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Kids’ Emergency Mental Health Needs Add To Safety Net’s Burden

Emergency rooms across the country are crowded with children in need of psychiatric care, and more and more of those kids are underinsured – either on Medicaid or without any insurance at all.

According to a new study, underinsured children accounted for 54 percent of emergency room psychiatric visits in 2007, up from 46 percent in 1999.

“They’re not getting access to providers beforehand,” said Zachary Pittsenbarger, one of the researchers presenting these statistics Friday at the American Academy of Pediatrics national conference in Boston. “For the publicly insured, the emergency room can be more convenient.”

Pittsenbarger and Rebekah Mannix of Children’s Hospital Boston analyzed data from a Centers for Disease Control and Prevention annual ambulatory care survey between 1999 and 2007. Children’s psychiatric emergencies increased from 2.4 percent to 3 percent of all pediatric visits over the eight-year period. Previous studies have charted similar trends, but this report is the first to show a disproportionate increase among the underinsured.

“The mental health burden is increasing in terms of the safety net,” said Jacqueline Grupp-Phelan, director of research for the division of pediatric emergency medicine at Cincinnati Children’s Hospital, who was not involved in the study. While the burden is evidently heavier among the underinsured, “all populations are underinsured when it comes to mental health,” leading to an increased reliance on emergency department care.

These visits tend to be labor and resource intensive, as Grupp-Phelan and others found in a 2009 study of 462 psychiatric emergencies. The children’s visits averaged more than five hours in length, with a third requiring lab tests and more than half ending up in hospital admission.

In this latest study, rates of hospital admission and transfer did not significantly increase between 1999 and 2007 – neither among the underinsured or overall. Pittsenbarger said it’s a sign that many children are coming in for not-so-serious issues that can be addressed earlier and elsewhere.

Another problem is that the mental health issue that triggers the child’s emergency visit usually requires ongoing attention to help the young patients “avoid further crises, ” Pittsenbarger said. “But after discharge, it can be harder for [the underinsured] to find a regular provider to provide long-term follow-up.”

Meanwhile, emergency physicians often struggle with providing the necessary referrals, and the ER itself can be over-stimulating and hectic, especially for children in crisis. “For good care, a provider has to know all the needs of a patient,” Pittsenbarger added, “and in the emergency room, we can only get a snapshot; it’s not the same depth or intricacy.”

Primary care providers can help alleviate the problem, but researchers and the American Academy of Pediatrics point out that systemic factors – such as limits on the number of covered visits – complicate treatment in this setting, too.

More significantly, Medicaid and other insurers  provide comparatively small provider reimbursement for mental health care and require higher co-pays from patients. The mental health parity law signed in 2008 was meant to equalize mental health coverage with other conditions, but it hasn’t been fully implemented or enforced.

“I’m hopeful that when the law is fully implemented it may make a difference, but that would only be in the conditions the law recognizes,” said Jane Foy, chair of the AAP’s mental health task force, noting how nearly one in five children don’t have all the symptoms for a psychiatric diagnosis that would qualify for reimbursement, yet they still need care.

Aside from improved payment, Grupp-Phelan said primary care providers need to build up capacity for a range of mental health problems. “Primary care providers need a bread-and-butter understanding of mental health issues,” beyond  ADHD, she said.  Foy suggests having mental health specialists on staff as part of the solution.

Improved coordination and transfer between emergency rooms and outpatient providers should also help break the cycle.  Grupp-Phelan said she was optimistic that conditions would improve as accountable care organizations become widespread and the nation recognizes the cost savings of preventive mental health care.

“I think it’s an issue the health system as a whole faces, whether we prioritize care in an acute crisis setting or provide preventive care,” Pittsenbarger said. “This echoes in many areas, not just mental health.”