After more than 2,000 Missouri children diagnosed with mental illness were shifted from traditional Medicaid into three for-profit managed-care companies, the state’s hospitals noticed an alarming trend: a doubling in the percentage who had thoughts of suicide or attempted suicide.

Additionally, the average length of stay for these children in psychiatric hospitals dropped from 10 days to seven following the Medicaid change in May 2017, according to a study released this month by the Missouri Hospital Association.

The hospital association called on state Medicaid officials to investigate the study’s findings about children covered by the state-federal program for low-income families. The group acknowledged that factors other than the move to managed care could have played a role behind the increase, including social media, cyberbullying and lack of access to specialized mental health care.

While children with suicidal thoughts are at higher risk of suicide, the hospital association said it had no evidence that more children were taking their own lives after the move to managed care.

The growing number of suicides among children and youths has prompted national concern. The suicide rate in Missouri has doubled from 2.8 per 100,000 children in 2003 to 6.4 per 100,000 children in 2017, according to the hospital association. In that same time period, 735 Missouri children died by suicide.

The Missouri Health Plan Association, which represents the three Medicaid managed-care plans in the state, slammed the report. “This study is not peer-reviewed, it is based on a very small sample size and was clearly commissioned to attempt to further a predetermined hypothesis,” the group said in a statement.

Despite finding the study “fundamentally flawed,” the health plan association added that it was taking the findings “very seriously.”

Joan Alker, director of the Georgetown University Center for Children and Families, called the Missouri report “extremely troubling.” She said the new data set doesn’t prove managed care has caused any problem but does raise questions over whether children are getting adequate treatment.

“Managed care is an effort to save money and that is done by getting rid of unnecessary care or coordinating care better, but a lot of managed-care organizations cut corners,” she said.

Missouri’s top Medicaid official said he was aware that youth suicides had increased in the state since 2003, but he reacted cautiously to the report’s implied connection to the growing use of managed care since 2017. Missouri Medicaid shifted to managed care in the more populous areas of the state around St. Louis and Kansas City nearly a decade ago.

“We welcome collaborative conversations on how to address these problems, but cannot let those conversations devolve into finger pointing,” Missouri Medicaid Director Todd Richardson said in a statement. More research is needed into other factors, he said, such as access to follow-up care, medication compliance and differences in outcomes at facilities around the state.

Angela Kimball, national director of advocacy and public policy at the National Alliance on Mental Illness, said Medicaid managed care can be helpful in coordinating treatments and providing special services such as team-based care. But it can also “mean denying access to care or not approving services that are needed.”

Managed care works best when states provide strong oversight and clarity about the health plans’ goals, she said.

Kimball said that the move to managed care could play a role in more children acknowledging suicidal thoughts or attempts, but that greater awareness of mental health conditions and of suicide could factor in.

The study looked at the impact of the state’s shift of 160,000 low-income children living in 61 mostly rural counties from traditional fee-for-service Medicaid to managed care in 2017.

That included 2,152 children ages 5 to 19 who received inpatient mental health services before and after the switch to managed care. The study used hospital insurance claims data for the 18 months before the shift and 19 months after.

When these children were getting coverage through traditional Medicaid, about 10% had suicidal thoughts or made a suicide attempt in the 90 days after being discharged from an inpatient psychiatric hospital. That figure rose to nearly 19% after the move to managed care.

A similar increase was found analyzing children both 30 days and 60 days after discharge, according to the study.

Paul Gionfriddo, CEO of Mental Health America, a nonprofit that advocates for better care, said if managed care was working it would be making children healthier — meaning children with mental health issues would be less likely to think about suicide or attempt it.

“If this was my state where I was a public policy maker, I would be very nervous and concerned and open a public inquiry to examine what is happening,” said Gionfriddo, a former Connecticut state lawmaker.

Missouri hospitals and psychiatrists for years have speculated that the state’s move to require Medicaid enrollees to get coverage through private managed-care plans reduced their access to mental health services.

That’s because many private health plans have tightened the criteria for patients seeking inpatient care or reduced the length of their admission.

Alyson Wysong-Harder, a co-author of the study, called the data shocking. She is the CEO of Heartland Behavioral Health Services, a psychiatric facility in Nevada, Mo., which treats children and is about 90 miles south of Kansas City.

“We get these kids readmitted on a regular basis,” she said. “These are very vulnerable patients.”

Wysong-Harder said the lack of child psychiatrists in many communities means it’s vital that children get adequate time in the hospital to deal with their mental illness.

“They have this one opportunity often to get this critical care and to get their medications done right,” she said.

The lack of child psychiatrists is a problem for all health insurers, including Medicaid.

Although about 71% of physicians accept new Medicaid patients, only about one-third of psychiatrists do, according to a study released this year by the Medicaid and CHIP Payment and Access Commission.

If you know a child who has talked about contemplating suicide, get help by calling the National Suicide Prevention Lifeline at 1-800-273-8255, or use the online Lifeline Crisis Chat, both available 24 hours a day, seven days a week.