Saturday, September 27, 2008

After the Party: Updates on Rosie D. Implementation

After the celebration, I (like the rest of America) got a little preoccupied with the imminent collapse of our economic system.  Sorry - its been a few days since my last posting.
The Center for Public Representation recently issued a news bulletin, which is worth a look here.   They had four items:
1)  Final Medical Necessity Criteria:  It is good to hear that the criteria for determination of medical necessity are almost ready to be released;  we all knew that it would be a struggle to put that together and we fully expect that there will be controversy over them once that are released.  Their release, however, will be another landmark in this case.
2)  Response to CMA:  Folks should take a look at the forceful way that Secretary Bigby is arguing for the expansive and comprehensive services that will be needed to make wraparound services a reality in Massachusetts.  
3)  Revised State Plan Amendment:  This is also good to see;  an administration working to set policy that provides services for children and families.  We can only home that the Federal government sees the good in all of this as well.
4)  CSA:  Coming soon.  The Massachusetts Behavioral Health Partnership has put this on hold as well, trying to make this RFR consistent with the agreements that the Commonwealth is able to reach with the folks in Washington.
The last thing was a bit about screening.  I want to quote the article exactly, because I want my comments to be equally precise:
"The early data reports of the new behavioral health screening initiative indicate significant gaps remain in the Commonwealth. Although all children who visit their pediatrician or health care professional for a periodic EPSDT visit must now receive a behavioral health screening, only 25% did in the first six months since the new program was initiated on January 1, 2008. Of those who were properly screened, only 7% were identified as having a behavior health condition, even though national data indicates this figure is well over 10% and often approaching 20%. Finally, of those identified as having a behavior health condition, there was no data on the percentage who were referred for a mental health assessment, even though this figure should be approach 100%. Thus, despite the critical importance of behavioral health screening, as mandated by the Congress and ordered by the federal court, much remains to be done to ensure compliance with these mandates in Massachusetts."
In light of my experience in this area, I want make a couple of points:
1)  I am not troubled that MassHealth only found that 25% of EPSDT visits involved a behavioral health screen.  This program was implemented with almost no notice- it will take some practices more time than others to get up to speed.  Also, screening and billing may not match entirely.  Given that almost no-one was screened using a valid screening instrument prior to the Rosie D case,   getting to 25% is extraordinary.  That is at least a 100% increase.  Not bad for the first 6 months.  I suspect it will get to be a larger percentage of children over time.
2)  Billing and practice are not always in sync.  It is hard to change habits; it took me a while to remember to add the screening code to the billing sheets, and I know that some of my patients escaped without me billing for the screen that I did. 
3)  Rates of positive screens are low.  Research studies, where there is an interest in finding high rates of problems, almost invariably result in higher rates of case finding than we find in the real world.  For me, part of the problem is how to code the kids that we already knew had problems?  Are the "U2" referrals if they are already in treatment?  Or if they refuse treatment?  That happens in at least 50% of my positive screens-  that will look like underdiagnosis in the billing data.
4) No data on mental health referral:Here is where the "carve out" ideology gets in the way.  In our area, anyway, the act of making a referral is largely giving the phone numbers for several agencies to the mother.  The agencies won't let us book the appointment, as, in their experience, that leads to too many no shows.  And we often don't hear back regarding their their treatment plan.  So how can we tell who has been referred until we agree on what referral means?  The best that MassHealth can do is look at mental health billing records and compare them to the primary care record.
5)  Who were those patients? Please remember that the EPSDT visits during the school year (January to June) are likely to be younger, and the rates of mental illness are lower in that population.  I suspect that the number of screenings will increase in the summertime, when we are seeing all of the older kids for school and sports physicals.

Change is hard, whatever the system in which it is being promulgated.  I look forward to seeing the end of year numbers.

FEEDJIT Live Traffic Map