Well-child care in Medicaid: How is Connecticut doing?
November 20, 2001
Since 1969, federal law has required state Medicaid programs to cover well-child check ups for categorically eligible children under age 21 under the Early and Periodic Screening, Diagnosis and Treatment (EPSDT) requirement of the Medicaid statute. The schedule of check ups at specific ages and the services each visit must include are based on the recommendations of the American Academy of Pediatrics - the same schedule and services recommended for all American children.
Despite the federal requirement, many of the 182,249 children in Connecticut's Medicaid program1 do not receive those recommended EPSDT screenings. The federal Centers for Medicare and Medicaid Services (CMS), formerly the Health Care Financing Administration (HCFA), collects data from each state including how many children who were due for screens during the year got at least one (participant rate) and how many of the total number of screens due during the year were delivered (screening rate). The two rates differ because very young children are scheduled for more than one screen each year.
Connecticut has made a great deal of progress over the last decade in improving EPSDT rates. In 1991, Connecticut's screening rate was only 13% and participation rate was only 20%. By 2000, those rates had improved to 57% and 70%, respectively.
Source: CMS EPSDT data, 1991 to 2000
Nationally, there is some evidence that managed care can improve access to preventive care services.2 Connecticut's Medicaid program for children converted from fee-for-service to compulsory managed care in 1995. While EPSDT rates have increased since that time, improvements were occurring at roughly the same rate before managed care was implemented. There is no evidence that managed care has had any role in improving EPSDT rates in Connecticut.
Medical chart reviews conducted for the state by Qualidigm in 1998 and 2000, found that many of the EPSDT screens children receive are not complete. In the 1998 audit of 24 month old screens, reviewers found that while over 90% received height and weight measurements, less than half (47%) of sampled two year olds received a physical exam. Only 22 and 21%, received vision and hearing screenings, respectively.3 The 2000 medical record review found that over half of screens were missing one or more components (65% for newborns through 12 months, and 61% for children ages 5 to 11). More than half were not assessed for hearing (65%) and vision (58%) screenings. Dental health was assessed for fewer than 40% of children. Only 20% of adolescents were screened for depression, despite the fact that 10% of adolescents screened showed evidence of depression.4
State contracts with Connecticut's Medicaid managed care companies set 80% goals for both EPSDT screening and participation rates. Connecticut has never reached those goals. Our three neighboring states, Rhode Island, Massachusetts and New York, have made far more progress in improving EPSDT rates and all three exceed the 80% goal.
Source: CMS EPSDT data 1995-1998
Investigators from the federal General Accounting Office visiting Connecticut and four other states found inconsistent EPSDT data reporting, inadequate oversight mechanisms and a significant need for consumer education about the value of preventive care.5 While EPSDT is a critical component of care, it is only a beginning. Screens that identify problems must lead to productive referrals for treatment and eventually to improvements in health. Overall, much work remains to improve services to children in Connecticut's Medicaid program.