Whatever its final incarnation, the recently enacted landmark Patient Protection and Affordable Care Act will expand Medicaid eligibility and is expected by 2013 to provide coverage, including mental health care, to an estimated 4.1 million children currently uninsured. That's a good thing. But what will the quality of care be, especially for vulnerable children with special health care needs? Poor, according to a new report in the current online edition of the Journal of the American Academy of Child and Adolescent Psychiatry.
In cooperation with LA Care, one of the nation's largest public health plans, and the Los Angeles County Department of Mental Health (DMH), UCLA researchers looked at how well one of the most vulnerable groups of young patients were faring in the managed-care Medicaid system — children with attention-deficit/hyperactivity disorder, or ADHD. Led by Dr. Bonnie Zima, a UCLA professor of psychiatry, the researchers sought to compare how children diagnosed with ADHD under Medicaid fared in primary care (treatment by pediatricians and family medicine physicians) versus in specialty mental health clinics. Their goal was to compare both the nature of care and the end result.
The researchers found:
- The clinical severity of ADHD did not differ among children in primary care or specialty mental health care.
- There was little cross-over of children between the two sectors. If a child began treatment only in primary care, he or she had no contact with specialty mental health; the same pattern held true for children who were initially receiving care in specialty mental health. This prevented the two specialty areas from coordinating care.
- In primary care, most children with ADHD were appropriately prescribed stimulant medication to help their symptoms (the standard of care) but averaged only one to two follow-up visits a year with their doctor.
- In specialty mental health clinics, less than one-third of children received any stimulant medication, but they received psychosocial interventions, such as therapy and/or case management, averaging five or more visits per month.
- Overall, in both primary and specialty mental health care, about one-third of children with ADHD and impairment dropped out of care. Over time, the drop-out rate for children served in primary care clinics reached 50 percent.
- In both primary and specialty care, more than one-third of children prescribed stimulant medication failed to continue taking medication.
- Most tellingly, clinical outcomes such, as ADHD symptoms, functioning, academic achievement, parent distress, perceived benefit of treatment, and improved family functioning, were similar among children who remained in care and children who received no care at all.
The researchers used data supplied by LA Care and the DMH to look at the care of 530 children diagnosed with ADHD, a condition marked by excessive activity (hyperactivity), impulsivity and difficulties with focusing attention. The children, ages 5 to 11, received treatment in primary care or specialty mental health clinics from November 2004 through September 2006.
The investigators developed their data using a set of longitudinal analyses drawn from Medicaid service and pharmacy claims data, parent and child interviews, and school records to characterize the mental health care and clinical outcomes of children across three six-month time intervals. "With the support of National Institute of Mental Health research funds, we were able to link the agency's databases," Zima said. "This was a great example of a partnership between our health service research center here at UCLA and agency leaders at both the county and state level." Quality was poor in both the primary care and specialty care sectors, Zima said, but for different reasons.
Children in primary care received predominantly medication treatment, and one-quarter of the children had been prescribed a stimulant plus another type of psychotropic medication. Yet because follow-up visits were negligible, averaging one to two per year, there was little opportunity to monitor medication safety. In contrast, almost all children in specialty mental health clinics received some type of psychosocial intervention, such as therapy and/or case management, with an average of about five visits per month. Less than one-third of these children had at least one stimulant medication prescription filled. In both sectors, documentation of behavior therapy or parent training was missing in the agency databases.
"Despite these substantial differences in treatment and service-use intensity, the children we studied remained symptomatic over time, whether or not they were in care," Zima said. Findings from this study identified several areas for quality improvement for ADHD care, including a better alignment of the child's clinical severity with provider type, a greater number of follow-up visits, the use of stimulant medication in specialty mental health clinics, help for children to stay on their medications, and better agency data systems to document the delivery of recommended care and patient outcomes. With ADHD representing one of the most common mental health disorders — it affects 3 to 10 percent of children in the U.S. — improvement in care is critical, according to Zima. "The quality of care for ADHD is of high public health significance because it is the most common childhood psychiatric disorder, has established treatment, and can persist into adolescence and adulthood with devastating long-term consequences," Zima said.
The study was funded by the National Institute of Mental Health. Other authors included Regina Bussing, Lingqi Tang, Lily Zhang, Susan Ettner, Thomas R. Belin and Kenneth B. Wells. The authors report no conflict of interest. The UCLA Department of Psychiatry and Biobehavioral Sciences  is the home within the David Geffen School of Medicine at UCLA for faculty who are experts in the origins and treatment of disorders of complex human behavior. The department is part of the Semel Institute for Neuroscience and Human Behavior at UCLA , a world-leading interdisciplinary research and education institute devoted to the understanding of complex human behavior and the causes and consequences of neuropsychiatric disorders.