For Kids with ADHD, Does Greater Access to Care Mean Better Care?

Although the enactment of the Patient Protection and Affordable Care Act of 2010 has expanded Medicare benefits and improved access to care for many previously uninsured individuals, including children, the quality of this treatment is being questioned.

In an article published in the Journal of the American Academy of Child and Adolescent Psychiatry, Bonnie Zima, MD, MPH, and colleagues looked at the treatment of ADHD in 530 children aged 5 to 11 years receiving ADHD care in primary care or specialty mental health clinics from November 2004 through September 2006 in a large, countywide, managed care Medicaid program.

The investigators used a set of longitudinal analyses drawn from Medicaid service and pharmacy claims data, parent and child interviews, and school records to analyze and compare the mental health care and clinical outcomes of children across three 6-month time intervals.

Zima and colleagues chose to evaluate the quality of care among children with ADHD for two reasons: first, ADHD represents one of the most common mental health disorders, affecting 3% to 10% of children in the US; and second, more than one-third of the national healthcare expenditures for child mental disorders are paid for by Medicaid.

They found that despite a federal policy that requires medical necessity for Medicaid reimbursement of specialty mental health services, the clinical severity of the children in primary care and community mental health clinics did not differ. At three 6-month intervals, receipt of no care ranged from 34% to 44%, and unmet need for mental health services ranged from 13% to 20%. In primary care, 80% to 85% of children had at least one stimulant prescription filled and averaged one to two follow-up visits per year.

Less than one-third of children in specialty mental health clinics received any stimulant medication, but all received psychosocial interventions averaging more than five visits per month. In both sectors, stimulant medication refill prescription persistence was poor, ranging from 31% to 49%. With few exceptions, ADHD diagnosis, impairment, academic achievement, parent distress, and parent-reported treatment satisfaction, perceived benefit, and improved family functioning did not differ between children who remained in care and those who received no care.

“Findings from this study identify several areas for quality improvement for ADHD care within the managed care Medicaid program studied,” the researchers wrote. “These areas are alignment of the child's clinical severity with provider type, frequency of follow-up visits, stimulant medication use in specialty mental health, agency data infrastructure to document delivery of evidence-based psychosocial treatments, and stimulant medication refill prescription persistence. The enduring symptoms, impairment, and poor academic achievement of the children who remain in care and those untreated underscores the public health significance of improving the quality of care for publicly insured children with ADHD.”

Also included in the Journal of the American Academy of Child and Adolescent Psychiatry was an editorial in which Mark Olfson, MD, MPH, commented on the findings by Zima and colleagues. “The report,” he wrote, “adds renewed urgency to the call for reform of Medicaid-financed community care of children with ADHD. Closer clinical monitoring with more frequent follow-up contact may be needed to increase continuity of care. Improvements are also needed in medication management, especially in specialty mental health clinics.”

For more:

• Medicaid-funded ADHD Treatment for Children Misses the Mark
• Quality of Care for Childhood Attention-Deficit/Hyperactivity Disorder in a Managed Care Medicaid Program
• Evaluating the Quality of Community Care for Attention-Deficit/Hyperactivity Disorder