Medicare Compliance & Reimbursement

A number of states have come up with novel and successful Medicaid approaches to provide mental health care for children and young adults, according to child mental health expert and advocate Janice L. Cooper, PhD, in recent testimony to Congress.

Cooper explains that the purpose of her testimony was to "point out to legislators and plead with them about the need to ensure that funding supports what works for children, youth and their families -- or at least what works to the best of our knowledge." Instead, however, "Medicaid policy is moving in the opposite direction," cautions Cooper, director of child health and mental health for the National Center for Children in Poverty and a public health professor at Columbia University.

States using "out-of-the-box" thinking and approaches compared to traditional Medicaid programs include the following, according to Cooper:

New York: The outgoing Pataki administration launched an initiative that represents one of the largest investments in community-based mental health services for children and youth, says Cooper. "ClinicPlus, a $33 million initiative, is designed to significantly increase the capacity of community mental health," she says.

The initiative includes enhanced reimbursement rates for community mental health visits. It also includes a strong focus on early intervention and treatment, and on the delivery of school-based mental health services.

Simultaneously, New York established an evidence-based treatment dissemination center funded by the National Institute of Mental Health (NIMH) and the State of New York. The center plans to train over 600 providers. More than 200 clinicians have already been trained in trauma-focused cognitive behavioral therapy, an evidence-based treatment.

The idea of the center is to improve the capacity and competency of the workforce to deliver proven clinical strategies starting with trauma-based cognitive behavioral therapy, says Cooper. The center will then move on to other evidence-based practices until there is a "proliferation of clinicians trained in evidence-based treatment."

Cooper notes that a lot of research shows that what is provided as "treatment as usual" lacks efficacy. Thus, there's a push by mental health experts to move to treatment modalities that have an empirical base and have been tested. There's always the cautionary note that some evidence-based treatments have not been tested for populations of color, the extremely poor or native cultures, Cooper concedes.

"But there has been an adaptation of some practices to make them more culturally relevant, and trauma-focused cognitive-based therapy is one of these," she says.

Oregon: In 2003, the State of Oregon passed legislation mandating that within five years, 75 percent of all state human services funding must support evidence-based programs, including those for children and youth in the mental health and juvenile systems. "The state and stakeholders in mental health have worked to figure out what's evidence-based and effective across the board," Cooper says.

California: Proposition 63 created a millionaires' tax of 1 percent to fund new services in the mental health system. The tax anted up more funding than anyone expected, according to Cooper. California is now building local capacity for mental health services. The state has placed a "huge focus" on trying to address the issues of youth transitioning into adulthood.

That's important, says Cooper, because when young people who have required mental health care turn 18, they don't often have the level of severity of mental illness to move into the adult system. Thus, in many cases, they have to deteriorate before they can qualify for help, she notes.

The state is also supporting an early childhood mental health system, enhancing work with school-age children with behavioral symptoms. "The focus is on bringing in resources to do mental health consultation in child care centers and to work with schools to identify and intervene with children and youth as early as possible," notes Cooper.

Arizona: As the result of the Jason K v Eden landmark settlement, the state was required to change its mental health system from a traditional approach to one with more coordination and early intervention work, Cooper says. (Read about the Jason K case at http://www.youthlaw.org/litigation/ncyl_cases/healthmental_health/1.)

State policy leaders have stressed quality care, family involvement and dissemination of evidence-based mental health practices through a network of managed care organizations contracted with the state.

The state has also done some good things working with parent support organizations, Cooper says. One example is the Parent Improvement Center in Maricopa County where the state funds parents to work in service provision roles.

Arizona is also using Medicaid to fund parents to work in professional and paraprofessional roles with other parents, a strategy used by a number of states, she adds. "The model is really a parent-to-parent model where parents are trained to work with others parents. This expands the workforce capacity and supports enhanced family voice in the system of care," Cooper says.