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Recommendations to Address Inadequate Payment for Needed Services and Payor Coverage Limitations

Policy-Oriented Strategies

  • Revise payment systems to reflect the time and cognitive effort required by primary care, developmental-behavioral, and mental health clinicians to diagnose, treat, and manage pediatric ADHD—and compensate these services at levels that incentivize and support their use.
  • Support innovative partnerships between payers and clinicians to facilitate high-quality ADHD care. As new payment models are proposed, include input from practicing clinicians to inform insurance plans’ understanding of the resources needed to provide comprehensive ADHD care.
  • Require that payers’ medical directors who review pediatric ADHD protocols and medication formularies either have pediatric expertise or seek such expertise before making decisions that affect the management of pediatric patients with ADHD.
  • Advocate that health care payers’ rules for approval of developmental-behavioral and mental health care services and medications is consistent with best practice recommendations based on scientific evidence such as the AAP ADHD guideline. Payers should not use arbitrary step-based medication approval practices or force changes to a patient’s stable and effective medication plans because of cost-based formulary changes.
  • Advocate for better monitoring by the US Food and Drug Administration (FDA) of ADHD medication generic formulations in order to verify their equivalency to brand-name preparations in terms of potency and delivery.
  • Partner with CHADD (Children and Adults with Attention-Deficit/Hyperactivity Disorder) and other parent support groups to help advocate for positive changes in payers’ rules; these organizations provide a strong voice from families who face the challenges on a day-to-day basis.

Source:Systematic Barriers to the Care of Children and Adolescents with ADHD  taken from the AAP 2019 ADHD Guideline: Clinical Practice Guideline for the Diagnosis, Evaluation, and Treatment of Attention-Deficit/Hyperactivity Disorder (ADHD) in Children and Adolescents.