Economics of developmental/mental health screening at well-child visits
Freely available measures may seem initially like a bargain, but their excess demands on staff time not only are expensive but often deter one of the central goals of well-child visits.
Economics of developmental/mental health screening at well-child visitsLatest revision | Image Credit: © Studio Romantic - © Studio Romantic - stock.adobe.com.
Many pediatricians are surprised that screening for developmental/mental health issues helps practices run more efficiently and reduces clinic overhead. Benefits include fewer “Oh, by the way” concerns (maintaining or reducing the predicted length of visits)1; increased well-child visit (WCV) attendance among families at psychosocial risk2; easier delivery of difficult news3; improved family (and provider) satisfaction with care4; and greater adherence by parents to clinicians’ recommendations.5 In addition, effective screening may generate revenue for clinics.6
But not all screening tests offer such benefits and some actually lead to higher practice costs. Freely available measures (eg, milestone checklists, selected items from the Denver II, and the Survey of Well-being of Young Children) may seem initially like a bargain but their excess demands on staff/clinician time are not only expensive but often deter one of the central goals of WCVs: promoting development and teaching positive parenting skills. Because the Current Procedural Terminology (CPT) code for screening does not include relative value units for provider work, efficient and effective screening methods are needed, ie, it is optimal if measures can be completed independently by parents with minimal staff/clinician involvement.
The first 3 columns of the Table show the many challenges, time requirements, and expenses of no-cost instruments. Instructions for the far right column are included below the Table.
How to use the far right column of the Table as a worksheet
To begin, choose a week when approximately half of the encounters are WCVs and ask clinicians, extenders, and staff how often they experienced any of the challenges listed in the Table. You can then extrapolate hours per week to create an annual total. Assigning costs to annual time wasted is more challenging, but a pediatric productivity estimator with an interactive worksheet is available at https://tnscriptdoctor.com/productivity_estimator/. Also included on this site are fee schedules and real-time claims estimators. After determining the costs of annual hours, add annual expenses/revenue loss to create a grand total of wasted time-related costs and other expenses/lost revenue.
Better screening methods: Why and what?
Why do freely available tools lead to higher clinic costs? From an economic perspective, free measures lack the permanent revenue stream needed for ongoing improvements. In contrast, publishers of quality screens channel income into ensuring their instruments have proven utility and effectiveness for WCVs and overcome almost all the challenges and costs shown in the Table.
In a recent survey of American Academy of Pediatrics fellows,9 59% used quality instruments, either PEDS Tools (PEDS-R with or without PEDS: Developmental Milestones [PEDS:DM] [Screening]) or Ages & Stages Questionnaires (ASQ) Tools (the ASQ-3 plus an occasional ASQ: Social Emotional [ASQ:SE]). The publishers of both sets of measures charge a nominal fee for print materials. Slightly more costly are electronic applications,10,11 but these confer the following greater practice benefits by greatly reducing staff/provider time: Scoring is automated and a referral letter and a parent take-home summary are generated; parent portal options allow families to complete screens from home on a cell phone or computer prior to an encounter; they can be administered at telehealth visits (eg, with families who missed WCVs); they are online in English and Spanish with many other digital translations available; they are available in print for use in waiting rooms; and they serve as accurate screenings and as evidence-based surveillance when used between targeted visits.
Conclusion
After implementing 1 or both sets of tools, you can recomplete the Table, viewing and comparing changes to time and expenses. Improvement to the financial health of clinics, including increased WCV attendance and greater satisfaction with care (by staff/providers as well as families), should be apparent. Although the costs and practice benefits of effective accurate screening accrue for health care providers, for every $1.00 spent on early detection and early intervention, US taxpayers save approximately $17.003 because of higher graduation and employment rates and reductions in adjudication/incarceration expenses. Value? Truly priceless!
For more from our March Mental Health issue, including our cover story, "Incorporating mental health care into primary visits," click here.
References:
1. Schonwald A, Horan K, Huntington N. Developmental screening: is there enough time? Clin Pediatr (Phila). 2009;48(6):648-655. doi:10.1177/0009922809334350
2. Smith PK. Enhancing child development services in Medicaid managed care. Center for Health Care Strategies Inc. 2005. Accessed December 1, 2024. https://www.chcs.org/media/Toolkit.pdf
3. Glascoe FP, Marks KP, Poon J, Macias MM. Identifying and Addressing Developmental and Behavioral Problems: A Practical Guide for Medical and Non-medical Professionals, Trainees, Researchers and Advocates. Vandermeer Press; 2011.
4. Valado T, Tracey J, Goldfinger J, Briggs R. HealthySteps: transforming the promise of pediatric care. The Future of Children. 2019;29(1):99-122. https://files.eric.ed.gov/fulltext/EJ1220075.pdf
5. Guevara JP, Gerdes M, Localio R, et al. Effectiveness of developmental screening in an urban setting. Pediatrics. 2013;131(1):30-37. doi:10.1542/peds.2012-0765
6. Hughes C. Getting paid for screening and assessment services. Fam Pract Manag. 2017;24(6):25-29. https://www.aafp.org/pubs/fpm/issues/2017/1100/p25.html
7. Wolf ER, Hochheimer CJ, Sabo RT, et al. Gaps in well-child care attendance among primary care clinics serving low-income families. Pediatrics. 2018;142(5):e20174019. doi:10.1542/peds.2017-4019
8. Ronis SD, Grossberg R, Allen R, Hertz A, Kleinman LC. Estimated nonreimbursed costs for care coordination for children with medical complexity. Pediatrics. 2019;143(1):e20173562. doi:10.1542/peds.2017-3562
9. Coker TR, Gottschlich EA, Burr WH, Lipkin PH. Early childhood screening practices and barriers: a national survey of primary care pediatricians. Pediatrics. 2024;154(2):e2023065552. doi:10.1542/peds.2023-065552
10. Online developmental & behavioral screening for kids. PEDSTestOnline. 2020. Accessed December 1, 2024. https://pedstestonline.com/
11. Ages and Stages Questionnaires. Ages and Stages. Accessed January 2, 2025. https://agesandstages.com/
The modern-day foundation of how medical disinformation began
June 27th 2024A retracted paper that erroneously claimed the measles, mumps and rubella (MMR) vaccine caused autism has repercussions still being felt today around topics such as vaccination, misinformation and disinformation, and measles incidence rates.
