Abstract
But I would like to focus here on an article that brings many of these issues together on a larger canvas. Raghavan et al. have written an excellent article, “Medicaid Expenditures on Psychotropic Medications for Children in the Child Welfare System,” that addresses an issue we have all heard much about in a dispassionate and scholarly manner. (A recent and quite alarming 20/20 report by Diane Sawyer comes to mind as a counterexample.) For an in-depth understanding I suggest you read the article, but the takeaway is this: For a variety of reasons including family environment, social class, and heightened incidence of emotional and behavioral problems, children in the child welfare system cost Medicaid up to $840 a year more than similar children also on psychotropic medication but not in the child welfare system.
This is an illuminating view of a vulnerable population—vulnerable to psychiatric illness, but also more vulnerable than most to the failings of our mental health care system. This is in part because of, as Raghavan et al. write, “the emotional and behavioral consequences of maltreatment, and differences in access to psychosocial interventions.”
Raghavan et al. focus on the numbers, and for good reason. As they rightly point out, should Medicaid understand who in the system is being prescribed what at a higher rate, it could help the organization design a plan to bring costs down while maintaining an appropriate level of care. In the light of our obvious need to curtail health care costs, this is a noble goal.
Though Raghavan et al. are careful not to stray beyond the bounds of their inquiry by speculating about individual quality of care, the article cannot help but bring up the question of whether these children on whom we spend so much should be taking the medications prescribed to them. When discussing solutions such as “capitation” and “prior authorization” requiring “additional patient-level information prior to approval of reimbursement,” the suggestion of overmedication—or at least careless prescribing habits—is not far from the surface. Are these things undermining the psychiatric care of our most defenseless children?
Raghavan et al. give us a snapshot that suggests many answers. What we need to really understand this phenomenon is a fuller picture. Who is diagnosing these children? Who is prescribing the medication? Who is monitoring its effects?
As we all well know, diagnosis drives treatment, and treatment for childhood psychiatric disorders is proven to ward off a host of poor outcomes in the future, including school failure, drug abuse, interpersonal difficulties, and even suicide, which still takes 5,000 young people every year. Untreated psychiatric illness is a great drain not only on our nation's future but on our economy as well. The cost to Medicaid for psychopharmacological intervention may be high, but if the diagnosis is rigorous, and the prescription is correct, and monitoring is in place, then it's a bargain.