Kids and Health Care: Medicaid's Preventive Efforts
As we mentioned before, state CHIPs and other Medicaid programs have been surprisingly bad about encouraging preventive medicine. They tend to consider "early intervention" as an antagonistic process of invading a family's home and snatching some form of custody over a child with medical, cognitive, emotional or -- sometimes -- financial limitations that exist in the child's environment.
Clearly, state programs should find a better way to encourage preventive care.
And the politicians in Washington seem to realize this. Congress has provided for the coverage of early intervention services in a number of federal statutes: the Individuals with Disabilities Education Act provides federal funding for developmental and behavioral services for infants and children under age three who have developmental delays or are at risk of delays; the Maternal and Child Health Services Block Grant allows federal funding to ensure maternal and child access to quality health services and to increase the numbers of young children who receive checkups and needed follow-up care.
These services target the first few years of life and include health, education and social services. The health services include comprehensive diagnostic screenings, nutrition counseling, behavior therapy, physical and/or speech therapy, family support services and health education describing expected developmental milestones. This is a lot of ground -- maybe too much, since CHIPs don't get the preventive medical care to kids consistently or often.
The most promising of Medicaid's various preventive tools is the Early and Periodic Screening, Diagnosis and Treatment (EPSDT) benefit -- which even the federal government itself admits is an "underused" source of federal funding.
Medicaid-eligible children and youth under age 21 are entitled to receive EPSDT's comprehensive benefits. These benefits include: screening, diagnosis and treatment services and outreach. Four separate screening services -- medical, vision, hearing and dental -- must be offered at pre-determined, periodic intervals. From birth through age five, the American Academy of Pediatrics recommends 14 medical screening visits. For Medicaid-eligible children, the medical screen must include:
- a comprehensive health and intervention history that assesses both physical and mental health;
- a comprehensive, physical examination;
- appropriate immunizations;
- lab tests (including lead blood testing at 12 and 24 months and otherwise according to age and risk factors); and
- health education, including "anticipatory guidance to the child (or parent)."
The EPSDT screen is an essential early intervention service. Properly focused, this screen can be used to diagnose developmental problems and risks and to educate the child and family about expected developmental milestones and activities for maximizing the child's early growth. Therefore, it is critical for health care providers who are treating young children to know the full scope of EPSDT.
Many don't.
If an illness or condition is diagnosed during a screen, EPSDT requires state Medicaid agencies to "arrange for (directly or through referral to appropriate agencies, organizations or individuals) corrective treatment."
EPSDT benefits include all of the services that the state can cover under the Medicaid Act, whether or not such services are covered for adults. In addition, the Medicaid Act says the service must be covered for a child if it is "necessary...to correct or ameliorate defects and physical and mental illnesses and conditions."
Unfortunately, the Medicaid Act doesn't list covered services using the terminology that health care providers use. As a result, the program has been used more as a social services tool than a medical care tool.
Health care practitioners need to be paid for the early intervention services they provide. Unfortunately, the provision of these services has been hampered by lack of knowledge of funding sources. The Medicaid EPSDT program exists to provide comprehensive and continuous care to America's poor children and children with special health care needs. EPSDT screening forms have been developed that cue providers to early intervention services that should be provided during the screening encounter and that identify children needing follow-up intervention services. As recently illustrated by a federal circuit court of appeals, EPSDT is also a significant source of funding for the provision of early intervention treatment services that young children need.
