Interim Testimony by Marjan Linnell, MD, FAAP
House Committee on Public Health
May 17, 2018
Submitted on behalf of:
Texas Pediatric Society
Texas Medical Association
Chair Price, Vice Chair Sheffield, and Committee Members,
My name is Marjan Linnell, MD, FAAP, and I am a pediatrician at Austin Regional Clinic nearby in Kyle. I am testifying on behalf of the Texas Pediatric Society and the Texas Medical Association to provide insight and recommendations on this important charge. The following recommendations will improve the identification and treatment of children with mental health conditions and connect them with needed supports. This is especially important for children who have been exposed to trauma, which we know can gravely impact child development and health outcomes.
Increase Early Intervention and Treatment for Children with Behavioral Health Disorders
To ensure early identification and intervention for children with mental health conditions, we must ensure they have regular access to behavioral health screenings in multiple settings. In 2017, the legislature made great strides in ensuring physicians and providers can conduct and bill for mental health screening for adolescents enrolled in Medicaid at the annual well-child visit (House Bill 1600). We can continue this progress by promoting screening at earlier ages. As a general pediatrician, I must cover many aspects of child health during a 15-20- minute clinic visit, from developmental milestones to physical measurements to anticipatory guidance, such as asking parents about use of car seats. Having separate payment for behavioral health screenings at every appropriate age would help to ensure physicians have the infrastructure and administrative support to screen routinely for behavioral health conditions. It also is important for Texas to promote behavioral health screening in non-traditional settings, such as school-based health clinics. Given the amount of time children spend in school throughout childhood, promoting screenings in this setting is a great way to ensure early identification of children with potential behavioral health disorders before a crisis occurs.
Enhance the Pediatric Behavioral Health Workforce
Texas also must continue to support initiatives to enhance children’s access to mental health services. Texas’ pediatric behavioral health network remains severely strained. Though Texas is making strides in increasing the number of child and adolescent psychiatrists, psychologists, and other behavioral health care providers, pediatricians struggle to achieve timely referrals to appropriate specialists. Many psychiatrists and behavioral health providers — in rural and urban areas — no longer accept Medicaid or severely limit their participation. My colleagues and I struggle to make referrals in Austin. Medicaid physician payments have not been updated meaningfully in more than a decade, while overhead costs continue to grow. Our organizations urge this committee to strongly support efforts to update Medicaid payments and decrease administrative burdens.
We also recommend directing the Texas Health and Human Services Commission (HHSC) to revise the Medicaid managed care organization provider directories to clearly indicate which physicians and mental health providers provide evidence-based treatment modalities such as cognitive behavioral therapy (including trauma-focused cognitive behavioral therapy). Ready access to such information will improve primary care physicians’ ability to refer children to appropriate behavioral health services that can address a patient’s needs.
Last week, the HHSC issued proposed revisions to Medicaid telemedicine rules to ensure compliance with telemedicine reforms enacted in 2017. While we are still evaluating the proposed changes, we are hopeful the update will facilitate widespread use of telemedicine among child psychiatrists and primary care physicians, who can partner to use the technology to more effectively and efficiently co-manage complex patients. Given the shortage of child and adolescent psychiatrists, general pediatricians and family physicians often care for children with severe behavioral or emotional disorders, though many do so reluctantly fearing the child’s medical needs will be beyond their expertise. Having ready access to a specialist via telemedicine could increase primary care physician’s willingness to partner with a child psychiatrist in the care of these children, thus enhancing timely access to care. It goes without saying that Texas Medicaid payment policy for telemedicine must also ensure both the primary care physician and specialist receive equitable payment for their respective services.
Trauma-Informed Approaches and Recommendations
As previously mentioned, exposure to trauma can gravely affect child development and health outcomes. Several entities, our organizations included, provide continuing medical education (CME) that not only increases knowledge about the impact of childhood trauma and toxic stress but also helps physicians and providers incorporate this understanding into their practice. The Texas Pediatric Society (TPS) and Texas Medical Association (TMA) each had educational tracks dedicated to adverse childhood experiences (ACEs) at their respective annual meetings in Fall 2017. TMA also hosted similar opportunities for the Concho Valley County Medical Society and the Austin Psychiatric Society. This fall, TPS will conduct a central Texas learning collaborative centered around identifying and addressing childhood adversity and trauma. Additionally, the American Academy of Pediatrics (AAP) held a Trauma-Informed Pediatric Provider Course in Texas this spring. The Texas Health Steps online provider education module, Addressing Adverse Childhood Experiences Through Trauma-Informed Care, also provides a free opportunity to receive this education. These are just a few of the many educational opportunities available that keep physicians and providers abreast of the research and best practices surrounding childhood adversity and trauma.
Lastly, primary care and treating physicians caring for children in foster care must have ready access to a child’s trauma history. Without this information, physicians who care for these children cannot establish a baseline understanding of the child’s exposure to trauma. For instance, caseworkers have authority to share removal affidavits and/or caseworker narratives with a child’s physician, but that information is shared inconsistently across the state. Because caseworkers and caregivers are tasked with the coordination of so many different services and activities for children in foster care, finding a way to more easily facilitate this sharing of information would be helpful to ensure everyone has a foundational understanding of the child’s trauma.
Thank you for the opportunity to testify and for your focus on improving identification and treatment of mental health conditions in children, particularly children with exposure to trauma. The Texas Pediatric Society and Texas Medical Association look forward to continued partnership with the legislature in ensuring a brighter future for children.
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