Prevention Matters

The Department of Health and Human Services’ Office of Inspector General (IG) has just released a new report (OEI-05-08-00520) concluding that “Most children in nine selected States are not fully benefiting from Medicaid’s Early and Periodic Screening, Diagnostic, and Treatment (EPSDT) comprehensive screening services.”

For anyone concerned about the importance of expanding coverage for clinical preventive services under health reform, this report is a reminder that coverage alone isn’t enough to assure access.

The EPSDT program provides “a comprehensive and preventive child health program for children under the age of 21. Every State Medicaid program must offer the EPSDT benefit…In 2007, 31.5 million children were eligible for EPSDT…Services provided under the EPSDT benefit are intended to screen, diagnose, and treat children eligible for EPSDT services at early, regular intervals to avoid or minimize childhood illness. The EPSDT services cover four health-related areas: medical, vision, hearing, and dental. This study focused on medical, vision, and hearing screenings. Only medical screenings have components specifically required by the statute. Complete medical screenings under the EPSDT benefit must include the following five age-appropriate components: a comprehensive health and developmental history, a comprehensive unclothed physical examination, appropriate immunizations according to age and health history, appropriate laboratory tests, and health education.

States selected for the review included Arkansas, Florida, Idaho, Illinois, Missouri, North Carolina, Texas, Vermont and West Virginia.

The IG found that two primary factors contributed to children not receiving required screenings.

First, children did not receive the correct number of each type of screening. Second, when children received medical screenings, the screenings were often incomplete. These two factors taken together indicate that very few children received the correct number of complete screenings required by law.

Seventy-six percent of children, or 2.7 million children, in the States selected for the review did not receive all of the required number of medical, vision, and hearing screenings. Forty-one percent of children did not receive any required medical screenings. In addition, more than half of children did not receive any required vision or hearing screenings.

Fifty-five percent of children in the nine States received a medical screening during the study period. Of these children, 59 percent lacked at least one component of a complete medical screening. The component that children were missing most often was appropriate laboratory tests.

Officials from all nine selected States identified strategies to improve participation in the EPSDT and the completeness of medical screenings. The disconnection between States’ efforts to improve the EPSDT program and the low number of children receiving required screenings is difficult to account for, but it indicates that additional efforts are required.

Based on these findings, the IG recommended that CMS: (1) require States to report vision and hearing screenings, (2) collaborate with States and providers to develop effective strategies to encourage beneficiary participation in EPSDT screenings, (3) collaborate with States and providers to develop education and incentives for providers to encourage complete medical screenings, and (4) identify and disseminate promising State practices for increasing children’s participation in EPSDT screenings and providers’ delivery of complete medical screenings.

New requirements under Health Reform will require expanded coverage of clinical prevention services under Medicare and new individual and group private plans. To realize the benefits of these services it is essential the Administration require that new coverage be accompanied by effective strategies and resources to encourage participation.

E Ripley Forbes
Director, Government Affairs
Partnership for Prevention