Brief Summary of Engrossed Second Substitute Bill

Establishes the Children's Mental Health Work Group to review the barriers that exist in identifying and treating mental health issues in children with a particular focus on birth to age 5, and report to the Legislature by December 1, 2016.
Directs the Health Care Authority and the Department of Social and Health Services to identify issues related to network adequacy and report annually to the Legislature on the status of access to behavioral health services for children and youth.
Establishes a Partnership Access Line pilot program, in a rural region of the state, to provide an additional level of child mental health care support for primary care providers.
Directs the Joint Legislative Audit and Review Committee to conduct an inventory of the mental health service models available to students in schools, school districts, and Educational Service Districts and report its findings to the Legislature by October 31, 2016.
Requires that medical assistance programs cover annual universal screening and provider payments for depression for children ages 13 through 21.

Background:

Children's Mental Health Services.

Regional Support Networks and Behavioral Health Organizations. The Department of Social and Health Services (Department) contracts with regional support networks (RSN) to oversee the delivery of mental health services for adults and children who suffer from mental illness or severe emotional disturbance. An RSN may be a county, group of counties, or a nonprofit or for-profit entity. Regional Support Networks are required to provide:

crisis and involuntary treatment services for all residents in the region;
medically necessary community-based mental health treatment services covered under the state Medicaid plan for all Medicaid-eligible clients who meet access-to-care standards; and
limited other services for individuals not covered under the Medicaid program.

The Department's access-to-care standards provide RSNs and Behavioral Health Organizations (BHO) and their contracted community mental health agencies with guidelines to determine eligibility for authorization of mental health services for individuals served through the State of Washington's public mental health system. During the 2015 fiscal year, the Department provided mental health services to approximately 48,000 children through contracts with 11 RSNs.

Medicaid. The Health Care Authority (Authority) administers the Medicaid program, which is a state-federal program that pays for health care for low-income state residents who meet certain eligibility criteria. In Washington, Medicaid is called Apple Health. Apple Health for Kids is free for all children in families below 210 percent of the federal poverty level and families above that level may be eligible for the same coverage at a low cost. The Authority is responsible for providing medically necessary, community-based mental health treatment services, covered under the state Medicaid plan for all Medicaid-eligible clients who do not meet access-to-care standards.

Managed Care. Managed care is a prepaid, comprehensive system of medical and health care delivery, including preventive, primary, specialty, and ancillary health services. Healthy Options is the Authority's Medicaid managed care program.

Mental Health Services Available in Schools. Schools must respond to a broad range of behavioral and emotional needs that compromise students' and schools' successes. In 2013 the Legislature passed Engrossed Substitute House Bill 1336, which highlighted the mental health needs of students and required:

school counselors, social workers, psychologists, and nurses to complete a training in youth suicide screening and referral as a condition of certification;
each Educational Service District (ESD) to develop and maintain the capacity to offer training on youth suicide screening and referral, and on recognition, initial screening, and response to emotional or behavioral distress in students; and
school districts to adopt a plan for recognition, initial screening, and response to emotional or behavioral distress in students, and provide the plan to all staff annually.

Network Adequacy and Access to Services.

Federal regulations require states to have a written strategy for assessing and improving the quality of health care services offered by managed care organizations (MCOs), which must include standards for access to care. These standards are intended to ensure that each MCO maintains a network of providers that is sufficient to provide adequate access to Medicaid services covered under the contract between the state and the MCO. Regulations require that each MCO provide timely access to care and services. Federal regulations also require states to ensure that external quality reviews are conducted annually to evaluate the quality of, timeliness of, and access to care furnished by MCOs to enrollees.

The Partnership Access Line.

The Partnership Access Line (PAL) provides telephone-based child mental health consultation to primary care providers in Washington. The PAL employs child psychiatrists and social workers affiliated with Seattle Children's Hospital to deliver its consultation services. Primary care providers report using PAL for psychosocial treatment assistance for particularly high-needs children.

Depression Screenings.

The federal Affordable Care Act requires group and individual health plans to provide coverage without a cost-sharing requirement for several types of preventive health services. For infants, children, and adolescents, these services include evidence-informed preventive care and screenings provided for in the Health Resources Services Administration (HRSA) comprehensive guidelines. The HRSA's comprehensive guidelines have adopted the American Academy of Pediatric's "Periodicity Schedule of the Bright Futures Recommendations for Preventive Health Care" (Periodicity Schedule). The Periodicity Schedule establishes a recommended timetable for patients to receive preventive services from birth through 21 years of age. In 2015 the American Academy of Pediatrics updated the Periodicity Schedule, recommending annual depression screening for children ages 11 through 21 years of age.

Medicaid programs are not required to follow the Bright Futures guidelines. However, Medicaid includes benefits under the Early and Periodic Screening, Diagnostic, and Treatment Program (EPSDT) for enrollees under 21 years of age. The EPSDT covers health screening visits, which are regularly scheduled examinations and evaluations of the general physical and mental health, growth, development, and nutritional status of infants, children, and youth.

Summary of Engrossed Second Substitute Bill:

Children's Mental Health Services.

Children's Mental Health Work Group. The Children's Mental Health Work Group (Work Group) is established to identify barriers to access of mental health services for children and families, and to advise the Legislature on statewide mental health services for this population with a particular focus on children ages birth to 5. The Work Group is comprised of representatives from state and tribal governments, agencies, and nonprofit and for-profit entities. By December 1, 2016, the Work Group must submit a report to the Legislature that includes recommendations and an analysis on specified issue areas for the purposes of addressing the barriers that exist in receiving children's mental health services.

Mental Health Services Available in Schools. The Joint Legislative Audit and Review Committee (JLARC) must conduct an inventory of the mental health service models available to students through schools, districts, and the ESDs, and report its findings to the Legislature by October 31, 2016. The JLARC must perform the inventory using data that is already collected by schools, school districts, and the ESDs. The JLARC must not collect or review student-level data and must not include student-level data in the report.

Review of Network Adequacy and Access to Services.

Beginning December 1, 2017, the Authority and the Department must report annually to the Legislature on the status of access to behavioral health services for children and youth. The annual report must include specified data components broken down by age, gender, and race and ethnicity.

The Partnership Access Line.

The Authority must expand PAL services by establishing the PAL Plus pilot program (PAL Plus) in a rural region of the state. The PAL Plus will provide an additional level of child mental health care support services for primary care providers through regionally based mental health service providers. Mental health service providers will deliver in person and over the phone: evaluation and diagnostic support; individual patient care progress tracking; behavior management coaching; and other evidence-supported psychosocial care supports. The PAL team of child psychiatrists and psychologists will provide mental health service providers with the necessary training and supports. Additionally, the PAL team will promote the use of behavioral health therapies and encourage the use of psychotropic medications as a last resort. The PAL Plus services are targeted at families with Medicaid coverage who receive children's mental health treatment from their primary care providers. The Authority must monitor PAL Plus service outcomes and provide a preliminary evaluation of the program to the Legislature by December 31, 2017, with a final report due on December 31, 2018.

Depression Screening.

Medical assistance programs must cover annual universal screening and provider payments for depression for children ages 13 through 21, as recommended by the Bright Futures Guidelines of the American Academy of Pediatrics, as they existed on January 1, 2016. The coverage is subject to the availability of funds.

Staff Summary of Public Testimony (Early Learning & Human Services):

(In support) It is estimated that 20 percent of children have a mental health issue and less than 1 percent of these children are receiving services. Given that the expulsion rate in preschools is significantly higher than in the K-12 system, it is clear that mental health issues are impacting children at a very young age. Addressing children's mental health needs as soon as possible will improve health and education outcomes. The bill would establish a work group to analyze and provide recommendations on the barriers that exist for children and families to successfully navigate the health care system. Additionally, the bill would require medical assistance programs to provide payment for depression screens for youth ages 11 through 21, as recommended by the American Academy of Pediatrics.

Pediatricians and primary care providers are significantly concerned with the lack of timely access to behavioral health care for children and youth. Primary pediatric care is the front line for identifying and coordinating treatment for children's mental health needs. The PALs telephone consultation line should be expanded so primary care providers and pediatricians have timely advice on how to best serve the children in their care experiencing a mental health issue.

There is a huge gap between the number of young children who are receiving mental health services and the number who are in need of those services. Health care billing systems often fail to look at the family as a treatment dyad, and therefore do not provide training to parents on how to address the needs of their child with a behavioral health problem. In many parts of the state there are very few or no mental health practitioners that are adequately trained to provide early childhood mental health services. The bill will provide a positive step forward by focusing on early intervention and reviewing how to best serve children birth to age 5. Additionally, the bill requires the collection of data on the availability of behavioral health services for children, which will allow for informed recommendations on how to best address issues with network adequacy.

(Opposed) This bill aims to enact universal mental health screening for depression, which will lead to an increase in the psychiatric diagnosis and resultant drugging of youth. Nationally, youth in foster care are prescribed psychotropic medications seven times more often than youth who are not in foster care. Therefore, the bill should have language that limits the use of psychotropic medication for children. Drugs are not cures and at best they mask symptoms. This bill could be vastly improved by removing the mental health screening requirement and including language that limits the use of psychiatric drugs.

(Other) Washington is currently in crisis when it comes to children's mental health, especially for adolescents. Legislation should expand the PAL, as this program could have the capacity to expand children's mental health care across the state and provide services to children sooner. Hospitals are experiencing children boarding in emergency room departments because they have nowhere else to go. Currently, most in-patient programs for youth have a waitlist. However, many of the children in need of services do not necessarily require that level of care. These children would benefit immensely from a step-down or partial hospitalization program.

Staff Summary of Public Testimony (Appropriations):

(In support) It is good to focus on children's mental health because the systems are such that one in five children that need services do not receive them. The Provider Access Line (PAL) is a good investment to coordinate mental health care in a rural area, which can prevent incidents of costly psychiatric inpatient care. The majority of current PAL consult calls are about a medication question, and 85 percent of the time the recommendations are for nonmedication interventions. The goal is to reduce medication and increase evidence-based treatments for young people. The bill leverages the existing PAL resource to support integrated care.

The needs of children are underserved. This is a national problem that goes back to the 1960s. The research is not good on identifying constructive steps. The Work Group can identify solutions. It is unfortunate that children do not get the help they need because they are amenable to treatment at a young age. A study found that if kids get the help they need, they do better at school, need fewer professional services, and generate fewer juvenile justice costs. The lack of affordable and available mental health services drives children to the child welfare system or the juvenile justice system because those are the only ways to get them help.

A fairly large group of people have come together to look at children's mental health. Best practices are not always known by parents, youth, primary care providers, school counselors, and others. Many children have fallen through the cracks. The go-to system for children's mental health has seemed to be the regional support networks. The point of this bill is to address access and accountability and to make sure children can get to the services they need as early as possible so they do not need a more intensive setting down the road. Very young children exhibit behavioral problems from trauma and many are expelled from child care and prekindergarten programs. Children need help when they begin exhibiting problems.

(Opposed) None.