Rates of Suicidality Following Psychiatric Hospitalizations for Children in Missouri

A June 2016 report from the Hospital Industry Data Institute highlighted some of the devastating effects of the increasing demand for mental health services amid an increasingly constrained supply of such services in Missouri. Among those effects, the report found that hospital utilization for suicide ideation among children and adolescents in Missouri had grown nearly 900 percent during the previous decade. Suicide among children and adolescents continues to be an escalating public health crisis in the U.S. A wide array of factors are considered by experts to be contributing to this trend, including social media, cyberbullying, increased use of antidepressants and lack of access to specialized mental health care. The incidence of suicidality — defined as suicide ideation or attempt — is far more prevalent than the rate of completed suicide among children and adolescents. Research shows that for every adolescent suicide, there are between 50 and 100 additional children who have attempted suicide.

The problem of child and adolescent suicide is acutely pervasive in Missouri. It is the second-leading cause of death in the state among children ages 5 to 19. At 6.4 suicide deaths per 100,000 children in this age group, Missouri had the 11th-highest rate of child and adolescent suicide in the country during 2017. In addition, the rate of child and adolescent suicide is growing more rapidly in Missouri compared to the country as a whole. Between 2003 and 2017, the rate of suicide for children and adolescents increased from 2.8 to 6.4 in Missouri, a relative increase of 129 percent.

One potential driver of the disparities in child and adolescent suicide observed in Missouri is the shortage of mental health providers specializing in behavioral care for children. Compounding issues related to shortages of mental health professionals in the state are reports of Medicaid managed care organizations imposing aggressive utilization reviews when certifying inpatient psychiatric hospital admissions and continued stays that result in payment of care that is far below national averages and commercial payers. As a result, psychiatric hospitals in Missouri feel pressure to prematurely discharge patients that may not be completely stable, or risk treating these patients with no reimbursement for that care.

A network of eight Missouri hospitals and health systems formed in 2016 to evaluate disparities in authorized services for behavioral care that they provide to children and adolescents with Medicaid managed care compared to fee-for-service. The network compiled a variety of data on observed differences in care authorized for children with Medicaid fee-for-service and individual Medicaid managed care organizations. The network’s most recent data found that MCOs account for the majority of child and adolescent psychiatric admissions, and they deny claims for more than one out of four admissions following discharge — this is 7.9 times the denial rate of Medicaid FFS. In addition, Medicaid MCOs refuse reimbursement for 11.4 percent of the total patient days during approved hospitalizations, and they require psychiatrists to spend significantly more time with added administrative burden justifying prescribed levels of care to physicians employed by the health plans. The profound differences in the levels of care authorized by Medicaid MCOs raise serious concerns on the financial sustainability of treatment for their beneficiaries, and more importantly, on the potential for adverse health outcomes for children with Medicaid managed care coverage.