Sunday, December 9, 2007

Rosie D.: Update for Pediatricians

I'm thinking of sending this into the Mass AAP Newsletter: I would appreciate your thoughts on it's message.
Pediatricians in Massachusetts know that it is hard to arrange adequate care for our patients with mental health issues. Psychiatrists are scarce, therapists are overwhelmed, the evidence-base for the diagnosis and treatment of mental illness in children is inadequate and parents are often frustrated lack of coordination and communication between the various systems that work with this high risk population. Last year, the frustration led to a class-action lawsuit, called Rosie D.v. Romney,Patrick, in which US District Court found that the Commonwealth of Massachusetts had provided “(1) inadequate or non-existent medical assessments and coordination of needed services for children with serious emotional disturbances (SED), and (2) inadequate or non-existent in-home behavioral support services for the same group.”.[1] The court found “overwhelming” evidence from the testimony of the witnesses from both sides of the case that diagnosis and treatment is not addressed in a systematic way. Although this court was not in a position to rule on the adequacy of mental health services for children in the private insurance system, they did note that these problems were not specific to Medicaid, but endemic to all children in Massachusetts.

In developing a settlement in this case, the Court has required that MassHealth change the way in which it provides services to families at all levels. These changes will be implemented over the next two years, and will require us to practice a more comprehensive approach to childhood mental health issues than we have in the past. You will see changes in the ways in which we identify, evaluate, treat and coordinate care for children with serious emotional disturbance. The settlement calls for these changes to occur over the next two years, with the first change happening as you read this.

As of January 1, 2008, pediatricians will be required screen children with a validated screening instrument (See Table 1)

as part of the Early and Periodic Diagnostic, Screening and Treatment (EPSDT) program within MassHealth. Due to the efforts of Walther Harrison and the MCAAP’s Mental Health Task Force, we will be able to bill for the screening using the Developmental/ Behavioral Screening procedure code 96110, and will get some additional reimbursement for providing this service as part of our well-child care. Children who screen positive will require assessment and triage to one of MassHealth’s Behavioral Health Providers for further evaluation and treatment. While this may happen informally within your practice, and is certainly in line with the AAP’s new Bright Futures recommendations, the new system will require you to implement a formal screening protocol using evidence-based tools; that change will require some work on your part.

So, within your practice:

1) Pick your screening instruments: The approved instruments each have strengths and weaknesses- you and your partners need to decide what works for you. My practice has decided to use the PEDS for children under 5 years of age, except at age 18 months, when we will use the MCHAT, and the PSC/PSC-Y for the children 5 and over. For more discussion on this, check out my blog at

2) Fit the screening into your flow: The instruments need to get into the hands of parents; enlist your staff in figuring out how to make that happen. Waiting room, pre-visit mail-out, in the exam room- all have pros and cons that bear discussion with staff, as they are the ones who will make this work.

3) Know your options for referral: Unfortunately, the list of mental health providers in our area changes pretty regularly, so someone has to keep it updated. The Massachusetts Behavioral Health Partership has a great on-line directory at their website ( which often serves as a good place to start.

Over the next several months, MassHealth, working through the Massachusetts Behavioral Health Partnership and the five Managed Care Organizations that provide mental health services to our patients, will be implementing new forms of evaluation and case management. This is going to be complicated- stay tuned for further developments. More detailed information on the complexitiy of this implementation can be found in the excellent report “Implementing the Rosie D. Remedy: The Opportunities and Challenges of Restructuring a System of Care for Children’s Mental Health in Massachusetts” available at no cost from the Massachusetts Medicaid Policy Institute. ( Those with more interest should consider joining the Mental Health Taskforce (contact the at the Catherine Haggerty at the MCAAP office for more details).

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