Report on the Development and Implementation of EPSDT Required Medicaid Services for Children and Adolescents with Severe Emotional Disturbances in the Commonwealth of Pennsylvania
DAVID K. NACE M.D.

October 15, 2004

Rosie D. v. Romney

I.PURPOSE

I have been retained by the Center for Public Representation of 22 Green Street, Northampton, Massachusetts to provide a description of the evolution of Medicaid funded mental health services under Pennsylvania’s EPSDT program for children and adolescents. This review focuses on: (1) the process that evolved in Pennsylvania for establishing a program of home-based, community-based, and school- based psychiatric treatment and rehabilitative (“wraparound”) services; and (2) an update on the current status of the program today.

II.QUALIFICATIONS

This report is based on my professional credentials as a child and adolescent psychiatrist, as well as my experiences as one of the initial providers of home-based, community-based, and school-based (“wraparound”) psychiatric treatment and rehabilitative services to children and adolescents in Pittsburgh (Allegheny County), Pennsylvania. My credentials include an undergraduate degreefrom the Philadelphia College of Pharmacy and Science (magda cum laude), a medical degree from the University of Pittsburgh School of Medicine, a residency and fellowship in general and child and adolescent psychiatry at the University of Pittsburgh Medical Center, and board certification by the American Board of Psychiatry and Neurology.

My experience as a practicing child and adolescent psychiatrist in Pennsylvania began in the early 1990’s. From 1991 – 1993, I served as a practicing psychiatrist at the Northern Southwest Community MHMR Center in Pittsburgh PA, where I was responsible for supervising multidisciplinary teams and case management services at this nonprofit community mental health center serving over 100,000 members. From 1993-1995, I was the medical director of the Allegheny Children’s Initiative, a nonprofit corporation founded to provide case management and family based services for children and adolescents who needed assistance beyond the traditional array of mental health services, and who had emotional and behavioral problems that inhibited functioning in their homes, educational and/or community settings. I was responsible for supervising the clinical teams for the case management program as well as for wraparound and mobile crisis services negotiated through an individual application process under Medicaid. From 1992-1995, I also held a faculty position with the University of Pittsburgh School of Medicine’s Department of Psychiatry (Division of Child and Adolescent Psychiatry). In addition, I was a member of the medical staff at the University’s Western Psychiatric Institute and Clinic, where I was directly responsible for spearheading the development and implementation of community based partial hospitalization, intensive ambulatory, mobile crisis, and community and home-based treatment services for children and adolescents. Since 1995, I have held positions as national medical director with the behavioral health divisions of both Aetna (VP, Chief Medical Officer, 1995 – 1998) and United Health Group (SVP, Corporate Medical Director 1998-2004).

Over the past 15 years, I have been active in a leadership capacity with the American Academy of Child and Adolescent Psychiatry (AACAP), the American Psychiatric Association (APA), and the Association for Ambulatory Behavioral Healthcare (AABH). I was one of the first chairmen of the Managed Care Task Force of the American Academy of Child and Adolescent Psychiatry, served two terms on the board of directors for the Association of Ambulatory Behavioral Healthcare, and continue to hold the longest standing appointment on the Council of Economic Affair’s Managed Care Committee with the American Psychiatric Association. I am also past Chairman and board member of the American Managed Behavioral Healthcare Association. Over the last decade I have served as a board member or consultant for numerous healthcare related advisory boards, foundations, associations, and task forces, including the Child’s Mental Health Alliance of the Robert Wood Johnson Foundation, the Leonard Davis Institute of Health Economics with the Wharton School of Business, and the United Nations Business Council.

My CV is attached for additional reference.

III.INFORMATION REVIEWED
  • Rosie D. v. Jane M. Swift, Complaint, United States District Court, District of Massachusetts, Western Division.
  • Bruce Kamradt, “Program Review of Community Mental Health Services for Children with Serious Emotional Needs in the Northern and Southern Regions of Massachusetts - Rosie D. v. Jane M. Swift” September 2004.
  • DMA EPSDT Regulations, 130 CMR 450.140 et seq.
  • Kirk T. v. Feather O. Houston, Complaint, NO. 99-CV-3253, United States District Court, Eastern District of Pennsylvania; June 25, 1999.
  • Larry K. v. Snider, Complaint, NO. 91-680, United States District Court, Eastern District of Pennsylvania; January 6, 1993.
  • “Outpatient Psychiatric Services for Children Under 21 years of Age”, Pennsylvania Medical Assistance Bulletin # 01-94-01, 41-94-01, 48-94-01,4994-01, 50-94-01; January 1, 1994. (DMA006610-DMA006624)
  • “Accessing Outpatient Wraparound Mental Health Services not Currently Included in the Medical Assistance Program Fee Schedule for Eligible Children Under 21 Years of Age”, Pennsylvania Medical Assistance Bulletin # 1153-95-01; September 8, 1995. (DMA006627-DMA006652)
  • “Guidelines for Best Practice: Child and Adolescent Mental Health Services”, Pennsylvania Department of Public Welfare Office of Mental Health and Substance Abuse Services, Harrisburg, PA; April 2000. (DMA047154-DMA047,263)
IV.SUMMARY OF OPINIONS
  1. Prior to an EPSDT lawsuit in 1991 (Larry K v. Snider), there was a lack of home-based, community-based, and school-based behavioral rehabilitative and therapeutic services in Pennsylvania available to address the behavioral health needs of severely emotionally disturbed children and adolescents.
  2. Due to the absence of commercial or Medicaid billing codes or reimbursement mechanism for home-based, community-based, and school-based professional mental health services, physicians, psychologists, and other behavioral health professionals did not prescribe or recommend them, despite a clear need for such services to support the severely emotionally disturbed child and family in their home.
  3. As a result of a settlement resulting from the Larry K v Snider lawsuit, Pennsylvania established a process for requesting and receiving reimbursement for home-based, school-based, and community-based behavioral services from Medicaid through a case-by-case application process.
  4. While this development was positive, the complexity and difficulty of requesting and creating home-based, community-based, and school-based professional mental health services on a child-by-child basis through the individual application process discouraged many clinicians from recommending them, despite the significant number of children who needed them.
  5. Subsequently, the Pennsylvania Medicaid agency created a fee schedule that allowed for several of the most frequently requested services (i.e. mobile therapy, therapeutic staff support, and behavioral specialist consultants), which provided an incentive for some practitioners and agencies to recommend or begin to provide these services
  6. Prior to a second EPSDT lawsuit in 1999 (Kirk T. v. Houstoun), the administrative paperwork, approval requirements, and inadequate reimbursement rates for these home-based, community-based, and school-based professional mental health services created a barrier to effectively delivering the services in a timely manner to children and adolescents.
  7. Pennsylvania subsequently responded by providing detailed program descriptions, simplified administrative billing processes, quality assurance reporting requirements, increased reimbursement rates, and specific training and written resources to support providers who wished to provide the services. In addition, a tracking mechanism was put into place to support the timely delivery of these services.
  8. As a result of these changes, an increased number of clinicians and agencies in Pennsylvania began to recommend and deliver these services for a significant number of children who required them. Currently, home-based, school-based, and community-based behavioral services are widely utilized in Pennsylvania, in both fee-for -service and managed Medicaid environments, and are effective in supporting children with serious emotional disturbances to remain in their homes and communities.

9.In light of Pennsylvania’s experience, Massachusetts’ EPSDT regulation that allows a Medicaid recipient or treating clinician to specially request a service, like home-based services, which is not covered or provided by an MCO, is not likely to result in the provision of medically necessary home-based behavioral services for children. Individual applications for needed home-based and community-based services that must be designed, proposed, coordinated, and integrated between several providers -- absent specific and realistic procedures, timelines, technical support, and assurances of defined and reasonable reimbursement that supports training, recruitment, and retention of qualified service providers -- is not an effective or practical way to ensure that medically necessary services are provided.

V.ANALYSIS SUPPORTING OPINIONS

When I first began to practice child and adolescent psychiatry in Pennsylvania in the early 1990’s, Medicaid eligible children with serious emotional disturbances (SED) were only eligible to receive traditional clinic-based or hospital-based mental health services as provided on the Medicaid fee schedule at that time. The Pennsylvania Medical Assistance (Medicaid) program and fee schedule did not include services that could be tailored to meet the specific needs of these children. More specifically, Pennsylvania did not allow for the reimbursement of services to assess or address these children’s problems where they occurred – i.e. in their homes, schools, or community outside of school. Because there was no Medicaid billing code for clinically focused family-based, school-based, or community-based services provided by the state, physicians and other behavioral health professionals did not recommend or deliver these services. This situation existed despite a clear need for evaluation and treatment services to be delivered where the children lived out their lives. As a result of these dynamics, there was an absence of professionals or agencies that were trained, qualified, competent, or willing to provide such services.

It should be noted that there were two, albeit inadequate, exceptions to this void: (1) there were some school-based services available where children were identified with severe emotional needs by the school system. However, these were limited to services that provided some educational benefit, i.e. special education services; and (2) Pennsylvania’s social service arm of Children and Youth Services provided for limited in-home services that were primarily aimed to provide family-based social interventions, or to assess if out-of-home protective services, such as foster care or residential placement were required. Neither of these services provided medically necessary, behavioral health evaluation or treatment services. They had a primary focus on the family, as opposed to the child, and the services were social intervention in nature. The services did not evolve from or address the results of a comprehensive psychiatric or psychological evaluation of the child, did not focus on the specific symptoms or behavioral health condition of the child, did not provide funding for these services by Medicaid. As a result, families with children with severely emotional disturbances were often left with no alternative other than relinquishing custody of their children to the state’s foster care system. This was often the only mechanism to obtain services for their child, through residential or foster care placement outside of the child’s home and community from Pennsylvania’s child social services. The only other alternative was to have the child hospitalized in the state’s psychiatric hospital system. Not surprisingly, doctors and mental health professionals did not recommend home-based and community-based services for low-income children, since these were not available under Pennsylvania’s Medicaid program.

In 1991, a complaint was filed (Larry K. v Snider) challenging Pennsylvania’s failure to meet its obligations under Medicaid, specifically under the EPSDT entitlement, which required that the Commonwealth “provide all necessary health care diagnostic services, treatment and other measures… to correct or ameliorate defects and physical and mental illnesses and conditions”. Up until that point, Pennsylvania had not focused on its responsibilities under EPSDT for children with mental or behavioral health conditions. The case of Larry K. involved an 8-year-old boy with attention deficit disorder and conduct disorder who was confined in a mental hospital because the state refused to pay for residential treatment unless the child’s parents gave custody to the foster care system. Through a settlement with Pennsylvania, the state agreed that Medicaid would pay for medically necessary residential treatment as well as for home-based, school-based, or community-based “wraparound” mental health services for children and adolescents under age 21. The concept of “wraparound” services was used to refer to medically necessary, behavioral health rehabilitative and treatment services that would be provided in the home, the school, and the community outside of school to address the individualized needs of the child.

Following the Larry K. settlement, providers were asked to submit individual Medicaid applications on a child-by-child basis as a mechanism to obtain reimbursement for such services. The individual application process consisted of submitting detailed assessments, results of interagency team meetings, as well as documentation demonstrating collaboration and input of the child, all pertinent family members, pertinent community supports, school representatives, and existing and proposed treatment providers. The submission required a psychiatrist or psychologist to prescribe the proposed services as part of a medically necessary treatment plan. Thus, on a case-by-case basis, the specific types of services to be delivered had to be “brainstormed” around the specific needs of each individual child. Providers willing to provide the proposed services had to be identified, and a proposed budget for the services submitted for review. Each proposal was designed in collaboration with an interagency team, which required participation of the state Medicaid office, and in turn needed to be submitted to the state agency for review and approval prior to the services being delivered. In addition, the minimum duration of such individual approvals was for four months, at which time a second application had to be submitted.

Needless to say, the cost and effort for providers to perform the brainstorming, create a service proposal, convene an interagency team, and submit a proposal was significant, especially since reimbursement could only be assured if the proposal was approved by the state, and then only for four months. To make matters worse, once a plan was submitted, there could be a period of many weeks or even months before a response was received, which often simply requested additional information. Finally, given that such services had not been reimbursable in the past, the service proposals often were not that well conceptualized, and service providers that could deliver such services in the home, community, or schools were not readily available. Local providers usually did not have the experience or competence necessary to provide such services safely and effectively. Since mental health professionals often were not aware of this process or wraparound services in general, they did not regularly recommend these services.

Despite these obstacles, several organizations began to experiment with the application process to develop individually designed treatment plans for children that included community or home-based services. At the time, I was integrally involved with two such organizations in the Pittsburgh area: (1) The Allegheny Children’s Initiative, where I served as the child and adolescent psychiatrist overseeing case management services and the clinical supervision of community-based wraparound services; and (2) the Western Psychiatric Institute and Clinic, where I founded an adolescent partial hospital program in 1993, and provided the first community-based and home -based waiver submissions for the Institute. Both of these programs had the advantage of applying for and providing wraparound services within their existing program infrastructure. Thus, clinical staff could be cross-trained and provide clinical supervision for non-clinically trained therapeutic staff and aids to provide wraparound services. This reduced the financial risk and the time and resources needed to both apply for, and ultimately provide, the services, especially since there was no guarantee that the Commonwealth would approve payment for the services after significant work went into each child’s application. The process of providing these services involved negotiating and developing a strong relationship with local Medical Assistance (Medicaid) representatives. The procedure involved convening an interagency family meeting, inviting all current providers, relevant family members, child, educational system representatives, relevant community members, and a psychiatrist or psychologist to perform a thorough social, psychiatric, education, community, and support system evaluation. The team would then identify gaps and needs of the child, and “brainstorm” the type of mobile or community-based therapeutic services that could address the child’s clinical needs. The service proposal would then be drafted, receive the interagency team member’s agreement, and be submitted for review by the Commonwealth.