The Massachusetts Child Psychiatry Access Project:

Combining Innovation and Collaboration to Enhance

 Children's Mental Health Services in the Primary Care Setting

Read this article on our website.

The Catalyst Center has spent the last five years collecting and disseminating examples of innovative and effective state-based strategies that improve coverage and financing of care for children and youth with special health care needs (CYSHCN). In this issue of the Catalyst Center e-newsletter, we highlight one such program called the Massachusetts Child Psychiatry Access Project, or MCPAP. Initiated in Massachusetts in 2004, the MCPAP model has since been implemented in nine other states and is in the planning phase in three more. It is recognized by families and practitioners alike as a best practice in increasing access and quality of mental health care services for children.[1]

Let's start with some background information on the issues MCPAP was created to address. Many children with mental health needs can benefit from a variety of treatments and therapies; however, their access to these services is often quite limited due to several factors.[2] Families who seek care for their children with mental health needs frequently face long wait times for an appointment because of the scarcity of child psychiatrists, or must travel great distances to access a children's mental health professional who accepts the family's insurance. This results in increased transportation expenses as well as more time away from work or school. In the 2007 National Survey of Children's Health, nearly a third families of children with mental health needs reported their insurance was inadequate to meet their child's needs, in large part due to high out-of-pocket expenses.[3] In a recent survey of Massachusetts families, out-of-pocket costs were reported as the greatest barrier in accessing the mental health services their children need.[4] Families with private insurance often face limits in coverage around mental health services and/or lack coverage for wrap-around services, respite, or care coordination.[5] And, children who lack insurance altogether face significant barriers in accessing mental health care; if their families cannot afford to pay for services out-of-pocket, the children may not receive care at all.

Of particular concern to children with mental health needs and their families is the shortage of children's mental health professionals. A 2006 article published in the Journal of the American Academy of Child and Adolescent Psychiatry stated that there are 6,300 child psychiatrists currently in practice in the US - substantially less than the estimated national need of 30,000.[6] Furthermore, the number of these practitioners is not increasing at a rate substantial enough to meet the growing population of children who are identified as having mental health needs. A 2009 report by the American Academy of Child and Adolescent Psychiatry found that to simply maintain the current levels of psychiatric service provision to children, the US will need over 12,600 pediatric psychiatrists by 2020 - many more than the 8,312 psychiatrists anticipated to be in practice at that time. In fact, enrollment in pediatric psychiatry residency programs has actually been declining.[7]

Because of the ongoing shortage of pediatric mental health professionals and the growing need for children's mental health services, primary care physicians (PCPs) often have the responsibility of recognizing, diagnosing, treating and monitoring mental health disorders in children; however, PCPs face a challenge in receiving compensation for providing these services due to mental health "carve-outs". Many insurers - both public and private - require separate coding and billing for mental health services, thus carving them out from other health-related benefits. Because PCPs are not always credentialed to provide mental health services, they are often ineligible to bill for this care provision.[8] All of these barriers, both to the families in accessing care and to the PCPs in providing it, can mean the children who need mental health care do not receive it. This can result in continuation or exacerbation of the child's mental health illness, along with its consequences: compared to children without mental health needs, children with mental health needs are more likely to repeat a grade in school and to have poorly developed social skills; their parents are more likely to feel parenting-related stress and less likely to be in good physical and mental health; their families are more likely to struggle to find consistent, high-quality child care; and many parents are forced to quit their job or refuse employment to care for their child.  Ultimately, these concerns are the result of inadequate insurance or mental health care access, affordability, and/or quality, and demonstrate that children's mental health services is an area of substantial unmet need.[9]

In 2004, MCPAP was rolled out in Massachusetts as a pilot program to increase pediatricians' access to children's mental health consultations, including advice on prescribing psychotropic drugs to pediatric patients. Funded by the Massachusetts Department of Mental Health (DMH), the initiative was the offshoot of a meeting of Medicaid personnel from several New England states, convened to discuss concerns about the growing number of children enrolled in Medicaid who were being prescribed psychotropic medications by pediatricians.[10] Operated by the Massachusetts Behavioral Health Partnership, a managed care organization contracted with DMH, MCPAP enrolls primary care practices across the state, offering PCPs support in their care of children with mental health needs. PCPs treating children with mental health needs can access the consultation services via telephone within 30 minutes, Monday through Friday, connecting with child psychiatrists, psychologists, and social workers. In-person consultations can be arranged when necessary. These consultations can provide the PCPs with an assessment of the patient's clinical or psychiatric needs, answer the physician's questions about diagnosis and treatment, assist with referrals to mental health specialists, social workers and care coordinators, and provide the PCP with additional community resources to offer the family.[11]

A significant barrier to accessing children's mental health care is alleviated by MCPAP's "insurance-blind" policy; MCPAP is available for PCPs providing care to any child with mental health needs, regardless of the child's insurance status. In June 2009, 58.3% of children served through MCPAP had private insurance, 32.7% had public coverage only, 7.9% had both public and private coverage, and 1.1% were uninsured.[12]  As of December 2010, primary care practice enrollment in MCPAP reached 401 - nearly all primary care practices in the state. The utilization rate of physicians enrolled in MCPAP is also high, with between 65% and 75% of the enrolled primary care practices accessing MCPAP services each quarter. By December 2010, MCPAP was facilitating mental health consultations to PCPs who serve approximately 85% of Massachusetts children and youth. Its annual operating budget is $3.2 million at full implementation, which comes to $.018 per child, per month.[13]-[14]

A promising, innovative model to ensure accessible, affordable care with consultation from credentialed providers to children with mental health needs, MCPAP scores well with physicians and families alike.[15]  The MCPAP model has been replicated in Arkansas, Illinois, Iowa, Maine, New York, Ohio, Texas, Washington, and Wyoming, and is in the planning phases in Connecticut, New Jersey, and California. MCPAP is a cost-effective, comprehensive initiative for increasing access to mental health services for the children who need them. Visit the MCPAP website to learn more.

Read an article that mentions MCPAP and listen to a streaming newscast on the shortage of children's mental health professionals in Massachusetts on WBUR FM.

Like this example of a state-based innovative financing strategy?