Behavioral Health Screening Rate after Court-Mandated Program

The Task Force on Mental Health of the American Academy of Pediatrics has recently endorsed mental health screening in primary care as a way to help the effort to prevent mental health disorders for children and adolescents. Studies have shown that many parents arrive at a primary care visit with concerns about their children’s emotional condition. Other studies have found that 12% to 13% of children 4 to 16 years of age have significant psychological dysfunction. Screening usually involves assessing cohorts of children to determine their risk for a condition; in psychological health, clinicians use a variety of validated questionnaires or screening tools to conduct the assessments. In primary care, screening for conditions such as anemia and hypertension are expected and routine. Furthermore, as researchers have noted, general health and mental health are linked, making primary care practices a natural setting to screen for and address mental health issues. The Early Periodic Screen, Diagnosis, and Treatment (EPSDT) statute requires all states to provide Medicaid-eligible children with screening, Including “assessment of both physical and mental health development.” Nevertheless, a 2003 study demonstrated that about half of all states (n=23) had “no specialized behavioral screening tools and no behavioral health questions or prompts in their comprehensive screening tools.” This lack of compliance with EPSDT has prompted lawsuits in several states. Massachusetts was one of the states to experience an EPSDT mental health challenge. The court-ordered remedy is the implementation of enhancements and new services for children’s behavioral health under MassHealth, the state Medicaid program. As part of the enhancements, providers are required to conduct screenings for developmental and behavioral problems at all well-child visits or a parent request for all MassHealth members <21 years of age. The providers are reimbursed approximately $10 for each screening test performed and $25 for face-to-face evaluation and management time for a positive screen. The regulations requiring well-child screening went into effect December 31, 2007. Researchers recently conducted a retrospective review to assess the rates of screening and identification and treatment for behavioral problems using data from MassHealth following the start of the court-ordered screening and intervention. They reported results online in Archives of Pediatrics & Adolescent Medicine [doi:10.1001/archpediatrics.2011.18]. The primary outcomes measures of the review were the percentage of well-child visits that included a screen for mental health status, the percentage of screens that were identified as at risk, and the number of children seen for behavioral health evaluations. Immediately following the effective date of the screening requirement (first quarter of 2008), the percentage of well-child visits that included mental health screenings was 16.6%; in the first quarter of 2009 (1 year after the requirement went into effect), the percentage was 53.3%. The increase represents a change from 20,334 screens in the first quarter of 2008 to 63,555 screens in the first quarter of 2009. There were approximately 1600 children identified as at risk in the first quarter of 2008; in the first quarter of 2009, the number was nearly 5000. The study data also showed that the number of children with a behavioral health evaluation increased about 25% (from an average of 4543 to an average of 5175 per month), for the quarter starting in September 2008 compared with the quarter starting in September 2009. In conclusion, the researchers commented that the “data suggest payment and a supported mandate for use of a formal screening tool can substantially increase the identification of children at behavioral health risk. Findings suggest that increased screening may have the desired effect of increasing referrals for mental health services.”