MEDICAID
Stronger Efforts Needed to Ensure Children's Access to Health Screening Services

The extent to which children in Medicaid across the country are receiving EPSDT services is not fully known, but the available evidence indicates that many are not receiving these services. A comprehensive view is not possible because annual state reports to HCFA on the delivery of EPSDT services are unreliable and incomplete, particularly for children in managed care. The most reliable evidence comes from studies of specific EPSDT services, such as lead screening or dental services, and reviews conducted in a handful of states or covering the medical records of a relatively small number of patients. For example, prior studies we have conducted of lead screening and dental care nationwide found that most children in Medicaid do not receive services, although they are at significantly higher risk than other children. A Department of Health and Human Services (HHS) Office of Inspector General study specific to managed care similarly found that less than one-half of enrolled children in their sample received any EPSDT screens. These and other studies have found that several factors contribute to the lack of services. Some involve program issues, such as inadequate systems for ensuring that services are provided. Others involve beneficiary issues, such as parents' being unaware of the need for or availability of covered services.

The five states we visited were taking actions to improve the compiling and reporting of data to better monitor whether children were receiving services. For example, Wisconsin is in the process of linking several state databases to provide a more complete picture of the care being given to individual children in multiple settings. As an incentive for managed care plans to report all health screenings, New York publishes statistics that compare the performance of these plans on child health-access measures such as lead screening and well-child visits. The states were also acting to better ensure that providers and managed care plans delivered required services and to improve outreach and education to Medicaid children and families in need of services. California, for example, requires health plans to contract with local health departments to coordinate care for children, and Florida mails reminder letters to parents when their children are due for EPSDT screens.

Federal efforts to ensure that children are receiving services have focused largely on changing the format and specificity of state reports so that they can collect reliable information about the extent to which children are being screened. While these efforts take a positive step, they do not adequately address the difficulties that states face in obtaining information about EPSDT service delivery, particularly in capitated managed care settings in which payments are not directly tied to services provided.

Obtaining accurate data will require additional time and effort by states, plans, and providers. To identify areas for improvement, some HCFA regional offices have worked with states to assess EPSDT activities. For example, HCFA's San Francisco Regional Office conducted a collaborative review with California that helped identify such issues as gaps in informing beneficiaries about EPSDT benefits. HCFA has in recent years conducted eight studies in other regions or states that included any review of EPSDT, only four of which focused exclusively on EPSDT. Although many of the actions taken by one state to improve the delivery of services may apply to other states, HCFA does not have mechanisms in place for identifying and highlighting such actions. HCFA has recently signaled a renewed focus on EPSDT, proposing that it expand its role in overseeing and promoting state EPSDT activities. A specific plan for how HCFA  now called CMS will implement these efforts has not yet emerged.

We are recommending that CMS work with states to develop criteria and a timetable for assessing and improving the reporting and provision of EPSDT services. We are also recommending that CMS develop mechanisms for identifying and highlighting practices that could be used as models for other states. In commenting on a draft of this report, CMS generally concurred with our recommendations that the agency work with states on these criteria and time frames and develop mechanisms for sharing information among states, but said improvement plans may not be needed for all states. We clarified our recommendation to indicate that CMS should determine the need for state improvement plans based on the outcome of a consistent assessment of all states.