Programs Improve Care for Medicaid Children
Tex Med. 2010;106(12):31-34.
By Crystal Conde
If one of the Medicaid patients whom Harlingen pediatrician Stan Fisch, MD, and his associates treat has a mental health crisis and needs specialty care, the doctors may call on the state for SUPPORT.
A Texas Department of State Health Services (DSHS) program called Services Uniting Pediatrics & Psychiatry Outreaching to Texas (SUPPORT) links pediatricians' offices in seven regions with licensed practitioners of the healing arts. The licensed professional counselors deliver mental health services and assess Medicaid children for attention deficit hyperactivity disorder (ADHD), mania, anxiety, and autism spectrum disorders. The counselors and the pediatricians consult with a child and adolescent psychiatrist, who may assist the pediatrician with prescribing psychotropic medication. (See "SUPPORT Locations.")
Through SUPPORT, Dr. Fisch's practice, Harlingen Pediatrics Associates, hired a counselor who works on site and consults with six to eight patients per day.
"We've had a few cases of suicidal patients and those who've had panic attacks. Our licensed professional counselor was able to expedite referral of these patients to a child psychiatrist," said Dr. Fisch, chair of TMA's Committee on Physician Distribution and Health Care Access. "In addition to helping children with ADHD and those with mental health problems, our counselor also helps kids with asthma, enuresis, and obesity cope with their chronic illnesses and physical conditions. These kids and their parents need psychological help and support, too."
Dr. Fisch, chief executive officer of the practice, says 55 percent of the practice's patients are on Medicaid. He has been part of SUPPORT since its inception in 2008.
"Before SUPPORT, we managed to get along, but not very well," Dr. Fisch said. "For example, we never referred kids with enuresis to mental health professionals before this program. We prescribed medication instead. We weren't able to address the psychological elements of patients' health problems, such as uncertainty and anxiety associated with chronic disease in children."
Response to the licensed professional counselor by patients has been favorable, he says.
"Patients love the SUPPORT program. It's a very easy sell. Being able to offer mental health services to Medicaid children in our part of the world has been a blessing."
SUPPORT for Medicaid Children
Referring Medicaid patients to mental health specialists is no small feat. According to Texas Medical Board (TMB) statistics, as of May, Texas had only 326 child and adolescent psychiatrists. According to HHSC, as of February, Medicaid had enrolled about 2.5 million Texas children younger than 19 in the program. And, preliminary findings from the 2010 TMA Physician Survey indicate that only 42 percent of Texas physicians accept new Medicaid patients.
Gilberto Handal, MD, a professor in the Pediatric Infectious Diseases Department at Texas Tech University Health Sciences Center in El Paso, has participated in SUPPORT for the past two years.
In his group practice, once a pediatrician has identified a child who can benefit from counseling, the physician refers him or her to a licensed professional counselor who works on site. On average, the counselor sees six or seven children and their parents each day.
Dr. Handal's group also has a child psychologist on staff who advises the counselor and residents. The practice recently added a child psychiatrist who once a week provides guidance and counseling to residents and faculty members about patient management issues and psychopharmacology.
"Our experience with SUPPORT has been terrific. The satisfaction has been great, and we've been able to address many problems in our younger patients," Dr. Handal said. "We have seen success in overcoming obesity-related anxiety, tantrum management, encopresis and enuresis, management of depression, and gender identity issues. We also see children who have psychological problems as a result of the rampant murders in Juarez, Mexico, where many of our patients have relatives."
Dr. Handal, a member of TMA's Select Committee on Medicaid, CHIP, and the Uninsured and TMA's Committee on Child and Adolescent Health, adds that next year his practice will apply for subsidies from other foundations to continue offering the services of the licensed professional counselor.
"The importance of this process is the early introduction in the pediatric office of behavioral modification and parenting strategies. We need these interventions to help prevent an increase in child and adolescent mental health disorders, many of which will be more difficult and certainly more expensive to manage in the future," Dr. Handal said.
For more information about SUPPORT, contact Monica Trevino, project coordinator, at (210) 567-1798.
PASS It On
In addition to SUPPORT, another program improves access to pediatric subspecialty services for Medicaid children and offers rapid, expert consultation with pediatric subspecialists for primary care physicians. A University of Texas Southwestern Medical Center at Dallas program, Texas Pediatric Access to Subspecialists (Texas PASS), is a free service giving primary care physicians in 74 counties 24-hour telephone access to pediatric subspecialists at UT Southwestern and Children's Medical Center Dallas.
The program provides access to physicians in eight subspecialties: cardiology, child psychiatry, endocrinology, gastroenterology, hematology/oncology, infectious disease, nephrology, and neurology.
To view a list of participating subspecialists, log on to the Texas PASS website.
David Coble, MD, has been a pediatrician in Sherman for 37 years and practices at Memorial Clinic Pediatrics, where 95 percent of his patients are on Medicaid. He has participated in Texas PASS since it began last year and has consulted with subspecialists in psychiatry, neurology, endocrinology, hematology, gastroenterology, and infectious disease.
He commonly speaks to the subspecialists in the Texas PASS network about medication dosages, and they're able to answer his questions over the phone. But occasionally he needs to refer a patient to a subspecialist at Children's Medical Center Dallas.
"Recently, I saw a 40-day-old baby who was a new patient and who had some unusual physical findings. Within 30 minutes of contacting the nurse program coordinator for Texas PASS, I heard back from a neurologist who was able to have the infant admitted to the hospital," he said.
Before using Texas PASS, Dr. Coble says it could take hours for him to hear back from a subspecialist. (See "How to Use Texas PASS.")
Both Texas PASS and SUPPORT receive funding from the $150 million in strategic funds allocated from the 2007 Frew v. Hawkins settlement. The TMA Select Committee on Medicaid, CHIP, and the Uninsured, of which Dr. Fisch is a member, championed using money from Frew strategic initiative funds to develop programs to improve access to pediatric subspecialty services. The committee provided early input on the design of both programs.
Unfortunately, the Frew funding for Texas PASS ends next year and for SUPPORT in 2012. Thus, continued financing will require legislative authorization. In its fiscal year 2012-13 legislative appropriations request, the Texas Health and Human Services Commission (HHSC) included nearly $97 million to maintain strategic funds.
Since 2008, HHSC has allocated about $3.4 million per fiscal year for SUPPORT. Dr. Fisch and others hope that once funding ends for the program, Medicaid will pick up the tab to allow expansion to pediatric and primary care practices throughout the state. Private health plans are more likely to follow suit if Medicaid covers the services of licensed professional counselors, he believes.
HHSC Communications Director Stephanie Goodman says the commission is working on a plan for a more stable and flexible funding source for SUPPORT.
"The agency is developing policy to allow reimbursement for the type of services provided by SUPPORT through Medicaid. Once that policy is in place, any site statewide will be able to bill for these services directly through Medicaid," she said.
Dr. Coble values Texas PASS for its ability to give his Medicaid patients access to subspecialists and hopes the legislature will see value in the program, as well. He says he enjoys seeing Medicaid patients, but it's increasingly difficult to find subspecialists to care for them due to Texas' limited supply.
According to TMB statistics, as of May, the state was home to 58 pediatric endocrinologists, 45 pediatric gastroenterologists, 95 pediatric surgeons, and 19 pediatric orthopedists. To view TMB's physician demographics by specialty, visit www.tmb.state.tx.us/agency/statistics/demo/docs/docdemo.php.
"I hope HHSC continues to fund the Texas PASS program. It does a lot of good for the children on Medicaid I see," Dr. Coble said.
HHSC provides about $250,000 a year to cover the salaries, telephone network, database, and outreach communication for the Texas PASS program. All funds for the program go directly toward administration and marketing.
Funding for Texas PASS ends next year. According to UT Southwestern Texas PASS Program Coordinator Jeanne Nightingale, RN, HHSC is considering whether to continue funding Texas PASS.
Crystal Conde can be reached by telephone at (800) 880-1300, ext. 1385, or (512) 370-1385; by fax at (512) 370-1629; or by e-mail at Crystal Conde.
Nineteen licensed professional counselors work on site or travel to the following Services Uniting Pediatrics & Psychiatry Outreaching to Texas (SUPPORT) locations:
- Fort Worth: Cook Children's Network's Northside Neighborhood Clinic, Miller Neighborhood Clinic, McCart Neighborhood Clinic, and Arlington Neighborhood Clinic;
- Dallas: Parkland Hospital;
- El Paso: Texas Tech University Health Sciences Center's Alberta Clinic, Clint Clinic, Physicians East Clinic, and Montwood Wellness Center;
- Lubbock: Texas Tech University Health Sciences Center Department of Pediatrics;
- San Antonio: University Center for Community Health's Texas Diabetes Institute, Children's Health Center, and South Texas Center for Pediatric Care;
- Harlingen: Harlingen Pediatrics Associates; and
- Weslaco: Mid Valley Pediatric & Allergy Center.
At press time, about 7,000 Medicaid recipients had been screened under the program. Of those, about 15 percent had been prescribed psychotropic medication – most commonly for ADHD – by a child psychiatrist.
Stan Fisch, MD, chief executive officer of Harlingen Pediatrics Associates, chair of TMA's Committee on Physician Distribution and Health Care Access, and a member of TMA's Select Committee on Medicaid, CHIP, and the Uninsured, says the SUPPORT program has been successful in increasing the comfort level of primary care physicians in prescribing psychotropic medications, especially for ADHD.
"For children with other mental health issues and for kids with ADHD and comorbidities such as oppositional-defiant disorder, more than one medication may be needed or second-line medications may be needed. In those cases, we engage in a comanagement relationship with our licensed professional counselors and turn to a child psychiatrist for guidance," he said.
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How to Use Texas PASS
The Texas Pediatric Access to Subspecialists (Texas PASS) program serves many primary care physicians practicing in rural areas where they're less likely to have access to specialists than are those in urban areas, according to The University of Texas Southwestern Medical Center at Dallas. Any North Texas or North Central Texas primary care physician is eligible to participate in the program, regardless of whether the physician works in a rural or urban area. Although the program is a service for Medicaid-enrolled children, Texas PASS accepts all calls, regardless of a patient's insurance status.
To use Texas PASS, primary care physicians in Northeast or North Central Texas should follow these three steps:
- Have the Medicaid patient's chart available to relay the chief complaint and basic demographics to the program coordinator.
- Dial toll-free (877) 282-PASS (7277) to speak with a program coordinator who will take the information and connect you with a consulting UT Southwestern faculty subspecialist within 30 minutes.
- Discuss the case with a subspecialist and develop a plan of care for the patient. If a referral is necessary after the consultation, the program coordinator will provide a list of subspecialists available to see Medicaid patients and will facilitate that referral when possible. You will receive a follow-up letter for your patient's chart that may be used with your documentation to support the level of care you provide.
Call (877) 282-7277 to inquire about participating in Texas PASS.
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