Children's Access to Mental Health Care

Much of the conversation about health care reform has focused on the uninsured and on reducing the costs of medical care. Some attention has been paid to access to services, in particular, the effect of declining numbers of primary care physicians available to treat patients. Often left out of the discussion is access to mental health care.

It's been known for some time that the majority of children and adolescents with mental illness are not getting the treatment they need. The Surgeon General reported ten years ago that 1 in 5 children and adolescents have a diagnosable mental illness; 1 in 10 suffer significant impairment in their day-to-day lives; yet, only 20% of those needing treatment in any one year are identified and receive mental health services.



A recent study illustrates some of the reasons children don't get treatment. A survey of primary care physicians found that two-thirds report being unable to get outpatient mental health services for their patients. Internists, family practitioners, and pediatricians all reported similar problems in referring patients due to no or inadequate health insurance. But it was the pediatricians who reported the greatest difficulty due to health plan barriers and a shortage of mental health providers.(Cunningham, P. J. (Apr. 14, 2009). "Beyond Parity: Primary Care Physicians’ Perspectives on Access to Mental Health Care, Health Affairs Web Exclusive, w490–w500.)

In an op-ed in the Boston Globe, pediatrician Claudia Gold describes her problems in referring children she treats for ADHD when they develop symptoms of serious mental illness. Although the standard-of-care requires referral to a specialist, she has difficulty finding child psychiatrists who can take her patients. In the meantime, she remains responsible for their care. She asks:

So how have we gotten to this unfortunate situation where primary care doctors, who are clearly not qualified, are expected and encouraged to treat children with serious mental illness? I believe three main factors are at work. First, the pharmaceutical industry has been successful at promoting the idea that a pill will fix these often complex problems. Second, the insurance industry has made it very difficult for primary care doctors to refer patients for any mental health services. And third, there is a severe shortage of child psychiatrists.

In my area of the country (outside of Washington, D.C.), the shortage is not so much the number of available child psychiatrists but the number who participate in insurance panels. There is no monetary incentive for them to accept insurance. They can easily fill their practices with patients whose parents are willing to pay their fee. Families who must use their insurance may have to wait two to three months for an appointment.

Primary care physicians are put in the unenviable position of being asked to fill the gap in psychiatric services despite their all-too-justified reservations about doing so. Dr. Rob of Musings of a Distractible Mind tells his own story about a child patient needing medication, and I credit his post for raising my awareness of the primary care physician's side of the problem. He also offers a solution--raise low reimbursement rates to encourage more physicians to specialize in psychiatry.
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This post was featured in Grand Rounds, Vol. 5, No. 47 - Cost Containment In Healthcare : The Covert Rationing Blog