Mental health access for children needs attention

Jennifer Pannone needed help.

The resident of Schenectady, N.Y., was pregnant, a global pandemic was unfolding and her fiancé had committed suicide weeks earlier, on New Year’s Day 2020.

Despite getting support from a local health system, including more than 50 referrals to behavioral health specialists, she has not been able to find a specialist who was accepting new patients.

“When everything shut down, so did all the counseling and the resources,” Pannone said. “With COVID sending everybody home, a lot of providers were not accepting new patients. I am still on a waiting lists to get a mental health provider.”

Pannone said her motivation to seek care has not only been for her own well-being, but out of concern that her issues with anxiety and depression will negatively affect her 8-month-old daughter Victoria in the long term. While she waits, Pannone said she is doing her best to keep up a positive appearance.

“I just try and stay busy and smile for her,” Pannone said. “When it really hurts deep down inside you just try and cover that up so she doesn’t pick up on that.”

Scenarios like this are unfolding across the country, creating the potential for a mental health crisis in coming months and years.

“It’s hard to overestimate the impact that the pandemic has had on behavioral health issues, especially among children,” said John Snook, director of government relations and strategic initiatives for the National Association for Behavioral Healthcare. “Where we’re struggling still is making sure that people can get the mental healthcare they need when they need it.”

Yet despite the need for services, many of the same barriers that have been responsible for hindering access to behavioral healthcare services in the past—provider shortages, narrow networks and weak reimbursement—also have limited care options for children and created a backlog that could take the healthcare system years to rectify.

Dr. David Axelson, chief of psychiatry and behavioral health at Nationwide Children’s Hospital in Columbus, Ohio, said his unit saw nearly 6,000 kids for psychiatric crises during 2020, an 13% increase over 2019.

Nationwide Children’s was better prepared to handle the influx because in March of 2020 it had opened its Behavioral Health Pavilion, a nine-story, 386,000-square-foot facility.

Axelson said observation and stabilization units in the pavilion have helped decrease the percentage of kids admitted as inpatients, which makes more space available for the most severe cases. “It allows for the best and most efficient utilization off our most limited resource, which is essentially our psychiatric providers,” Axelson said.

In spite of such efforts, Dr. Ken Duckworth, chief medical officer at the National Alliance for Mental Illness, said the fundamental problem with pediatric mental healthcare in the U.S. remains one of its oldest—an inadequate supply of professionals to handle the demand.

According to the American Academy of Pediatrics, there are about 9.75 pediatric psychiatrists for every 100,000 children in the U.S., with some states having fewer than 4 for every 100,000. Meanwhile, the American Academy of Child and Adolescent Psychiatry estimated the level of need to be 47 child psychiatrists for every 100,000. And with most providers concentrated in urban areas, the current supply levels leave about 70% of counties without a child psychiatrist.

The pandemic has only added to the wide gulf between supply and demand. “It takes about eight months to make a true mental health pandemic tsunami, but it takes about eight years to make a social worker,” Duckworth said. “So really the problem is kind of right there.”

Pannone said her inability to find a behavioral healthcare provider for care has not only due to a shortage of providers but also because of the difficulty in finding a professional who accepts her insurance.

Insurers that offer limited in-network options for access to behavioral healthcare services has become more common in recent years, which some have termed ghost networks.

“When a family goes to their private insurance they pull up their plan and they say they want to find a provider, but there’s a whole bunch of problems that start from just that premise,” said Mary Giliberti, executive vice president of policy for advocacy organization Mental Health America.

Giliberti said many families seeking behavioral healthcare services for children start by looking for a child psychiatrist, which she equated to visiting a surgeon for a wellness check.

She said many specialists listed in a patient’s coverage network oftentimes do not take an individual’s insurance for payment. Patients are then stuck with the choice of either paying the full cost for services or forgoing treatment.

“It’s been a huge problem pre-pandemic, during the pandemic, and ongoing,” Giliberti said.

Narrower in-networks for behavioral healthcare services have replaced more blatant insurance coverage restrictions that were banned after passage of the Mental Health Parity and Addiction Equity Act in 2008.

But it remains difficult for families with public and private insurance plans to get their children access to mental health services.

Kristen Choi, an adolescent psychiatric nurse and assistant professor at UCLA School of Nursing, said access to behavioral healthcare services can be even more difficult to get for those covered by Medicaid and the Children’s Health Insurance Program, with reimbursement rates on average much lower than commercial payers.

“There is no provider network for people who have public insurance,” Choi said. “On paper it might look like you have great benefits and because we have all of these parity laws that mental health services will be covered, but if there are no providers who take your insurance it doesn’t matter.”

Dr. Stuart Lustig, national medical executive for behavioral health at Cigna, acknowledged the problem of narrow behavioral healthcare provider networks for children can be challenging, especially for those living in more rural areas where the number of professionals is limited.

He said alternative care mechanisms like telehealth or support from a social worker or other professional trained to help patients better manage their stress and anxiety issues can be helpful ways to expand access, since most individuals who experience a behavioral health issue involve issues that are mild to moderate in severity.

“If we think about how to expand the pool of resources that are available and appropriate, it doesn’t necessarily have to be that highly trained—and not as available—child psychiatrist,” Lustig said. “But I also think the network challenges have improved and the digital capabilities are helping us there as well.”

While increased use of telehealth has helped mitigate some of the demand challenges brought on by the pandemic, many see the need for more substantive changes in how pediatric mental healthcare services are paid for and delivered to handle the long-term needs many children may face after the pandemic.

Snook, of the National Association for Behavioral Healthcare, said he was hopeful reform efforts like California’s mental health reform law that went into effect Jan. 1 will become a model other states will adopt. The law requires insurers to provide full coverage for all mental health and substance use disorders and establishes a set of uniform standards for insurers to follow regarding what is deemed a medically necessary treatment. The provisions are designed to reduce the ability of commercial payers to deny coverage.

“I think we are seeing all across the board policymakers on every level recognizing mental health needs in a way that they haven’t before,” Snook said. “Having that conversation about what an effective mental health system looks like is that much more important because it is top of mind for everyone right now.”