Buying What Works Pays Off: Cost-Effectiveness of Evidence-BasedInterventionsBRYAN SAMUELS, COMMISSIONERADMINISTRATION ON CHILDREN, YOUTH & FAMILIES
CMS ENCOURAGES USE OF EPSDT TO IDENTIFYTRAUMA AMONG CHILDREN WHO HAVE BEENMALTREATED• CMCS Informational Bulletin dated March 27, 2013: Prevention and Early Identification of Mental Health and Substance Use Conditions• Highlights that “Children exposed to trauma, including maltreatment, family violence, and neglect, exhibit symptoms consistent with individuals diagnosed with post-traumatic stress disorder, attention deficit/hyper-activity disorder, depression, and conduct disorder/oppositional defiant disorder.”• Outlines elements of EPSDT benefit that are particularly relevant to prevention and detection of mental health and substance abuse disorders. 4/16/2013 2
MENTAL HEALTH IN CHILD WELFARE MH Prescriptions MH Services Any MH Use 70% 60% 50% 40% 30% 20% 10% 0% Ages 0-5 Ages 6-11 Ages 12+ 4/16/2013 3Data Source: USDHHS
MOST COMMON MENTAL HEALTH DIAGNOSES AMONG CHILDREN IN FOSTER CARE RECEIVING PSYCHOTROPIC MEDICATIONS 40% 30% 20% 10% 0% ADHD Depression Conduct/ Bipolar Disorder Oppositional Defiant DisorderZito, JM; et al. (2008). Psychotropic medication patterns among youth in foster care. 4/16/2013 4Pediatrics. 121(1): e157.
MEDICAID IS ALREADTY PAYING FOR TRAUMAINTERVENTIONS: SYMPTOMS THAT OVERLAP WITH CHILDTRAUMA AND MENTAL ILLNESSMental Illness Overlapping Symptoms Trauma Restless, hyperactive, disorganized, and/orAttention Deficit/ agitated activity; difficulty sleeping, poor Child TraumaHyperactivity Disorder concentration, and hypervigilant motor activityOppositional Defiant A predominance of angry outbursts and Child TraumaDisorder irritabilityAnxiety Disorder (incl.Social Avoidance of feared stimuli, physiologic andAnxiety, Obsessive- psychological hyperarousal upon exposureCompulsive to feared stimuli, sleep Child TraumaDisorder, Generalized problems, hypervigilance, and increasedAnxiety Disorder, or startle reactionphobia Self-injurious behaviors as avoidant copingMajor Depressive with trauma reminders, social withdrawal, Child TraumaDisorder affective numbing, and/or sleeping difficulties (Griffin, McClelland, Holzberg, Stolbach, Maj, &Kisiel , 2012) 4/16/2013 5
ESTABLISHING A COST-EFFECTIVE SERVICES ARRAY Current Investments Replacement Investments Triple P – Positive Parenting Classes Parenting Program® De-scaling Investing what doesn’t Fluoxetine Trauma-Focused in what work (Psychotropic Cognitive Behavior does Medication) Therapy (TF-CBT) Child-Parent Generic Counseling Psychotherapy (CPP) INEFFECTIVE RESEARCH-BASED APPROACHES APPROACHES How much it would What is currently The amount neededCALCULATION cost to implement a minus being spent on an = upfront to implement particular evidence- ineffective the evidence-based based intervention intervention to try to intervention address the issue(s) In Year 3, 4 and/or 5: Expected savings due to improved child and family outcomes from use of evidence-based intervention(s) to address the issue(s) 4/16/2013 6
AROUND THE COUNTRY: EBPs REIMBURSED BYMEDICAID Multidimensional Treatment Foster Care (MTFC) • Hawaii, Nebraska, California, Tennessee Parent-Child Interaction Therapy (PCIT) • New Jersey, Delaware, Iowa, DC, Illinois, Oklahoma Multisystemic Therapy (MST) • Tennessee, New Jersey, Arizona, DC, New Mexico Functional Family Therapy (FFT) • New Jersey, Louisiana, DC, Washington Cognitive Behavioral Therapy (CBT) • New Jersey, North Carolina, Delaware, South Carolina Incredible Years (IY) • Oregon, Florida, Texas, New York 4/16/2013 7
SCREENING AND ASSESSMENT UNDER EPSDT “[Massachusetts] implemented new regulations requiring primary care providers to screen for developmental and behavioral problems for all MassHealth members younger than 21 years. Providers are required to use validated, standardized screening tools from a list provided by the state and are currently reimbursed approximately $10 for each screening test performed and an additional $25 for face-to-face evaluation and management time for a positive screen. Prior to these regulations, even the mandated screening under EPSDT did not require the use of specified tools and was not a distinct, uniformly reimbursable service.”Kuhlthau, K; Jellinek, M; White, G; VanCleave, J; Simons, J; & Murphy, M. (2011). Increases inbehavioral health screening in pediatric care for Massachusetts Medicaid patients. Archives of Pediatric 4/16/2013 8and Adolescent Medicine. 165(7):660.
A COMMITMENT TO PROMOTING WELL-BEING FORCHILDREN AND FAMILIES MEANS:1. Focus on child & family level outcomes2. Monitor progress for reduced symptoms and improved child/youth functioning3. Proactive approach to social and emotional needs4. Developmentally specific approach5. Promotion of healthy relationships6. Build capacity to deliver EBPs 4/16/2013 9