Childhood ADHD and Medicaid

A study out of UCLA shows that there is a need for significant improvement in the delivery of ADHD care to children on Medicaid.  The study was published in the Journal of the American Academy of Child and Adolescent Psychiatry and a summary can be found at Medscape.

The study followed over 500 children with ADHD.  All were on Medi-Cal (California’s Medicaid program) and were observed over a one-year period.  Some participated solely in primary care treatment, while others received “specialty care” in mental health clinics.  (Because this was an observational study, children were not randomized or assigned to each group, but were simply followed over their course of treatment.)  The study found that at the end of the year, both groups of children fared the same on measures of ADHD symptoms, functioning, academic achievement, family function, and other parameters.

How did primary care differ from “specialty” care?  For one thing, children in the primary care group received stimulant medication 85% of the time (nearly all of these children received a prescription for some medication) but that was about it:  They only followed up with their providers an average of 1 or 2 times in the entire
one-year followup period, and their prescription refill rate was less than 40%.  (50% dropped out of care.)

On the other hand, over 90% of the children in the specialty care group received some sort of psychosocial treatment, and only 40% of these children received medication (30% received stimulants).  Office visits were far more frequent in this population, too, averaging over 5 per month for the duration of the one-year study.

So on the face of it, one might predict that specialty treatment would provide much better care; children had far more frequent contact with their providers, medications were used judiciously (one would assume), and psychosocial interventions were included.  However, the end result was that children did not fare differently in each group.  Academic scores and measures of clinical impairment and “parent distress” were similar in both groups.  Dropout rates and medication discontinuation rates were also similar in each group.

One obvious limitation of this study, which the authors emphasize, is that this is not a randomized trial, but rather an observational study of “real world” patients.  But then again, that’s what they wanted to do:  to observe whether mental health clinics provided better ADHD care.   Two unfortunate conclusions can be drawn.  First, primary care mental health clinics do very little to treat childhood ADHD (cynically, one might look at the data and conclude that they simply “throw meds at the problem” with little to no follow-up).  Secondly, even when these clinics do refer children to a higher level of care, the outcomes aren’t that much better (and the resource costs are undoubtedly much higher).

With the promised expansion of the Medicaid program under PPACA, more children will be receiving care, with mental health as a priority area.  Hopefully, studies like this one will prompt us not simply to provide more care to the increased number of children that will undoubtedly seek it, but to provide better care along the way.

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