Friday, January 30, 2009


From the New England Alliance for Children's Health
Last night the Senate passed the Children's Health Insurance Program Reauthorization Act of 2009 by a vote of 66-32. Ten of 12 New England Senators voted for the bill. Senator Gregg (R-NH) voted against the bill, and Senator Kennedy (D-MA) did not vote. The entire role call can be found below.

The bill included the ICHIA provision, which eliminates the current five-year waiting period for legally residing immigrant children. In addition, a number of amendments that would have weakened the bill were defeated.

Senator Baucus (D-MT) has expressed hope that the Senate bill can be sent to the House for a vote rather than sending the House and Senate bills to a conference committee.
Vote Summary
YEAs - 66
All Democrats voted for the bill along with the following Republicans: Alexander (R-TN), Collins (R-ME), Corker (R-TN), Hutchison (R-TX), Lugar (R-IN), Martinez (R-FL), Murkowski (R-AK), Snowe (R-ME), Specter (R-PA)
Akaka (D-HI) Alexander (R-TN) Baucus (D-MT) Bayh (D-IN) Begich (D-AK) Bennet (D-CO) Bingaman (D-NM) Boxer (D-CA) Brown (D-OH) Burris (D-IL) Byrd (D-WV) Cantwell (D-WA)Cardin (D-MD) Carper (D-DE) Casey (D-PA) Collins (R-ME) Conrad (D-ND) Corker (R-TN) Dodd (D-CT) Dorgan (D-ND) Durbin (D-IL) Feingold (D-WI) Feinstein (D-CA) Gillibrand (D-NY) Hagan (D-NC) Harkin (D-IA) Hutchison (R-TX) Inouye (D-HI) Johnson (D-SD) Kaufman (D-DE) Kerry (D-MA) Klobuchar (D-MN) Kohl (D-WI) Landrieu (D-LA) Lautenberg (D-NJ) Leahy (D-VT) Levin (D-MI) Lieberman (ID-CT) Lincoln (D-AR) Lugar (R-IN) Martinez (R-FL) McCaskill (D-MO) Menendez (D-NJ) Merkley (D-OR) Mikulski (D-MD) Murkowski (R-AK) Murray (D-WA) Nelson (D-FL) Nelson (D-NE) Pryor (D-AR) Reed (D-RI) Reid (D-NV) Rockefeller (D-WV) Sanders (I-VT) Schumer (D-NY) Shaheen (D-NH) Snowe (R-ME) Specter (R-PA) Stabenow (D-MI) Tester (D-MT) Udall (D-CO) Udall (D-NM) Warner (D-VA) Webb (D-VA) Whitehouse (D-RI) Wyden (D-OR)

NAYs - 33
Barrasso (R-WY) Bennett (R-UT) Bond (R-MO) Brownback (R-KS) Bunning (R-KY) Burr (R-NC) Chambliss (R-GA) Coburn (R-OK) Cochran (R-MS) Cornyn (R-TX) Crapo (R-ID) DeMint (R-SC) Ensign (R-NV) Enzi (R-WY) Graham (R-SC) Grassley (R-IA) Gregg (R-NH) Hatch (R-UT) Inhofe (R-OK) Isakson (R-GA) Johanns (R-NE) Kyl (R-AZ) McCain (R-AZ) McConnell (R-KY) Risch (R-ID) Roberts (R-KS) Sessions (R-AL) Shelby (R-AL) Thune (R-SD) Vitter (R-LA) Voinovich (R-OH) Wicker (R-MS)
Not Voting
Kennedy (D-MA)

Thursday, January 29, 2009

Psychopharmacology and the Evidence and the Eye of the Beholder

I hadn't run into CounterPunch before- it is an on-line journal of political commentary that prides itself on pulling no punches.  Their article, "Why Hold Up a Drug Just Because It's Dangerous? Fragile: Handle with Risperdal" is worth a read (Get it here.)   She shows how the J& J funding of the "Center of the Study of Pediatric Psychopathology" at MGH was part of a marketing campaign designed to push the limits of acceptable usage for a medication that was initially approved for a very limited set of circumstances, and the dangers of the removal of the barriers that constitute the separation of business and diagnosis.  We've seen this now in so many different medications (e.g. Neurontin, Vioxx) that it really suggests a system problem with the structure of the process of drug development and Federal regulation.  I have faith that this will be dealt with, but the question for us as practitioners and parents is simple:  Given that we live in an imperfect system, where the sources of our information are tainted, how do we know when to medicate and when to refrain from medicating?  I've been mixed up in this business for a while, and have a few ideas for some practical rules that I would like to share.

1)  Always remember that there are no medications that have no side effects.   The only question is whether the side effects are less of a problem than the condition that you are trying to treat.  This should underlie all discussions of medication with children.
2)  Always point out that we know less about the new medications than we do about the older ones.  The phrase, "the devil we know" comes to mind, especially in dealing with methylphenidate and its brothers.  The new stuff always looks better, and we almost always find eventually that it is not quite as good as initially advertised.
3)  We know less about medications in combination than we do about medications alone.  The greater the number of medications we are using on an individual patient, the closer we are moving to experimental medicine.  This doesn't mean we shouldn't do it;  it does mean that we need to watch carefully, and listen to the parents and children about how these combinations are influencing their lives.
4)  Diagnosis in children is fluid.  Parents often tell me that "bipolar was ruled out in the eval" or something like that;  I usually try (gently) to point out that we actually don't know if this is still true 1 or 2 years later.  Kids develop, which is their wonderful strength, but it makes it hard to fit them into neat psychiatric categories.  Makes them hard to study.
I liken the use of psychoactive medications in children to a journey in the woods-  we have a few well-defined trails (like stimulants and ADHD and SSRIs and depression/anxiety), but a lot of what we do is akin to hiking off the trail.  Sometimes you have to do it, especially if you are a family "lost in the woods",  but bush-wacking the psychotropic "road less traveled" can be dangerous, and merits full disclosure.  The danger of marketing campaigns like the one used for risperdal is that they make us forget that we are actually in uncharted territory.

Tuesday, January 27, 2009

News Flash: Budget Cuts and Rosie D.

From the CBHI:

An Important Message from CBHI

MassHealth has recently filed a motion in United States District Court seeking a partial extension of the service implementation deadline in the class action lawsuit known as “Rosie D. v. Romney”.

The proposed modification would extend the implementation deadline for four services: In-Home Behavioral Services, In-Home Therapy Services, Therapeutic Mentoring and Crisis Stabilization --- moving the start date twelve months from June 30, 2009 to July 1, 2010. The original implementation deadline of June 30, 2009 would remain for Intensive Care Coordination (ICC), Mobile Crisis Intervention and Caregiver Peer-to-Peer Support. (Note that all of these services must be approved by the federal Center for Medicare and Medicaid Services (CMS) prior to implementation. CMS has approved ICC. Approval for all other services is pending.)

MassHealth has made a careful decision not to request an extension for the implementation deadline for ICC, Caregiver Peer-to-Peer Support and Mobile Crisis Intervention. ICC is the “heart” of the new system, addressing the most significant unmet need identified by the Court: the lack of comprehensive care coordination for MassHealth children and youth across the State with a serious emotional disturbance. Caregiver Peer-to-Peer Support, which is provided by “Family Partners,” is an integral part of ICC. Mobile Crisis Intervention will be provided by teams of mental health professionals trained to work with children and youth and their families and will be an essential resource for providing behavioral health services to children and youth living at home. MassHealth believes that these services, in combination with the current Family Stabilization Team (FST) service, will go along way in this proposed first wave of implementation towards meeting the needs identified by the Court.

Currently, MassHealth is on track to implement all services by the current June 30, 2009 deadline and, pending the Court’s action on this request, MassHealth will continue all implementation activities to meet this deadline.

MassHealth’s decision to file a motion to modify the implementation schedule comes in the wake of the state and nation’s severe fiscal crisis. Decreased state revenues forced Governor Patrick to implement a fiscal action plan in October, cutting $1.053 billion from the state budget including $353.7 million from the Executive Office of Health and Human Services ($292 million from MassHealth alone).

Unfortunately, the economy has not improved. Governor Patrick recently announced the need to reduce current state spending by another $1 billion and Administration and Legislative officials anticipate even more cuts to the state budget in State Fiscal Year 2010, which begins July 1, 2009.

MassHealth Has Few Options
During an economic downturn, demand for Medicaid goes up as more people fall into poverty, lose their employer-provided health insurance coverage and become uninsured. Given further budget cuts that will be announced soon, MassHealth has three ways to respond. MassHealth can: 1) reduce the number of people eligible to receive services, 2) reduce the services available to eligible people or 3) decrease the amount paid for these services.

MassHealth’s top priority has been to maintain eligibility standards to protect its core mission, as well as the structure of the Commonwealth’s 2006 health care reform law. In order to continue to provide services, MassHealth has, so far, primarily reduced or contained growth in payments to providers for services. In the current fiscal year, MassHealth is holding provider reimbursements for most services to prior fiscal year levels, forgoing planned rate enhancements for physicians, community health centers, adult dental providers and managed care capitation rates.

Hospital spending will be decreased in the areas of direct medical education, heightened pay for performance standards and other rate changes. Additionally, in the area of Behavioral Health, all planned rate increases to providers in FY09 have been eliminated and utilization management activities have been increased.

Opportunity for Improved Implementation
Given the harsh realities of the economic downturn, the state’s budget shortfall and the certainty of further cuts in public service, MassHealth believes that the proposed implementation schedule provides a more realistic plan for implementing high-quality services.

The successful implementation of Intensive Care Coordination (ICC) will be the foundation for the success of the new system as a whole. By establishing ICC first, including the Caregiver Peer-to-Peer Support service that plays an integral role, and allowing that foundation to settle for a year, we will likely be more successful when we add the “next floor” to that foundation with the implementation of the other services.

Additionally, the implementation of In-Home Therapy, which will replace FST, will likely be the second-most-used service behind ICC. The launch of this service is a tremendous opportunity to enhance the availability of high-quality, effective, community-based clinical services for children and youth with mental health needs, and their families. There are important emerging best practices and evidence-based practices in this field. A 12-month implementation delay would also allow us to incorporate the latest research and best practices into the design, implementation and training activities for In-Home Therapy.

Again, MassHealth remains on track to implement all services by the original implementation deadline established by the Court. We strongly believe, however, that the amended implementation schedule, if approved by the Court, will help to protect other state services while allowing for a better implementation of higher quality services for the many children, youth and families that will be served.

We will continue to keep you informed.
Well, this certainly is an unexpected twist.  The request is not unreasonable;  in essence the State is pleading for a little more time to get to the place that we all want to go without cutting it from the parts of Medicaid that are not covered under the lawsuit.  The budget is very tight; the fact that the Commonwealth is risking to cost of litigation to defer this expense makes me think that they are going to be very bad indeed.  So, what is an advocate to do?

1)  Fight it (and I don't doubt for a second that the the CPR is thinking about this as we speak):  This would be a natural response.  This runs the risk, however, of splitting the mental health community, and driving a wedge within many coalitions;  if the judge says "no", then the Commonwealth will have many other programs that will need to be cut more.  And the quality of the programs built in this style will likely be low.
2)  Don't fight it:  The judge may respect that the defendants are being reasonable, and really work with the plaintiffs  to ensure the ICC and Home-based services are in place.  It really isn't in anyones interest for this to fail.
3)  Fight it a little and compromise: Perhaps one could think:  "We do need to fight this- it is ones job as a plaintiff."   I hope that we don't do this.  Eventually, we have to accept that we can only do what we have the resources to do, and it is worth not getting our partners upset.  Another year may not be so long to wait, especially when, for some of these services,  we may not actually know how to do them properly.  Getting ICC and HBT on line is going really tax our workforce on July 1-  getting those services up and running will help a lot of kids.  Of course, getting the rest of the services up and running will help more.

As the old Chinese curse goes:  "May you live in interesting times!"  We will see how this dance plays out.

Monday, January 26, 2009

Hunger, Housing, Homelessness and Hope: Advocating for Children at the State Level

First, for all you who have been watching the stigmatization of mental illness play out against the Iraq War, I commend you to this excellent Op-Ed piece in Monday's New York Times.  I think that author is right on the mark, although I think that the medal for soldiers affected by PTSD should be a broken heart, rather than a black one.
Mental health in adults clearly results in homelessness, hunger and housing problems;  any program that mitigates these risk factors is likely to impact the mental health of children.  Health Care for All organized a wonderful session at the Statehouse, laying out the arguments for mitigating the impact of poverty on children.  We heard how hunger is linked to school failure; we heard how homelessness makes education nearly impossible.  "Hunger is written on children's bodies, minds and spirit" says Deborah Frank, a researcher at Boston University whose work has been seminal to our understanding of the relationship between food policy and children's health.  We heard the stories to illustrate these points:  the child who changed school as his housing changed, the child who was hospitalized after the child couldn't feed him enough, the child who binges on junk food because it is quick and accessible and she is hungry-  there isn't any healthy  food in the larder.  The assembled Food Banks and Homeless advocates and the Children's Health Action Council have an agenda, but the key to that agenda is to recognize that all of this stuff hangs together in a way;  to cut one piece is to cut all of them.  In the words of Benjamin Franklin, we must all hang together or we should certainly all hang separately.

So what legislation is this unlikely band of brothers and sisters promoting to maintain and improve the health of children in the Commonwealth?  Many things:

Preserving the funding in the current budget:
- Early Intervention (Line-Item 4513-1020), Healthy Start (LI-4000-0895),  Children's Medical Security Plan (LI-4000-0990), and Enrollment Outreach (LI 4000-0352)
-Massachusetts Rental Voucher Program (LI-7004-9024) and Get the Lead Out (LI-7004-1966
-Hunger Prevention (44000-1001), School Breakfast and Summer Food (LI-7053-1925), WIC (4513-1002) and Emergency Food Assistance (LI-2511-0105)
Add new legal protections:
-An Act to Assure Continuity of Health Coverage
-An Act to Ensure Equitable Health Coverage for All Children.
-An Act Ensuring Access to the Health Care for Children and Young Adults
-An Act to Prevent Homelessness Among Recipients of Transitional Assistance
Of course, I would add two others:
-An Act Establishing the Massachusetts Childhood Vaccines Program
-An Act Relative to Coordination of Children's Mental Health Care

I will get the Bill Numbers and links to the text once they are posted.  So, there you have the tasks before us.  Got a lot of work to do, to ensure that children are cared for.

Sunday, January 25, 2009

The Monthly Access Report: How Hard Is It to Get Your Child Into Treatment?

Mamacate was back with another comment today-  I really should get her to post on this blog more regularly, as she has much good insight into the current "non-system" based on what sounds like much hard experience:
I feel like we have immense resources compared to the average family dealing with this--financial flexibility to pay out of pocket for assessments, graduate-level education that makes it difficult for the school to intimidate us, jobs that are flexible enough to allow for us to run off to appointments across the state and IEP meetings that last for hours, and the time and educational background to read and understand peer-reviewed research on these diagnoses (not to mention an academic account that allows me to pull full-text from most journals). How, if we're struggling like this with the resources we have, can it be for parents who have to punch a clock, or those for whom signing that $4,000 promissory for the first neuropsych would risk financial ruin? It can't really be this bad....can it?
The short answer is:  "Yes, it can."  We hear all of the time how hard it is for parents, busy with work and kids and all that that entails, can't get appointments, can't see the right specialists, and are not heard as they try to cope with their child's mental illness.  The Massachusetts Behavioral Health Partnership actually puts out numbers, fairly regularly, based on reports from the various agencies who contract to see Masshealth patients.  What do they say?

The report comes on a spreadsheet;  the first five pages are devoted to children and the next five pages are devoted to children.  In Worcester, the intake evaluations were listed as having a 4-5 week delay at all of the agencies, with another 4-6 week delay in getting into therapy and 6-8 weeks after that to get a psycho-pharmocology evaluation.  Things are a bit better at the one agency in Southbridge (1 week to intake, 1 week until therapy and 5 weeks for the psychiatrist)  Similarly, Fitchburg is difficult, but not as bad as Worcester.  The hard bit in the North and South of Worcester County is that there are very few agencies, so many of the people go into Worcester for services.  For adolescents, it looks the same.  Hard to be reassuring to a family when it is going to be 10-19 weeks before they are through the entire process.

Is this different?  Well, I happened to have saved (in my usual packrat style) the same report from January 2006.  At that time, the waits were 1-2 weeks for intake, 1-2 weeks for therapy and 5-6 weeks for psycho-pharmacology.  It would be interesting, but tedious, to do an agency by agency comparison, but it looks to me like we are seeing a system on the verge (or maybe over the verge) of being swamped.  We sort of expected this after we began screening children in the Commonwealth for mental illness, and I suspect it was not helped by the economic downturn, which has placed tremendous strain on mental health agencies throughout the Commonwealth.  Whatever the reason, the need for more workforce is clearly real, and services are hard to access.  High quality services are even harder to access.  

Mamacate is correct-  what is one do do on a single income with an inflexible job and limited transportation?  This will be the critical question as the Rosie D remedy rolls into the next phase.

Saturday, January 24, 2009

End Disparities in Health Care of the Disabled:

I was invited as the Secretary for REDD (Rights, Equality for the Dignity of the Disabled) group to provide a testimony about our group's priorities to area state legislators at the Easter Seals Office in Worcester. For those who do not what REDD is or does, REDD is a group of volunteer advocates with/out disabilities dedicated to supporting and fighting for the civil rights for persons with disabilities in Central Massachusetts. Since REDD's inceptions in 1996, some of our accomplishments include getting accessible taxicabs in Worcester and extending the length of the platform at Union Station, so persons with disabilities would have access to more than two cars in boarding on and off the trains. After I spoke about REDD's two priorities: Transportation and Emergency Preparedness, I changed hats as a private resident who works in mental health to speak about the proposed bill called "Disabilities and Disparities in Health Care," sponsored by Senator Richard Moore.

As a licensed mental health clinician, I support this bill as our profession needs to learn how to work and to counsel persons with disabilities. I said that the mental health profession is operating from the 1950's mode in how some clinicians inappropriately talk to this community. If Disabilities is included as a "minority group" with other ethnic groups, then the profession will learn more about this culture's health and behavioral needs on an equal footing along with these groups. I pushed for the profession to learn sensitivity training in how they counsel this community as it is badly needed and ignored.

The Disability Policy Consortium, a private entity, that lobbies for specific causes across all disabilities, will be coming out with their own study on several health indicators such as "Smoking,"and "Behavioral Risk Factors," affecting these populations this year.

Bill: Disabilities and Disparities in Healthcare as posted on

This bill is also part of the Disability Policy Consortium's 2009-2010's Legislative Agenda: Below is the wording of this bill:

Health Disparities Council SECTION:
1. Section 16O of Chapter 6A of the General Laws, 1as appearing in the 2006 Official Edition, is hereby amended by adding after “HIV/AIDS”in line 8, the following: “disabilities”Health Care Quality and Cost Council. SECTION 2. Section 16K of Chapter 6A of the General Laws is further amended by deleting 57 subsections (h) and (i) and replacing them with the following new language:(h) The council, in consultation with its advisory committee, shall develop annual health care cost containment goals. The goals shall be designed to promote affordable, high-quality, safe, effective, timely, efficient, equitable and patient centered health care. The council shall also establish goals that are intended to reduce health care disparities in racial, ethnic and disabled communities.

Contact: Shawn (SEN)"

RATIONALE: While “Universal Health Care” has been the rallying cry of advocates for healthcare reform in Massachusetts, a quieter, but no less important focus has been on health care disparities. The Commonwealth of Massachusetts landmark healthcare reform legislation and the creation of the “Commonwealth Connector” extending health insurance to hundreds of thousand of more citizens has sharpened the national debate on Universal Health Care. Data on racial and cultural disparities along with advocacy on behalf of those who have clearly been racially, ethnically and culturally discriminated against by the previous healthcare and insurance system, helped to lay the foundation for healthcare reform. The discussion of health care disparities has been limited to primarily to ethnicity, and race, issues that highlighted the efforts at healthcare reform. The purpose of this paper is to show that the categories used to measure and discuss disparity in healthcare must be expanded to include people with disabilities. It is the conclusion of the DPC that the discussion on disparities in health care must be changed to include people with disabilities. If, on the other hand, policy advocates choose to continue to focus solely on ethnic and racial factors, the title of the debate should be changed from “health care disparities” to “racism in the health care system."

Robbin Miller

Friday, January 23, 2009

A Health Care Conversation: Unmasking the Stigma

William Moyers, the son of commentator Bill Moyers, is the guest speaker at this morning's "Healthcare Conversation" at the Beechwood in Worcester.  His book talks about his struggle, and he has spent the last few decades working to raise awareness and break down the stigma associated with mental illness and substance abuse.  Lots of people in the room, politicians and providers, most of the leaders of health care in Worcester County.  The talk was sponsored by the Health Foundation, and, given the reform efforts in play in the Commonwealth and the country, the topic is important.  Substance abuse is a mental illness, but the impact on the rest of health care system is huge.
His story is that of "everyman", a youth who experimented and got hooked, fell into the depths and managed to go "clean and sober" in 1994.  He made sure that we understood that people with the chronic illness of substance abuse look like us, and live among us, invisible and in need of help.  Substance abuse is a mixture of nature and nurture; as he put it, while he voluntarily experimented with substances in adolescent, it was the structure of his brain meant that he quickly developed a "baffling inability to 'just say no'".  He wanted us to understand that treatment works, but that it takes time (4 rounds of treatment before he was able to enter long-term recovery).  It is a story that is common, but that needs to be told over and over again, because, despite the science, many persist in believing that addiction is moral weakness rather than a real disease.  He is an excellent speaker;  I suspect that his book is worth reading.  I especially liked his last point, that as a child of privilege, he may have access to resources that mean that, while addiction doesn't discriminate, treatment still does.   What he really wanted us to know is that addiction treatment NEEDS to be part of the health care reform that comes out of the new Obama administration.
He's right, of course, but how does that translate into policy?
1)  Change the war on drugs:  Interdicting supply hasn't worked;  we need to put equal energy (or more energy) into things like drug courts and treatment of those incarcerated.
2)  Implement parity at both the Federal and State level:  The devil is in the details, and the details are written in the Labor Department at the Federal level.  We need to be sure that intent of the law is not undermined in the writing of the rules.
3)  Organize:  Local coalitions, national organizations;  we all need to have a voice in this process.
It occurs to me that, while he focused on substance abuse, the same could be said for other forms of mental illness.  There was more, but I had to leave to go to another meeting.  I guess you should all read the book.

Wednesday, January 21, 2009

A Parent's Point of View: Mamacate's Comment

My last post before the wonder of Inauguration Day spoke of the problem of balancing the known and the unknown in dealing with childhood behavioral problems (the post with the cute "Goldilocks" title).  Many of you probably don't open the comments,  and a person named "Mamacate" left one that I thought deserved elevation to "posting status".  Here is is, to give us all a parent's perspective on this problem:

You're right, of course, but as a parent who has been struggling to get a meaningful diagnosis (not to mention meaningful help) over the past three-plus years, it's tough to be the proverbial porridge. We're still caught in the middle of the "is it or aint it" bipolar debate, and at this point I think there are maybe one or two clinicians in the state willing to make that diagnosis in a 6-year-old, at least among those from whom we should accept such a diagnosis.

I realize now, when we are in a much better place, with at least a partial diagnosis, that our ability to cope, and our unwillingness to bring our 35-pound three-year-old to the ER or to call the police, etc. because of his behaviors is a major reason we didn't get better help sooner. We were desperate, but we sought help calmly and appropriately, and we were turned away at every attempt, while care providers and teachers freaked out and called his behaviors some of the most extreme they'd ever seen. Because we didn't access crisis supports we know to be inappropriate for kids, we struggled for three years with advice to provide more consistent discipline.

I know that individual cases don't necessarily transfer to public health policy, and we fit the profile of the kinds of parents who stereotypically would have unrealistic expectations for behavior that might translate into medicating a normal, but temperamentally-challenging child. Yet I wonder if these kinds of armchair critiques of overmedicating kids (not to mention the terrible ethics violations among those advocating the bipolar diagnosis in young children) are putting theory over practice and making it hard for families to access really needed help.

I think about how much better things might have been if we had been able to get an accurate diagnosis earlier, and if we could have avoided years of having our parenting questioned, having frankly bad advice on how to discipline our son. We have finally found out (by traveling across the state for an evaluation that we had to pay for out of pocket because no one will take our private insurance for a neuropsych eval and we'd have to sue our school to get them to pay) that he has AS as well as possibly a mood disorder, and actually needs to learn in a much more structured way than most kids--typical discipline doesn't work-- and we spent years being told to do(and following through on) the opposite.

Like you say, clinicians don't have time to get in our lives in the same way we are, and certainly there are parents who don't have the ability to judge the difference between mild behavior problems and organic mental illness or developmental disability. And we rely on clinicians to help us answer those very questions. I don't know how you can make that determination in a fifteen-minute appointment, but I don't think moving toward a more conservative approach to diagnosing kids, at least for most clinicians, is going to help the kids who really need help. Just a parent perspective.
As a pediatric practitioner, what do I take from this?  A few things, but I am interested in hearing yours:
1)  Parents want both an explanation and help.  I would be really interested to have been a fly on the wall to record the words used by the various assessors.   I suspect they were trying to enunciate the facts (we honestly don't know how to label these things yet), and may have even said things like "provisional diagnosis"-  to a parent, that can seem like an unwillingness to make a diagnosis.  I have had a similar experience with ADHD-  I have a rule in my head about not diagnosing it before kindergarten, mostly because the data on medication efficacy in pre-schoolers is so iffy- and many parents perceive that as arbitrary and unfair.  It seems to the parent that, in our current model, we don't really offer help to the parent without a diagnosis, and that to withhold a diagnosis is to withhold help.  That is really frustrating.
2)  Parents want both explanation and help.  I know, and Mamacate knows, that this cannot be done in a 15 minute visit-  that this is complicated and requires time to do it right.  And yet, we set up systems that don't reward us for that time (ie  we are paid more for 4 fifteen minute medication checks than we are for a one hour consultation, and we lose more if the person with the one hour appointment fails to come to the office, than if one of the four fifteen minute people fails to come in.  AND we can use our prescribing power to lure the "short visit" patients back to the office.  Explanation and help require time-  as long as we are paid by the piece, that won' t happen.  
3)  Parents want the help to be effective.  Is it organic, is it manageable by behavior modification, will medications help?  Blame is unimportant, outcome is everything to a parent.  So, whatever we do, we need to be constantly checking in with the parent, modifying the plan in light of results and changing circumstances and bringing in the expertise that we need to make it all work.  Parents don't want drugs, necessarily, but whatever we do, they want it to work.

Nice work, Mamacate.  Hope you are feeling a bit more hopeful now- it sounds like it will still be a long road.   If you want posting privileges, just drop me a line.  You can write on this blog anytime.

Tuesday, January 20, 2009

On the Mall on 1.20.09: Yes We Can!

So, why does a trained professional spend 5 hours to get in front of a Jumbotron on the Washington Mall to see an inauguration that could have viewed in many more comfortable places around the country?

One could argue that the inauguration of Barack Obama heralds the opportunity to begin to develop a system of health care that is comprehensive and integrates mental health care with the primary care system in a way that benefits children and families.  One could argue that, and, while in DC, I attended a "Doctors for Obama" event that allowed us to discuss that and many other ideas for improving the system.

But that wasn't why.

One could argue that fixing the health care system requires us to get the economy under control, and that "fix" requires us all to get behind the President and the people who understand the economy to fix a very broken system.  One could argue that, and at the "Rhode Island Inauguration Breakfast", we heard about the changes that need to happen to create the infrastructure necessary to salvage the system.

But that wasn't why.

One could say that this election addresses race in a way that we as a nation have never tried to do in the past, that the election of an African-American shatters one more glass wall between us and the society envisioned by Dr. King, in which a person is judged, "not be the color of his skin, but the content of his character".  Our African-American community was there in force, to witness this extraordinary piece of history, and I was proud to stand with them.

But that wasn't why.

It really comes down to my favorite quote from Barbara Kingsolver,  who wrote that "
"It's not some perfect ideal we're working toward that keeps us going...I don't expect to see perfection before I die... What keeps you going isn't some fine destination but just the road you're on, and the fact that you know how to drive. You keep your eyes open, you see this damned-to-hell world you got born into, and you ask yourself,
"What life can I live that will let me breathe in & out and love somebody or something and not run off screaming into the woods."
I was there to affirm my commitment to change, to meet some of the others who are looking to make change and to prepare myself for the task ahead.  
And while I was there, something remarkable happened.  An American President, instead of telling us how great we were, or how great we are or how he will make things all better, called on us all to do something to make America a better place.  A President called on us to to remember, not Abraham Lincoln, but George Washington.  He called on us to get past the small stuff and to make change in the small that could be rolled into change on a massive scale.  He called on us, in reality, to be the country that de Tocqueville saw, a nation of small groups engaged in civic improvement for the public good.   And he called on us to do it in good humor, with dignity and grace.  Sounds hopelessly idealistic, no?  Perhaps.  I left invigorated, engaged and ready to begin the work.

We have a lot of work to do.  But we can do it.  Yes, we can.

Monday, January 19, 2009

DC is crowded

I am taking a little break from Massachusetts, and am currently in DC, awaiting the inauguration of the next President, Barack Hussein Obama (I like the way that rolls off of my tongue).  The atmosphere is electric, the subways are as crowded as they say and I suspect that you will get a better view on YouTube.  But, sometimes you just want to be there. 
Posting may be intermittent over the next few days.  More to follow.

Saturday, January 17, 2009

Goldilocks and mental health: What is just right?

An article in today's Milford Post raises an interesting point, although oversteps a significant boundary in making the point.  Jacob Azerrad, a clinical psychologist from Lexington, questions the need to use medications, especially powerful medications like the atypical antipsychotics, in young children with behavioral problems.  He is correct to say that the second generation of antipsychotics is not as risk-free as initially advertised.  This week's New England Journal of Medicine points out that there is an association between use of atyptical antipsychotics and sudden cardiac death;  users were about twice as likely as non-users to undergo sudden cardiac death, although they weren't looking specifically at children.  I think that he is also correct  to say that many parents "over-medicalize" behavioral issues that are really just part of normal development.  That, in fact, is the job of the pediatric and behavioral health specialist, to reassure parents that a lot of the rambunctious behavior of two year olds is just that and doesn't require medication.
On the other hand, bipolar disorder and other serious emotional disturbances do exist in the world, and the parents of teens and young adults who really do have these problems will tell you that they perceived a qualitative difference in their behaviors as early as age 2.  I am really not sure that I could have perceived that difference in a diagnostic sense at that time, but I am willing to believe that the brain can have problems in both hardware and software at a young age, and that parents know more than I do about their own kids.  So, given that I don't want to "overtreat", how do I not "underdiagnose"?  I don't think that it is an easy thing to do.   I often feel like Goldilocks confronting the porridge, looking for the balance that is "just right". 
Because of that, I am a bit reluctant to cast aspersions on those who try, especially in difficult cases like that of Rebecca Riley, the young girl who died of a clonidine overdose last year.  The child clearly had major behavioral issues;  she may or may not have merited the diagnose of bipolar disorder, but she was clearly a challenging case that resulted in the worst possible outcome.  And yet, she had lots of care:  DSS, a psychiatrist, counselors, day care folks and parents were all wrestling with her demons along with her.  I know that the system failed her;  I am not at all certain which part of the system did so.   I suspect that the key in her case might have been better communication within the team; but I recognize that absent more information, I really don't know. 
It is on this dilemma that our task remains:  how do we build a system that respects the perspective of families, is based on the science of child development as we currently understand it, and appropriately uses the tools at hand to help the families and children?  It ain't easy.

Friday, January 16, 2009

From the Weekly Dig: HEAD CASE: The dilemma of affordable mental health care

Interesting article on the coming Mental Health workforce crisis.  Comments to follow.
I haven't had time to post much this week, and was feeling a bit guilty about it, hence the quick post earlier in the day.  I found the article just before I went into a strategic planning session, thought it was interesting, and realized that I hadn't said much about workforce development lately.  Hence the link above.    The article, I thought, was a reasonably good attempt to get at the problem that neither legislation or a lawsuit will solve:  we can find lots of kids who would benefit from services, but we have an awfully hard time getting them to the services, even when the insurance is paying for it.  The heart of the article to me is quoted below:
But “coverage” does not necessarily mean “care,” according to Ann Stillman of M-Power, a mental health advocacy group based in Roxbury. None of the plans permit us the outpatient support that we need," she says. "The outpatient counseling visits are too limited, often hospital inpatient times are too limited. They aren’t the support system on an outpatient basis that we need to stay well." Toby Fisher, policy director for National Alliance on Mental Illness, agrees. "What we have found with folks with a mental illness is that often they have to wait long periods of time to get an appointment," he says. "Particularly with child psychiatrists, there seems to be a shortage of qualified psychiatrists willing to take that insurance."

When the Dig called 100 psychiatric treatment providers in Greater Boston who take MassHealth, posing as a patient with MassHealth insurance, we asked each office if they were accepting new patients. Of 100 providers, 51 were not accepting new patients and 26 required the patient to have a primary care physician at a specific hospital. Nine of the providers listed had disconnected numbers, doctors who had stopped practicing or had failed to supply the office’s new number. Six offices failed to return calls. Eight offices were accepting new patients.

Jennifer Kritz, spokeswoman for the Executive Office of Health and Human Services, says MassHealth has not received any complaints. "MassHealth sets access and availability standards for managed care plans, which do day to day operations for member claims, including behavioral health visits," she says. "By our regulations, those managed care plans are required to tell us if they aren't meeting our standards."

What is more interesting to me, though, are the comments that this article provoked.  One, on the Digg website, really show have much fear people have of the recognition and treatment of mental illness.  The authors rightly point out that Massachusetts has more mental health workers than does many other states, but then suggests that this leads to overmedication.  The point of increasing the social worker and psychologists is avoid over medication.  But, for some, that is just not the perception.
The other is from my friend Robbin, who is really mad and really thinks that most of the problems in the mental health system are the consequence of parental indecision.  Her tone is sharper than usual, and than I like to hear.  I hope that she is able to work out her issues with MassHealth.  We certainly need the folks to who to refer.

Tuesday, January 13, 2009

The Campaign Continues: A Few Thoughts from the CMHC meeting

There were about 30 people around the table at today's meeting of the Children's Mental Health Campaign, and there was less cheer than one would expect from a group that successfully passed an Omnibus Bill in a single legislative session.  Why?  To quote a former President, "It's the economy, stupid".  
The Budget:  The Governor is going to announce another batch of 9C cuts soon, and noone knows what is going to be cut, creating much anxiety.  People speculated about this and that, but the bottom line is that things are going to be cut, we don't know what and when it happens, it will likely affect the marginal folks.  The last cuts created a "trickle down" effect- bits of this and that that create the system out of the pieces of care provided were lost, but agencies have rallied to make the impact much less than it could have been.  It is also complicated because the discussion around these cuts will roll into the discussion around next years budget.  We were also cautioned to watch for "silent cuts"-  freezing new enrollments in DCF daycare, for example, will hurt new kids entering the DCF system and gradually erode the system across the state.  We all agreed that we need to show the impact of these cuts in real life- we need to collect the stories that illustrate the impact these cuts and make sure that people know about them.
Implementing Chapter 321:  After that somewhat depressing set of thoughts, we moved onto the meat of the meeting.  Early returns say that the system is lining up behind the system change embodied in Yolanda's Law.  Members of the group have met with several Secretaries, a few Commissioners and some insurers, all of whom are supportive of the process going forward.  It is complicated- figuring out who is responsible for which services is not at all easy to do.  There are, as one would expect, some push back, as the bill requires a lot of reports and commissions.  As mentioned above, state government is cutting people, and people are needed to make this happen.  At many of these meetings, there was an effort to figure out how to integrate this process with the parallel process that is going on with Rosie D.  The most interesting report that I heard was about the implementation of the Mental Health Parity law;  the Commissioners of Insurance and Mental Health are hard at work to develop the language to define what Mental Health parity is in the Commonwealth.  One of the group joked, "I just love going to meetings", and it seems that that is good- the Administration seems to be trying really hard do the right thing.
Several of the sub-committees have started within the coalition; one on the school-mental health collaboration and another on interagency teams.  The Coalition seems to be lining itself up with the various subgroups that are developing the response to Chapter 321 in a way to assure that the regulations reflect the intent of the legislation.  All of the state agencies involved are wrestling with the notion that this is a parallel process to the implementation of the Rosie D. initiative, and want to make it into a seamless system that focuses on the child.
Re-Filing the Collateral Bill:  This was the only part of the Omnibus Bill that didn't get through, and it will be re-filed.  As we found last summer, the cost of this to the insurer's would be minimal;  it is going to be submitted again, by Representatives Balzer and Tolman, named "An Act Relative to the Coordination of Children's Mental Health Care", and one should stay tuned for future developments.
Forums in Boston:  The Campaign is working with the Boston Public Health Commission to put out a series of forums across the city, highlighting the problem of children's mental health.
So, despite the fiscal doom and gloom, we ended on a pretty upbeat note.  The Bill is being implemented, but the process is slow;  we all are really looking forward to seeing some benefits accrue for the children.  

The action steps?
1)  Watch for and document the ways in which 9C cuts are affecting the mental health of Children in your community.  
2)  Watch for and push for the passage of the "An Act Relative to the Coordination of Children's Mental Health Care".
3)  Join a working group that developing the plan to move forward with Yolanda's Law.

And stay tuned.

Sunday, January 11, 2009

One Small Point: Not Really a Failure of the Law...

I confess to not following the Stuart Little analogy in Robbin's post on the MBHP Alert #55.  However, I do hear her annoyance at the additional procedure's needed to provide mental health services, and hope that she is able to forge a more collaborative relationship with those charged with administering the money.   

I must correct her impression of the role of the law in this matter.  Over the course of the last few years, we have had two "legal" forces at work, creating change in the mental health system.  The Rosie D. case, which is the driving force behind the "mobile crisis interventions and home-based therapy interventions" is aimed solely at those children with Serious Emotional Disturbance.  I suspect that those children will have no trouble being authorized for more visits;  their ICC case-manager will see to that.  The new Children's Mental Health Law actually says little about the Crisis Teams or the Home-Based Therapy, but does aim to create an environment in which increased access to the outpatient therapy could happen.  Both of them would argue that the nature and duration of treatment is the result of a discussion between the family and the therapist.  But, as long as we are paying folks on a fee-for-service basis,  it is likely that the payor will want to exert some oversight over the process, and, as the money grows tighter, that oversight will become more onerous.

Robbin's point final point is still well taken.  As we build a Cadillac (or should I say Mercedes, in the current environment?) for the children with Serious Emotional Disturbance, we need to be careful not to forget to leave some gas in the tank of the Taurus that serves the majority of children with mental health problems in the Commonwealth.  The relationship between a child and  a therapist is the key to the successful management of the children, to PREVENT them from developing a Severe Emotional Disturbance.  That is something that we must strive to preserve.

One failure of the new Children's Mental Health Law

Does anyone remember seeing the movie, "Stuart Little," where the alley cats said sarcastically to the house cat, "A pet cat for a mouse." "How can that be?" In the real animal world, it is usually the cat that have the "pet mouses" and not vice versa. How does this example apply to the mental health field for children?

Mass Behavioral Health Partnership (MBHP) issued Alert # 55 (December 22nd 2008) stating new changes in how they will authorize Outpatient Mental Health Services for Adults and Children. As a FYI, adults, 19 years of age and older will get 12 units authorized for a 180 day period (six months), while children and adolescents, 18 years old and under will get 14 units authorized for a 180 day period (six months). However, if a child or adult needs additional sessions within this time period for example, weekly visits due to the severity of a client's mental health symptoms, MBHP now requires the clinician to have a telephonic meeting with them to scrutinize the updated treatment plan that is submitted to them for review.

This new procedure is highly insulting for a clinician to "beg" for more services from not only from MBHP but also from other health insurance providers who will be following the same protocol as well. I am aware of the economic climate to control costs in a shaky economy in the healthcare arena. However, it is the clinicians training and expertise in children's mental health that needs to be respected and not undermined by insurers.

While the new children' mental health law will have services in place for mobile crisis interventions and at home therapy interventions for families, it fails to advocate for improved outpatient services for children. It is the clinicians that know how long it will take to treat their clients' symptoms and not the insurers. If a child does not receive additional sessions within the authorized time period, the child will be at risk for hospitalization or residential treatment that will cost the insurance companies more money to pay for. Last but not least..this stricter requirement to "beg" for more sessions from "the big mouse" will not help retain and/or recruit clinicians to service children with mental health needs.

Robbin Miller

Thursday, January 8, 2009

Stigma Reinforced: Purple Hearts and PTSD

What does this news item from the New York Times say about our view of mental illness?
The Pentagon has decided that it will not award the Purple Heart, the hallowed medal given to those wounded or killed by enemy action, to war veterans who suffer from post-traumatic stress disorder because it is not a physical wound.
On the one hand, it is yet another example of how our society feels that mental illness is just in the same class as physical illness; even when clearly inflicted by the by enemy action,  damage to one's psyche is simply not in the same class as a bullet in the great toe.  Traumatic brain injury and post-traumatic stress disorder are the major wounds inflicted in the this war, but our returning veterans struggle to in much the same way our children have struggled, with inadequate screening and assessment and overextended treatment facilities within the VA system.
On the other hand, it is a sign of how far we have come that the Pentagon even asked the question.  PSTD has been a consequence of warfare for generations;  in the Civil War, it wasn't spoken of;  in the Great War (WWI), it was lumped together with Combat Stress Reaction and called "shell shock", felt by many to be a sign of weak character.  In the Second World War, it morphed into "battle fatigue", which, because it was often treated with "rest", had an underlying sense of weak character to many (but not those who experienced it).  No one, I think, even considered giving a Purple Heart for those conditions.  Now, we have a relatively well defined set of clinical conditions that accept the notion that the brain, the most complicated organ in the body, can be injured and malfunction in the course of a life.  What we don't have yet is the sense to honor those who undergo such injury in our name.  When we are able to do that, we will actually have achieve mental health parity.

But at least we are finally asking the question.
The New York Times opined today;  similar observations on a national scale.

Wednesday, January 7, 2009

CBHI Reminders: I may try to listen in.

I wasn't able to join this call.  Anyone know how it went?
From the CBHI:

Provider Conference Call
Behavioral Health providers and interested parties are invited to join the next statewide conference call on the Massachusetts CANS tool on Friday, January 9, 2009 from 12:00 p.m. to 1:00 p.m. Jack Simons, Assistant Director of the Children's Behavioral Health Initiative and other Commonwealth staff will:
  • discuss instructions for using the recently released CANS Application
  • provide information on "Consent" (who will see data)
  • answer your CANS related questions
CANS Conference Call Information
Date: January 9, 2009
Time: 12:00 pm - 1:00 pm
Phone: 866-565-6580
Passcode: 9593452 

Please call at least 5 minutes before the conference call begins. In addition to asking questions "live" during the call, questions can be forwarded in advance to

CANS Job Aids
CBHI Job Aids for end-users of the CANS Application are now available. The aids were developed to provide an on-the-job reference for entering MassHealth member information into the CANS Application. They contain easy to follow examples examples and illustrations to help support and keep end-users on track and confident. The CBHI Job Aids are available for downloading at the CBHI web site: (click on Information for Providers and the link for the CANS tool under the first heading).

Boston Area Family Forum
The Executive Office of Health and Human Services is continuing to hold its series of Family Forums across the state on the Children's Behavioral Health Initiative. The next forum is scheduled for Thursday, January 22, 2009, 6:00 pm - 8:00 pm at the Boston Public Library - Copley Branch, Mezzanine Conference Room, 700 Boylston Street, Boston, MA. 

Representatives from EOHHS, MassHealth and other state agencies will provide information on upcoming services; solicit family feedback on how to measure the success of this new effort, and answer questions about CBHI and how it may affect your family. Please send your RSVP to or call (617) 573-1832. To request an accommodation, please call (617) 573-1832 or TTY: (800) 872-0166.

Tuesday, January 6, 2009

Another Point of View: A Health Care Discussion in Westborough, MA

I was invited to participate in another Health Care discussion last week; the convener, Silvia Corvera MD said that I could post her summary.  I posted my reflection on it last week here:

December 30th, 2008
Westborough, MA

All participants (listed omitted) agreed on an ultimate goal of achieving universal high quality health care at a cost commensurate with the health value provided to the individual and to society.

Two key challenges were identified: Excessive costs inherent to the current system and uneven access to health care. Universal health care will remain unfeasible unless costs are contained, and unless access both to insurance and health care provision are improved.

The Obama administration has a tremendous opportunity to demonstrate its commitment to solving the difficult problem of health care reform by agreeing to an ethical value-driven construct. We suggest announcing in the Inaugural Address a commitment to universal health care for children 0-18 years of age by the year 2010. Moreover, as a non-earmarked economic stimulus, it should immediately provide the NIH with the funds to support the research proposals that already exist and have been deemed meritorious through peer review.

The main problems identified and discussed were that of COST and ACCESS.
A. PROBLEM OF COST:  On the issue of cost the key question identified was, what drives increasing medical costs?  Two factors were identified:
1. Medical care is reimbursed for procedures done and tests conducted, not for health outcomes achieved. This leads to a technology supply-driven demand with no accountability for value.
2. Medical care is being increasingly provided for diseases that arise from societal behaviors that can and should be prevented.
Recommendations on cost control:
1. Medical care reimbursement should be commensurate with health value achieved, rather than with procedures or tests conducted. However, there are no appropriate metrics for health value. For example, we don’t know how to measure health outcome as a function of disease severity. Thus, the NIH must support research into, and disseminate information about:
a) The definition of value in health care (e.g. how does the physician’s time spent with a patient translate into improved health outcome, versus the prescription of yet another new drug or the request for yet another test? How is health improvement quantified? What makes sense to patients and their families as a positive outcome in a chronic or terminal disease?)
b) The design and integration of coordinated systems of care. Health care is provided by a team of providers not physicians alone. The concept that all health care is provided by or managed by physicians alone is part of the problem. The most effective healthcare is provided by teams of healthcare professionals. In community health centers in rural or inner city areas effective health management teams may not always need to include a physician. The future of healthcare is going to need a broader vision of the healthcare team and a significant amount of workforce development at all levels to create the providers who are most successful in these settings. The federal government should provide direct support for the development and analysis of systems that encourage collaborative multidisciplinary approaches to chronic disease reimbursed as disease management bundles
c) Understanding the relationship between cost and quality of care.
2. The federal government should aggressively intervene to promote lifestyle changes to prevent lifestyle-linked diseases. These include smoking-related diseases, obesity-relate diseases and AIDS. The federal government should immediately:
a) Require all food packages to prominently display calorie count per serving.
b) Provide tax incentives to all restaurants and fast food establishments that prominently display calorie counts per serving.
c) Require all buildings receiving federal funds to prominently display the location of stairwells, and encourage their use.
d) Provide tax incentives for health-promoting workplace designs (e.g. mini treadmills, pacers, etc)
e) Require and fund a minimum number of hours dedicated to physical education and sports in public schools. Exercise is linked to improved scholastic outcome, thus this promotes academic and physical well-being.
f) Implement a counter-marketing strategy against unhealthy food consumption pressures (e.g. “super-sizing”).
g) Ban the incorporation of high fructose corn syrup into products
h) Enact a uniformly high federal tax on cigarettes.
i) Enact routine testing for HIV.
j) Require the public school system to incorporate into the science curriculum the scientific basis of diseases such as diabetes, cancer and AIDS, and their links to lifestyle choices.

On the issue of access, there was agreement on the notion that uneven access leads to health care disparity. Both access to health insurance, as well as access to health services need to be enhanced. Several key issues hampering access to health services were identified:
1. Access to services is hampered by economic, racial and linguistic barriers.
2. Access to services is hampered by a current reimbursement system that does not encourage the development of relationships between primary care physicians and patients.
Recommendations on Access:
1. Support the integration of the public school system into the solution to healthcare. Teachers are often the first to identify health problems in children of diverse backgrounds, but mechanisms should be developed to help teachers direct children and their families into the health care system.
2. Support the creation of community health centers that incorporate into their creation input from patients as well as teams of care providers in the community. This patient-centered approach can help overcome barriers to care.
3. Implement a marketing and public information strategy to enhance recruitment of students into primary care health care team professions.

It is fascinating to me to see how two different groups saw the same problem from two different directions.  I look forward to seeing how the Administration combines them.

Monday, January 5, 2009

Change is Here: How many kids Have we screened so far?

I had a chance to read the latest report on the Rosie D. remedy on the Rosie D website last night.  According to the Child Behavioral Health Initiative, formal behavioral health screening under EPSDT has increased drastically since the CBHI began training and Medicaid began reimbursing pediatric health providers for screening using one of nine approved screening instruments.  In the last quarter,  40%-50% of those eligible for screening got it.  Now, these data come from billing records and billing sometimes lags behind practice, but in their last report to the Court, the CBHI said that roughly 40% of children who had a health maintenance visit under EPSDT were screened.  Over the first nine months of 2008, over 100,000 screens were performed, and, on average, about 10% of them were positive.  Please keep in mind that, for the younger children, more than one screen may have been performed over the course of a year, but this implies that something on the order 10,000 children have been identified as warranting further investigation for behavioral health problems in the Commonwealth of Massachusetts.  

10,000 children identified.  With only 40% of the screens done that we intend to happen eventually.  Now, all of these children do not have Serious Emotional Disturbances,  but most of them will require more than a pat on the head to help with these issues.  My experience, especially with the PSC, is that it doesn't find mild problems.  I have also found that it is sometimes hard to convince those with problems to seek help.  But, our statewide experience to date says that there are a lot of kids out there who need help, and that we best get on with this CSA process so that we can help them.  This tidbit of information has just whet my appetite for more information.  How accurate were these screens?  How many of the families that were identified as needing help wanted help?  How many of the families identified as needing help were able to get it?  How often was the help helpful?  Did any of this massive effort make a difference in the lives of the Commonwealth's children? 

MassHealth and the CBHI have done a great job in bringing us to this point.  We have integrated behavioral health into the thinking of the pediatric workforce on a scale that is scarcely matched in the country.  We screen, we identify,  and we try to make the system work for children.  And we will do more of this over the coming year.  They are to be congratulated for leading us to this point.

Screening was the easy part.  Now we have some real work to do.

Friday, January 2, 2009

A New Year: How Fares the Screening?

Last year at this time, we were implementing universal behavioral health screening in primary care practices around the Commonwealth, and there was much concern that it would take to long and that the findings would overwhelm the mental health system.  Our practice has been doing the screens pretty consistently now for a while- let me talk about in the context of a typical winter day in the office.
After Staff meeting (new influenza vaccine shipment arrived, so be sure to offer shots to those who want it), we start with the patients.  My morning has 4 check-ups, an ADHD follow-up and three children with acute illness (light morning, lots of folks away over Christmastime, I guess).  The first is an 18 month old, new to the practice, with a positive M-CHAT.  After introductions (both parents are here for the visit), we discuss the findings- turns out the child is already seeing a developmental specialist and early intervention because of prematurity.  The new two are school-aged siblings with normal PSC scores;  life for them seems to be going well.  The last young man is a 14 year/old with a history of a depression, who we referred for mental health services last spring, here for his annual physical.  His Y-PSC and CRAFFT are both negative, and yet, in conversation, I find that I am concerned: he still seems depressed to me, despite the negative screen.  He is not interested in reconnecting with counseling, and happy with his schoolwork and friends at the present time.  Not sure about him;  I feel like we've missed something, and yet, we followed all of the rules and protocols.I am way behind now, and must move along.  The illnesses are indeed routine-a cold, an ear infection, a cough of unknown origin.  The young lad with ADHD, however, is a bit interesting.  Diagnosed by me and a psychologist 3 years ago, he improved with stimulant medication which developing headache and major weight loss, so much so that we elected to go with behavior modification and no medications.  Now he is older and bigger and not doing well in the 5th or 6th grade.  The family wants to try medication again.  We discuss side effects and identify behavioral markers for his treatment, and, after 30 minutes, we part, to check in in a month to see what his weight has done.  And I've worked through lunch.
Screening for behavior health in our office has gotten to be so routine that I don't think that it takes up much time for us; what takes time is dealing with behavioral health issues we identify, and in this morning, that was 37% of my patients at three different developmental stages and with three different sets of problems.  Two of them are already hooked into the developmental health/ mental health systems;  why did I have to spend so much time with them?  Well, I may be getting slow in my old and curmudgeonly way, but the reality is that I spent the time talking to be sure that they were in the right place and comfortable with the management that they were getting.  In point of fact, I spent another 10 minutes with one of those families in the evening, double checking things and being sure that they were comfortable with the plan.  Screening is not taking up my time.  Management is.
The afternoon has 4 well child visits, 3 ADHD follow-up and 9 acute sick visits- pretty typical for this time of year.  The screenings at all of the well-visits are negative- well three are negative, one wasn't completed by the family of a three year old and, since I was a bit late getting into the room, I didn't ask the father to fill it out at that point.  One of the ADHD checks was a 17 year old who wanted to stop taking medication, a request that I am always joyful to honor.  He thinks that he has matured to the point where he can manage his ADHD without medication, and indeed has been doing so for the last month.  We discussed the need for honest self-assessment and assuring that he graduates and I wished him good luck.  I will see him for his pre-college physical in the spring, so we will see if it indeed has gone according to plan.  The sick visits back up a bit toward the end of the day; a couple of kids need x-rays, and that always slows us down.  Still, when I don't have to actively manage mental health issues, I actually get done on time.
So, we had 8 physicals, 7 of whom were screened as per protocol, and 1 of whom was positive, as well as 4 other visits focusing on mental/ behavioral health issues in a day with 24 patient visits booked.  Our screening rate for the practice as a whole is about that, our positive rate is still about 10% and our success at referring the positives for more complete evaluation is running about 30%, usually because the family is ambivalent about the need,  the intake process is time-consuming and services are available at inconvenient times and places.  Screening hasn't transformed our practice;  as I have said in the past, I worry more about the kids that the screening misses, like my 14 year/old patient from the morning.    For our practice, at least, it has served mainly to remind us that 20%-30%  of our patients have mental health issues, and that they are likely to be active at the time of a check-up about 10% of the time.  I am curious to see if that experience is similar to folks in other parts of the state.  Drop me a comment one way or the other.

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