Wednesday, April 16, 2008

An Act Relevant to Children's Mental Health: Do we have the Ways and Means?

Another gorgeous spring day, but today, faithful reader, I am forcing myself to stay inside and blog (I just can't see the screen in the sun, and I get distracted by bicycles and the like if I go outside). So, over the last few weeks, I have met with a number of folks at the State House about S.2518 (I wrote about this last month). So what's happened since then?

The bill is under consideration by the Senate Ways and Means Committee, who are, appropriately, trying to decide if the Commonwealth can afford this legislation. The legislation does essentially 5 things:
• Create a system so that school personnel will be able to receive mental health consultation and guidance.
• Requires insurance companies to pay mental health professionals for the time they spend on “collateral services,” or coordination of care with other important adults in a child’s life.
• Promotes behavioral health screening for children during visits to their doctors.
• Encourages behavioral health screening for very young children in childcare and preschool settings.
• Processes to move children with mental health needs to a community based or residential program.

The insurance industry, as one might suspect, is against the bill because of the "unfunded" mandate. Otherwise, the only fight is over the cost, because, as you know, this year in Massachusetts has a tight budget. I am not a budget expert; I've met budget experts and I have tremendous respect for what they do. There is, however, one flaw in the "cost-benefit" analysis process that makes this difficult. We don't know how to measure the cost of not treating children with mental illness. And, when the state is figuring out the cost savings, there are factors that they need to consider:
1) Early vs. late treatment: We know that an ounce of prevention is worth a pound of cure, yet we are so often reluctant to pay for that ounce. We have data supporting early intervention in many forms; surely there is benefit to making is easy and stigma-free to access mental health services. School consultation, child care screening, office-based screening all affect that.
2) Evidence-based treatment: Many plans restrict mental health treatment to a certain number of visits on the notion that the "evidence" doesn't support the treatment planned. While we want medical practice to be based on the evidence, the Ways and Means folks should remember that "lack of evidence" often means "no one has done the study". In mental health, for example, medications are assessed in randomized controlled trials supported by PHARMA; other forms of treatment get less study because there are fewer large funders interested in studying them. The precepts of evidence-based medicine are clear on this point: when the study hasn't been done, don't ignore the practical experience of excellent clinicians. Sometimes, by being too restrictive in the short run, we cost ourselves more in the long run.
3) Cost-shifting: I have had patients who have told me that they are trying to shift their child's insurance from their private plan to Medicaid, because the mental benefits on Medicaid are better than those in the private plan. As the state moves forward in the implementation of the Rosie D. case, the benefit of MassHealth will increase; without requiring the private insurance companies to cover community-based services and care-coordination services, there will be a tremendous incentive for payers and parents to "cost-shift" to optimize their child's care. Without this bill, the Commonwealth will be left holding the bill.
4) Economies of scale: DSS, DYS, DMH, DPH (Substance abuse), DOE- all of this gemisch of alphabetically defined agencies work on the same kids at various times. This legislation requires the kind of interdepartmental collaboration that Secretary Bigby has called for; through better collaboration, there will be some savings, but more importantly, there will be better care. Our children deserve a structure that is integrated and focused on their best interest. If that costs a little more, I'm OK with that.

It will be really hard to measure these cost-savings. Sometimes action requires people to understand the broad impact of a plan while allowing the details to sort themselves out later. And, for children's mental health, the time is NOW.

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