Evaluation of EPSDT programs in the tape-to-tape states

34 Pages·1995·1.3 MB·English

by  Hill, Ian, 1958-

HealthSystemsResearch,Inc.
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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
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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.
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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.
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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
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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).
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HealthSvstemsResearch.