Mental health issues

Health Care Financing Review, Fall, 2004 by Peggy A. Clark

INTRODUCTION

This issue focuses largely on mental health issues. Five of the articles deal directly or indirectly with children's mental health matters in the context of Medicaid. This overview compares and discusses the findings of these articles in some detail before briefly outlining the remaining articles on more specialized topics.

The President's New Freedom Commission on Mental Health issued its final report in July 2003, setting forth a number of key goals and findings. Among those particularly relevant to matters discussed in this issue is Goal 1, which emphasized, "Mental health is essential to overall health ...," and Goal 3, that disparities in mental health services [specifically, the underserving of minority populations] should be eliminated. In 2004, SAMSHA expects to issue its action agenda for implementing the Commission's recommendations. A key part of that agenda will be the conduct of research to understand disparities in mental health treatment and provide a basis for their elimination. The first three articles in this issue contain findings that underscore the continued existence of the disparities noted by the Commission, and, to some extent, particularize those disparities--information that can be helpful in addressing this critical problem.

Children's Mental Health Services under Medicaid

The article by Larson, Miller, Sharma, and Manderscheid examines data on service use and payments for children in racial/ethnic subgroups in Medicaid Programs of four States, and compares the service use of children treated for mental health/substance abuse conditions with those without such conditions. The authors note previous findings that mental health problems among children and adolescents affect about 10 to 20 percent of children age 9-13, and that treatment rates appear to be increasing. Most importantly, they note that previous evidence suggests that the overall rate of diagnosable mental health/ substance abuse disorders is comparable across racial and ethnic groups. In this article, the authors present updated analyses of Medicaid data that predate many State health care reform initiatives in order to provide baseline data for the analysis of reforms. The Larson et al. study resulted in a number of complex findings concerning demographic differences in treatment rates and types of conditions treated for various groups. Particularly striking are the findings that: nearly all diagnoses are more common among Medicaid recipients who are white; mental health/substance abuse diagnoses among white claimants are over two times the rate of diagnoses of children in other racial or ethnic groups combined; and major depression, bipolar disorders, and other psychoses are nearly three times more common among white child/adolescent claimants than youth in other race/ethnicity groups. Not surprisingly, similar findings of concern related to disparities in the actual use of mental health/substance abuse services, such as physician services and inpatient hospital care. Their article closes with some helpful suggestions as to approaches to address disparities in diagnosis and treatment of mental health/substance abuse disorders, noting that, ultimately, public insurance programs such as Medicaid "... must use multiple points of leverage to increase access, address stigma and misperceptions of care, and influence the quality of care delivered."

The article by Saunders and Heflinger examines the effects of introducing Medicaid managed care into a previously fee-for-service (FFS) environment on children and adolescents' access to behavioral health care services, and on the mix of such services that will be available. It does this by comparing access and service mix in Mississippi (FFS) and Tennessee (managed care). It also examines access and service mix in these States based on race, sex, age, and Medicaid enrollment category. The study found, among other things, that although each State experienced positive annual growth in behavioral health service access (with the exception of Tennessee's overnight services), female and minority youth were less likely to access behavioral health services, both overall and by type of service. The authors comment that their logistic regressions "... offer evidence that managed care not only reduces access to behavioral services overall and both access to and mix of inpatient services ..., but it also may lead to reductions in specialty outpatient services as well." In the Medicaid categories, the authors report "... a consistent pattern of lower access to behavioral health services among poverty-related youth and greater access of foster care youth relative to youth on supplemental security income."

On the other hand, the authors state: "Nevertheless, the news [coming from this study] is not all bad for managed care ..." explaining that Tennessee experienced significant positive increases in case management services. This suggests that the problem of reduced access to mental health service providers is offset by increased use of the services of case managers.