Is Class Action an Effective Means for Improving Youth Behavioral Health Services?

Background and Purpose

The Early Periodic Screening, Diagnosis, and Treatment (EPSDT) provision in Medicaid was designed to ensure access to preventative health behavioral health care. In the past two decades, legal advocacy organizations filed class actions against state Medicaid programs alleging violations EPSDT for young people with serious mental illness to improve access and quality of care. Resulting consent decrees and court ordered remedies forced the redesign of public sector behavioral health systems across several states. Other states, eager to avoid such action, proactively adopted the structures and interventions favored by the courts. These advocacy efforts are lauded as an example of effective advocacy, however little research has examined what, if any, impact the changes have on the behavioral health of young people or their families. This paper traces the outcomes of the Rosie D class action lawsuit in the Commonwealth of Massachusetts, making use of data collected in three studies to discuss the impact of the case over time.

Methods

The Massachusetts Practice Review (MPR)utilized a mixed methods approach to assess the quality of care provided for a subset of randomly selected Medicaid behavioral health recipients under the age of 18 (n=122, annually). Trained reviewers use a protocol to elicit specific information on 14 domains that examine practice quality and the progress of the youth and family since enrollment. Data collected from records and interviews for each were triangulated to assign a numeric quality score.

In addition, this paper utilized data from behavioral health assessments for Medicaid youth who received either treatment as usual or treatment as usual plus new care coordination services. The two groups of youth were propensity score matched and their psychiatric and family functioning scores were compared across time utilizing hierarchical linear modeling.

A qualitative study of the families of youth with co-occurring behavioral health and developmental needs utilized family journey mapping to examine the experiences of youth and their families post implementation of the Rosie D. system of care.

This paper triangulates data across these three studies, conducted across a decade.

Results

Findings suggest that the the Rosie D. remedy expanded service offerings, but did not necessarily ensure the services received were of high quality or improved outcomes from treatment as usual. Notably poor assessment and treatment planning, one of the initial complaints in the lawsuit received poor scores post implementation from both trained reviewers (MPRs) and were a documented source of frustration for families in journey maps. New care coordination mechanisms introduced by the court remedy resulted in poorer treatment trajectories for youth who received the serve than those who did not, and parent journey maps reflected ongoing negative experiences with care coordination.

Conclusions

Class action lawsuits against Medicaid-funded behavioral health systems are successful at forcing system redesign but may be less successful at ensuring such changes result in improved access to or outcomes of behavioral health care for young people. Careful attention must be paid to remedy and consent decree plans over time to ensure that the intended outcomes are indeed achieved.