Sunday, April 5, 2009

April is Here: Three Months Until the New Mental Health Order, and We are Still Trying to Get Screening Right

One thing that has been ongoing is the controversy over screening of newborns in the first six months of life.  The Court, in it's desire to enforce the EPSDT standard, has asked (and when a Court asks, it is not actually a question) that the provider's screen for SED at ALL EPSDT visits.  The problem is that 4 of those visits occur in the first 6 months of life, an age for which we have no tools that y predict a child's future risk of development of SED with any diagnostic certainty.  On the MassHealth approved list of screening tools, in fact, we are given the option of the PEDS at the 1 week, 2 month and 4 month visit.  Bad choice.  So bad, in fact, that the Primary Care doctors just aren't doing it.  Looking at the screening data,  it seems that only 20% of children at those visits are getting bills for screening (as opposed to something approaching 50-60% in older kids.
Our subcommittee met last week,  to try to formulate an alternative for the docs who are just trying to make this work.  Seemed to us we had three options:
1)  Status quo:  Let it stay the way is is now.  Parents unhappy, doctors unhappy, insurance providers unhappy and the judge unhappy.  Not an option.  
2)  Screen for something useful:  Caregiver depression is the obvious candidate;  we have good evidence that parental mood affects child development.
3)  Hold off on screening until we have a decent screener to use.  Ellen Perrin at Tufts is working on it.
There was a lot of discussion, and the verdict is in:  we want to do number 2.  If I can quote our elegant statement:

 [O]ur recommendations for mental health screening of infants under 6 months of age [reflect] the dissatisfaction of both providers and parents regarding the current choice of screening measures for infants of 1,2 and 4 months of age. We agree that the current infant screening measures are an inadequate screen for mental health problems in this age group and should be considered optional rather than mandated. On the other hand, there is substantial evidence that screening for caregiver depression is an effective way to improve the mental health of young infants..Therefore, we recommend that two validated instruments (the Edinburgh and the PHQ2) should be approved for use at the 1,2 and 4 month well child visits in accordance with the mandate currently in place to screen infants and children at every well child visit. Of note, a similar mandate has been implemented successfully in Illinois with Medicaid reimbursement.
Several committee members wanted to skip screening altogether in the "under six month olds", but the group as a whole felt that the opportunity to screen should not be squandered.   We also felt that, at the present time, the best evidence was for screening of caretaker depression (rather than infnat behavior)   Hopefully, they are listening to our recommendations.  Kudos to Mike Yogman for the great language and his leadership on this one.

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