It’s been two years since the American Academy of Pediatrics declared a national state of emergency in children’s mental health. Yet sadly, very little has changed. This year, 25 percent of youth have been diagnosed with a mental health condition. More than 20 percent of teens have seriously considered suicide, and more than 40 percent of high school students reported that they’d felt so sad or hopeless within the past year that they were unable to do their regular activities. These grim statistics continue to rise annually. Our kids are struggling, and our urgent responsibility is to help them. To do that, we must deal with the issues of insurance contracting, networks, and reimbursement in the commercial market. After all, half of all kids in America are covered by commercial insurance.
The mechanics of insurance don’t make headlines, but if you have ever tried to find outpatient mental health treatment or a therapeutic residential program for a child, they matter a lot. I have worked with hundreds of families who have tried to find in-network providers, to only find their emotional distress compounded by financial distress, once they realize care is denied, or there aren’t any providers, or they must resort to “out-of-network” services (that come with high-deductible, out of pocket maxes, and co-insurance requirements) to meet their child’s needs.
Our national conversation is focused on the provider shortage, and we need to address that problem. Still, many providers working with children today opt out of the insurance system (either completely or at least out of the in-network system) because of the administrative complexity and low reimbursement. And right now, youth mental health providers can’t make it work in-network. We must maximize the resources we have now while we are investing in the future workforce. Focusing on insurance is one way to do that.
The Biden Administration Proposed Rule to put more teeth in the bipartisan Paul Wellstone and Pete Domenici Mental Health Parity & Addiction Equity Act (MHPAEA) is a good step forward. As a reminder, the bipartisan MHPAEA prevented health insurance plans and issuers from implementing more stringent benefit limitations on mental health and substance use disorder benefits than they apply to medical/surgical benefits.
Unfortunately, those benefit limitations and administrative complexities still exist. For a provider seeking to join an insurer’s network to serve their members, getting responses from plans, rate negotiations, and loading providers into the network’s website can take upwards of a year. Additionally, technical challenges frequently lead to directory inaccuracies about providers and services.
To be fair, commercial insurance reimbursement is relatively new for youth mental health, so it is not surprising there have been growing pains. That said, some payors are much better than others. And it is urgent, for those that haven’t been able to step up, to catch up and make kids’ mental health treatment as important as their physical health.
In addition to reducing administrative burdens and increasing reimbursement, we can fix Current Procedural Terminology (CPT) codes. Young people are not “small adults.” They have different mental health needs, different brains and nervous systems, and a developing sense of self. Which is why we need treatment that recognizes this. For the young people we serve, we are required to bill CPT codes intended for adults, despite the differences in best practices between youth and adults. The definitions behind Intensive Outpatient and Partial Hospital Programs are related to adults, and often substance use too. For example, in partial hospitalization programs, the CPT code requires five hours of clinical work. In this setting, young people need structure but not as much clinical work as an adult. They would benefit more from experiential and engaging therapy. Youth need smaller group sizes, lower caseloads, more varied interventions and treatments, and a lot more family systems work.
Given these challenges, we end up attempting to cover many high-intensity interventions through single case agreements (SCA), which are contracts of coverage negotiated with a health plan for a specific insured child. However, these SCAs are frequently denied. And the appeals process can be a challenge for families who don’t understand the system. We need to find creative ways to cover intensive treatment for youth. Providers struggle with the authorization processes and the appeals can be a challenge for families who don’t understand the system. Our patients regularly report payors offering in-network options that are not clinically appropriate for their child’s needs, which creates another barrier to care. Strengthening and accelerating the ability to obtain authorization for treatment–both in and out of network–for higher levels of care would be a meaningful step to expand access to care.
We need innovation in mental health services, but that is even further out of reach. The appropriate teen-tailored interventions don’t fit into traditional insurance boxes and State definitions of care. Our programs, for example, have been designed with decades of experience into what works for youth with mental health and substance disorder needs. As experts, we know these are the approaches that minimize symptoms and keep youth, family, and community functioning in a healthy way – that is more likely to prevent higher intensity and higher-cost interventions in the future.
By addressing these issues, we can begin to address the national state of emergency in children’s mental health. If we fail to act, this crisis will continue.
Alex Stavros is a health care executive.
