Beyond the Byline: Kids' unchecked mental health needs pose long-term consequences

Modern Healthcare public health reporter Steven Ross Johnson and hospital operations reporter Alex Kacik talk about how the COVID-19 pandemic compounded systemic shortfalls in behavioral healthcare.

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Music Credit: Coffee by Cambo

Alex Kacik: Hello and welcome back to Modern Healthcare's Beyond the Byline, where we offer a behind the scenes look into our reporting. I'm your host, Alex Kacik. I write about hospital operations for Modern Healthcare. Today, I'm talking with Steven Johnson, our public health reporter, to discuss how the pandemic is impacting kids' mental health. Hey, Steven. Thanks for coming on.

Steven Johnson: Hey. Thank you for having me.

Alex Kacik: For years, you've written about how the healthcare system hasn't served folks with depression, anxiety, and other behavioral health issues. Well, I know you've covered a lot on the adult side, but this is an opportunity for you to get into the pediatric side, with this really great special report you came out with last week on the topic. I'm wondering, how has COVID-19 compounded these systemic shortfalls?

Steven Johnson: You know, I think in some respects, COVID has really only exacerbated many of the longstanding access problems behavioral healthcare systems had for years. Before the pandemic, you had a system where a little more than 42% of adults who experienced a mental health issue got treatment and just about half of children under age 17 received services. I think COVID has done really two things to worsen the problem. First, it's extended isolation at home. It's caused stress to many families. That's manifested into increased tension at home, which has led to increased rates of domestic abuse. That's all on the farther, more severe end, but then on the less severe end, more moderate end, just a lot of family tension, which causes stress, and young children exposed to that become ... That affects them, especially at younger ages when they're still developing emotionally.

So second, school has been a big support, which I didn't realize going into this report, how much of a help that school, having just a school building, where kids come in and teachers and school nurses can assess them, identify any potential problems they may have, that's played a big part in terms of helping to catch kids early on for emotional and psychological issues. Without that, now that schools have been closing, classes have moved to online, that's really hurt the ability for healthcare providers to be able to provide early interventions to kids.

Alex Kacik: There's one line in your special report that stood out to me, "The rising need among children for mental health services has many fearful that without more robust support, the country faces a tsunami of unmet needs that the health system will not recover from for years." So we see behavioral health issues, and tied so often with chronic conditions, whether it's anxiety, depression, or what have you, have a way of compounding underlying issues, and I imagine can not only stress your body and how you recover, but also, you'll require more services down the road. I'm wondering, just in terms of these unchecked mental health needs, how those can manifest in the healthcare system over the long term.

Steven Johnson: Well, I think you hit it exactly on that point. You hit it right on the head in terms of what's at risk here. Having a mental health disorder often goes hand in hand with having poor health outcomes, physical health outcomes, whether that's caused by developing riskier health behaviors, like smoking or substance abuse, or being less able to manage your chronic health conditions. Now, obviously with children it's different, because one, average wise they're usually much healthier than adults, but early on, if they start developing these disorders or psychological issues and they go unchecked, unmanaged, untreated, over time of their development, that affects them to a point where it can manifest into disorders.

Most people with full fledged diagnosed mental health disorders don't begin to even show symptoms until they're about 14 years old. So many experts believe that many of the signs that a child might be having a potential issue down the road can be detected earlier in age, but because it's developed into a full blown disorder, then they may have fallen through the cracks. And as you said before, that can manifest into issues regarding physical health, where you're using healthcare much more often, and then obviously the cost of that healthcare goes up.

Alex Kacik: It seems like we're hitting a turning point of sorts where folks are starting to legitimize the link between mental and physical health. And I don't know if the healthcare system has caught up yet to offer the right type of care to address both these needs. But I do seem relatively a little bit more hopeful that as folks recognize how vital the holistic element of care is, I imagine there are some best practices emerging. Do you see that recognition at least play out more among these health systems or providers that you talk to?

Steven Johnson: I think it's much more prevalent in the adult care setting, as opposed to pediatrics. There's been a big push for a number of years, looking at trying to integrate behavioral healthcare within the primary care settings. Though there's been a bigger push, I believe there's been a bigger push in the adult patients. Pediatrics, there are still a few providers that are doing it, but it's not as robust as you see it in adults. I think that systems that are incorporating social factors, such as poverty and food insecurity, housing issues, stable housing issues, and even the effects of racial discrimination, as part of their mental health risk assessments for children, I think that's been helpful because it enables them to think more holistically about all possible conditions that can impact a child's emotional and psychological development.

In doing this report, I talked to a few providers who are doing that. And I think that one of the overall common themes, even if different systems have different programs and different strategies as to how they go about addressing this issue, I think one overall common theme that many of them have is that they try to create multiple points of contact to identify a child having a mental health issue, whether it is having a partnership with the school, whether a community organization or a church, or just the parents, or usually it's a combination of all of them. But I think those kinds of collaborations become a basic tenant of the strategies that they employ.

Alex Kacik: Let's talk about access for a second and then maybe we can get into reimbursement, but you talked with a couple families, one of which, they were struggling to get counseling for several of their kids during the pandemic, another one who is a wife and mother and had gone through a major traumatic event with her husband and then worried about her eight month old. I'm wondering, what did you learn from them as they tried to get services for their young ones? Were they available, and were there barriers to access?

Steven Johnson: I guess the one key takeaway that I got from both talking with Emily Hangen and Jennifer Pannone was just the pure sense of desperation that parents must be feeling right now as they seek help for not just themselves, but their families, and finding that there was few to no options available right now. Even if they do everything right, even if they have everything that they need in terms of they have resources, they have insurance coverage, they're eligible to get this kind of care, and yet because there's such a backlog for people who are just like them, who need those services, they either find themselves unable to access an available provider or being put on a waiting list for months.

It creates a system where you find yourself jumping through one hoop, then you find that there's another hoop and there's another hoop. So once you jump through the initial hoop of, okay, even accepting that, okay, I may have an issue that I need help to address, that's one. And believe me, I'm not minimizing that. That's a big hurdle for many people to overcome. Just admitting there's an issue is very important, a vital first step.

Once you get past that, then trying to access a behavioral healthcare specialist when there is just purely no one available, people are saying that, "Hey, we're not taking on new patients," that's another hurdle you've got to jump over. You've got to find someone who's even taking patients. Then once you do that, you've got to find someone who takes your particular brand of insurance. And then once you get past that, if you're lucky enough to get past that, well, first you may have to wait. And then after you wait, then you may have to figure out a way to come up with the money out of your own pocket, even with insurance considered, to be able to pay for the services that you're getting. So it creates a system where it really incentivizes people to give up a lot of times or to delay care.

Alex Kacik: And the Healthcare Cost Institute adds some data, just looking at the claims data and the reimbursement rates for mental health services, and I think this is mostly for adults, but enrollees in private plans spent more out of pocket because they went out of network for mental health services more than six times as often as for other types of services. So this is a real issue here. And I imagine, I think there were some waivers involved in terms of payment parity. I know payment parity, I know there's some state laws involving that when it comes to telehealth. I'm wondering if you get into, you know, we're seeing shortages particularly for specialists, so I imagine the pediatric side, especially, in rural areas and just areas that aren't highly populated.

So do you think telehealth can fill the void in some of these access issues, but also, is it sustainable from a reimbursement perspective? Do you think that there's the financial incentives that would allow these care gaps to be filled via that medium?
Steven Johnson:    Put simply, in a word, no, right now. Telehealth has certainly been helpful during this time in terms of increasing the number of patients a professional can see, as well as expanding the geographic scope in which they can provide services. So people in more rural parts of the country can get telehealth counseling from someone out of state, especially if they live in an area where there is a shortage of pediatric behavioral healthcare specialists. And you mentioned the shortages in terms of the workforce, you see that on the adult end. It's especially bad in pediatrics.

So any problems with shortages you see on adult behavioral healthcare [inaudible], just multiply that by two or three when it comes to pediatrics. I think that some of the regulatory changes that were made during the public health emergency, as a result of the public health emergency, have been positive in terms of incentivizing. There's more changes that need to be made. I think the two tests for telehealth in terms of what it's able to do, in terms of providing greater access, is going to be once the pandemic ends and you have people that are more confident or feeling better about going into the hospital or into the care setting in person.

With that being said, the quintessential problem still exists, which is a shortage, just an overall shortage of providers, even with telehealth. Telehealth helps in a sense that it helps to help those providers that are there, I guess broaden the scope of their services, to spread them a little more thin, for lack of a better term, but the problem still exists that there's just not enough providers. The workforce is just inadequate in terms of its numbers to meet the level of demand that's needed.

I think one of the things that struck me in doing the report the most was when I spoke with Dr. Ken Duckworth at the National Alliance for Mental Illness, who said bluntly, "It takes eight years to make a social worker. It only took roughly eight months to create this mental healthcare pandemic." So the problem is one that was years in the making. And it's likely going to take that long, if not longer, to solve it.

Alex Kacik: I'd be interested to hear, too, if you follow up with some of those families down the road to see how they're doing and see if they've been able to get the help they need for their kids and for themselves.

Well, hey, can't thank you enough, Steven, for this work. It's so important, and we appreciate you and all you do. And thanks for coming on with me. I really, really thank you so much.

Steven Johnson: Oh, thank you.

Alex Kacik: Thank you all for listening. If you'd like to subscribe and support our work, there's a link in the show notes. You can subscribe to Beyond the Byline wherever you listen to your podcasts and you can stay connected with our work by following Steven and I and Modern Healthcare on Twitter and LinkedIn. We appreciate your support.