The Q&A: Bethanie Van Horne

With each issue, Trib+Health brings you an interview with experts on issues related to health care. Here is this week's subject:

Bethanie Van Horne is the assistant director of State Initiatives at UTHealth's Children's Learning Institute. Van Horne, who previously worked at Children at Risk, was the first author of a study that evaluated the reasons why Texas children were hospitalized between 2004 and 2010. Among the study's key findings were that children between 10 and 14 years old are most likely to be hospitalized due to mental illness, while pregnancy was the most likely reason for teenagers between 15 and 17. 

Editor's note: This interview has been edited for length and clarity.

Trib+Health: Why did you decide to undertake this study?

Bethanie Van Horne: We did it a little backwards. We got this data, and we initially were looking at it for a project to find out how many kids had been hospitalized for child abuse. So we started down that path, and then we started looking at mental health, and then we realized we really needed to look at why kids are hospitalized at all so that we could put into context. So when we look at mental health, is 40,000 kids being hospitalized for mental health a big deal, a small deal? We wanted to put the different diseases that we were interested in looking at into context.

Trib+Health: So what were your biggest findings?

Van Horne: There were a few. The first one that we were not shocked about is that the No. 1 reason why kids are hospitalized is for birth. Most kids are born in the hospital in Texas and the United States, so that wasn’t a big finding. The second one around newborns and kids in the first year of life was that issues in the newborn period were really expensive, especially when the kids were born at prematurity or had congenital malformations. A lot of those kids are not discharged in the first month and are discharged sometime within that first year and are really, really expensive. They are super expensive, so obviously a lot of people are trying to figure out how to reduce prematurity. It’s pretty important and pretty cost-saving.

Another one is around mental health. So once you got into the teenage years, 10 to 14 and 15 to 17, mental health was a big issue and reason why people were hospitalized. It was the No. 1 reason for 10- to 14-year-olds and the second highest reason for 15- to 17-year-olds, but that was only because pregnancy was No. 1. Mental health is a huge reason why kids are hospitalized, which we weren’t expecting at all.

Trib+Health: Why is it that the mental health hospitalizations are so high and even increased during the time of this study?

Van Horne: It was really the only major diagnostic code that increased during the study, so that was shocking. There’s two ways to look at it. One could be that we're really good at identifying them when they’re in the hospital. The way we looked at these is by major diagnostic code, and that’s done by the discharge diagnosis. So if a physician were to identify that, and that goes in their chart, and there is a billing attached to it, that’s picked up by the coding system. So we’re either really good and getting much better at identifying it, or, what I think is probably more likely, is we don’t have very good outpatient care and so these kids are getting to a critical period where they have to be hospitalized.

Trib+Health: So what’s wrong with outpatient care? Your paper mentions a shortage in mental health physicians, but are there any other reasons that drive up hospitalizations?

Van Horne: This study took place between 2004 and 2010, before the Affordable Care Act, when insurance companies were not mandated to have behavioral health care as part of their package. So if you aren’t able to see a psychologist or psychiatrist that’s not paid for by your insurance and you’re having to pay out of pocket, you might wait until it gets too critical and you have to go to the hospital. Or there is nobody to see you due to this shortage issue. You’re looking around for a person to help you and you can’t find somebody or it would take you too long to get help.

Trib+Health: So what can policymakers do to help solve that problem? 

Van Horne: This session, Mental Health America of Greater Houston supported some bills and a couple of them passed. One would be trying to boost the number of medical providers, incentivizing medical providers to do behavioral health. It doesn’t necessarily have to be a psychiatrist but someone along the spectrum — psychologists, social workers, counselors. There was a little bit of money toward that this session. But obviously we need more people in those fields, and helping them would be one way to get folks in the field. Especially when you’re going to school for social work, social work doesn't pay a whole lot of money, so to take on student loans to not make a whole lot of money that you’d probably make with just a bachelor's degree isn’t that enticing. So we have to make those positions, I think, a little bit more enticing. 

Legislators also need to remember that children do not grow up in a vacuum. They grow up in families. And when parents lack insurance coverage and are unable to afford or access their own physical and mental health care, it greatly impacts their children. Studies around adverse childhood experiences, experiences such as having a parent with a mental illness or the death of a parent, show that the impact of these events can be lifelong and very serious. In addition to helping incentivize mental health care workers with tuition and student loan aid, we could also think about the advantages of ensuring parents are able to be healthy, engaged parents who might be able to mitigate or detect mental health issues before they become so critical they need to be hospitalized. Additionally, the children hospitalized for mental illness in our study are going to grow up and start families of their own, and many likely need ongoing access to mental health services in order to be productive and contributing members of society. This study highlights some areas of need for both children and adults in Texas.

Trib+Health: Your study pointed out that Texas’ teen pregnancy rates are higher than the national average? Why might that be and what can be done to fix that?

Van Horne:We have a lot of controversy over what the education should be of teenagers and kids in school around sexual health and sex education, and we continue to have high pregnancy rates. So I think fully educating kids on what their biology is and multiple different ways about not getting pregnant whether they are or are not going to engage in sexual activity is one thing. And we continually have issues around abortion and locations like Planned Parenthood that people can go access for contraceptive care. But if they can’t access contraceptive care and get the education and the access to it, they can’t use it. So that makes it challenging. 

Trib+Health: The paper also suggests there should be a bigger focus on comprehensive care. What is that and how would it work?

Van Horne: There’s several different models of comprehensive care. But in terms of having care that isn’t just you go to the doctor and I see you when I have the flu and that’s all I see you for. There is care that is wrap-around and you make sure that when you’re going in you're being seen for any issues that you may have. I think especially with mental health, you could go to your regular physician and your mom might say, "Hey, she's got these issues. What do I do?" and they refer you somewhere else. That referral chain is very challenging, and we saw that when we looked at older women with postpartum depression. There's just a break in the referral chain when you call and have to get another doctor and you have to make an appointment and don't know where to go, etc. So those models where there’s integrated care and comprehensive care in one location are really helpful because you know where you go, the appointment can be set, and it's not such a burden to get to that appointment.