Parents with children in psychological distress often discover that mental healthcare for kids isn’t as easy to come by as they might have expected. School administrators have a conflicted relationship with their students’ mental healthcare needs—uncertain whether to default to trauma-informed care or legal protection—and pediatric mental health professionals frequently refuse to deal with insurance. As a result, many kids experiencing a mental health crisis end up in the Emergency Room (ER). John Santopietro, MD, DFAPA, physician-in-chief at Behavioral Health Network and senior vice president at Hartford HealthCare, says there aren’t sufficient services for them upstream, and when children and teens can’t access the right level of service, they have nowhere else to go. “Emergency rooms are chaotic and designed for medical emergencies—car accidents, gunshot wounds, and heart attacks. They are not the ideal space for a family taking care of a child experiencing a mental health crisis.” He says, unfortunately, the ER is often a family’s entry point into the convoluted United States mental health system, with kids spending inordinate amounts of time waiting for help. Wait times for children and teens can be significantly longer than for adults, and communities across the country are concerned. For instance, in Vermont last year, roughly 73 children in severe psychiatric distress spent an average of 3.5 days waiting in the University of Vermont Medical Center’s emergency room, and some spent much longer. A study released in the April issue of Pediatrics noted a significant increase in child and young adult psychiatric ER visits, which increased 28% between 2011 and 2015. The most substantial increases were among adolescents (54%) as well as African American (53%) and Hispanic patients (91%). The number of suicide-related visits were 2.5 times greater in 2015 than in 2011.
Patricia Rehmer, MSN, ACHE, a nationally recognized leader in mental health and substance abuse and former Commissioner of the Connecticut Department of Mental Health and Addiction Services, says it’s not necessarily that there are less funds directed to mental healthcare for children. In Connecticut, for example, mental health for kids and adolescents is wrapped into the welfare system and protective services and in the public mental health system for children 18 and older. That said, Rehmer highlights that there’s a shortage of child psychologists, many of whom don’t take insurance, and families are reluctant to accept early identification for fear that their child will be labeled and stigmatized against. “At the beginning of their mental health struggles, kids may be identified with emotional disturbances at school. Parents push back, though, because they don’t want it in their children’s school records. They don’t want their kids identified for all sorts of reasons, but primarily, they don’t want their children to face discrimination. By the time kids are acting out or their parents can’t ignore it anymore, they are in crisis.” At the same time, says Dr. Santopietro, schools are increasingly reactive, defaulting to the ER if kids say something that might be construed as provocative or a signal that they are at risk of harming themselves or someone else. He says administrators often send kids to the ER at the end of the day, making it difficult for the medical and psychiatric team to get collateral information from the school. “Kids end up stuck in the ER while the team tries to piece together the story, and in many cases, it’s unclear whether the school’s response was appropriate.”
There are limited options for children, particularly for those too young to enter a state hospital. Rehmer says in Connecticut, state hospitals won’t take kids under age 11, which can result in extended stays in acute care units. For example, a seven-year-old who needs a longer-term inpatient hospitalization may end up staying on the unit just because there’s no place for the child to go. Rehmer says it’s a philosophical policy issue. “I get it: it’s not good to have a seven-year-old on an inpatient psychiatric unit. On the other hand, it’s not okay to have nowhere for a seven-year-old to go.” She says on the acute care unit, the kids with recurrent stays are seeing other kids come and go, while they may be there 100-160 days. “It’s not a good situation. Nobody really knows what to do with the really little ones.” Rehmer says until kids turn 11, mental health professionals and families try to come up with treatment plans to keep children out of the hospital as long as they can. “Often, everyone is just waiting until their 11th birthday so they can go into the state system. More options instantly become available, including residential programs. We often talk about getting upstream, but we are losing these years in-between. This represents a small percentage; nonetheless, we don’t have an answer for these kids.”
Rehmer says while many parents have a plan of what they will do if their child experiences a medical emergency, they aren’t coming up with contingency plans for if their child suffers a psychological one. During a crisis is not the ideal time to come up with the best laid out plan, so parents default to the only strategy they do know: what to do in case of a medical emergency. “By the time parents seek services, when their child is in the middle of a crisis, they don’t have time to get on the internet and determine the optimal steps to take. Instead, they end up in the ER, which is probably the worst place to take your kid because it’s so traumatizing.” Parents may also desperately search for options in the community, but there aren’t enough child and adolescent mental health professionals, which creates a supply and demand problem. As a result, those working in mental health can, and often do, refuse insurance and are only available to families with cash on hand. “They don’t need to take insurance, and they certainly don’t need to take Medicaid funding or kids covered under the Children’s Health Insurance Program (CHIP).”
There are more than 15 million kids in the U.S. who need the specialized expertise of a psychiatrist but only 8,300 practicing child and adolescent psychiatrists. Only 55% of psychiatrists accept insurance, resulting in barriers to access for many of the kids most in need. Rehmer says it varies state-to-state because Medicaid rates vary state-to-state, but in Connecticut, Medicaid rates for psychiatric care are low. She says with low reimbursement rates, mental health professionals get to a point where they don’t want to deal with insurance paperwork. “A large number of psychiatrists in the state of Connecticut take cash only. It doesn’t mean they won’t give you a diagnosis for your insurance form, but they are not going to interact with insurance companies. Almost 90% of child and adolescent psychiatrists do this because they can. There are fewer of them, and they can determine the terms themselves.”
It’s easy to blame child and adolescent mental health professionals for not accepting children in need of help, but it’s a layered issue that’s plagued with discrimination and insurance challenges. Dr. Santopietro says the rates for reimbursement for mental health have not kept pace with those by insurance for other specialties. What makes the process even more complicated is that health insurance provider lists aren’t frequently updated, so parents may have to spend long hours calling the professionals listed only to find out that they’ve retired or no longer take their insurance, or that the listed phone number was incorrect. A study published by the International Journal of Health Services tried to replicate the experience of parents attempting to obtain psychiatric care for their child. The researchers used Blue Cross Blue Shield’s online database of in-network providers and found that child psychiatrists were half as likely to see new patients than pediatricians, and the mean wait time for psychiatry appointments were 30 days longer. Callers who said they carried Medicaid were 15% less likely to obtain appointments than those who said they had private insurance or the ability to pay out of pocket. The researchers think higher mental health reimbursement rates and less administrative paperwork would improve access for patients.
Dr. Santopietro says that while reimbursement rates continue to be low and the amount of money put into pediatric mental health has remained a static percentage of the GDP (Gross Domestic Product), what drives the healthcare market is shifting. He is optimistic that this will push the industry toward investment in child and adolescent mental health. “We are in a transformative moment because the healthcare market is going to break us as a nation, so we finally have to be responsible stewards of the dollars we spend. When we do that, we look at what drives cost, and untreated mental health is a big part of that: for every dollar we spend in mental health, we save $7 in overall healthcare spending. For every dollar we spend in upstream services for kids—so they don’t end up in the ER and don’t end up developing a more severe mental illness—would be even higher than that, making it a crucial investment.”
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