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Improving Behavioral Screening Rates for Medicaid-Eligible Children
After Massachusetts was ordered to comply more fully with a provision in the federal government’s Early Periodic Screening, Diagnosis, and Treatment (EPSDT) statute requiring states to provide mental health assessments for children enrolled in Medicaid in addition to physical assessments, the state implemented measures to satisfy this mandate. A recent study on the effects of the new policies [Arch Pediatr Adolesc Med. 2011;165(7):660-664] determined that in the first quarter of 2009, almost a year after the rules became effective, more than half of Medicaid well-child visits incorporated behavioral screening. This rate was nearly the rate reported for the first quarter of 2008. Although a lower percentage of children screened were found to be at risk for behavioral health problems, the authors said so many more children received the screening that substantially more at-risk children were identified. Among the regulations Massachusetts adopted was the requirement that primary care providers conduct development and behavioral screening at well-child visits or as requested by parents for Medicaid subscribers ≤21 years of age. The physicians are restricted to 8 state-approved assessment tools, all of which are validated, standardized screening tests for behavioral health concerns. Reimbursement for each screening test is $10 plus $25 to meet with patients and caregivers to discuss positive screening results and recommendations. The state used several methods, including the media and direct mailings, to promote awareness of the new regulations among pediatricians, family practice physicians, and members of MassHealth, the state’s Medicaid program. The state also hosted educational sessions for Massachusetts providers and facilitated telephone consultations with physicians experienced in behavioral health screening. The well-child screening regulations became effective December 31, 2007. To assess whether they helped the state meet its goal of increasing compliance with the EPSDT statute, the research team reviewed reports and data for Massachusetts Medicaid subscribers on claims from January 2008 to December 2009. These included figures on well-child visits, behavioral screenings conducted (based on procedure codes), and the rate of psychosocial problems identified through screening. When the authors compared procedure codes documented for well-child visits during the first quarter of 2008 with those from the first quarter of 2009, they observed a >3-fold increase in the proportion of visits that included behavioral screening (16.6% vs 53.6%, respectively). In absolute numbers, 20,334 screens were performed at well-child visits in the first quarter of 2008, leading to the identification of approximately 1600 at-risk children, jumping to 63,555 visits with behavioral screenings in the first quarter of 2009, during which 5000 children were designated as at risk. The authors estimated that the new regulations increased the number of at-risk children identified by 14,200 annually. The proportion of behavioral screenings with positive findings declined from 11.6% in the first quarter of 2008 to 9.2% in the first quarter of 2009. The authors hypothesized that this was because, prior to the new regulations mandating all children be screened, physicians were more likely to target children for screening who were suspected of having behavioral issues. Additional state Medicaid data revealed that 25% more children received a behavioral health evaluation in the fourth quarter of 2009 as compared with the fourth quarter of 2008. The authors said they lacked information to determine whether the enhanced pediatric screening program played a role in increasing the rate of evaluations. The findings of this study suggest that the measures Massachusetts put in place in December 2007 helped the state overcome its obstacles to universal psychosocial/developmental screening of children enrolled in Medicaid. The study does not assess whether more screening led to better outcomes for the children or improved access to mental health services. “We are unable to determine whether the right children are receiving the right services or whether these services resulted in improvements in children’s well-being,” concluded the authors. They recommended additional studies weigh these important questions.