Blue Cross Erects New Barriers to Care
US News Health & Medicine 11/11/02 Selected paragraphs from
The Demons of Childhood Young brains break. Then comes the broken
care system
BY MARIANNE SZEGEDY-MASZAK
http://www.usnews.com/usnews/issue/021111/health/11kids.htm
When Alex McAbee turned 7, many of the happy accomplishments of childhood
were missing from his short, tortured life. Indeed, he had not even learned
to read, nor had he doffed a corny cap and gown to graduate from
kindergarten. Instead, his milestones included several expulsions from day
care, one after he had given a child a concussion...
That road through hell is a familiar one for parents of children with
emotional disorders. It begins at home and runs through the schools and
into the offices of pediatricians, psychiatrists, psychologists,
cardiologists, child neurologists, behavioral pediatricians, and social
workers. All of these specialists could tell that there was something
seriously wrong with Alex, but the problem was figuring out exactly what.
Now 9, Alex has been diagnosed at various times as having
autism, attention deficit disorder, bipolar disorder, and oppositional
defiant disorder. Each diagnosis, of course, required different medicines.
Many failed, and some actually exacerbated the problem.
Pediatricians and family practitioners prescribe over 85 percent of the
psychiatric drugs today and, according to the surgeon general's report, two
thirds of mental health visits are to primary-care physicians. "Clearly,
half the patients I see have some kind of serious emotional problem," says
pediatrician David Kaplan, chief of adolescent medicine at Children's
Hospital in Denver. "Over the last five years I have been prescribing and
managing more and more kids on psychotropic medication. It's a huge change
in practice for us in adolescent medicine."
And not for the better. Kaplan and other pediatricians point out that the
combination of more difficult cases and few available child psychiatrists
leads them to dole out medicine they are neither trained in nor comfortable
with prescribing. Some pediatricians, like Kaplan, who are affiliated with
large hospitals or academic institutions, can consult with the child
psychiatrist down the hall when confronted with a vexing case. But most
don't have that luxury.
Before grim experience teaches them otherwise, desperate parents of
mentally ill children assume that mental health services, like those for
physical ailments, will proceed through some relatively predictable steps.
The pediatrician refers you to a specialist, you get an appointment within
a few weeks, the child is examined, medication is prescribed or a procedure
is scheduled, and everything is reimbursed by insurance.The result is a
massive maldistribution of services, with especially limited options for
troubled children in rural or low-income areas. For example, there is less
than 1 child psychiatrist per 100,000 young people in Mississippi, while
there are nearly 20 per 100,000 in Massachusetts. Nebraska reported this
year that it has barely enough mental health specialists to help children
who are suicidal or in crisis.
Even if there is access to a mental health provider, there is the other
problem of paying for the care. Although almost half of all children have
some sort of private insurance coverage, the vast majority of those with
psychiatric disorders are covered only by specialized "behavioral health
carve-outs." What this means is that insurance companies have split off
mental health care from primary care. Rather than a physician simply
authorizing services, a "reviewer" or "gatekeeper" working for the
insurance company determines what care will be reimbursed, in effect
determining both the quality and the nature of the care. A recent Rand
Health Program study showed that eliminating gatekeepers would most likely
not raise costs for HMOs, but insurers have lobbied hard against equal
treatment for mental disorders.
...
It is the end of the day. The boys are back from school, the family
therapist has come and gone, Alex and Hudson are playing outside with a
neighbor's child, and Brandon is getting ready to go to a church function
with friends. A stew simmers on the stove. Tom Troyer, 56, sits in an easy
chair in the living room of the house he shares with his extended family. A
tall man with the sturdy competence of his Hoosier upbringing, Troyer
concedes he never gave mental illness a second thought until it afflicted
his family. He has since become a passionate advocate for the mentally ill.
"I remember that someone in our church once said that Alex was probably
possessed by the Devil," he recalls. "Now don't get me wrong, I believe in
demonic possession. But that is not what is wrong with Alex and Hudson.
They are ill. It's that simple. And the illness is as medical as
diabetes."
In the end, Troyer's simple statement encapsulates much of what has gone
wrong in the care for children with a serious mental illness. His grandsons
are representative of both the promise and the crisis in children's mental
health. The old cliché that children are the future holds special resonance
in these cases, but troubling questions linger: Which children and, more
important, what kind of future?
I could add my $33,000 worth, but this stands well on its own. For more
about my own patients and family
The Status of Mental Health and Health Insurance in Nebraska
Underserved - Overview and Models
Main web site www.ruralmedicaleducation.org
