The youth mental health crisis is dire, necessitating a hard look at primary and behavioral health care integration as a solution.
To be sure, nearly one in five children currently suffer from a mental health condition, yet only 20% of them receive care from a psychiatrist, psychologist, or other specialist. This unmet need was apparent before the pandemic and only worsened over the last year and a half. Notably, mental health-related emergency department visits among adolescents aged 12-17 grew 31% from 2019 to 2020. Due to the rising rates, the American Academy of Pediatrics, the Children’s Hospital Association, and the American Academy of Child and Adolescent Psychiatry (AACAP) declared the mental health crisis among children a national emergency in October.
Despite the need for care, children often face long wait times for appointments, which is sadly to be expected considering the shortage of mental health providers. The number of providers per 100,000 children is around 10, four times less than the number needed to meet demand, according to AACAP.
Medicaid, which covers 27 million children under the age of 18, is an ideal platform to reach a significant number of children. Nearly a quarter of kids on Medicaid (6.4 million) have an identified behavioral health condition; however, it is likely that this number is much higher due to behavioral health issues that go untreated and undiagnosed. Among Medicaid and Children’s Health Insurance Program (CHIP) beneficiaries under the age of 18, the number of children receiving mental health services dropped by 50% from February to October 2020.
Integration is a particularly promising approach to improving care for children. In integrated settings, primary care and behavioral health providers work together to ensure the care of the entire individual. Children rely heavily on primary care for their health needs, and so it is practical to meet children where they are: their pediatrician’s office. Early detection is important. Without it, mental health conditions can become more severe, causing problems at home and school, and making it more difficult to form relationships.
Because Medicaid managed care organizations (MCOs) cover such a large fraction of children enrolled in Medicaid (75%), they are well positioned to play an important role in integration and in improving care for children. The existing payment structure in MCOs makes them an ideal home for integration. Moreover, MCOs already have well-defined quality metrics, delivery standards, and payment methodologies through which integration can be applied, enforced, and incentivized.
Key members of Congress have signaled that they are drafting policy solutions for consideration in 2022. The Senate Finance Committee requested input from stakeholders in September to better understand how Congress can address the growing need for mental health and substance use care, including improving access to behavioral health care for children and young people, and increasing integration.
BPC’s Behavioral Health Integration Task Force released a report in March 2021 with recommendations that can make a difference for kids. The recommendations would provide pediatricians and other primary care providers with the necessary incentives and support to handle more mild to moderate behavioral health services. The recommendations would also improve primary care access to behavioral health specialist consultations, which would consume less specialist time than would full referrals. In addition, training initiatives and technical assistance for integration can help bridge the gap of unmet care needs, increase access to culturally competent care, and, together with reforms to federal reimbursement and workforce growth programs, help make integration possible.
BPC’s task force made the following key recommendations:
Addressing provider network adequacy is key to improving access to behavioral health care for kids, as many specialists listed in health plan networks aren’t taking new patients or have long wait times. As such, the task force recommended improving network performance standards, including reinstating the time and distance-to-provider standards for Medicaid network adequacy and requiring two additional quantitative measures.
In 2016, Medicaid created time and distance standards to measure MCO network adequacy, but replaced this with a broader quantitative standard in 2020. Although states have the option to keep the time and distance standard or replace it with a different quantitative standard, the task force has recommended that CMS revise and reinstate the time and distance standard as well as require two additional quantitative standards. These new standards would address patient wait times and the number of providers accepting new patients. This change is estimated to add 800 to 900 behavioral health providers to Medicaid managed care networks, improve access for 500,000 to 800,000 enrollees, and save the federal government $105 million over 10 years.
The task force recommended providing early guidance and technical assistance to states and MCOs to help them prepare for upcoming FY 2024 congressionally mandated reporting requirements on Medicaid core measurement sets. The mandatory core set of behavioral health measures should include measures of behavioral health integration.
In 2021, the voluntary quality core set for children enrolled in Medicaid and CHIP included eight primary care measures and four behavioral health measures. However, in 2024, states will be required to report on two sets of quality measures, including a core set for children in Medicaid and CHIP. The task force recommended that the final mandatory core sets include evidence-based measures to indicate integration of behavioral health into primary care. Providing early guidance and technical assistance to states and MCOs at least two years in advance of the reporting requirement would help show which measures states should be reporting, since the core sets are currently updated annually.
Additionally, technical assistance provided by CMS would address problems such as data collection for reporting, measure calculations, and measure incorporation into value-based initiatives. Providing early guidance and technical assistance would not only yield a better understanding regarding behavioral health outcomes for children but would also improve health equity in managed care. If incorporated into a value-based payment plan, states could also incentivize behavioral health integration by linking MCO payment to performance measures.
The task force recommended CMS include measures of behavioral health integration in the Medicaid managed care quality rating system and that CMS recommend states set a minimum rating for MCOs on performance measures.
CMS released a managed care final rule in November 2020, which revised an earlier rule establishing its role in coordinating with states and other stakeholders to identify performance measures and a methodology for the forthcoming Medicaid and CHIP Managed Care Quality Rating System. The final rule indicated the Quality Rating System will align with Medicare’s Star Rating System and other quality initiatives. CMS will develop a minimum set of mandatory performance measures that states must use whether states implement the CMS-developed Quality Rating System or a state alternative Quality Rating System.
CMS should include measures of behavioral integration in the mandatory performance measures that will be part of the Quality Rating System, to increase transparency around MCO behavioral health integration performance. Reporting on the performance of integration within managed care plans can also assist beneficiaries in understanding plan distinctions. Some states have already adopted quality rating systems in advance of the requirement and use the system to improve health plan performance through financial incentives. For example, states such as Florida and Michigan tie 86% and 61% of their quality measures to financial incentives, respectively. However, it is unclear whether states will use performance ratings for MCO oversight and accountability.
The task force recommended that HHS establish core, minimum standards essential for integration to establish core service and quality standards to improve accountability for integrating care and aligning network performance standards across payers and health plans.
Currently, private and public health programs do not have a standard definition of integrated care, nor are there core service and quality standards. Behavioral health provider access is not guaranteed, which is a barrier to acquiring care. Establishing performance and quality standards that apply across payment and health systems is essential to integrating behavioral health and ensuring the number of physicians is sufficient to provide services to children.
Policymakers can help the behavioral health crisis that children are experiencing by paving the way for integration. The previously mentioned recommendations from BPC’s task force help to identify those barriers for integration that matter most in meeting the behavioral health care needs of children. To read in more detail about BPC’s recommendations, click the link below to the full report.
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