Care for childhood ADHD in the managed care Medicaid program studied failed to meet the Institute of Medicine s definition of quality that requires “consistency with current professional knowledge” and “improved likelihood of desired health outcomes”.2
More than one-third of children were receiving no care when interviewed at baseline, a rate double the national rate for adults.38
Despite similar clinical severity, treatment approaches for children were strikingly different in primary care and specialty mental health clinics. Children in primary care received predominantly medication treatment, as recommended by treatment guidelines,8, 39, 40
at rates that exceed earlier estimates in community-based primary care.27
Follow-up visits however were on average roughly once per year, a rate similar to that found in other primary care settings.25
The low follow-up visit rate falls short of the National Quality Forum-endorsed standards41
and substantially below nationally recommended psychotropic medication treatment and monitoring.42
In contrast, almost all children in specialty mental health clinics received psychosocial interventions, averaging about five visits per month, and less than one-third of children had at least one stimulant medication prescription filled, a rate consistent with other community-based samples.43, 44
In both sectors, documentation of evidence-based psychosocial treatment for ADHD (i.e., behavior therapy) was missing in the agency databases, and stimulant medication refill prescription persistence was poor but also at rates similar to other community-based populations.43, 45
Despite substantial differences in treatment and service use intensity, children remained symptomatic over time whether or not they were in care, with few exceptions.
Contrary to our hypothesis, children with greater clinical severity were not more likely to access specialty mental health care. There was also little evidence of cross-care sector contact over time. In this large county-wide program, prior authorization from the primary care provider (i.e., “gatekeeper”) is not required to access Medicaid-funded specialty mental health services. Parents may also directly access specialty mental health services which are supported by a patchwork of Medicaid-funded and state legislated programs. Further, there is little infrastructure or incentives to support the transfer of children stabilized in mental health clinics back to primary care or more clinically complex children from primary care to specialty mental health clinics. Together, these findings raise questions about whether the policy that requires medical necessity for Medicaid reimbursement is sufficient to reserve specialty mental health resources for those with greater need. In addition, these findings support future research to develop quality improvement interventions, which are ideally compatible with health information technologies, which promote alignment of the child s clinical severity with provider type as well as improved coordination of care across primary and specialty mental health care providers.
The striking differences in treatment approaches may reflect variation in provider training or clinic workflow. In community-based specialty mental health programs, clinic workflow does not usually follow the medical model found in primary care clinics. Children in specialty mental health clinics may be more likely to have a trial of psychosocial treatment because access to therapists is greater.2
During this study s time period, at the county agency level there was no implementation of treatment protocols that specify a trial of behavior therapy prior to medication evaluation (personal communication, W. Arroyo, June, 14, 2010). Low stimulant medication treatment rates in specialty mental health clinics may occur because access to the physician is often restricted to children identified by non-medically trained professionals as meriting a medication evaluation.28
Nevertheless, differences in provider training do not explain the greater use of combined psychotropic medication in primary care, and is consistent with pediatrician opinion that psychopharmacology is a priority area for continued medical education.22
In future research, comparisons of ADHD care across providers in primary care and specialty mental health care settings should consider adding a study arm for children served in specialty mental health clinics in which the intake evaluation is conducted by a child psychiatrist followed by referral to a therapist to examine whether detection of ADHD, adherence to evidence-based practices, clinical outcomes, and cost-savings over time is improved compared to usual care in specialty mental health programs.
Although linking of child-level data with Medicaid data is a “powerful and under-used resource for health services research,”35
this study s findings also underscore the need for improved Medicaid data infrastructure to assess and monitor even broad indices of quality of care for children with ADHD.5
A substantial proportion of children had poor contact information in their Medicaid data, suggesting that these data have limited capacity to be used by agencies for quality improvement interventions, such as parent education or prevention programs. The use of recommended behavior therapy, like parent training, may be underestimated in both sectors because procedure codes for Medicaid service encounter data do not specify use of evidence-based psychosocial treatments. Mental health visits in primary care may be under-reported because of lack of procedural parity in Medicaid reimbursement for mental health services delivered in primary care.28, 29
Additionally, within specialty mental health clinics, similar procedure codes for psychosocial interventions may be billed for by therapists from a variety of disciplines, making it problematic to examine how quality of care varies by provider type. Further, there is no single standard for measuring prescription refill persistence using Medicaid pharmacy claims data.35
The cut-point for acceptable stimulant medication availability, which accounts for possible drug holidays on weekends, was developed for this study. This approach may overestimate medication refill persistence because some children may receive treatment with two stimulant medications daily or underestimate it because the gap between prescriptions filled for each specific type of stimulant medication was not measured.46
Future data analyses will examine the agreement between parent-reported care processes and medication adherence with Medicaid data, and explore predictors of agreement in service use and medication treatment.
Of note, conclusions about the effectiveness of treatment cannot be made because children were not randomized to treatment groups. Unlike the Multimodal Treatment Study of Children with ADHD that included a community care arm,47
this is an observational study for which a natural comparison group emerged over time. High functional impairment among children who remained in specialty mental health clinics compared to children receiving no care is consistent with prior studies that suggest clinical need drives service use.15
Some clinical outcomes may also have been missed because it was beyond the scope of this study s design and budget to conduct follow-up home interviews for this relatively large community-based population of children and administer a more comprehensive battery of clinical measures. Further, the consistently high rate of positive treatment perceptions by parents may not necessarily be incongruent with poor clinical outcomes, as these are not indicators of good technical care48
and have been found only minimally associated with youth-reported improvement in functioning.49
This study has several additional limitations. More than one-half (56%) of the children eligible for enrollment into the study could not be contacted by telephone, and weighting adjustment for selection and non-response does not include unmeasured variables that could also contribute to selection bias. Thus, even weighted data may not be representative of children that met eligibility criteria within the managed care Medicaid program for the study time period. Unmet need for mental health services may be underestimated because impairment due to ADHD symptoms was required for the diagnosis50
as well as global impairment,51
and duration of symptoms was not included in the operational definition of clinical severity. Using only past year ADHD diagnosis as the indicator of mental health service need, 26–28% of children had unmet need during the three 6 month-time intervals. Unmet need also may be overestimated if asymptomatic patients included those that were successfully treated, but this is less likely because stimulant medication refill prescription persistence was poor. Conclusions about medication treatment appropriateness cannot be made because some disorders for which psychotropic medication treatment may be clinically indicated was not assessed. Initial and maintenance phases of treatment also cannot be defined to assess adherence to most national quality indicators for ADHD because children did not enter the study when starting a new episode of care. Further, findings are not generalizable to children in other managed care Medicaid programs or other states because administrative approaches of mental health services by state Medicaid agencies widely varies.32, 52
Nevertheless, this is the first quality of care study for childhood ADHD in a large managed care Medicaid program that combines four data sources and examines how care processes and clinical outcomes compare across primary care and specialty mental health clinics over time. Findings from this study identify several areas for quality improvement for ADHD care within the managed care Medicaid program studied. These areas are alignment of the child s clinical severity with provider type, frequency of follow-up visits, stimulant medication use in specialty mental health, agency data infrastructure to document delivery of evidence-based psychosocial treatments, and stimulant medication refill prescription persistence. The enduring symptoms, impairment, and poor academic achievement of the children who remain in care and those untreated underscores the public health significance of improving the quality of care for publicly-insured children with ADHD. As advocacy for diagnostic and procedural parity in Medicaid reimbursement for mental health services across primary and specialty mental health care sectors continues, may there also be public investment in improving the quality of care delivered in both care sectors.