Overprescribing for Medicaid kids sparked by behavioral health provider shortage

The CMS has revealed that physicians may be overprescribing psychotherapeutic medication to children on Medicaid or CHIP, which may be due to inadequate access to behavioral health specialists.

The U.S. is experiencing a shortage of child psychiatrists, and many don't accept Medicaid, according to a new study from the CMS' Center for Medicare and Medicaid Innovation released in the April edition of the Journal of Behavioral Health Services & Research.

"Many children may be receiving treatment from practitioners who lack sufficient expertise to manage drug therapy effectively," the study said. "Medications may be over prescribed when concurrent behavioral health therapies are not available or are underutilized."

Innovation Center researchers reviewed Medicaid administrative data that tracked diagnoses, prescription drug fills, and payment data from 2006 to 2009, the last year there is comparable nationwide data.

During that time period, the number of Medicaid and CHIP beneficiaries diagnosed with disruptive behavior disorders such as attention-deficit disorder, oppositional defiant disorder or conduct disorder increased 24.5%. But the overall increase in pediatric Medicaid and Children's Health Insurance Program enrollment was only 8.8% during that same period.

All in all, 24.9 million prescriptions were filled in 2009 for children diagnosed with disruptive behavior disorders, costing Medicaid $2 billion. That was up nearly 28% from 19.5 million prescriptions for $1.62 billion in 2006.

Psychotherapeutic drug claims represented 30% to 40% of prescription claims, but over half of prescription costs of all drug claims for children in Medicaid and CHIP.

The Innovation Center expressed significant concerns over the trends it saw in kids under 6; drug treatment is not recommended as a first-line treatment for most behavior disorders in this age range. Still, psychotherapeutic drugs represented 16.5% of total prescriptions filled for children age 5 and younger in 2006, accounting for 30% of their Medicaid prescription payments in 2006 and 28.1% in 2009.

"The high proportion of psychotherapeutic drug use and costs related to (behavioral disorder) treatment is of special concern if drugs are prescribed inappropriately or in lieu of other services, especially for younger children," the study said.

Researchers say the results should spur reform efforts to address prescribing trends.

One possibility would be to increase Medicaid pay rates for child psychiatrists. Currently, they receive approximately $75 per session on average, according to Dr. Christopher Bellonci, chief medical officer at Judge Baker Children's Center in Boston.

Research has shown children with behavioral problems benefit from therapy that focuses on teaching kids and their parents skills to manage disruptive behavior. The therapy only lasts for a few sessions, versus traditional psychotherapy, so Medicaid wouldn't be facing long-term costs for children, Bellonci said. However, behavioral health specialists trained in these methods often don't accept Medicaid because the sessions can cost around $200.

"The concern with medication is that they don't teach skills, and to continue to benefit from them you have to stay on them," Bellonci said. "The issue is the longer you're on some of these medications, the greater risk of side effects."

Bellonci said those side effects can include extreme weight loss or gain, and the latter puts kids at greater risk of diabetes and heart disease.

The CMS could also address the trend by paying for doctor visits that let a pediatrician work with parents to mitigate disruptive behaviors before a child's condition progresses to a point that medication is needed, according to Dr. Cori Meredith Green, a pediatrician at Weill Cornell Medicine.

"Primary-care clinicians need to take on some of the care for children with mental and behavioral health problems due to a shortage of specialists," Green said.