Will more screenings correspond with more treatment?

It took a federal judge’s order to make Massachusetts implement routine behavioral health screenings during well-child visits and get the state’s Medicaid agency to reimburse pediatricians for them.

But it’s unclear what will make sure children identified as having mental health concerns get the treatment they need, even as Massachusetts leads the nation in screening the youngest and most vulnerable children.

“The bottom line is that there are far too few providers willing to see children, whether they’re psychologists or social workers, who take insurance, because the reimbursement is still way too low,” says Michael Yogman, M.D., a pediatrician who chairs the Children’s Mental Health Task Force at the Massachusetts Chapter of the American Academy of Pediatrics.

“There’s far too much in the way of drugs and far too little in the way of counseling, CBT, other kinds of evidence-based treatments that we know work better than meds for kids,” Yogman adds.

In 2011 and 2012, Massachusetts screened 69 percent of its low-income children under age six, according to Massachusetts Budget and Policy Center data in the national Kids Count report. The national average was just 30 percent. Second highest North Carolina screened 52 percent of children under six.

In January 2006, a U.S. District Court judge ruled in the class action lawsuit Rosie D. v. Patrick (initially filed in 2001 as Rosie D. v. Romney) that the state’s Medicaid program, MassHealth, must arrange for screening during regular well-child visits, the first such court mandate for a state Medicaid program. Mandatory screening for Medicaid-covered patients under 21 began January 1, 2008 and most commercial insurers began reimbursing for screening at the same time. A state-wide outreach program provided training and a list of eight approved screening tests for primary care providers. MassHealth set the reimbursement for such testing at $9.73.

More than one third of positively screened children did not receive a behavioral health care referral and only about five percent of visits were associated with billed behavioral health services in a study published online last November in Clinical Pediatrics. Researchers examined billing data from two Massachusetts General Hospital affiliated community health clinics in Chelsea and Revere and found only a modest 11 percent increase in billings for behavioral health treatment from 2007 to 2009.

“Visit notes reviewed for this study mentioned issues such as six-month waiting lists for mental health services for bilingual children,” noted the study by Giusy Romano-Clarke, M.D., J. Michael Murphy, Ed.D. and their colleagues. The authors concluded that screening “appears to be an important, but modest, intervention to address unmet mental health care needs; it is not the only solution.”

Studies have looked at how screening tools are received by different demographic populations and the challenges posed by language and literacy limitations. In one study, Latino families had a high rate of incomplete forms when given self-administered screening questionnaires but improved completion rates when the questionnaire was administered orally by a staff person.

Sometimes a question doesn’t translate well, says Karen A. Hacker, M.D., MPH, former executive director of the Institute for Community Health in Cambridge, Mass., and now director of the Allegheny County Health Department in Pittsburgh. Hacker has conducted extensive research on the effectiveness of screenings.

“On one tool, there’s a question that ‘My child acts as if driven by a motor,’ sort of an ADHD (question),” Hacker says. “Doesn’t translate well into Chinese.”

Hacker and her colleagues have a paper in review looking at children who screened positive to see what kind of services they were receiving. A larger study is ongoing to compare services utilized before and after the Massachusetts policy took effect. So far, it appears the biggest predictor of a child receiving treatment is having had a past treatment experience, Hacker adds.

Hacker led a study published online last December in Pediatrics that found children newly identified as having mental health concerns were more likely to be girls, younger, minority and from rural residences. Boys ages five to seven-years-old who were Hispanic, from an urban zip code, in foster care and having a history of behavioral health concerns were the most likely to screen positive.