Why you must discuss mental health coverage with patients

Consistency is key to adequate mental health care, but researchers say children and adolescents who experience gaps in their Medicaid coverage also face disruptions in their care.

Researchers from the University of Louisville in Kentucky analyzed predictors of gaps in insurance coverage and the impact of those gaps on children receiving Medicaid using Kentucky Medicaid records from 2012 to 2014 for children aged 1 to 17 years. Any gaps of 45 days or more were included in the analysis. An abstract related to the team’s research was released at the Pediatric Academic Societies meeting on April 30, 2016.

William D Lohr, MD, of the University of Louisville and one of the report’s authors, says the team was not surprised to find that foster situations were proactive in coverage, with children in foster care more likely to be continuously enrolled in Medicaid.

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What was surprising, he says, was a higher incidence of adolescent males who were not receiving medications and were disruptive or aggressive. Whether they were noncompliant in the medications or did not receive them for another reason was unclear, Lohr says.

Overall, 78.8% of children had no gaps in insurance coverage, according to the analysis. Those that did experience gaps in coverage, however, were less likely to be prescribed psychotropic or antipsychotic medications, or receive advocated psychosocial therapy.

“Gaps in insurance coverage may have detrimental impacts for managing Medicaid children with mental disorders,” the research team wrote in the abstract. “Gaps in coverage lead to less prescribing of medication and less psychosocial therapy being employed, which has been well established to be beneficial. In addition, advocated follow up (metabolic monitoring) is detrimentally impacted. Establishing ways to decrease gaps in insurance coverage is needed.”

Lohr says he hopes that the report increases awareness among physicians about the challenges children and adolescents face in getting the mental health care treatment and medication they need.

“We hope that pediatricians will be more aware of certain populations, specifically older males. Take time to research with families and find out where they are with their coverage and guide them,” Lohr says.

There’s a disconnect between what families and physicians think should happen after a mental health care visit, and what families are able to maintain, Lohr says. Many families are also reluctant to discuss their ability to pay for care, and it’s up to physicians to bring up the subject, he says.

NEXT: What reforms are being considered?

Several reforms are currently being considered, and a 2015 Government Accountability Office report issued last year on mental health highlighted the poor coordination among government agencies in providing mental health services, and “significant challenges” for individuals with mental health problems to get the care they need. There are several movements underway to improve mental health care, including a proposed bill in the House and another in the Senate. There is also the Mental Health Parity and Addiction Equity Act which was enacted in 2008 and took effect in 2014. When combined with the Patient Protection and Affordable Care Act, the provisions in the parity act were expected to significantly improve coverage for mental health services. Although the parity act applied to health plans—requiring them to cover mental health services at the same level as medical services—legislators have pushed state-run Medicaid programs to follow suit.

However, according to the National Alliance on Mental Illness (NAMI), state mental health services funding has been slashed throughout the recession as states grapple with budget constraints. Between 2009 and 2012, states cuts $4.35 billion in mental health services, and while some states are recovering financially, the cuts continue in others. Rhode Island cut $33.6 million—nearly a 20% reduction—and Michigan cuts its mental health and substance abuse budget by $156 million. In Alaska, where mental health funding was cut by 37% from 2009 to 2012, further reductions were made in both 2013 and 2014, according to NAMI. More than 20 states have increased mental health funding in the past few years, but the increases did little to restore the substantial cuts made to their budgets in previous years.

A recent report from Mental Health America (MHA) revealed similar trends, noting that only 22% of severely depressed youth receive adequate, consistent treatment for their mental health problems. In its latest report, “The State of Mental Health in America,” MHA reveals that there was a 1.2% increase in youth depression and a 1.3% increase in severe youth depression from 2001 to 2013. Cost and coverage are problems, too. According to the report, 57% of adults with mental health problems nationally receive no treatment and 18% are uninsured. Those trends are not much better for children and adolescents, with 64% who had depression left without treatment, and 63% with severe depression lacking access to outpatient services.

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Access is also a problem, and one that varies greatly across the country. According to MHA, there were about 250 individuals per mental health provider in states like Massachusetts, Maine, and Vermont compared to 1100 individuals per mental health providers in states like West Virginia, Texas, and Alabama.

Groups like the National Council offer a number of free resources to help support mental health services, particularly where funding and access are limited. The organization is working to spread the word about its Mental Health First Aid program, which aims to bring recognition to supporting mental health emergencies in the same manner as heart attacks or strokes.