Evaluation of EPSDT programs in the tape-to-tape states PDF
Preview Evaluation of EPSDT programs in the tape-to-tape states
HealthSystemsResearch,Inc. 2021LStreetNWSuite400 WashingtonDC20036 (202)828.5100 Fax:(202)728.9469 EVALUATIONOFEPSDTPROGRAMSINTHETAPE-TO-TAPESTATES VOLUMEI: SYNTHESISOFEPSDTCASESTUDYREPORTS Submittedto: OfficeofResearchandDemonstrations HealthCareFinancingAdministration Baltimore,MD Preparedby: IanHillandBethZimmerman HealthSystemsResearch,Inc. Washington,D.C. Undersubcontractwith: SysteMetrics,aDivisionofTheMEDSTATGroup Washington,D.C. Contract#500-92-066 3May1995 Acknowledgements HealthSystemsResearch,Inc.andSysteMetrics,aDivisionofTheMEDSTATGroupwouldlike toextendsincereappreciationtothemanyMedicaidandpublichealthofficialsandproviderswho gavesogenerouslyoftheirtimeduringthedevelopmentofthisreport. Specifically,wewouldlike tothankthefollowingpeople: InCalifornia: GordonCumming,RuthRange,MarideeGregory,MarianDalsey,HarrietTaylor, SherylGonzalez,MichaelQuinn,andKarenFlanniganofChildren'sMedicalServices,andJack Toney,JacquesBarber,DorrieChildress,GeneHiehle,JeanCrew,AngelineMrva,Richard Iniguez,TeriBarthels,GeorgeBabcock,andCarlMilleroftheMedicalCareServicesProgram, bothintheDepartmentofHealthServices. Ourthanksalsotothenumerouslocal-levelprogram officialsandproviderswhotookthetimetoexplaintheirprogramstous: MarciaBrittonofthe SacramentoCountyHealthDepartment,ChildHealthandDisabilityPrevention(CHDP)program, SacramentoCcntyCHDPprovidersDr.Gilb< tSimonandtheMolinaMedicalCenter;Iantha ThompsonandDavidNorrisoftheMercedCountyCHDPprogram;MichaelFordandDonna EarleyoftheW LyHealthDepartment;ConnieBledsoeoftheMercedCountyHuman ServicesAgency;Dr.DavidSimonsonoftheChild'sAvenueClinicinMerced;BobIsomandEva Mourad-HelmyoftheContraCostaCountyCHDPprogram;GwenEasteroftheContraCosta DepartmentofSocialServices;JudyLuorooftheContraCostaHealthPlan;Dr.SteveFeldmanof HilltopPediatricsandDr.RonGreenofRainbowPediatricsinContraCostaCounty;AllisonJames andJaredFineoftheAlamedaCountyCHDPprogram;LindaBantaandJoanMarrettiofthe AlamedaCountyDepartmentofSocialServices;Drs.DavisandPatton,pediatriciansinAlameda County;andDr.ChaseofAlameda'sChildren'sHospital. ThanksarealsoextendedtoCharlotte Newhart,formerlyoftheCaliforniaDistrictoftheAmericanAcademyofPediatricsandcurrently withDistrictIXoftheAmericanCollegeofObstetriciansandGynecologists. InGeorgia: RussellToal,JackieFoster-Rice,andBettyeSayloroftheDepartmentofMedical Assistance;RolandoThome,JudyBodner,AnnVaussen,andWilleneSmithoftheDepartmentof HumanResources,DivisionofPublicHealth;NanceWhiteofthe"Powerline"HotlineforMaternal andChildHealth;NobleMaseru,SharonWilliams,AliceJackson,andJuanitaMaddoxofthe AtlantaPublicSchoolSystem;PatriciaMathews,MyrticeStevens,andClaudetteHeyligerofthe SouthwestCommunityHospitalPrimaryCareCenterinAtlanta;EcleamusRicks,LavonnePainter, andthenursingandbillingstaffsoftheFultonCountyHealthDepartment;LynnFeldman,Deborah Adams,EvelynWilderson,andGailRobertsoftheLowndesCountyHealthDepartment;Sarah Richardson,MaryRoseMayo,andDonnaHudsonofthePlainsMedicalCenter,Stuart-Webster RuralHealth,Inc.;MargorieAlmond,FrankieEvans,LaverneHumphrey,GregJarres,Betty Perry,andVivianRumphoftheBibbCountyDepartmentofFamilyandChildrenServices;and MichaelFinch,apediatricgastroenterologistinprivatepracticeinAtlanta. InMichigan: VernSmith,BillKeller,KandyLester,LindaMcCartel,DonVeCaseyandRandy RothfussintheMichiganDepartmentofSocialServices;DeniseHolmes,DougPaterson,Terri Wright,andLonnieJohnsonintheMichiganDepartmentofPublicHealth;VictoriaBinion,Alyce Hayden,DeniceBanks,PatsyBell,CarolJohnson,andAnnChapmanintheCityofDetroit DepartmentofHealth;BruceBragg,DeanSienko,BruceMiller,SallyShears,JudyWilliams,and LindaRobertsofInghamCountyHealthDepartment;BetsyStropeofInghamCountyDepartment ofSocialServices;RickDryzga,DonnaJacobs,andMarilynRammoftheBayCountyHealth Department;PaulShaheenoftheMichiganCouncilforMaternalandChildHealth;MariettaDerr ofBayPediatrics;andMelbaMullingsatOmniCare,Inc. InTennessee: MannyMartins,SusieBaird,JaniceThornton,JohnnyGore,BillHuffines,Theresa Clarke,BillyMoates,DorisHoneycutt,KenBarker,MelbaFurmin,YvonneWood,andJulia PattonintheTennesseeDepartmentofHealth,BureauofMedicaid;JeaneceSeals,JudyWomak, andMarshaNeuenschwander,intheTennesseeDepartmentofHealth,BureauofHealthServices; MaryAnneCalahanintheTennesseeDepartmentofRamanServices;SarahWillisinthe TennesseeDepartmentofEducation;PaulVandermeerandSteveReedintheTennesseeDepartment ofFinanceandAdministration;BeverlyHolbrook,PatsyAnnMcCall,DebbieJenkins,Martha Ellison,JoanHolder,MaryBessHarper,andBrendaMartininthePerryCountyHealth Department;Dr.AndyAverett,ageneralpractitionerinthetownofLinden;CarolDanielsand NancyStewartoftheTiptonCountyofficeoftheDepartmentofHumanServices:Da.myPerry, GloriaLaVelle,RamonaStrickland,LauraJones,andJeanSimontonoftheTiptonCountyHealth Department;Dr.WilliamTerrel,apediatricianinMemphis;JaniceHoskinsoftheMemphisHealth Center;CathyJohnstonandDorothyHamiltonoftheNorthsideSchool-BasedClinicatNorthside HighSchoolinMemphis;LonnieHudsonoftheMemphis/ShelbyCountyDepartmentofHuman Services;KathyCanleyandLauraLittleoftheMemphis/ShelbyCountyHealthDepartment;Betty Thompson,AnnetteGoodrum,AnnDuncan,SylviaVincent,JackieWoods,LauraMassa,Barbara Wehby,DeloresLocke,andAlyceSimmonsoftheNashville/DavidsonCountyHealthDepartment. AtSysteMetrics,theauthorswouldliketothankMarilynEllwood,whoservedasProjectDirector untilNovember1994,NormaGavin,LisaHerz,andKathleenAdamsfortheirguidanceand feedbackonallphasesoftheproject,aswellasfortheirassistancewiththeconductofindividual sitevisits. Weareindebtedalsotothemembersoftheproject'sTechnicalAdvisoryGroup- CharlesHomer,TedJoyce,JanetPerloff,SaraRosenbaum,andDennisWilliams-fortheir insightfulcommentsondraftreports. ThisreportwascompletedunderacontractwiththeOfficeofResearchandDemonstrationsatthe HealthCareFinancingAdministration. TheauthorswouldliketothankfederalProjectOfficer FeatherDavisforherguidanceandassistancethroughoutthedevelopmentofthisreport. HpalthSv«;tpm<;Rp«;p»rrh Inr TableofContents I. OverviewoftheObjectivesandStructureoftheEPSDTEvaluation: ProcessAnalysisComponent 1 II. BackgroundonStateEPSDTPrograms 4 HI. EPSDTProvisionsoftheOmnibusBudgetReconciliationActof1989 8 IV. StateResponsestoOBRA-89 10 V. SummaryandIssuesfortheFuture 16 iii Health Su«tpm<;Rpcparrh Inr I. OverviewoftheObjectivesandStructureoftheEPSDTEvaluation: ProcessAnalysisComponent TheEarlyandPeriodicScreening,DiagnosisandTreatment(EPSDT)programwasestablishedin 1967asthepediatriccomponentoftheMedicaidprogram. Thegoaloftheprogramisto periodicallyscreenMedicaid-enrolledchildrenthroughouttheirdevelopment,upto21yearsofage, inordertodetectcorrectableconditionsearlyand,inturn,provideappropriatetreatmentservices. Sinceitsinception,however,theprogram'ssuccessinscreeningandtreatingeligiblechildrenhas fallenshortofpolicymakers',programofficials'andadvocates'expectationsforavarietyof complexreasons. Theseincludeinsufficientoutreach,inadequateproviderparticipation,and variablecoverageacrossthestatesofbothscreeningandtreatmentservices. Toaddressthese shortfalls,CongressincludedseveralprovisionsintheOmnibusBudgetReconciliationActof1989 (OBRA-89)designedtoincreasetheproportionofchildrenscreened,broadenprovider participation,andexpandbenefitcoverage,amongotherenhancements. In1992,theHealthC^eFinaningAdministration(HCFA)awardedathree-yearcontractto SysteMetrics,aDivisionoftheMEDSTATGroupanditssubcontractor,HealthSystemsResearch, Inc.(HSR),toevaluatetheimpactofOBRA-89ondieperformanceoftheEPSDTprogram. Specifically,HCFAaskedtheevaluatorstomeasureOBRA-89'simpactinthefour"Tape-to-Tape" states-California,Georgia,MichiganandTennessee-forwhichuniformresearchfileshavebeen constructedfromMedicaideligibilityandclaimsdata. TheEPSDTevaluationincludesbothoutcomesandprocessanalysiscomponents;HSRis responsiblefortheprocessanalysis. Perthecontractscopeofwork,theprocessanalysisentailed conductingsitevisitstothefourstudystatesduringthefirstprojectyearand,basedonthefindings ofthesitevisits,developingdetailedcasestudyreports. Thequalitativeknowledgegainedthrough thecasestudiesregardinghowthestatesoperatetheirEPSDTprogramsand,inparticular,how programpolicieschangedasaresultoftheOBRA-89legislationprovidetheprojectw5thcritical insightsintothefactorsthatcontributetostates'successesand/orfailuresrelatedtoEPSDT. In addition,thenarrativesallowtheresearchteamtomorefullyunderstandandaccuratelyinterpret theoutcomesandimplicationsofthevariousquantitativeanalysesbeingconductedunderother aspectsofthisevaluation. ThisfinalreportpresentstheresultsofHSR'sprocessandisorganizedintotwovolumes,as describedbelow: VolumeI,asynthesisoftheprocessevaluationfindings,presentsanoverviewof thestructureandtimingofthesitevisits, backgroundontheEPSDTprogramand OBRA-89,asummaryofthestudystates'responsestoOBRA-89,andadiscussion ofOBRA-89'soverallimpactandfuturechallengesfacingtheEPSDTprogram. VolumeIIpresentsthefourindividualcasestudyreportsontheEPSDTprograms inCalifornia,Georgia,Michigan,andTennesseeandanalyzestheimpactthat OBRA-89hashadoneachofthesestate'sprograms. Anintroductiontothecase 1 Hpalth^u<;tpm<Pocoarrh Inr studyreports,includinganoverviewofhowthesereportsareorganized,maybe foundintheGuidetoVolumeIIpresentedatthebeginningofthedocument. A. StructureandTimingoftheSiteVisits ThisreportisbasedonfindingsfromsitevisitsconductedbetweenAprilandAugust1993. Each sitevisitwasledbyIanHill,AssociateDirectorofHSR,whowasaccompaniedontwoofthevisits byHSRPolicyAssociateBethZimmermanand,inallcases,byamemberoftheSysteMetrics researchteam. SysteMetricsstaffwereincludedonthesitevisittomaximizethepotentialfor integratingtheoutcomesandprocessanalyses. Thevisits,eachlastingbetweenfourandfivedays, wereorganizedasfollows: Onthefirstdayofeachvisit,theevaluationteammetwithkeystateofficials responsibleforadministeringvariousaspectsoftheEPSDTprogram,including Medicaid,MaternalandChild'lealth,andSocialServiceadministrators. In^rJcr^learnhowoperationsvaryacrosslocalservicedeliverysystems,the remainingtimeduringeachvisitwasspentconductingvisitsandinterviewsin diverselocalities,includinglargeurbancities,medium-sizedtowns,andrural communities. Duringthesevisits,meetingswereheldwithlocalofficialssuchas city/countyhealthadministrators,federally-fundedCommunityHealthCenter directors,physicianandnursingproviders,andsocialservicesstaff. ThevisitswereconductedaccordingtothescheduleshowninTable1-1below. Interviewersusedtwostructured,comprehensiveprotocols-thefirsttargetedtostateofficialsand thesecondtolocalofficialsandproviders~toobtainconsistentinformationacrosssites. Specific topicsexploredduringtheinterviewsincluded: Informing,enrollment,andoutreachactivities; ProviderparticipationinEPSDT,includingthedeliveryofpreventivecareoutside theEPSDTsystem; PoliciesregardingEPSDTscreens,includingperiodicityschedules,leadscreening, andimmunizations; Diagnosticandtreatmentservices; StatereportingofEPSDTparticipationdata;and SpecialinitiativestointegrateEPSDTwithmanagedcare,earlyinterventionand school-basedhealthservices. 2 Inallcases,discussionsaddressedwhether,andhow,policiesandproceduresintheseareashad changedinresponsetoOBRA-89. Table1-1. K1TPVISITRfHEniflLF. State Localities SiteVisitTeam Date Tennessee Isfashville/DavidsonCounty IanHill April1993 \lemphis/ShelbyCounty MarilynEllwood PerryCounty 1iptonCounty Michigan E>etroit TanHill May1993 IilghamCounty LisaHerz EayCounty Georgia Fu'tonCounty IanHill June1993 ElibbCounty BethZimmerman L.owndesCounty NormaGavin Flains California SacramentoCounty IanHill August1993 /damedaCounty BethZimmermani CContraCostaCounty KathleenAdams HdercedCounty B. StructureofVolumeI TheremainderofVolumeIisdividedintofourmajorsections,asfollows: SectionIIprovidesbackgroundinformationonhowEPSDTprogramsgenerally operateinthestudystates,includingdescriptionsofinformingandoutreach strategies,thecontentanddeliveryofEPSDTscreeningexaminations,providers whorenderEPSDTscreens,andthedeliveryofdiagnosticandtreatmentservices. SectionIIIdescribestheprovisionsofOBRA-89thatweredesignedtoenhancethe capacityoftheEPSDTprogramtoserveeligiblechildren. Thespecificprovisions discussedincludethoseto: increasetheproportionofeligiblechildrenthatreceive screeningservices;ensureanadequatesupplyofMedicaidproviders;enhancethe scopeandavailabilityofEPSDTscreens;andimprovethelinkagesbetween screeningexamsandneededdiagnosisandtreatmentservices. 3 HealthSvstemsResearch. SectionIVsummarizesthestudystates'responsestotheprovisionscontainedin OBRA-89. SectionVconcludesVolumeIbysummarizingtheoverallimpactofOBRA-89in thefourstudystatesanddiscussingmajorissuesandchallengesfacingtheEPSDT programinthefuture. II. BackgroundonStateEPSDTPrograms ToprovideacontextfordiscussionofOBRA-89provisionsandthestudystates'responsestothem, thissectionprovidesabriefoverviewofhowEPSDTprogramsgenerallyoperateinthefourstudy states: California,Georgia,Michigan,andTennessee. Fourmajorprogramareasarediscussed below: informingandoutreach;theEPSDTscreen;screeningproviders;andthedeliveryof diagnosticandtreatmentservices. A. InformingandOutreach TheMedicaidstatuterequiresthatallfamiliesbeinformedabouttheavailabilityofEPSDTbenefits astheybecomeeligibleforMedicaid. Whileallstatesmustfulfillthisinformingrequirement,the statuteprovidesthemconsiderableflexibilityindesigningtheprocessesthroughwhichfamiliesare toldaboutEPSDTand/orlinkedtoitsservices. Generally,familieswitheligiblechildrenareinitiallytoldaboutEPSDTduringtheMedicaid enrollmentprocess. Thesocialserviceworkerverballyexplainsthefreebenefitsthatcanbe obtainedthroughtheEPSDTprogramandtheimportanceofpreventivecare,andmayalsoprovide thefamilywithwrittenmaterialsuchasabrochure. Then,theparentisusuallyaskedwhetherthey wouldliketheirchild(orchildren)toparticipateinEPSDTandwhethertheyneedassistancein findingaproviderorarrangingtransportation. Unfortunately,EPSDTinformingtypicallyreceivesverylittleemphasisduringtheoverallMedicaid eligibilityprocess;eligibilityinterviewscantakeseveralhoursandoftenincludeassessmentsofnot onlyeligibilityforMedicaid,butforAFDC,FoodStamps,andotherrelatedprograms,aswell. Examplesprovidedduringthesitevisitsdescribingtheapproachestoinformingusedinthestudy stateshighlightthispoint: Tennessee's12-minuteinformationalvideotointroducepersonsapplyingfor assistancetothevariousavailablesocialserviceprogramsdevotesonly30seconds totheEPSDTprogram; InMichigan,justfiveminutesoftheaverageone-hourinterviewistypicallyspent discussingEPSDT;and 4 HealthSvstemsResearch. InGeorgia,itwasreportedthatthequestionaskingfamiliesiftheywouldliketo participateinEPSDTisaskedonpage24ofa26-pageAFDC/Medicaidapplication. Inmoststates,effortstoenrollfamiliesinEPSDTarelimitedtothoseconductedduringthe eligibilityinterviewdescribedabove. However,intheearly1990s,approximatelyone-thirdof statesnationwideengagedinadditionaloutreachactivities,typicallyinconjunctionwithstateand/or localpublichealthdepartments(HillandBreyel,1991;NationalGovernors'Association,1992). Interestingly,allfourstatesinthisevaluationinvolvelocalhealthdepartmentsinadditionaloutreach activitiesbeyondtheinformingprovidedduringtheMedicaideligibilityprocess. Although variationsexistacrossthestudystates,outreachstrategiestypicallyincludesendinglettersand/or placingphonecallstofamiliestoinformthemoftheimportanceofEPSDTscreensandtooffer assistancewithfindingprovidersandarrangingtransportation. Inonlyalimitednumberofsites wereresourcesreportedtobesufficienttoallowforhomevisitstoberoutinelyconducted,although publichealthofficialsacrossthestudystatesdescribedhomevisitsasthemosteffectivemeansof engagingfamilies. Asindicatedabove,s'lfours^idystatesconductadditionaloutreachtonewenrolleesbeyondthe informingprovidedduringtheMedicaideligibilityprocess. Inthreeofthesestates(Georgia, Michigan,andTennessee),alleligiblechildrenaittargetedforadditionalcontact,althoughresource limitationshaverequiredhealthdepartmentstofocustheireffortsoncertainsubsetsofthe population(typicallyinfantsandyoungchildren). InCalifornia,however,additionaloutreachis explicitlylimitedonlytofamilieswhoexpressaninterestintheprogramduringtheMedicaid eligibilityinterview. B. TheEPSDTScreen ThekeyprinciplebehindtheEPSDTprogramistheprovisionofcomprehensive,periodic well-childexams,referredtoas"screens." Byprovidingchildrenwithperiodicscreening examinations,theEPSDTprogramisdesignedtodetectproblemsearlyand,therefore,avoid preventableillnesses. AsdefinedinMedicaidregulations,1acomprehensiveEPSDTscreenmustincludethefollowing components: Acomprehensivehealthanddevelopmentalhistory(includingevaluationofboth physicalandmentalhealthdevelopment); Acomprehensiveunclothedphysicalexam; Immunizationsappropriatetoageandhealthhistory; SocialSecurityAct,42U.S.C.§1396d(r)(SuppV1993). 5 HealthSvstemsResearch.
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