Teens Falling Short on Key Health-Improvement Goals
As federal legislators begin to consider expansion and overhaul of the nation's health care system, researchers are highlighting the unmet health needs of many adolescents—an age cohort that is especially likely to depend on emergency rooms for routine medical care or go without any care.
A lack of access to many areas of health care, including mental health and substance use, is a crucial problem among older youth, whose dynamic physical and psychological development can result in quickly developing health problems related to one or both of those areas, according to recent research from the National Research Council (NRC) and the Institute of Medicine (IOM).
Adolescents' “developmental complexities and risky behavior, together with the need to extend their care beyond the usual disease- and injury-focused services, are key considerations in any attempt to reform the nation's chaotic health care system—especially if adolescents are to benefit,” said Robert Lawrence, M.D., a professor of medicine at Johns Hopkins University School of Medicine, and colleagues in a report on U.S. adolescent health services by the NRC and IOM.
That study's findings were released in December 2008 and included recommendations to improve health services for adolescents, whom they categorized as youth aged 10 to 19.
The researchers found limited recent progress in improving the overall health of adolescents, as measured by data collected through the Centers for Disease Control and Prevention's (CDC) Healthy People 2010. That initiative has found that since 2000, adolescents' health outcomes have improved in only three of its 21 objectives: behaviors leading to pregnancy, tobacco use, and unintentional injury.
Categories in which the CDC found worsening adolescent health since 2000 included death, suicides, and binge drinking, as well as the ability to access needed mental health treatment.
Among the prominent obstacles to adequate health care for adolescents, the IOM and NRC researchers pointed out, are problems stemming from access to care. For example, more than 5 million adolescents aged 10 to 18 are uninsured, and adolescents are in the age group most likely to depend on emergency departments for routine health care.
The authors found evidence that specialty services in mental health and substance use treatment in particular are not accessible to most adolescents, and the available services in “safety-net settings” frequently fail to address the needs of adolescents who seek care.
“Even when such services are accessible, many adolescents may not find them acceptable because of concerns that confidentiality is not fully ensured, especially in such sensitive domains as substance use or sexual and reproductive health,” wrote Lawrence and colleagues.
Even adolescents insured through private health plans frequently face high cost-sharing requirements and a shortage of clinicians and health workers trained to treat them and willing to take their insurance. These limitations are most frequently seen among conditions that require counseling or case management of multiple health problems—conditions such as substance abuse and other mental illnesses, which are “particularly problematic for adolescents,” the researchers noted.
How to locate and organize mental health and substance use screening and treatment services in a way that adolescents feel more comfortable has been a leading challenge, according to research by Shay Bilchik, director of the Center for Juvenile Justice Reform at Georgetown University Public Policy Institute and a study author.
“We obviously want high-quality medical care, but there are continuing questions about whether the care we have is reaching a significant number of kids,” Bilchik told Psychiatric News.
Reform Recommendations Offered
Informing parents that their children may be eligible for public health plans is one of the simpler solutions the authors urged for the undertreatment of health conditions among adolescents. A less demanding, public-insurance enrollment process also might go a long way toward encouraging participation.
More involved changes to public and private health care systems include changing payment approaches so that adolescents' primary care providers are encouraged to make disease prevention, health promotion, and mental health major components of routine health services. The authors called for an approach similar to the “medical home” model urged by some health reform advocates, which designates one clinician to coordinate screening, assessment, health management, and referrals to specialty care.
One health system reform that the authors urged would direct clinicians to“ monitor behavior that increases risk in such areas as injury, mental health, oral health, substance use, violence, eating disorders, sexual activity, and exercise.”
Consent, Confidentiality Issues Crucial
The authors also called for a review of state laws and regulations concerning the rights of minor adolescents to give their own consent for health services and receive those services on a confidential basis in certain situations.
Especially in mental health, including substance use, the researchers emphasized, a balance is needed between maintaining the confidentiality of information regarding the care of underage adolescents and encouraging involvement of parents and families in that care.
They also called on health-profession regulatory bodies involved in adolescent care to incorporate a minimal set of competencies in such care as part of their licensing, certification, and accreditation requirements.
Comparative questionnaires have found that adolescent patients often felt poorly understood after interactions with health care providers who had rated the same interaction as successful, Bilchik said.
“Training of the part of the health care workforce that regularly works with adolescents really needs attention,” Bilchik said.
Federal and state policymakers also were urged to ensure that all adolescents have comprehensive, continuous health insurance coverage. This most expensive recommendation could include assuring access to Medicaid or other forms of health insurance coverage for especially vulnerable or underserved groups of adolescents. The researchers also called for State Children's Health Insurance Program (SCHIP) policies that increase enrollment and retention of eligible but uninsured adolescents.
SCHIP enrollments nationwide could rise in the near future as a result of a SCHIP expansion signed by President Barack Obama in February (see MH Parity Mandate Added to SCHIP, Giving More Children Access to Care).
“This is far from health care reform, but it is a necessary start,” said Rep. Henry Waxman (D-Calif.), chair of the Energy and Commerce Committee, which has primary jurisdiction over SCHIP.
The SCHIP expansion mandates that federal mental health parity coverage provisions enacted in 2008 for private health plans also apply to coverage funded through SCHIP.
The NRC/IOM study “Adolescent Health Services: Missing Opportunities” is posted at<www.iom.edu/CMS/12552/35625/%2060680.aspx>.▪
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Published online: 6 March 2009
Published in print: March 6, 2009
Notes
The ability of adolescents to obtain needed mental health care, including for substance use, is limited by lack of insurance, high cost, and privacy concerns, among other factors.
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