Dec 31, 2000
In the National Action Agenda for Children's Mental Health, the U.S. Surgeon General warns that the nation is facing a public crisis in caring for children and adolescents with behavioral, psychological, and emotional problems. The report, released in January 2001, notes that 1 in 10 young people suffer from mental illness severe enough to cause some level of impairment. Yet fewer than 20 percent of these children receive needed treatment in any given year.
Efforts to improve mental health care for children and adolescents are under way and include parity laws for private insurance and the reorganization of public services. (Parity laws mandate equal coverage for mental health and physical health care.) At the policy level, however, many of these efforts are hindered by the lack of an up-to-date, comprehensive national picture of which troubled children are getting care, how much it costs to provide it, who pays for that care, and how resources are being used. In fact, the most recent child-oriented studies, limited primarily to adolescents, report data that are 15 years old, predating the rapid growth of managed care. Moreover, since that time, a number of advances have been made in treating mental illness.
A team of RAND researchers has assembled a current national picture of mental health costs and utilization for children ages 1–17. Among their key findings:
Health care planners and policymakers can get up-to-date, comprehensive figures on what the United States spends on mental health services for people in general. But they run into a dead end when looking specifically for national data on young people. This knowledge gap is often blamed on the complexity of the system that delivers mental health care for children.
Some data do exist for children and adolescents, but they are scattered throughout countless insurance databases, national survey results, and government statistics. The RAND team culled more than a dozen data sources to find information on utilization and expenditures. Their study focused on young people ages 1–17 as a whole, as well as subgroups: preschoolers (1–5), children (6–11), and adolescents (12–17).
Key features of the current picture of mental health care for youth are highlighted below.
Estimates indicate that around 9 percent of youth need help with emotional problems. But on average, three-fourths of them are not being treated (see the figure).
The data reveal ethnic and racial disparities: Hispanic young people are the least likely of all groups to access specialty care, even though they and African American children have the highest rates of need. Around 7 percent of all families cite financial barriers for not getting their troubled youth the mental health care they need.
|All youth (ages 1–17)||Preschoolers (ages 1–5)||Children (ages 6–11)||Adolescents (ages 12–17)|
|Other mental health services||74||20||22||32|
The past 15 years have seen a major shift away from inpatient care to community services for children and adolescents.
"This [move to outpatient care] represents a significant shift in mode of treatment over the past 15 years (and) highlights the importance of updating the national estimates of the utilization and cost of mental health service use among children," the RAND researchers reported.
On average, only 5–7 percent of all youth are treated by mental health specialists each year.
Although the data are sparse, they suggest that many troubled youth are turning to the family doctor for help. For example, more than one-third of mental health visits by privately insured children are to a primary care physician rather than to a specialist. A similar trend can be seen for adults.
More than $1 billion was spent in 1998 on psychotropic medications to treat, on average, 4 percent of all youth, predominantly those ages 6–17.
"In the past two decades, nowhere have changes been more dramatic than in the use of psychotropic medication," the researchers reported. They attributed the change to the development of more effective and safer medications and to more physicians and parents being willing to use them for troubled children.
This finding runs contrary to the popular notion that Medicaid recipients generate the majority of the costs. In fact, they generate only about one-quarter of the costs. However, Medicaid recipients account for more services per child because they make up only about 16 percent of the child population. Privately insured children, who make up about 70 percent of the child population, account for far more services as a group.
From the data, the researchers could only tell what kind of insurance coverage the children had, not if that insurance actually paid for the mental health services. For example, even when children have private insurance, more than half of the mental health services they receive are covered in other ways. Many services are provided outside of insurance plans, such as through schools. Some children may receive care through charity and public providers, or their families pay out-of-pocket when they reach the coverage limit on their private insurance.
The researchers found many limitations in the data available for their study. Nevertheless, their findings provide an updated national picture of utilization and costs that can serve as a starting point for policy discussions on improving mental health services for children and adolescents.
Key features of that picture:
Efforts to improve the quality of mental health care for children and adolescents clearly cannot be limited to specialty care. In addition, reform efforts must also consider the major variations in costs that the study found across age groups, type of services provided, and insurance status. Different policies will affect certain subgroups differently.