expansion of early intervention activities “because we don’t have enough resources to treat the severely disturbed children and adolescents who we already know about”. This sets up a vicious cycle that is fueled by low reimbursement rates (Minnesota’s reimbursement for EPSDT ChildTeen Checkup screening is one tenth of California’s reimbursement), and a reactive rather than a proactive approach of oversight of mental health activities in the state by Human Services (a reactive system) rather than Health (a public health model). Attempts to “fix” Minnesota’s mental health “system” will fail until the core problem, lack of early intervention, is solved.
Although school staff are often aware of the signs of children’s mental health disorders, they are often reluctant to recommend mental health assessments due to federal law that potentially puts schools in the position of having to pay for mental health treatment for students who have significant mental health needs. Children and adolescents frequently go on and off of Medicaid, and this disrupts continuity of mental health care. School-linked grants from Minnesota DHS have provided support for on-site, co-located school mental health services. This has been a grant-based pilot project for at least a dozen years, and is not sustainable without grants in its present form.
TEFRA provides an option for families of severely disturbed children and adolescents to be able to access Medicaid benefits, but the copay for TEFRA may be so high for upper middle class families as to discourage enrollment.
Although there have been increases over the years in Medicaid reimbursement for mental health services, the rates remain low when compared to other medical services. This low reimbursement rate is a nation-wide issue, affecting both Medicaid and private insurance rates, and significantly contributes to a lack of evidence-based clinically effective services.
A Solution
Although the management (some would say micromanagement) of DHS’ children’s mental health activities has been reluctant to consider sweeping reforms as those described above, an analysis of cost benefits would help focus the issues. In 1995, I was asked by Minnesota DHS to analyze costs to Minnesota Medical Assistance in children’s mental health. Data indicated that 1% of children and adolescents were using up 25% of the mental health budget, and that 6% were using up 80% of the budget. There was a significant lack of early intervention activities and poor continuity of care. I recommended increasing reimbursement rates for outpatient services. This was not done to a significant degree. This imbalance of resources was, in large part, due to lack of adequate outpatient services and poor reimbursement rates. I would be curious to see if the statistics have changed significantly in the ensuing 22 years.
In my opinion, Minnesota has the opportunity to conduct a cost-benefit analysis, including costs in juvenile probation, social services, health and mental health related to untreated or undertreated mental health disorders. I believe that this analysis would support my recommendations and be a first step in successfully implementing a public health model for children’s mental health in Minnesota. In my opinion, implementing my recommendations would:
More information
Please refer to my report, Solving Minnesota’s Perpetual Mental Health Crisis, for further information on a potential public health model of mental health.
Technical assistance for this report was provided by Elizabeth Freeman and Frank Rider from the American Institute for Research:
About the Author
William Dikel, M.D. (dikel002@umn.edu, www.williamdikel.com) is a consulting child and adolescent psychiatrist who provides local (Minnesota) and national consultation, assisting school districts meet the needs of students who have mental health disorders. He provides diagnostic evaluations, in-service presentations, consultation, expert testimony in special education due process hearings, and program planning and development services. Dr. Dikel specializes in assisting districts enter into relationships with mental health clinics in order to provide school based treatment services.
Research clearly indicates that early intervention (screening, diagnosis and treatment at early stages of a health problem) is the most clinically effective and cost effective intervention. This is well understood in the public health community regarding a wide variety of medical disorders. Unfortunately, this is not the case for mental health disorders. Mental Health advocates have actually been advised to not encourage expansion of early intervention activities “because we don’t have enough resources to treat the severely disturbed children and adolescents who we already know about”. This sets up a vicious cycle that is fueled by low reimbursement rates (Minnesota’s reimbursement for EPSDT ChildTeen Checkup screening is one tenth of California’s reimbursement), and a reactive rather than a proactive approach of oversight of mental health activities in the state by Human Services (a reactive system) rather than Health (a public health model). Attempts to “fix” Minnesota’s mental health “system” will fail until the core problem, lack of early intervention, is solved.
Although school staff are often aware of the signs of children’s mental health disorders, they are often reluctant to recommend mental health assessments due to federal law that potentially puts schools in the position of having to pay for mental health treatment for students who have significant mental health needs. Children and adolescents frequently go on and off of Medicaid, and this disrupts continuity of mental health care. School-linked grants from Minnesota DHS have provided support for on-site, co-located school mental health services. This has been a grant-based pilot project for at least a dozen years, and is not sustainable without grants in its present form.
TEFRA provides an option for families of severely disturbed children and adolescents to be able to access Medicaid benefits, but the copay for TEFRA may be so high for upper middle class families as to discourage enrollment.
Although there have been increases over the years in Medicaid reimbursement for mental health services, the rates remain low when compared to other medical services. This low reimbursement rate is a nation-wide issue, affecting both Medicaid and private insurance rates, and significantly contributes to a lack of evidence-based clinically effective services.
A Solution
- Have Medicaid (Medical Assistance) be available at no charge for all children and adolescents who meet Minnesota’s criteria for Severely Emotionally Disturbed status. This would result in continuity of care, reduced reluctance of schools to identify mental health problems and would provide impetus for early intervention services. Ideally, all children and adolescents would have adequate insurance coverage, but this is a necessary first step.
- Allow schools to bill Medicaid not only for IEP related services for students who are in special education, but for all students who meet medical necessity criteria. Approximately 18% of students have mental health disorders, and 5% are severely emotionally disturbed. Only approximately 2% of students are receiving special education EBD services, a category of students who tend to have severe emotional and behavioral disorders. Many of these EBD students would not have required special education if they had received appropriate mental health services when they were in general education. The vast majority of students who have mental health disorders are not in special education.
- Expand the Medicaid benefit set to fully cover ancillary services that are now being reimbursed by DHS school-linked grants. This would help transition the present grant-based model into a sustainable model. The benefit set has been expanded somewhat, with a number of restrictions, but more needs to be done to make the model sustainable.
- Significantly increase Medicaid reimbursement for mental health screening, diagnosis and treatment
- Provide oversight of HMO contracts and fee for service activities regarding the provision of mandated mental health review and screening as a component of EPSDT (Child Teen Checkup). The last time that this was done (1999), data indicated that only 6% of eligible children and adolescents received a full screening, and only 2% were referred for mental health assessment. No follow up study, to my knowledge, has been done since that time, and the data now gathered by DHS does not address this issue. Chart reviews, as were done in 1999, would be required to provide data and accountability to this system, until a revision of the data collection process takes place.
Although the management (some would say micromanagement) of DHS’ children’s mental health activities has been reluctant to consider sweeping reforms as those described above, an analysis of cost benefits would help focus the issues. In 1995, I was asked by Minnesota DHS to analyze costs to Minnesota Medical Assistance in children’s mental health. Data indicated that 1% of children and adolescents were using up 25% of the mental health budget, and that 6% were using up 80% of the budget. There was a significant lack of early intervention activities and poor continuity of care. I recommended increasing reimbursement rates for outpatient services. This was not done to a significant degree. This imbalance of resources was, in large part, due to lack of adequate outpatient services and poor reimbursement rates. I would be curious to see if the statistics have changed significantly in the ensuing 22 years.
In my opinion, Minnesota has the opportunity to conduct a cost-benefit analysis, including costs in juvenile probation, social services, health and mental health related to untreated or undertreated mental health disorders. I believe that this analysis would support my recommendations and be a first step in successfully implementing a public health model for children’s mental health in Minnesota. In my opinion, implementing my recommendations would:
- Significantly prevent severe emotional disturbances in many youths
- Reduce the number of students referred for EBD special education services
- Improve the workforce capacity of mental health providers
- Reduce antisocial behavior in many youth who have ADHD, mood disorders, etc.
- Improve school performance and reduce behavioral incidents in atrisk students
- Provide improved continuity of care
- Create a sustainable school mental health system in Minnesota
- Create an accountable children’s mental health system in Minnesota
More information
Please refer to my report, Solving Minnesota’s Perpetual Mental Health Crisis, for further information on a potential public health model of mental health.
Technical assistance for this report was provided by Elizabeth Freeman and Frank Rider from the American Institute for Research:
About the Author
William Dikel, M.D. (dikel002@umn.edu, www.williamdikel.com) is a consulting child and adolescent psychiatrist who provides local (Minnesota) and national consultation, assisting school districts meet the needs of students who have mental health disorders. He provides diagnostic evaluations, in-service presentations, consultation, expert testimony in special education due process hearings, and program planning and development services. Dr. Dikel specializes in assisting districts enter into relationships with mental health clinics in order to provide school based treatment services.