What happens when a child is referred for psychological testing but his insurance does not cover even half of the cost? What about when this child has needs far greater than what a school’s counseling department can diagnose? Who will help him?
Over the past 30 years, these questions and others have plagued Jerold Pollak, Ph.D., ABPP, ABN. A forensic psychologist with the Portsmouth, N.H.-based Seacoast Mental Health Center for the past 12 years, Pollak has seen countless adolescents and children for diagnostic testing. Pollak has seen how difficult it is for families to get proper testing for their children, partly because much of the treatment is not covered by managed care.
Rather than let a child drop through the cracks or ask psychologists to donate up to 75 percent of their time pro bono, Pollak has found a way to work with the schools, families and insurance companies that will make it work for all three entities – and keep the child from getting caught in the middle.
Q: Tell us about the problems you have seen with children receiving proper treatment.
A: I’ve been testing children and adolescents for my entire career and it’s become impossible to get some kids evaluated. First, you’ve got the managed care companies saying, let the schools do it and the schools say we do not have the time or the skills.
Even when the managed care companies do cover it, they end up covering maybe 20 percent of the cost of what it is to do these evaluations if you figure out the amount of time it takes. The kids and families get to be the hot potato in the middle of all these competing systems.
Q: Why is the need for testing high?
A: There are so many kids on so many different psychiatric medicines these days who really are not being properly evaluated. They are just going through what I call “drive-by assessments.” The primary care doctor or a psychiatrist puts them on medicines and has anyone really looked at this kid that carefully to see what is going on? I just think children and adolescents are being short-changed around appropriate mental health assessments.
Q: What are the financial burdens for the parents?
A: Families can’t manage it because the costs usually exceed what they can afford or what the insurance policy will pay.
Q: And this ends up becoming a financial burden for the psychologist?
A: When I did a lot of these assessments, we had situations where, to get it done right, to help the kid, the psychologist would have to eat enormous amounts of time pro bono. We’d go to educational planning meetings and no one could pay for it. If you didn’t go, you would shortchange the kid or you went and ate the time and got angry about it. There is also no real payment for all the records that psychologists often have to go through to properly evaluate the kid.
I know a lot of psychologists have started to steer clear of doing child and adolescent assessments because we can’t get adequately paid and how much can you do year after year?
Q: But you have a solution?
A: Maybe we can more consistently work something out where psychologists in the community can partner with schools more around the cost-sharing piece.
The basic idea is that if you have a complicated kid, diagnostically complicated, one of the best ways to manage this is for the school to say we could use the input of a psychologist in the community.
The schools are overrun with referrals and they can’t even begin to properly evaluate the sheer number of kids who need it. Even if the numbers were smaller many of these kids are too complicated for a typical special education department. They don’t have the expertise.
On the other hand, a psychologist in the community may be fairly ignorant about how schools operate and how the results of testing can be effectively utilized in the school setting. So the whole idea of the school and community psychologist collaborating, even if there wasn’t a big reimbursement and payment problem, is generally a good idea – sometimes the community psychologist has expertise and diagnosis that the school department does not have. And the school department has a good working knowledge of the school environment that the child is expected to function in.
Q: How would the testing be split?
A: If the school would do the academic skills assessment – reading, writing, spelling and an IQ test – that will save the family $600. And one of psychologists at the clinic or the teaching hospital will do the rest of it. We’ll assess his suicidality and depression or work with the family dynamics. Everybody does the part they are comfortable with and the family doesn’t end up going poor to pay for it and the psychologist doesn’t have to virtually work pro bono for case after case.
Q: Does this work for the school systems?
A: I have found the schools that I work with to be receptive. After you explain that this kid has some substantial needs, maybe more than the school thought and it would be in school’s interest to do some of this, they see that it makes sense. I’ve seen it work very nicely.
The other thing about the school being involved is that kids spend most of their lives in school. It is in the school’s interest to have a good assessment on a kid because they have to deal with him one way or the other. They have to educate him, keep the kid behaving appropriately. In many ways getting the school on board is just generally a good idea.
Q: What types of cases are we talking about?
A: This is not for every kid but for those who have complicated neuro-psychiatric conditions. They pose a significant problem for the school and a significant problem in terms of their functioning in the community and at home. It is particularly useful with children who are considered at risk for some serious outcomes like suicide, aggression at school, threat assessments.
Frankly, for a child with a reading or writing disability, the schools are more than capable of taking care of that. They don’t even deal with managed care around that because they won’t pay for learning assessments.
Q: How do we change the system so that psychological testing would be more fully covered in the first place?
A: First of all, the medical community has not appropriately stepped up in terms of advocating for psychological testing for children. Most MDs, including most child psychiatrists and pediatric neurologists, don’t know much about psychological testing. They need some good training around psychological testing, what it can offer, when it is clearly indicated and how poorly reimbursed it is.
I think psychologists should offer workshops to psychiatric societies or groups. This training is not happening in med schools or residencies.
APA could also do more about advocating about how useful psychological testing is, particularly for kids and adolescents and about how difficult it is for parents to get it paid for.
The reality is that with managed care here in N.H., we have had situations where the insurance companies would pay the equivalent of the time it would take to maybe give a kid an IQ test and a couple of self report rating scales test. Then the insurance is gone and that’s only the beginning of the assessment not the end.
So, you say, now what do we do?
By Catherine Robertson Souter