Transcript Medicaid and Pediatric Health What they Didn’t Teach You

Medicaid and Behavioral Health Screenings
What the Law Requires
Jay E. Sicklick, Deputy Director
Center for Children’s Advocacy
Director – Medical Legal Partnership
January 9, 2014
Overview and Goals
 What does the law have to do with
mental health screenings?
 Medicaid as foundation for screenings
 Best practice vs. overburdening requirement
 Massachusetts case study
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Case Study: Billy M.
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4 years old
In primary care office for well-care exam
Presents with no speech or language delays
Academically solid in pre-school setting
Psycho-Educ. Eval. at above normal range
But conduct poor due to “behavioral issues”
(Mom called frequently to pick son up early)
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Case Study: Billy M.
 Mom shares that Billy has recently
been described as using aggressive
behavior and inappropriate language
 Unbeknownst to you, Mom has
history of bipolar disorder
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Case Study: Billy M.
What is the PCP’s next step?
1. Tell mom to wait and see what
happens and call back?
2. Make a referral? To whom?
3. Conduct a brief validated screen
for mental health red flags?
Why or Why Not?
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Screening: Why vs. Why Not
Why?
– Medicaid/Husky A
insured child
under 21… law
requires screening
– Reimbursement
available for
developmental
and behavioral
screens
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Why?
– Commercial
insurance will
reimburse as well
– Appropriate
practice as
defined by AAP
What If We Do Not Screen?
 In any given year, more than 1 in 5
Connecticut children struggle with mental
health or substance abuse
 More than 50% do not receive treatment
 51% had - or were at risk of - court
involvement, juvenile justice intervention,
court referral for families with service needs
Source: Andrea M. Spencer, PhD, Center for Children’s Advocacy
Blind Spot: Impact of Missed Early Warning Signs on Children’s Mental Health (2012)
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Medicaid 101
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Title XIX of SSA (1965)
Join federal/state program
CMS federal agency oversees Medicaid
State agency compliance thru
administration & waiver system
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Mental Heath Screening = Primary Care
or Mental Heath Screening ≠ Primary Care?
Federal Medicaid Law
• Early and Periodic Screening, Diagnosis
and Treatment (EPSDT)*
(Medicaid’s child health component)
• EPSDT mandatory set of services and benefits for
children under 21 enrolled in Medicaid
• 1 in 3 U.S. children under 6 are eligible for Medicaid
*Source: 42 U.S.C. § 1396d(r)(1) et seq.
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Origins of EPSDT
“…the early years are
the critical years …
Our goal must be clear –
to give every child the
chance to fulfill his promise.”
(Special Message to the
Congress Recommending a
12 Point Program for
America's Children and Youth
Feb. 8, 1967)
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What is EPSDT?
• Early ‒ Identify problems starting at birth
• Periodic ‒ Check children's health at periodic,
age-appropriate intervals
• Screening ‒ Conduct physical, mental,
developmental, dental, hearing, vision, and other
screening tests to detect potential conditions
• Diagnosis ‒ Perform diagnostic tests to follow
up when a risk is identified
• Treatment ‒ Treat the conditions identified
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EPSDT and Screening
 EPSDT vital to ensure that young children
receive appropriate health, mental health,
and developmental services
 Screening to detect physical and mental
conditions must be covered at
 established, periodic intervals
(periodic screens) and
 whenever a problem is suspected
(inter-periodic screens)
42 U.S.C. § 1396d(r)(1) et seq. (emphasis added).
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EPSDT and Screening
What is Screening under EPSDT?
– Includes comprehensive health and developmental history, unclothed
physical exam, appropriate immunizations, laboratory tests, and health
education.
– Dental, vision, and hearing services are required, including appropriate
screening, diagnostic, and treatment.
Treatment component of EPSDT is broadly defined.
Federal law states that treatment must include any "necessary health
care, diagnostic services, treatment, and other measures" that fall
within the federal definition of medical assistance (as described in
Section 1905(a) of the Social Security Act) that are needed to "correct
or ameliorate defects and physical and mental illnesses and conditions
discovered by the screening services.”
42 U.S.C. § 1396d(r)(1) et seq. (emphasis added).
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EPSDT and Screening:
What is Covered?
All medically necessary diagnostic and
treatment services within the federal
definition of Medicaid medical assistance
must be covered, regardless of whether or
not such services are otherwise covered
under the state Medicaid plan for adults
ages 21 and older.
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EPSDT Non-Compliance?
Bring on the Lawsuits
Rosie D. v. Romney
 Mass district court screening delivery system in
primary care was woefully inadequate for
state’s Medicaid children and lack of communitybased mental health systems violated EPSDT
 Ordered MASS Health (Medicaid Agency) to
design comprehensive screening and referral
system for children at risk insured through MA
 Compliance ensured through data collection
(EPSDT numbers)
Rosie D. v. Romney, 410 F. Supp. 2d 18 (2006).
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Rosie D. Outcomes
Reported Mental Health Screenings at Well-Child Visits
80.00%
70.00%
67%
60.00%
58%
50.00%
Reported Mental Health
Screenings at Well-Child Visits
40.00%
30.00%
20.00%
10.00%
14.46%
0.00%
2008 Q1
2009 Q4
2011 Q3
Teen Screen at Columbia University, Rosie D. and Mental Health Screening (2010);
MassHealth Quarterly Screening Data: April-June 2011.
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Positive Screen = Referrals
Rosie D. Outcomes
60,000
50,000
50,535
Number of Children
Screened Positive for
Mental Health Disorders
40,000
30,000
20,000
10,000
0
1,533
2008 Q1
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2009 Q3
Teen Screen at Columbia
University, Rosie D. and Mental
Health Screening (2010)
Referrals = Intervention
Rosie D. Outcomes
5.00%
4.50%
4.70%
4.00%
3.50%
3.00%
3.50%
2.50%
Number of Youth Receiving
Any Remedy Service
2.00%
1.50%
1.00%
0.50%
0.00%
FY 2010
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FY 2011
Def.’s Report on Implementation
(Jan. 1 2012).
Positive Screens = Referrals
 Oregon Study utilized ASQ
ASQ compared to Pediatric Developmental
Impression (PDI)
PDI on scale from typical–questionable–delayed
 224% increase in referral rate in a year
PDIs alone = 42% of referrals
Hollie Hix-Small et al., Impact of Implementing Developmental Screening at 12 and 24
Months in a Pediatric Practice, 120 PEDIATRICS 381 (2007).
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Importance of Screening Instruments
 PDIs missed children at risk
 67.5% of delayed cases only identified by ASQ
 45.1% of early intervention eligible children
missed by PDI
 Generally
 38% of 12 month cases missed by PDI
 23% of 24 month cases missed by PDI
Hollie Hix-Small et al., Impact of Implementing Developmental Screening at 12 and 24 Months
in a Pediatric Practice, 120 PEDIATRICS 381 (2007).
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Where Has It Led?
CCA Proposed Legislation
2011 Session of Connecticut GA
 DSS to develop reimbursement strategies
to provide support for PCPs to conduct
screenings in primary care setting
 DSS requested convening of a task force
rather than pursue legislative initiative
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Where Has It Lead?
Behavioral Health Screening Task Force
Examination of delivery systems to ensure that screenings are
promoted, supported and reimbursed in primary care.
Players
DSS
DCF
CT Chapter – AAP
CT Council of C&A Psychiatrists (CCCAP)
ACAP
DDS – Birth to Three
CHDI
CT Behavioral Health Partnership (CT-BHP)
School based health centers (SBHC)
Early Childcare Systems – Head Start
OPM
CHN – CT
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Where Has It Led?
 BH Task Force met monthly
Aug 2012 – Mar 2013
 Experts in-state and out-of-state (Mass e.g.)
 Information obtained, recommendations provided
 Mass Experience – PCC feedback
 Not exceptionally burdensome,
infrastructure working
 MCPAP as a workable idea and resource
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Where Has It Led?
Massachusetts Feedback
 PCPs balked at screenings
 Curriculum developed
 Validated screens – in public domain
 PCP’s found …
 50% already receiving BH treatment
 40% handled with practical advice –
clinician training
 10% referred to “system” for BH treatment
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Where Does It Lead?
Task Force Recommendations - Mar 2013
 R/Q PCPs in MA/HUSKY Program to perform
annual behavioral health screens using validated
instrument from ages 1 - 17
 Instruments used must be validated and
recommended by AAP (and approved by DSS)
 Providers will receive $18 per screen through DSS
 DSS must maintain claims data and report quarterly
 DSS to work with AAP to develop curriculum and
trainings for PCPs
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Where Does It Lead?
Recommendations (continued)
 DSS work with Behavioral Health experts (CT Council
on Child & Adol. Psychiatrists and CHDI, etc.) to assist
PCP’s on the “What to do Next” questions …
 DSS shall participate in formation of child psychiatry
access project in CT – if enacted by GA
 Task force meets semi-annually to review data and
revise recommendations etc.
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Where Does It Lead?
General Themes
 Develop support to encourage PCPs to meet the
challenge of conducting MH screens
 Education to PCPs that reimbursement is available for
those practices not already seeking or to those practices
where reimbursement is not included (in bundled rate)
 Support DSS’s Person Centered Medical Home (PCMH)
initiative (resources)
 Know that the threat of a lawsuit lurks in the background
(a la Rosie D.)
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Jay E. Sicklick, Esq.
Deputy Director, Center for Children’s Advocacy
Director, Medical-Legal Partnership Project
[email protected]