Paul Lanier, MSW, Ph.D. is an Associate Professor in the School of Social Work at the University of North Carolina at Chapel Hill, where he teaches courses in social policy and program evaluation. He is also a research fellow at the UNC Cecil G. Sheps Center for Health Services Research and the UNC Injury Prevention Research Center. Lanier received his doctoral degree from the Brown School at Washington University in St. Louis. His current research focuses on developing, evaluating, and scaling-up evidence-based prevention programs in child welfare, mental health and early childhood systems.
Q: You’ve done several studies on psychiatric residential treatment facilities (PRTFs). How effective are they?
A: There is a lot of variation between PRTFs settings. Keeping in mind that it is a treatment setting, what really matters for clinical effectiveness are the providers and what they do inside PRTFs.
There is very little evidence on what interventions delivered inside PRTFs are most effective for which kids. Our review of the published research literature on this topic did not find evidence supporting the effectiveness of PRTFs, in general, for child behavioral health.
Q: What do we know about the treatments kids receive while in PRTFs?
A: Medicaid data is insufficient to give us a good picture of the treatments kids get in PRTFs, but it shows which medications they receive. We were troubled to find that 88% of youth in PRTFs receive an antipsychotic medication. That’s more than the number who receive antidepressants (60%) or medication for ADHD (52%).
We are not able to assess the appropriateness of any medication or treatment in our analysis.
Q: How many North Carolina kids go to PRTFs?
A: Ouranalysisof Medicaid data shows a large increase in the number of kids sent to PRTFs in the last eight years. A total of 1,000 youth each year entered a PRTF between 2015 and 2022. Of those, 26% were in the public foster care system in 2015. By 2022, 42% of kids in PRTFs came from the foster care system.
There has also been a big increase in the number of kids who were sent to out-of-state PRTFs. In 2016, 27% of youth were sent to a PRTF outside of N.C. By 2022, that number was 44%.
Q: How much does North Carolina spend on PRTFs?
A: We found that in the past five years, over $550 million in Medicaid spending has gone to PRTF placements. The number was more than $120 million in 2022 alone. That’s about $100,000 per child per year.
That raises the question of whether North Carolina is getting a return on its investment.
The Centers for Medicare & Medicaid Services (CMS) did a demonstration project a few years ago on home and community-based alternative treatments to PRTFs. It found the community-based approach was much more cost-effective and youth outcomes were better. This suggests North Carolina is likely spending too much money and needs to be smarter about what it’s paying for.
