Tears always flow at some point. It’s inevitable.  

We are sitting with a father whose coffee grows cold and whose exhaustion is shared by his wife, who is wary of telling her story as she fully expects to be told, yet again, “We can’t help you now.” She carries this rejection from meeting to meeting while she watches her child and family continue to deteriorate.    

These rejections sting and force the family into greater desperation and deeper isolation.

Edward “Ned” Breslin

The stories differ in nuance only, but the themes are similar: a family coming apart because of a child whose trauma is growing but whose trauma is “not significant enough yet” to warrant a response from anyone who can help.

Tears often start flowing in these conversations when families recount how their child has been expelled from multiple schools for their behavior or attempted suicide, or how the strain is destroying their marriage.  

Megan Vogels

All feel alone and abandoned, as friends and even other family members pull away – even when they are needed the most.  Sleep is elusive, and tempers boil over. Police are often involved, and child welfare has certainly intervened.  

The family may be struggling, but they have not yet met a seemingly arbitrary funding and medical threshold known as “medical necessity,” which would qualify them for the services they need to heal. 

Medical necessity criteria are standards used by all health insurance companies to decide whether treatments or health care supplies recommended by a health provider are reasonable, necessary, and appropriate. Additionally, medical necessity broadly refers to treatments or interventions that are the least invasive and reasonably expected to show symptom improvement. 

READ: Colorado Sun opinion columnists.

In the abstract, that broad definition might not sound so bad. In practice, however, when applied to children and adolescents with mental and behavioral health problems, this definition can be elusive, devastating and sadly result in a child qualifying for treatment too late. 

Since the medical necessity qualifications for mental and behavioral health treatments and interventions impose restrictions resulting in treatments that are too late, many families do not receive what they need when they first need support, and begin the steady descent into greater disfunction and pain. Insurance-funded support for treatment will not occur unless they, quite simply, get worse.   

“But how much worse can it get?” whispers the wife under her breath. 

The designation of “medical necessity” might makes sense for traditional, physical health needs. If I go to my doctor complaining of heart problems, she will not start with open heart surgery.

Instead, she’ll first do some tests, maybe take some labs, evaluate my heart functioning, and come up with a diagnosis and a non-invasive treatment plan that could be simple: dietary changes or taking medication.

It is not until we’ve tried a few things before the consideration of something like open heart surgery might be discussed. This is in part to manage our health, the risks, and the finances behind different levels of treatment. 

Trauma and mental health are not as simple to assess, to diagnose, to treat or to finance.  

Insurers, who of course need to draw lines and make decisions, have unintentionally created a nightmare that falls disproportionately on the families who are trying to seek therapy and navigate the trauma that unfolds in their homes. 

Importantly, the burden this puts on providers – the case managers, therapists and psychiatrists who work so hard every day to do the best for families – is immense.

It is tremendously complicated for health care professionals to navigate the various funding and qualifications systems to get mental health treatment authorized (frequently this takes several steps and appeals), and the pain and the burden they feel for “denying” a family the support they need is generally under-appreciated. Nobody entered social work to turn families away. 

But this burden on professionals is nothing compared to the pain and burden on families. The fears, hopelessness and isolation get worse, as do their problems. Children are removed from their homes, parents lose jobs and often divorce, or the unthinkable happens: suicide. 

Colorado teen suicide rates increased by 58% between 2016 and 2019, making it the cause of one in five adolescent deaths across our great state. While suicide and the drivers behind it are complicated and multifaceted, we have met too many families who believe that their child’s suicide could have been prevented had their child and family received help sooner.

We’re so tired of sitting with families over cups of cold coffee and hearing this story repeat itself. We must all advocate for the health insurance industry to radically change medical necessity thresholds for things like trauma and mental health – and build alliances between families and case workers instead conflicts. No one should have to wait for their lives and trauma to get worse. 

Everyone should get the help they need when they need it.  

Edward D. Breslin is president and CEO of Tennyson Center for Children. Megan Vogels is Chief Strategy Officer for Tennyson.

Megan Vogels

Special to The Colorado Sun

Edward D. Breslin

Special to The Colorado Sun Twitter: @NedBreslin