The deleterious consequences of substance use impact all age groups across the lifespan. Whether caring for newborns exposed to substances in utero, children whose parents have substance use disorders or adolescents and young adults experiencing the onset of a substance use disorder, pediatricians provide medically necessary substance use screening, assessment and treatment linkage services.
Pediatricians also tackle numerous challenges in connecting patients to high-quality, pediatric-specific prevention and treatment services, which are lacking in many communities.
Although evidence shows that substance use primary prevention, early intervention and treatment services have significant benefit for patients, families and society, payment and coverage for this care remain insufficient to meet the demand.
The updated AAP policy statement Improving Substance Use Prevention, Assessment, and Treatment Financing to Enhance Equity and Improve Outcomes Among Children, Adolescents, and Young Adults provides recommendations for Congress, federal and state policymakers, and public and private payers. The policy, from the Committee on Substance Use and Prevention and the Committee on Child Health Financing, is available at https://doi.org/10.1542/peds.2022-057992 and will be published in the July issue of Pediatrics.
Access lacking
In 2020, about 1.6 million U.S. adolescents ages 12-17 years had a substance use disorder in the past year, but less than one in 10 of those who needed treatment received it, according to the 2020 National Survey on Drug Use and Health (https://bit.ly/3M4Bb0I).
A multitude of evidence-based strategies address the prevention and treatment of substance use within pediatric care settings; however, these statistics highlight that more needs to be done to improve access to these services.
Evidence-based primary prevention strategies shown to be feasible to implement in primary care include family-based programs such as Triple P, Family Check-Up and the Incredible Years. Universal screening, brief intervention and referral to treatment (SBIRT) allow pediatric clinicians to intervene early with adolescents and young adults who use substances. Integrated behavioral health models, which encompass consultation, care coordination and co-location of behavioral health clinicians in primary care, can be implemented in pediatric care settings to prevent and treat substance use.
Despite the growing evidence supporting the feasibility and effectiveness of these strategies, implementation remains difficult. Further, Black, Hispanic and American Indian/Alaska Native individuals experience substantial disparities in treatment access, which are linked to social, economic and criminal justice inequities.
A variety of solutions are necessary to address these inequities and implementation challenges.
Financing barriers
The report outlines multiple financing barriers to achieving optimal outcomes among those affected by substance use. These include:
- lack of insurance coverage (uninsurance) and inadequate coverage (underinsurance) among a substantial number of children, adolescents and young adults;
- limitations in the scope of benefits, high out-of-pocket costs and inadequate payments for those with insurance;
- suboptimal payment rates and funding for screening, prevention and treatment services, which contribute to a shortage of ambulatory and inpatient substance use services;
- lack of payment for collaborative care services provided via integrated behavioral health models, including behavioral health “carve-out” contracts that do not allow clinicians to bill for certain services in primary care and lack of payment for medical and behavioral health visits provided on the same day.
Selected recommendations
The policy statement includes 32 recommendations for policymakers and payers to improve coverage, payment and access to substance use prevention, assessment and treatment services for children, adolescents and young adults. Among the recommendations are the following:
- Enact and enforce laws, in addition to the Mental Health Parity and Addiction Equity Act of 2008, that make coverage of the management of substance use and substance use disorders equal to the coverage of other chronic conditions.
- Work with payers to ensure that separate payments are made for all covered services, including preventive, medical, substance use and other mental health services, including those provided on the same day.
- Identify and utilize new revenue sources, such as taxes on state legalized cannabis or opioid settlement funds obtained by states and local governments, to directly address the public health issues posed by substance use disorders, such as the need for harm-reduction services.
- Support payment mechanisms that incentivize the development and use of integrated behavioral health models within pediatric primary care.
- Provide reasonable payment for counseling, coordination and consultation procedure codes to enable primary care pediatricians to provide evidence-based prevention services for substance use.
Dr. Camenga is a lead author of the policy statement and a member of the Committee on Substance Use and Prevention.
