The National Mental Health Association (NMHA) is pleased to provide this report as a means to facilitate better access to mental health services for children in Arizona (please note, throughout this report, the terms "children" and "youths" are used to refer to infants through adolescents). Achieving significant improvements in such access is indeed a primary goal of NMHA, as it is critical to building the just, humane and healthy society that is the driving vision behind all of our efforts. This product was made possible through the generous support of St. Luke's Charitable Health Trust.
This particular report focuses on two major processes that are designed to direct youths (and adult consumers) to the most appropriate treatment settings, but which can restrict access to services:
- "level-of-care criteria," which depict the requirements for accessing or remaining in a particular treatment setting; and
- medical necessity definitions, which are often broad with vague language that influence initial access to services, then are often stipulated in state or local regulations.
Despite the existence of many national and statewide quality monitoring bodies, there is very little information available that compares the quality of operational policies impacting children who are covered under managed care. As a result, there has been very little opportunity to hold up the better practices that have been accomplished as models that other MCOs can replicate. This report identifies these practices, as well as makes specific recommendations about how to improve these policies in both public and private sector programs.
It is our hope that advocates will utilize this document as a tool for achieving meaningful reform. We believe this information could effectively be used to:
- Help employers, public agencies, and general healthcare MCOs make more informed decisions when selecting among prospective bidders or monitoring the ongoing quality of vendors of mental health benefits for youths; and
- Help managed care entities and regional behavioral health authorities improve the quality of their processes for authorizing children's services.
Please be aware that this report is based only on the level-of-care criteria and medical necessity definitions provided by the parties included in the study. Of note, two of these organizations have stated that while some of the substantive policies we were looking for aren't in these documents (e.g. cultural competency and family involvement), they are contained in their other policy materials. However, NMHA and the panel contend that these elements are essential to treatment authorization decisions, and they need to be integrated into level-of-care criteria and medical necessity definitions.
We also found it disconcerting that policies are "housed" within different types of documents in different RBHAs, which does not facilitate ready access to clinicians, consumers, parents and other stakeholders.
There are global findings from this study that are worth noting here. Some refer directly to medical necessity definitions and level-of-care criteria analyzed for this report, and others reflect systemic problems in operating policies that interface with medical necessity and level-of-care criteria protocols.
- The state of Arizona, its RBHAs, managed care organizations, and other decision-makers need to develop developmentally appropriate tools for children, including level of functioning assessments, service checklists, medical necessity definitions, and level of-care-criteria.
- Decision-makers need to involve families and child-serving providers more actively in developing protocols. Many of the recommendations in this report reflect this need.
- Decision-makers should encourage the usage of techniques that encourage the most accurate diagnosis, including the use of differential diagnoses when appropriate. However, the absence of a definitive diagnosis should not preclude access to a given treatment setting.
- Decision-makers need to stress consistency in definitions throughout the state, with special emphasis on the terms "medical necessity" and "family."
- Because there are significant gaps in services available to youths throughout the state, decision-makers need to work to broaden provider networks, to enhance provider training, as well as allow for authorization of the next highest level of service when the most appropriate service for a child is not available. Cultural competency within networks is another area identified as needing additional attention.
- Decision-makers need to ensure that children and adolescents are not discharged without a discharge plan that includes family involvement.
- Decision-makers need to address the difficulties that arise with adolescents who are transitioning into the adult mental health delivery system.
- While emphasizing the strengths of the youth and his/her family is efficacious, clinicians on the panel report feeling a pressure not to take this approach, for fear of being denied services. Decision-makers need to facilitate greater dialogue with the provider community about this subject area.
Many panelists noted that the medical necessity and level-of-criteria policies noted on paper are not consistent with their own experiences with the treatment systemboth positively and negatively. However, we believe this report is an essential first step that will need to be followed by a second generation project addressing the implementation and ongoing application of such policies, as well as their impact on children and their families.
We hope that readers of this report will use it to facilitate reforms. If we can provide support in these efforts, please contact NMHA's Healthcare Reform Advocacy Resource Center for additional assistance (703-838-7524). NMHA looks forward to working with all stakeholders to improve the quality of mental health services for children in Arizona.