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Researchers at Mathematica Policy Research Inc. in Washington, DC, and the federal government’s Substance Abuse and Mental Health Services Administration say states could put a wide-ranging mental health benefit for children and adolescents in place under the state Children’s Health Insurance Program (SCHIP) program for about $18 per month per enrollee, and they suggest that it would be worth the cost in the long run.
In an article in the November/ December 2000 issue of Health Affairs, they note that SCHIP plans are still evolving and states are experimenting with the structure of their mental health and substance abuse benefits.
The importance of good state mental health benefits was underscored earlier this year when U.S. Surgeon General David Satcher, MD, released a National Action Agenda for Children’s Mental Health, which outlines goals and strategies to improve services for children and adolescents with mental health problems, as well as their families.
In the United States, according to Satcher’s report, 10% of children and adolescents suffer from mental illness severe enough to cause some level of impairment. But it is estimated that in any given year, fewer than 20% of those children receive needed treatment. "The burden of suffering by children with mental health needs and their families has created a health crisis in this country," Mr. Satcher says. "Growing numbers of children are suffering needlessly because their emotional, behavioral, and developmental needs are not being met by the very institutions and systems that were created to take care of them."
Embry Howell, vice president at Mathematica, tells State Health Watch that rather than undertake original research, she and her government colleagues looked at past empirical studies on the mental health needs of children and adolescents and the types of services they receive when they are offered. They then developed a cost model based on a number of criteria and estimated the cost of offering a broad package of services under a number of assumptions.
States can provide coverage by expanding Medicaid, designing a separate insurance program, or combining the two approaches. States expanding Medicaid coverage must offer the full Medicaid benefit package, and states designing new programs must offer a benefit package that is comparable to one of three private benchmark insurance plans:
• the Federal Employees Health Benefits Program Blue Cross standard option plan;
• the state’s employee health benefit plan;
• the HMO with the largest number of commercially insured members in the state.
Of particular importance for mental health services, a SCHIP plan must include coverage that is equivalent to 75% of the actuarial value of the benchmark plan for four services: prescription drugs, mental health, vision, and hearing.
The survey of other studies indicated that mental health coverage differs greatly between Medicaid expansion and benchmark plans. "While both types of plans cover traditional inpatient and outpatient care," the article states, "Medicaid expansion plans are much more likely to cover residential, partial hospitalization, case management, and school health services."
States with benchmark SCHIP plans are allowed to charge copayments for services, which generally are not allowed for Medicaid expansion plans. Although day and visit limits are allowed under both options, most states do not use such limits extensively in their Medicaid expansion plans, meaning they are more common under benchmark plans.
Ms. Howell says the review of the literature supports Mr. Satcher’s concerns about prevalence, with estimates ranging from one-tenth to one-third of children and adolescents with a diagnosable mental health problem.
Poverty is associated with mental health problems, with prevalence rates somewhat higher for the poorest children then for higher-income children. The research also shows that at least 5% of children and adolescents in the United States use some mental health services each year. Generally, the Medicaid population has the highest rate of mental health service use, while privately insured children have the lowest rate.
Studies indicate that outpatient treatment shows the strongest evidence of effectiveness, and reasonable evidence also exists that partial hospitalization improves child behavior and family functioning. Evidence for the effectiveness of residential treatment centers and inpatient care is limited, Ms. Howell says, and community-based care generally is considered to be more cost-effective.
SCHIP plans with significant copayment requirements may disproportionately affect children and adolescents with mental disorders. Further, a recent study found the most common provider of care to be schools, which treated approximately 70% of children receiving mental health services. Ms. Howell’s article says that turnover in the SCHIP population creates issues of consistency in benefit coverage and source of care.
The article reports that studies suggest several features that are likely to be important in designing effective mental health benefits under SCHIP:
• broader coverage than found in typical private insurance plans;
• case management services;
• school-based care;
• limited copayments;
• Medicaid expansion programs for children with serious mental health problems since they are more likely to return to Medicaid.
Ms. Howell says the research and cost modeling "show that a broad range of mental health services can be supported under SCHIP for about $18 per month in 1998 constant dollars, or less if lower prevalence and utilization is assumed." She tells SHW the estimates were based on Medicaid and CHAMPUS utilization rates, which are likely to be much higher than SCHIP rates, meaning that the cost estimates might be too high.
Although a recent study of Medicaid capitation rates suggest that the $18 per month estimate could be lowered, Ms. Howell says there are "several reasons to be cautious in using capitation rates to make such judgments. Medicaid capitation rates often do not include the full scope of services that we have used in our estimates. It may be best to consider our estimate an upper bound for what could be expected under SCHIP should a broader range of services be covered."
[Contact Ms. Howell at (202) 484-5277.]