Early And Periodic Screening, Diagnosis, And Treatment Research Articles

Unraveling EPSDT and Pediatric Hospice Care: An Exploratory Policy Analysis.

Background: Medicaid is the most common of health care benefits for children at end of life. Early and Periodic Screening, Diagnosis, and Treatment (EPSDT) presents a complex policy scenario for children enrolled in the Medicaid hospice benefit, and specifically concurrent hospice care. Objective: The study purpose was to identify policy guidance on EPSDT and pediatric hospice care from state Medicaid documents. Methods: We conducted a descriptive exploratory study, using state-level Medicaid hospice documents. Manuals, policy transmittals, provider memos, policy updates, and other related documents were searched from 50 states and the District of Columbia. We created a comprehensive data extraction tool that enabled us to identify EPSDT-specific information. The appraisal of the documents was conducted under 3 main a priori themes: definitions, function, and administration. Results: Eleven states included EPSDT in their hospice documentation. Definitions for concurrent care and palliative care were sparse and inconsistent. Four states defined medically necessary criterion. Several states did not integrate EPSDT into the hospice or concurrent care benefit, while EPSDT functioned as part of the Medicaid hospice benefit in 3 states and another 4 included it in their concurrent hospice care program. Among all the states, procedures for EPSDT program administration varied widely, including care coordination and payment. Conclusion: We found significant variation in state documents on EPSDT and pediatric hospice care. Clear guidelines and consistent standards regarding EPSDT services and how they interface with hospice, concurrent hospice care, and palliative care would improve care for children and families.

Tobacco and Other Drug Use among Foster Care Adolescents in West Virginia.

This study presents tobacco and other drug use prevalence data from a statewide health screening program of foster care (FC) children in West Virginia, and explores associations with demographic and placement variables. Logistic regression analyses adjusted for age, sex, and body mass index were conducted to determine if placement type and geographic region were associated with tobacco and other drug use among FC adolescents screened in 2012-2013 by the Early Periodic Screening Diagnosis and Treatment (EPSDT), or HealthCheck WV. One-third of the 12-17 year-olds used tobacco and 24% used other drugs. Results from the logistic regression analyses showed that significant associations between tobacco and drug use and placement variables persisted after controlling for covariates. Adolescents in home placements were significantly less likely to use tobacco (AOR=0.294; 95% CI: 0.196-0.441) or drugs (AOR=0.269; 95%, CI: 0.164-0.443) than those in agency placements. Details of significant regional variations also are presented. This study provides evidence of tobacco and drug use in West Virginia's FC adolescents and highlights a need for appropriate interventions for this vulnerable population.

Teens and Preventive Care Use: Implications for EPSDT Outreach

Teens have low overall preventive care utilization compared to other age groups. Low health care use by teens is a result of a variety of complex economic, social, and cultural factors. This study, completed by one local community health board responsible for the administration of the Early Periodic Screening Diagnosis and Treatment (EPSDT) program, produced findings that enhanced outreach to teens and supported the medical providers who serve them. More than 800 teens and young adults from a variety of cultures and communities across an urban Minnesota county were surveyed to understand the conditions under which they do and do not seek medical care. Findings suggest teens with structural barriers associated with poverty such as lack of insurance and transportation to clinics could benefit from intentional connections to medical programs. Psychosocial barriers, revolving around trust, relationships with providers, communication, and privacy, might be ameliorated through enhanced education and targeted outreach to clinics and teens, activities appropriate under the objectives and program activities of EPSDT. This study could be replicated in any community to gather data unique to local populations being served.

Rural populations and early periodic screening, diagnosis, and treatment services: challenges and opportunities for local public health departments.

We examined geographic differences in Early Periodic Screening, Diagnosis, and Treatment (EPSDT) visits as the South Carolina Department of Health and Environmental Control (SCDHEC) transitioned from direct service provision (DSP) to assuring delivery within the larger health care system. We examined infant cohorts with continuous Medicaid coverage and normal birth weights from 1995 to 2010. Outcome variables included any EPSDT visit and the ratio of observed to expected visits. Change in SCDHEC market share over time by residence was the primary variable of interest. We used growth curve models to examine changes in EPSDT visits by rural areas and levels of DSP over time. A small proportion of the study population (10%) resided in rural counties that were more dependent on SCDHEC for DSP. The trajectory of not having visits among counties with high DSPs was steeper in rural areas (0.208; P = .001) compared with urban areas (0.145; P = .002). In counties with high DSPs, the slope of the predicted ratio in rural areas (-0.033; P < .001) was steeper than that of urban areas (-0.013; P < .001). Health departments operations continue to transition from DSP, which might decrease access to well-child care in rural communities. Health care reform provides opportunities for health departments to work with community partners to facilitate DSP from public to private sectors.

From EPSDT to EHBs: The Future of Pediatric Coverage Design Under Government Financed Health Insurance

We review the evolution of federal financing for child health care over the past 40 years. The Social Security Amendments of 1967 established the program of early and periodic screening, diagnosis and treatment (EPSDT) as a required Medicaid benefit. The EPSDT amendments directed agencies to cover "early and periodic" screening and diagnostic services to ascertain "defects" and "chronic conditions" in children, as well as health care and treatment needed to "correct or ameliorate" such defects and conditions discovered during the screening examinations. The 1997 enactment of the Children's Health Insurance Program (CHIP) shifted federal policy from the use of an early coverage standard to one that gives insurers much more discretion to define medical necessity and coverage exclusions. CHIP programs offer coverage that is narrower than the benefits available under Medicaid. The Affordable Care Act (ACA) requires significantly more classes of care to be covered than does CHIP but well below the level of coverage under Medicaid. Implementation of the ACA to date suggests that the US Department of Health and Human Services will only demand pediatric coverage pegged to the commercial insurance market standards, rather than Medicaid's unique pediatric coverage standard. Although EPSDT's emphasis on early, developmental, and ameliorative services might result in more comprehensive benefits for children, particularly those with special health needs, one might still describe the ACA coverage as providing a basic, minimal level of services from a distributive justice perspective. It may, however, vary from state to state. States have the authority to decide whether to use an EPSDT-style approach or to follow the more restrictive approach of commercial insurance plans. Advocacy at the state level will determine which approach different states take.

State Medicaid Early and Periodic Screening, Diagnosis, and Treatment guidelines: Adherence to professionally recommended best oral health practices

The authors evaluated the adherence of state Medicaid Early and Periodic Screening, Diagnosis, and Treatment (EPSDT) guidelines to recommended best oral health practices for infants and toddlers. The authors obtained state EPSDT guidelines via the Internet or from the Medicaid-CHIP State Dental Association, Washington. They identified best oral health practices through the American Academy of Pediatric Dentistry (AAPD), Chicago. They evaluated each EPSDT dental periodicity schedule with regard to the timing and content of seven key oral health domains. Thirty-two states and the District of Columbia (D.C.) had EPSDT dental periodicity schedules. With the exception of the dentist referral domain, 29 states (88 percent) adhered to the content and timing of best oral health practices, as established by the AAPD guideline. For the dentist referral domain, 31 of the 32 states and D.C. (94 percent) required referral of children to a dentist, but only 11 states (33 percent) adhered to best oral health practices by requiring referral by age 1 year. With the exception of the timing of the first dentist referral, there was high adherence to best oral health practices for infants and toddlers among states with separate EPSDT dental periodicity schedules. States with low adherence to best oral health practices, especially regarding the dental visit by age 1 year, can strengthen the oral health content of their EPSDT schedules by complying with the AAPD recommendations.

Commentary on “Well-Child Care in Infancy and Healthcare Services Utilization from Birth to 6 Years by Late Preterm Children Receiving Medicaid Benefits”

OBJECTIVES: The hypotheses tested are that healthy late preterm (LP) children receiving Medicaid benefits use more healthcare services from birth to 6 years than do full-term (FT) children and that those who make the recommended number of early and periodic screening, diagnosis, and treatment (EPSDT) visits in the first 2 years require fewer services than those with fewer visits. METHODS: Data represent all of the health encounters for a 6-year birth cohort (1996-2001) of LP and FT children in South Carolina continuously enrolled in Medicaid birth to 6 years (N = 25,940). Associations were examined between making the recommended number of EPSDT visits in the first 2 years and sick-child office visits, emergency department (ED) visits, hospital admissions and hospitalizations, and ED visits for ambulatory care-sensitive conditions (ACSCs). RESULTS: LP children used more sick-child office visits and hospital admissions (P < 0.001) from birth to 6 years than FT children. LP children with at least the recommended number of EPSDT visits had a greater adjusted rate of sick-child office visits (rate ratio 1.62, confidence interval 1.30-2.02) and a lower adjusted rate of ACSC ED visits (rate ratio 0.79, confidence interval 0.65-0.96) than those making fewer visits. Making the recommended number of EPSDT visits did not affect rates of non-ACSC ED visits or of hospitalizations. CONCLUSIONS: LP children use more healthcare services in the first 6 years of life than do FT children, and those making the recommended number of EPSDT visits may shift some of their healthcare provision from the ED to providers' offices.

Well-Child Care in Infancy and Healthcare Services Utilization From Birth to 6 Years by Late Preterm Children Receiving Medicaid Benefits

The hypotheses tested are that healthy late preterm (LP) children receiving Medicaid benefits use more healthcare services from birth to 6 years than do full-term (FT) children and that those who make the recommended number of early and periodic screening, diagnosis, and treatment (EPSDT) visits in the first 2 years require fewer services than those with fewer visits. Data represent all of the health encounters for a 6-year birth cohort (1996-2001) of LP and FT children in South Carolina continuously enrolled in Medicaid birth to 6 years (N = 25,940). Associations were examined between making the recommended number of EPSDT visits in the first 2 years and sick-child office visits, emergency department (ED) visits, hospital admissions and hospitalizations, and ED visits for ambulatory care-sensitive conditions (ACSCs). LP children used more sick-child office visits and hospital admissions (P < 0.001) from birth to 6 years than FT children. LP children with at least the recommended number of EPSDT visits had a greater adjusted rate of sick-child office visits (rate ratio 1.62, confidence interval 1.30-2.02) and a lower adjusted rate of ACSC ED visits (rate ratio 0.79, confidence interval 0.65-0.96) than those making fewer visits. Making the recommended number of EPSDT visits did not affect rates of non-ACSC ED visits or of hospitalizations. LP children use more healthcare services in the first 6 years of life than do FT children, and those making the recommended number of EPSDT visits may shift some of their healthcare provision from the ED to providers' offices.

Sidebar: North Carolina’s Health Check Program

The Early and Periodic Screening, Diagnosis, and Treatment (EPSDT) provisions of the Social Security Act [1] define Medicaid’s package of health benefits for beneficiaries under 21 years of age. Medicaid covers 35% of all children, and more than 60% of poor children nationwide. Through the EPSDT benefit, Medicaid has played a critical role in improving the health of our nation’s low-income children. Under federal EPSDT requirements, states must provide outreach to children with actual or potential health problems; ensure the availability of health and developmental assessments and of vision, dental, and hearing services; and ensure that medically necessary treatments are available to children. Health Check is North Carolina’s comprehensive Medicaid well-child benefit. The goal of Health Check’s prevention-oriented services is the early identification and treatment of conditions that can adversely impact children’s healthy growth and development. Low-income children are more likely to be born at a low birthweight, which is a significant risk factor for poor health over a lifetime. Impoverished children are more likely to be in fair or poor health, to experience significant environmental and interpersonal stress, to have problems with nutrition, to develop chronic medical conditions, and to suffer developmental delays or learning challenges [2]. For these children, early screening and intervention are essential, and these services are supported by North Carolina’s Health Check Program. Bright Futures’ recommendations for preventive pediatric health care [3] are theoryand evidence-based guidelines specifying the content of such care and the intervals at which it should be offered. Providers are advised to perform basic psychosocial and behavioral assessments as well as developmental surveillance at all well-child preventive care visits. North Carolina’s Health Check program currently covers the preventive care services outlined in these Bright Futures recommendations and has been a national leader in implementing bundled rates for financing this menu of comprehensive wellness services.

School Readiness Among Children Insured by Medicaid, South Carolina

IntroductionThe American Academy of Pediatrics recommends a schedule of age-specific well-child visits through age 21 years. For children insured by Medicaid, these visits are called Early and Periodic Screening, Diagnosis, and Treatment (EPSDT). These visits are designed to promote physical, emotional, and cognitive health. Six visits are recommended for the first year of life, 3 for the second year. We hypothesized that children with the recommended visits in the first 2 years of life would be more likely than others to be ready for school when they finish kindergarten.MethodsWe studied children insured by Medicaid in South Carolina, born during 2000 through 2002 (n = 21,998). Measures included the number of EPSDT visits in the first 2 years of life and an assessment of school readiness conducted at the end of kindergarten. We used logistic regression to examine the adjusted association between having the recommended visits and school readiness, controlling for characteristics of mothers, infants, prenatal care and delivery, and residence area.ResultsChildren with the recommended visits had 23% higher adjusted odds of being ready for school than those with fewer visits.ConclusionEPSDT may contribute to school readiness for children insured by Medicaid. Children having fewer than the recommended EPSDT visits may benefit from school readiness programs.

Reimbursement for AAC Devices

Reimbursement for AAC Devices

EHDI Services: Who Pays for What?

EHDI Services: Who Pays for What?

Well-Child Care in Infancy and Emergency Department Use by South Carolina Medicaid Children Birth to 6 Years Old

This analysis tests the hypothesis that children enrolled in Medicaid with the recommended early and periodic screening, diagnosis and treatment (EPSDT) visits in the first 24 months utilize fewer emergency department (ED) services birth to 6 years old than children with fewer visits. Data represent all health encounters for a 3-year birth cohort of South Carolina children continuously enrolled in Medicaid from birth to 6 years old (n = 18,512). The association between receiving the American Academy of Pediatrics recommended EPSDT visits and other health service utilization is examined. Children with the recommended EPSDT visits had a greater adjusted rate of sick-child visits with a primary care provider (rate ratio, 1.62; 95% CI 1.50- 1.76) and a lower adjusted rate of ED visits for ambulatory care-sensitive conditions (rate ratio, 0.88; 95% CI, 0.81-0.95). Recommended EPSDT use in infancy may be associated with a shift in health care from the ED to the office setting by children enrolled in Medicaid in the first six years of life.

Incorporating Recognition and Management of Perinatal and Postpartum Depression Into Pediatric Practice

Every year, more than 400,000 infants are born to mothers who are depressed, which makes perinatal depression the most underdiagnosed obstetric complication in America. Postpartum depression leads to increased costs of medical care, inappropriate medical care, child abuse and neglect, discontinuation of breastfeeding, and family dysfunction and adversely affects early brain development. Pediatric practices, as medical homes, can establish a system to implement postpartum depression screening and to identify and use community resources for the treatment and referral of the depressed mother and support for the mother-child (dyad) relationship. This system would have a positive effect on the health and well-being of the infant and family. State chapters of the American Academy of Pediatrics, working with state Early Periodic Screening, Diagnosis, and Treatment (EPSDT) and maternal and child health programs, can increase awareness of the need for perinatal depression screening in the obstetric and pediatric periodicity of care schedules and ensure payment. Pediatricians must advocate for workforce development for professionals who care for very young children and for promotion of evidence-based interventions focused on healthy attachment and parent-child relationships.

Ensuring Financial Access to Hearing Aids for Infants and Young Children

Many young children with permanent hearing loss do not receive hearing aids and related professional services, in part because of public and private financing limitations. In 2006 the Children's Audiology Financing Workgroup was convened by the National Center for Hearing Assessment and Management to evaluate and make recommendations about public and private financing of hearing aids and related professional services for 0- to 3-year-old children. The workgroup recommended 4 possible strategies for ensuring that all infants and young children with hearing loss have access to appropriate hearing aids and professional services: (1) clarify that the definition of assistive technology, which is a required service under Part C of the Individuals With Disabilities Education Act (IDEA), includes not only analog hearing aids but also digital hearing aids with appropriate features as needed by young children with hearing loss; (2) clarify for both state Medicaid and Children's Health Insurance Programs that digital hearing aids are almost always the medically necessary type of hearing aid required for infants and young children and should be covered under the Early and Periodic Screening, Diagnosis, and Treatment (EPSDT) program; (3) encourage the passage of private health insurance legislative mandates to require coverage of appropriate digital hearing aids and related professional services for infants and young children; and (4) establish hearing-aid loaner programs in every state. The costs of providing hearing aids to all 0- to 3-year old children in the United States are estimated here.

Cochlear Implant Coding

Cochlear Implant Coding

An Examination of the Psychometric Properties of the Pediatric Symptom Checklist With Children Enrolled in Medicaid

The federal Early and Periodic Screening, Diagnosis, and Treatment (EPSDT) program requires mental health screening of Medicaid-eligible children as part of primary care medical assessments. However, decisions related to selection of a screening tool remain with the states. States need access to brief, cost effective, easily administered screening tools to comply with these regulations. This paper examines the psychometric properties of the Pediatric Symptom Checklist (PSC) reported on 6,590 children ages 6-22 enrolled in Florida’s Medicaid program across seven areas of the state, whose caregivers participated in a mail survey at least once between 1998 and 2007. Results suggest the PSC has both good internal consistency and stability over time across children with varying health and mental health conditions. The PSC demonstrated excellent discriminant validity regarding its ability to differentiate among children with varying levels of disabilities. Evidence of the PSCs construct validity was found based on its significant associations with other measures in predicted directions. At the recommended cut-off score of 28, the PSC exhibited good sensitivity, specificity, positive predictive value, and negative predictive value. Collectively, these findings support the use of the PSC as an appropriate measure for screening the psychosocial needs of children enrolled in Medicaid.

Increasing California Children's Medicaid-Financed Mental Health Treatment by Vigorously Implementing Medicaid's Early Periodic Screening, Diagnosis, and Treatment (EPSDT) Program

Children living in poverty-especially children living in rural areas and in areas lacking a commitment to providing mental health care-have considerable unmet need for mental health treatment. Expansion of Medicaid's Early Periodic Screening, Diagnosis, and Treatment (EPSDT) program might help to address this problem. To evaluate whether a legally compelled expansion of mental health screening, treatment, and financing under EPSDT would translate into higher Medicaid penetration rates. Our particular focus was on changes in rural treatment systems and systems historically receiving low levels of state funding (ie, "underequity" counties). We used fixed-effects regression methods by observing 53 California county mental health plans over 36 quarters, yielding 1908 observations. Our models controlled for all static, county, and service system characteristics, and for ongoing linear trends in penetration rates. After controlling for previous trends, mental health treatment access increased following EPSDT mental health program expansion. The increase was greatest in rural systems, and counties that previously received less state funding which showed the greatest penetration rate increases. EPSDT mental health expansion and increased funding increased Medicaid-financed mental health treatment. The expansion efforts had the greatest effects in rural and underequity counties that faced the greatest barriers to mental health service use.

Policy Levers that Improve Low Income Children's Access to Mental Health Services

Medicaid programs are a major source of financing for mental health care for children and youth, and publicly insured children are more likely to use mental health services than privately insured or uninsured children.1'2 However, needs for mental health care are also very high in this population, so net unmet needs while lower than those estimated for children with private insurance or no insurance (73% compared with 79% and 87%, respectively2) are substantial.2'3 The reasons for high unmet needs for mental health care in the Medicaid covered population fall into 2 categories: first, a failure to recognize the problems, conceptualize them as mental health needs, and to seek care; and second, difficulties in accessing appropriate services and using them with appropriate intensity and continuity. In addition to the recognition problems inherent to behavioral/mental health conditions, low income children may not be identified as needing mental health services because families have a hard time accessing screening services for all health conditions, because primary care providers do not adequately screen for mental health or developmental delay problems, and/or because of the isolation of some families from the mediating activities of social service agencies.1'36 Identified children may end up not accessing appropriate follow-up treatment services because appropriate treatment resources are not available at all or have severe capacity limitations, because those identifying problems are not aware of the resources that are available, or because reimbursement restrictions limit the type and quantity of services covered.1'7 These are complex issues rooted in individual, family, health and social system characteristics, and are certainly not amenable to neat policy-level solutions. Yet the unique political structure of state Medicaid programs, governed by federal statutes but encompassing a wide variety of state level options for eligibility, benefits and delivery structure, with shared financing that allows states to secure federal matching funds to partially cover the costs of policy innovations, has encouraged many child health advocates and policy makers to propose Medicaid reforms as the pathway for improving rates of use and quality of care for covered children with mental health conditions. In this issue of Medical Care, Snowden et al report on a set of reforms put in place as part of a settlement of a suit against the State of California (T.L. v Belshe, CV-S-93-1782E.D.Cal, 1995) aimed at increasing access for children to appropriate mental health services.8 Like several suits against several states in the 1990s and early 2000s,9'10 this suit took advantage of the federal requirement that state Medicaid programs offer early periodic screening diagnosis and treatment (EPSDT) services and cover any medical conditions identified during the screening process to pressure California to increase rates of screening for mental health conditions and to increase access to appropriate treatment services for identified conditions. The reforms put in place by California in response to this suit involved assigning responsibility for the coverage of mental health treatment services to county mental health plans, broadening the definition of medically necessary treatments, allowing a broader range of specialists to be reimbursed for care, and covering 50% of the county share of

Using Bright Futures to Improve Community Child Health

&lt;P&gt;Just as &lt;cite&gt;Bright Futures Guidelines for the Health Supervision of Infants, Children, and Adolescents&lt;/cite&gt;, third edition, leads us to consider “a new approach to health supervision for children,” its publication prompts a reexamination of the opportunities to strengthen collaboration between the public and private entities that make up the children’s healthcare delivery system. Historically, public health agencies and assistance programs have functioned as a safety net for children’s healthcare. The Medicaid program was established in 1965 to provide essential medical services to low-income children and families. Medicaid’s Early Periodic Screening Diagnosis and Treatment (EPSDT) program supports access to a comprehensive array of health screenings and services; states must provide certain mandatory benefits and may elect to cover additional optional benefits. Efforts to promote high-quality child healthcare to the Medicaid population are therefore easily justified. However, within many states or regions, numerous health-related services are available but may not be connected — nor broadly applied — and poor reimbursement to primary care clinicians under the Medicaid program may further limit its impact on child health outcomes. When this occurs, the public health system must provide the necessary services.&lt;/P&gt;&lt;H4&gt;ABOUT THE AUTHORS&lt;/H4&gt;&lt;P&gt;Wendy S. Davis, MD, is Director, Division of Maternal and Child Health, Vermont Department of Health. Patricia Berry, MPH, and Judith S. Shaw EdD, MPH, are with the Department of Pediatrics, College of Medicine, University of Vermont. &lt;/P&gt; &lt;P&gt;Address correspondence to: Wendy S. Davis, MD, Director, Division of Maternal and Child Health, Vermont Department of Health, 108 Cherry Street, P.O. Box 70, Burlington, VT 05402-0070; fax: 802-863-7229; e-mail &lt;a href="mailto:wdavis@vdh.state.vt.us"&gt;wdavis@vdh.state.vt.us&lt;/a&gt;. &lt;/P&gt;&lt;P&gt;Dr. Davis and Dr. Shaw have participated in the writing of &lt;cite&gt;Bright Futures Guidelines for the Health Supervision of Infants, Children, and Adolescents&lt;/cite&gt;, third Edition, published by the American Academy of Pediatrics. Ms. Berry has disclosed no relevant financial relationships.&lt;/P&gt;&lt;H4&gt;EDUCATIONAL OBJECTIVES&lt;/H4&gt;&lt;OL&gt;&lt;LI&gt;Describe available state and federal public health agencies with which healthcare professionals may partner in child health improvement activities.&lt;/LI&lt;LI&gt;Assess one’s ability to utilize the revised &lt;cite&gt;Bright Futures Guidelines for Health Supervision&lt;/cite&gt; in guiding community child health planning.&lt;/LI&gt;&lt;LI&gt;Identify opportunities for collaboration in implementing activities related to the Bright Futures theme “Promoting Community Relationships and Resources.”&lt;/LI&gt;&lt;/OL&gt;