Medicaid Preventive Services: Concerted Efforts Needed to Ensure Beneficiaries Receive Services
Published: 2009-08-14T00:00:00

Fast Facts:

Highlights:
section_title: Why GAO Did This Study
paragraphs: Medicaid, a federal-state program that finances health care for certain low-income populations, can play a critical role in the provision of preventive services, which help prevent, diagnose, and manage health conditions. GAO examined available data to assess (1) the extent to which Medicaid children and adults have certain health conditions and receive certain preventive services, (2) for Medicaid children, state monitoring and promotion of the provision of preventive services, (3) for Medicaid adults, state coverage of preventive services, and (4) federal oversight by the Centers for Medicare & Medicaid Services (CMS). GAO analyzed data from nationally representative surveys: the National Health and Nutrition Examination Survey (NHANES), which includes physical examinations of participants, and the Medical Expenditure Panel Survey (MEPS). GAO also surveyed state Medicaid directors and interviewed federal officials.
section_title: What GAO Found
paragraphs: Nationally representative data suggest that a large proportion of children and adults in Medicaid have certain health conditions, particularly obesity, that can be identified or managed by preventive services, and adults' receipt of preventive services varies widely. For Medicaid children, NHANES data from 1999 through 2006 suggest that 18 percent of children aged 2 through 20 were obese, 4 percent of children aged 8 through 20 had high blood pressure, and 10 percent of children aged 6 through 20 had high cholesterol. Furthermore, MEPS data from 2003 through 2006 suggest that many Medicaid children were not receiving well-child check ups. For Medicaid adults aged 21 through 64, NHANES data suggest that more than half were obese or had diabetes, high cholesterol, high blood pressure, or a combination. MEPS data suggest that receipt of preventive services varied widely by service: receipt of some services, such as blood pressure tests, was high, but receipt of several other services was low. MEPS data also suggest that a lower percentage of Medicaid adults received preventive services compared to privately insured adults. For children in Medicaid, who generally are entitled to coverage of comprehensive health screenings, including well-child check ups, as part of the federally required EPSDT benefit, most but not all states reported to GAO that they monitored or set goals related to children's utilization of preventive services and had undertaken initiatives to promote their provision. Nine states reported that they did not monitor children's utilization of specific preventive services. Forty-seven states reported having multiple initiatives to improve the provision of preventive services to children. For adults in Medicaid, for whom states' Medicaid coverage of preventive services is generally not required, most states reported to GAO that they covered most but not all of eight recommended preventive services that GAO reviewed. Nearly all state Medicaid programs, 49 and 48 respectively, reported covering cervical cancer screening and mammography, and three-quarters or more states reported covering four other preventive services. Two additional recommended services--intensive counseling to address obesity or to address high cholesterol--were reported as covered by fewer than one-third of states. For children in Medicaid, CMS oversees the provision of preventive services through state EPSDT reports and reviews of EPSDT programs, but gaps in oversight remain; for adults, oversight is more limited. For children, state reports showed that, on average, 58 percent of Medicaid children who were eligible for an EPSDT service in 2007 received one; far below the federal goal of 80 percent. CMS reviewed only 11 state EPSDT programs between April 2001 and June 2009. Few states reporting low rates of service provision were reviewed. CMS guidance to states may also have gaps: a 2006 study raised concerns that providers may not be aware of coverage of obesity-related services for Medicaid children. CMS has recognized the need for but has not yet begun drafting guidance on such coverage. For adults, CMS has provided some related guidance to states, but not on the reviewed preventive services.

section_title: Letter
paragraphs: As one of the nation’s largest health insurers, Medicaid—a joint federal  and state program that finances health care coverage for certain low- income individuals and families—can play a critical role in helping ensure  that the nation’s children and adults receive preventive services.  Preventive services can prevent health conditions from occurring, or  screen for or diagnose existing health conditions. For example, body mass  index (BMI) measurements are used to screen for obesity, and  mammograms for breast cancer. Preventive services also include services  to manage diagnosed health conditions and prevent certain conditions  from worsening, for example, weight-reduction counseling to help manage  obesity.
Medicaid, overseen at the federal level by the Centers for Medicare &  Medicaid Services (CMS), an agency within the Department of Health and  Human Services (HHS), provided health coverage for over 60 million low- income individuals in 2008. CMS oversees state Medicaid programs in part  by providing guidance on federal requirements, approving state Medicaid  plans, and reviewing program operations. For managed care, whereby  states contract with managed care organizations to serve Medicaid  beneficiaries, CMS’s oversight includes reviewing and approving states’  managed care contracts. For eligible children in Medicaid under age 21,  preventive services are generally addressed through Medicaid’s Early and  Periodic Screening, Diagnostic and Treatment (EPSDT) benefit. Under  federal law, the EPSDT benefit generally entitles children in Medicaid to  receive coverage of periodic screening services—often termed well-child  check ups—that include a comprehensive health and developmental  history, a comprehensive physical exam, appropriate immunizations,  laboratory tests, and health education. For adults aged 21 and older in  Medicaid, coverage of preventive services is generally not required.
Ensuring that children and adults in the United States receive preventive  services is a federal priority. For example, CMS has a yearly goal that each  state provide EPSDT well-child check ups to at least 80 percent of the  Medicaid children in the state who should receive one, based on the state’s  periodicity schedule. As part of its Healthy People 2010 initiative, HHS has  also established health goals for the nation, including increasing the  proportion of children and adults who receive several types of preventive  services, for example, cholesterol tests. In addition, HHS sponsors the  United States Preventive Services Task Force (USPSTF), which evaluates  a broad range of preventive services for specific age and risk groups and  makes recommendations that those that are clinically effective should be  incorporated routinely into primary health care for specific populations.  Certain preventive services, including USPSTF-recommended services— such as colorectal cancer screening, mammograms, and diabetes  screening—are covered by the Medicare program, the federal health  program for individuals age 65 and over.
Because of the importance of preventive services and the role Medicaid  can play in providing them, you asked for information about preventive  services for children and adults in the Medicaid program. This report  examines  1.  the extent to which children and adults in Medicaid have certain health  conditions that can be identified or managed by preventive services,  and the extent to which they receive such services; 2.  for children in Medicaid, for whom coverage of EPSDT services is  generally required, the extent to which state Medicaid programs  monitor and promote the provision of preventive services; 3.  for adults in Medicaid, for whom coverage of preventive services is  generally not required, the extent to which state Medicaid programs  cover recommended preventive services; and 4.  the extent to which CMS oversees the provision of preventive services  for children and adults in Medicaid.
To provide information on health conditions and receipt of certain  preventive services, we analyzed data from different nationally  representative surveys that focus on each respective area.
To examine health conditions, we analyzed data from HHS’s National  Health and Nutrition Examination Survey (NHANES), conducted by the  Centers for Disease Control and Prevention (CDC). NHANES directly  measures health conditions through physical examinations and laboratory  tests, and interviews participants about topics such as insurance coverage  and prior diagnoses of health conditions. We used data from 1999 through  2006 (the most recent available). We grouped NHANES data from surveys  conducted from 1999 through 2006 in order to include a sufficient number  of survey participants to reliably assess health conditions in the Medicaid  population. For children, we estimated the prevalence of certain health  conditions that can be identified or managed as part of EPSDT services  and were prevalent enough to examine reliably: high blood pressure, high  cholesterol, and obesity. For adults, we estimated the prevalence of  certain health conditions that can be identified or managed by USPSTF  recommended preventive services and were prevalent enough to examine  reliably: high blood pressure, high cholesterol, obesity, and diabetes. For  both adults and children, we analyzed data for the Medicaid and privately  insured populations.
To examine receipt of services, we analyzed available data from the  Medical Expenditure Panel Survey (MEPS), administered by HHS’s Agency  for Healthcare Research and Quality (AHRQ), which interviews  participants about reasons for medical visits and use of specific health  care services. We used data from 2003 through 2006 (the most recent  available). For children, we used available MEPS data from interviews  with a parent or other adult in the child’s household to estimate receipt of  well-child check ups and certain other services that could occur during  EPSDT well-child check ups: blood pressure tests, weight and height  measurement, and diet or exercise counseling. For adults, we used MEPS  data to estimate receipt of seven recommended preventive services:  blood pressure tests, cholesterol tests, cervical cancer screening,  mammography, colorectal cancer screening, diet and exercise counseling,  and influenza immunizations. In addition, to estimate receipt of diabetes  screening, a recommended preventive service for which MEPS data were  not available, we analyzed data from a related HHS survey, the 2006  National Health Interview Survey (NHIS). For both adults and children,  we analyzed data for the Medicaid and privately insured populations.
To assess state Medicaid programs’ monitoring and promotion of the  provision of preventive services to children, we surveyed 51 state  Medicaid directors (in 50 states and the District of Columbia). The survey  asked about states’ monitoring of children’s utilization of specific  preventive services in their fee-for-service and managed care programs,  goals for children’s utilization of specific services and whether or not they  were meeting these goals, and recent initiatives states had undertaken to  promote preventive services. All 51 state Medicaid directors responded to  the survey.
To determine the extent to which state Medicaid programs cover  recommended preventive services for adults, we surveyed state Medicaid  directors about whether the state Medicaid program covered eight  recommended preventive services: cholesterol tests, cervical cancer  screening, mammography, colorectal cancer screening, intensive  counseling to manage obesity, intensive counseling to manage high  cholesterol, influenza immunizations, and diabetes screening. We also  asked about coverage of well-adult check ups and health risk assessments,  which provide an opportunity for beneficiaries to receive some  recommended preventive services such as blood pressure tests and  obesity screening. To examine the extent to which state Medicaid  programs delineate coverage of specific preventive services through their  contracts with managed care organizations, we obtained and reviewed  sections of contracts describing what services were covered for the largest  Medicaid managed care organizations from up to two states in each of the  10 CMS regions and interviewed an expert on Medicaid managed care  contracts. We did not evaluate these Medicaid managed care  arrangements to determine whether managed care organizations were  covering services for Medicaid enrollees. We limited our review to  contract provisions we identified to provide a description of such  provisions.
To examine CMS oversight of the provision of preventive services for  children and adults in Medicaid, we interviewed and obtained related  documentation from CMS officials, including officials in CMS’s 10 regional  offices, about their oversight activities and initiatives related to the  preventive services in our review. We reviewed data from 2000 through  2007 reported by state Medicaid programs to CMS on the provision of  EPSDT well-child check ups in their programs, CMS reports summarizing  results of their EPSDT program reviews (conducted between April 2001  and June 2009), and State Medicaid Director letters and other guidance  issued by CMS related to preventive services. We also surveyed state  Medicaid directors about the support states receive, or would like, from  CMS related to coverage or oversight of preventive services. Activities  related to dental services in Medicaid were not included in the scope of  this report due to related work conducted in 2008.
To assess the reliability of NHANES, MEPS, and NHIS data, we spoke with  knowledgeable agency officials, reviewed related documentation, and  compared our results to published data. To establish the reliability of our  survey data, we spoke with knowledgeable state and federal agency  officials in developing the survey, pretested the survey questions, and  followed up with state Medicaid officials to achieve a 100 percent  response rate and, in some cases, to confirm certain responses. We  determined these data sources to be reliable for the purposes of this  report. Appendixes I, II, and III contain more information on our NHANES  analysis, our MEPS and NHIS analyses, and our survey of state Medicaid  directors.
We conducted our work from May 2008 through August 2009 in  accordance with generally accepted government auditing standards. Those  standards require that we plan and perform the audit to obtain sufficient,  appropriate evidence to provide a reasonable basis for our findings and  conclusions based on our audit objectives. We believe the evidence  obtained provides a reasonable basis for our findings and conclusions  based on our audit objectives.
subsections: section_title: Background
paragraphs: The term preventive services refers to a range of services aimed at  preventing and diagnosing serious heath conditions among adults and  children, as well as managing health conditions through early treatment to  prevent them from worsening. Generally, preventive services are intended  for the following three purposes:    Prevent a health condition from occurring at all. Immunizations to  prevent diseases such as influenza or pneumonia qualify as this first type  of preventive service, called primary prevention.
Prevent or slow a condition’s progression to a more significant  health condition by detecting a disease in its early stages.  Mammograms to detect breast cancer and other screening tests to detect  disease early are examples of this second type of preventive service, called  secondary prevention.
Prevent or slow a condition’s progression to a more significant  health condition by minimizing the consequences of a disease.  Services that help management of existing health conditions, such as diet  or exercise counseling to manage obesity or medication to manage high  blood pressure, are examples of this third type of preventive service,  called tertiary prevention.
Preventive services can help prevent or manage a number of serious  health conditions, such as heart disease, diabetes, obesity, and cancer. For  example, heart disease and stroke are leading causes of death and  disability in the United States, and the risk of developing these conditions  can be substantially reduced if high blood pressure and cholesterol— which can develop in children as well as adults—are detected early and  managed through diet, exercise, medication, or a combination. Similarly,  diabetes is a leading cause of blindness, renal disease, and amputation,  and also contributes to heart disease. Early diagnosis and management of  diabetes, by controlling levels of blood glucose, blood pressure, and  cholesterol, can reduce the risk of these and other diabetes complications.  Finally, the importance of obesity as a health problem for both children  and adults in the United States is increasingly apparent. Obesity is  associated with an increased risk of many other serious conditions,  including heart disease, stroke, diabetes, and several types of cancer.  Overweight and obese children are at risk of health problems during their  youth, such as diabetes, and are more likely than other children to become  obese adults. Intensive counseling about diet, exercise, or both can  promote sustained weight loss for obese adults.
The federal government has established national health objectives and  goals to monitor the health of the U.S. population, and several reflect the  importance of preventive services. Healthy People 2010, coordinated by  the Office of Disease Prevention and Health Promotion within HHS, is a  statement of national health objectives designed to identify the most  significant preventable threats to health and to establish national goals to  reduce these threats to certain target levels. Some of the national goals  established through Healthy People 2010 include  reducing the proportion of children and adults who are obese,  reducing the proportion of adults with high blood pressure and high blood  cholesterol, reducing the overall rate of diabetes and increasing the proportion of  adults with diabetes whose condition has been diagnosed, and increasing the proportion of children and adults who receive  recommended preventive screening tests and immunizations.
Recent reviews of progress toward these goals, however, in some cases  show no progress or even movement away from certain goals,  underscoring the importance of continued attention to prevention.
subsections: section_title: State Medicaid Programs Must Cover Comprehensive Health Check Ups for Children
paragraphs: Under federal law, state Medicaid programs generally must cover EPSDT  services for children under age 21. A key component of EPSDT services  is that it entitles children to coverage of well-child check ups, which may  target health conditions for which growing children are at risk, such as  obesity. An EPSDT well-child check up must include a comprehensive  health and developmental history, a comprehensive unclothed physical  exam, appropriate immunizations and laboratory tests, and health  education. EPSDT well-child check ups may be a vehicle to provide  preventive services to children, such as measurement of height and  weight, nutrition assessment and counseling, immunizations, blood  pressure screening, and cholesterol and other appropriate laboratory tests.
State Medicaid programs must provide EPSDT services at intervals which  meet reasonable standards of medical and dental practice as determined  by the state and as medically necessary to determine the existence of a  suspected illness or condition. Accordingly, states either develop their  own periodicity schedules, that is, age-specific timetables that identify  when EPSDT well-child check ups and other EPSDT services should  occur, or they may adopt a nationally recognized schedule, such as that of  the American Academy of Pediatrics, which recommends well-child check  ups once each year or more frequently, depending on age. State periodicity  schedules for fiscal year 2006 generally specified multiple well-child check  ups per year for children aged 0 through 2, one well-child check up per  year for children aged 3 through 5, and a well-child check up every 1 to   2 years for children aged 6 through 20.
The Omnibus Budget Reconciliation Act of 1989 (OBRA 89) required the  Secretary of HHS to set annual goals for children’s receipt of EPSDT  services, and CMS established a yearly goal that each state provide  EPSDT well-child check ups to at least 80 percent of the Medicaid children  in the state who should receive one, based on the state’s periodicity  schedule. Under the authority of OBRA 89, CMS also requires that states  submit annual EPSDT reports known as the CMS 416. Along with other  information, the CMS 416 captures the information used to measure  progress toward the 80 percent goal. On the CMS 416, this information is  termed the EPSDT participant ratio.
section_title: State Medicaid Programs Are Not Required to Cover Preventive Services for Adults
paragraphs: For Medicaid adults, Medicaid programs generally are not required to  cover preventive services. States operate their Medicaid programs within  broad federal requirements which generally require states to cover certain  mandatory benefit categories, such as “physician services” and provide  states the choice to cover a range of additional optional benefit categories,  thereby creating programs that may differ from state to state. As federal  Medicaid law does not define preventive services or include these services  under a mandatory benefit category, states can opt to cover various  preventive services for adults under different categories. For example,  states may choose to cover certain preventive services as part of  “preventive, diagnostic, and screening services,” an optional benefit  category under Medicaid. They may also choose to cover other specific  preventive services such as cholesterol tests under other mandatory or  other optional benefit categories. CMS officials said they do not track the  specific preventive services covered for adults by each state Medicaid  program.
section_title: National Surveys Show That Certain Health Conditions Are Prevalent among Children and Adults in Medicaid, and Receipt of Recommended Preventive Services Varies Widely
paragraphs: National survey data suggest that children in Medicaid under age 21 are at  risk of certain health conditions, particularly obesity, that can be identified  or managed by preventive services, and many are not receiving well-child  check ups. The same surveys suggest that Medicaid adults are also an at- risk population—nearly 60 percent were estimated to have at least one  health condition we reviewed that can be identified or managed by  preventive services—and their receipt of preventive services varied widely  depending on the service.
subsections: section_title: For Medicaid Children, Obesity Is a Health Condition of Great Concern: Nearly One in Five Examined Were Obese
paragraphs: Obesity is a serious health concern for children enrolled in Medicaid.  NHANES examinations conducted from 1999 through 2006 suggest that  nearly one in five children in Medicaid aged 2 through 20 (an estimated   18 percent) were obese. These rates of obesity are well above the Healthy  People 2010 target goal of reducing to 5 percent the proportion of children  nationwide who are obese or overweight (see fig. 1). Furthermore, about  half (an estimated 54 percent) of the Medicaid children who were obese,  or their parents, reported that the child had not previously been diagnosed  as overweight. Among privately insured children, an estimated 14 percent  were obese.
The NHANES examinations also revealed that some children in Medicaid  have other potentially serious health conditions that can be identified and  managed by preventive services. Among Medicaid children aged 8 through  20 years, an estimated 4 percent had high blood pressure. Among Medicaid  children aged 6 through 20 years, an estimated 10 percent had high  cholesterol. These rates were generally similar to estimates for privately  insured children.
section_title: Among Medicaid Children, Almost Half Did Not Receive a Well-Child Check Up during a 2-Year Period
paragraphs: MEPS data from 2003 through 2006 suggest that many children in Medicaid  do not regularly receive well-child check ups. Children in Medicaid are  generally eligible for a well-child check up at least once every 1 to   2 years, but an estimated 41 percent of children in Medicaid aged 2  through 20 had not received a well-child check up during the previous   2-year period. This proportion varied by the children’s age: for example,  an estimated 22 percent of children in Medicaid aged 2 through 4,   40 percent of children in Medicaid aged 5 through 7, and 48 percent of  children in Medicaid aged 8 through 10 had not received a well-child check  up during the previous 2 year period (see fig. 2). In comparison, the  estimated proportions of privately insured children who had received a  well-child check up were generally similar.
Similarly, our analysis of MEPS data also showed that, for children in  Medicaid, reported rates of receipt of certain specific preventive services  that could occur during a well-child check up were correspondingly low.  For example, an estimated 37 percent of children in Medicaid aged 2  through 20 had not had a blood pressure test, and an estimated 48 percent  of children in Medicaid aged 2 through 17 had not received diet or exercise  advice from a health care professional during the 2 years prior to the  survey. The data suggest, however, that most children in Medicaid aged 2  through 17—an estimated 88 percent—had their height and weight  measured by a health care professional during the 2 years prior to the  survey. The estimated rates of receipt of blood pressure tests, height and  weight measurement, and diet or exercise advice were generally similar  for children in Medicaid and privately insured children.
section_title: Among Medicaid Adults, Nearly 6 in 10 Had One or More Health Conditions that Could Be Identified or Managed by Preventive Services
paragraphs: NHANES data suggest that a majority of adults in Medicaid aged 21  through 64 have at least one potentially serious health condition. An  estimated 57 percent of Medicaid adults had obesity, diabetes, high  cholesterol, high blood pressure, or a combination of these conditions.  Obesity was the most common of these health conditions; an estimated   42 percent of adults in Medicaid aged 21 through 64 were obese (see   fig. 3).
As with children in Medicaid, the rate of obesity among adults aged 21  through 64 in Medicaid was well above national goals—the estimated   42 percent rate of obesity among Medicaid adults was nearly three times  higher than the Healthy People 2010 target goal of 15 percent. The  estimated rate of obesity among adults in Medicaid was also somewhat  higher than the estimated rate among privately insured adults, which was  32 percent. Adults in Medicaid were almost twice as likely to have diabetes  compared to privately insured adults: 13 percent of examined adults in  Medicaid were estimated to have diabetes, compared to 7 percent of  privately insured adults. Estimated rates of high blood pressure and high  cholesterol were similar between both health insurance groups (see fig. 3).
The NHANES interview data also suggest that a large proportion of adults  in Medicaid found to have these health conditions may not have been  aware of them prior to participation in the NHANES examination. An  estimated 40 percent of adults in Medicaid found to have one or more of  the health conditions we reviewed had at least one condition that they  reported had not been previously diagnosed. The percentage of adults in  Medicaid who reported that their health condition had not been previously  diagnosed varied by condition: for example, an estimated 17 percent of  adults in Medicaid with diabetes reported that this condition had not been  previously diagnosed, while an estimated 35 percent of those with high  cholesterol reported that this condition had not been previously diagnosed  (see fig. 4). These estimates were similar to those of privately insured  adults.
section_title: Medicaid Adults’ Receipt of Recommended Preventive Services Varied Widely by Service
paragraphs: MEPS data suggest that Medicaid adults’ receipt of recommended  preventive services varied widely by service. For example, an estimated   93 percent of adults in Medicaid aged 21 through 64 received a blood  pressure test during the 2 years prior to the survey. Similarly, an estimated  90 percent of women in Medicaid aged 21 through 64 received a cervical  cancer screening during the 3 years prior to the survey. However,  estimated rates of receipt were lower for other important recommended  preventive services. For example, only an estimated 41 percent of adults   in Medicaid aged 50 through 64 had ever received a colorectal cancer  screening test. Similarly, estimates based on NHIS data suggest that only  33 percent of adults in Medicaid aged 21 through 64 with high blood  pressure had received a screening test for diabetes within the past   3 years (see fig. 5).
As compared to the privately insured adult population, MEPS and NHIS  data show that a lower percentage of adults in Medicaid received certain  recommended preventive services, in particular, mammograms,  cholesterol tests, diabetes screening, or colorectal cancer screening,  within recommended time frames. Medicaid and privately insured adults  were estimated to be about equally likely to receive recommended blood  pressure tests, diet or exercise advice, and influenza immunizations within  recommended time frames.
section_title: For Children in Medicaid, Most State Medicaid Programs Reported Monitoring and Promoting the Provision of Preventive Services
paragraphs: Most state Medicaid programs reported on our survey that they monitored  and set goals for children’s utilization of certain preventive services. Most  states also reported undertaking multiple initiatives since 2004 to promote  preventive services.
subsections: section_title: Most State Medicaid Programs Reported Monitoring and Setting Goals for Medicaid Children’s Utilization of Preventive Services
paragraphs: In response to our survey, most of the 51 state Medicaid programs  reported that they monitored utilization of one or more preventive  services by children in Medicaid. For example, when asked whether they  monitored children’s utilization of Medicaid well-child check ups or health  risk assessments, 42 states reported doing so. States less frequently  reported monitoring utilization of specific services that could be provided  during these well-child check ups, such as blood pressure tests or obesity  screenings (see fig. 6).
When asked the reasons why they were not conducting more monitoring  of children’s utilization of preventive services in Medicaid (beyond  federally required monitoring through the CMS 416), the top two reasons  states chose were “administrative burden” and “technology challenges.”
In addition to monitoring specific preventive services, about two-thirds of  state Medicaid programs reported that the state had established its own  target goals or benchmarks for children’s utilization of preventive services,  in addition to the CMS goal that each state provide EPSDT well-child  check ups to at least 80 percent of Medicaid children in a state who should  receive one, based on the state’s periodicity schedule. For example, 33  states reported they had established utilization goals of their own,  separate from CMS’s 80 percent goal, for children’s well-child check ups.  Twenty-six states reported goals for the total number of any preventive  services received, and 12 states reported utilization goals for at least one  specific preventive service such as obesity screening, diabetes screening,  blood pressure tests, cholesterol tests, or cervical cancer screening. States  that had established goals often reported, however, that not all of their  goals were being met. For example, of the states with a goal for children’s  utilization of well-child check ups, 42 percent reported that the goal was  not being met. The top two reasons states cited as reasons they believed  they were not meeting utilization goals were beneficiaries missing  appointments and beneficiaries or their families not being concerned  about receiving preventive services. A few states also mentioned  difficulties with tracking service utilization.
Although most state Medicaid programs reported monitoring and setting  goals for children’s utilization of preventive services, these efforts differ by  type of service delivery system; programs more often monitor or set goals  for services provided to children in managed care than for services  provided to children in fee-for-service delivery systems. For example, of  the 37 states reporting that at least some children in Medicaid were  enrolled in managed care, 33 (89 percent) reported monitoring well-child  check ups provided through managed care organizations. In contrast, of  the 47 programs reporting that at least some children received services  through a fee-for-service delivery system, 26 (55 percent) reported  monitoring utilization of well-child check ups provided by fee-for-service  providers. Similarly, goals for children’s utilization of preventive services  were most often targeted to managed care organizations. For example, 25  of 37 states with children enrolled in Medicaid managed care organizations  (68 percent) reported having established goals for the managed care  organizations’ provision of well-child check ups, compared to 16 of 47  Medicaid programs (34 percent) with children in fee-for-service.
section_title: Most State Medicaid Programs Reported Multiple Initiatives Aimed at Improving Provision of Preventive Services for Children in Medicaid and Viewed Certain Initiatives as Successful
paragraphs: Most state Medicaid programs (47), reported conducting multiple  initiatives since 2004 to improve providers’ provision of preventive  services to children in Medicaid, most commonly  educating pediatric providers about coverage of preventive services   (42 states),  increasing payment rates for pediatric providers for office visits or  specific preventive services (37 states),  streamlining payment processing (29 states), and  starting a provider advisory panel (29 states).
States that had implemented one or more of the above four initiatives  often viewed them as successful. About half of the states implementing  them reported that the initiative had resulted in some improvement or  major improvement. Most of the other half reported that they did not  know the extent of improvement; only a few states reported that any of the  initiatives had not resulted in improvement.
State Medicaid programs also reported conducting several types of  initiatives directed at Medicaid beneficiaries, such as encouraging  children’s use of preventive services through direct mail or telephone  outreach, and many also reported initiatives specifically targeted at  reducing obesity in Medicaid children. For example, 37 states reported  initiatives to educate providers to conduct obesity screening or counseling  for Medicaid children, and 12 states reported implementing family-based  childhood obesity prevention programs.
section_title: For Adults, Most State Medicaid Programs Reported Covering Some but Not All Recommended Preventive Services
paragraphs: Most state Medicaid programs reported that they choose to cover some  but not all of the preventive services we asked about on our survey. Of the  eight recommended services we asked about, the services that were most  commonly reported as covered for adults were cervical cancer screenings  and mammograms, which were covered by 49 and 48 states, respectively.  Four additional preventive services were reported as covered for adults by  three-quarters or more of the 51 states. These four services were diabetes  screenings, cholesterol tests, colorectal cancer screenings, and influenza  immunizations. The remaining two recommended services—intensive  counseling for adults with obesity and intensive counseling for adults with  high cholesterol—were reported as covered for adults by less than one- third of states. Thirteen states (25 percent) reported covering intensive  counseling for obese adults and 14 states (27 percent) reported covering  intensive counseling for adults with high cholesterol (see fig. 7). Thirty- nine states reported covering well-adult check ups or health risk  assessments for adults, which provide an opportunity for delivering other  recommended preventive services such as blood pressure tests and  obesity screenings. (See appendix III for more detailed survey results.)
In examining a selected, non-generalizable sample of 18 state Medicaid  programs’ Medicaid managed care contracts, we found wide variation in  the extent to which the contracts delineated coverage expectations for  specific preventive services. As we have previously reported, specific and  comprehensive contract language helps ensure that managed care  organizations know their responsibilities and can be held accountable for  delivering services. According to one expert on Medicaid managed care  contracts, state Medicaid programs run the risk that managed care  organizations may not cover certain services the program intends to cover  if Medicaid managed care contracts lack specific and comprehensive  contract language related to covered services. Three of the contracts did  not specifically refer to any of the preventive services that state Medicaid  programs reported were required to be covered by managed care  organizations in those states. By contrast, two contracts specifically  referred to all of the preventive services that the state reported covering.
section_title: CMS Oversight of the Provision of Preventive Services Primarily Focuses on Children’s Services, and Gaps in Oversight Remain
paragraphs: CMS oversight is primarily focused on children’s receipt of EPSDT  services, and consists largely of collecting state EPSDT reports. CMS has  conducted few reviews of EPSDT programs, including those that CMS 416  reports indicate have low participant ratios—the information used to  assess progress toward CMS’s goal that each state provide EPSDT well- child check ups to at least 80 percent of the Medicaid children in the state  who should receive one, based on the state’s periodicity schedule. For  adults in Medicaid, CMS has issued some guidance related to preventive  services and shared some best practices.
subsections: section_title: For Children in Medicaid, CMS Oversight Focuses Largely on Collecting State EPSDT Reports; CMS Reviews Few EPSDT Programs, Including Those with Low Participant Ratios
paragraphs: CMS oversight of preventive services for children in Medicaid centers on  the annual collection of the required CMS 416 report from each state  Medicaid program on the provision of EPSDT services for children in  Medicaid. We reported in 2001 that CMS 416 reports were often not timely  or accurate, but since that time, CMS officials told us they had taken  steps to improve the underlying data, and state and national health  association officials concurred that the data has improved. For example,  we reported in 2001 that underlying data for the CMS 416 may not be  accurate in part because of incomplete data on service utilization by  children in managed care. In 2007, we reported that officials from several  states and national health associations stated that, although the CMS 416  was limited in its usefulness for oversight, the quality and completeness of  the underlying data that states used to prepare the CMS 416, including the  data collected from managed care organizations, had improved since  2001.
State Medicaid programs’ CMS 416 reports continue to show gaps in the  provision of EPSDT services to Medicaid children. CMS uses the  participant ratio from the CMS 416 to measure progress toward CMS’s goal  that each state provide EPSDT well-child check ups to at least 80 percent  of the Medicaid children in the state who should receive one, based on the  state’s periodicity schedule. By contrast, in fiscal year 2007, the national  average participant ratio among 51 states reporting on the CMS 416 was   58 percent, and no state reported a ratio of 80 percent or more. Individual  states reported ratios ranging from 25 to 79 percent, and 11 states had  ratios under 50 percent (see fig. 8). Participant ratios from fiscal years  2000 through 2006 are generally consistent with those in fiscal year 2007,  though there is some variation between years. For example, in fiscal year  2006, 2 states reported participant ratios greater than 80 percent, and   15 states reported ratios under 50 percent.
Although the completeness and accuracy of the CMS 416 data may have  improved in recent years, according to agency officials, the CMS 416 is still  limited for oversight purposes. For example, the form does not  differentiate between the delivery of services for children in managed care  and fee-for-service programs or illuminate possible factors contributing to  low receipt of services. We reported in 2007 that many officials from  national health associations told us the CMS 416 did not provide enough  information to allow CMS to assess the effectiveness of states’ EPSDT  programs. One official who works with many state Medicaid agencies told  us that states do not generally use the CMS 416 to inform their monitoring  and quality improvement activities.
In addition to collecting the CMS 416, CMS officials also oversee the  provision of preventive services to children in Medicaid through  occasional reviews of individual state EPSDT programs, which are  conducted by CMS regional offices; we previously reported such reviews  were helpful in illuminating policy and process concerns as well as  innovative practices of states. The reviews look at how states meet  statutory requirements—such as ensuring that all eligible Medicaid  beneficiaries under 21 are informed of and have access to EPSDT  services—and are conducted with the intent of identifying deficiencies  and providing recommendations and guidance to states to help improve  their programs. For example, one review assessed a state’s performance in  ensuring that managed care organizations and providers understood the  benefits available under EPSDT and their respective responsibilities for  providing these services. Another review investigated whether a state had  developed an appropriate periodicity schedule and examined coordination  of children’s care in the context of a managed care service delivery  system. CMS’s EPSDT reviews have also examined data collection and  reporting—for example, one review examined the extent to which a state  collected CMS 416 data in accordance with instructions and used the data  to measure progress and define areas for improvement.
EPSDT program reviews can and have resulted in recommendations and  corrective action plans intended to improve the provision of EPSDT  services. The reviews have also highlighted best practices that could be  emulated by other state Medicaid programs.
Recommendations—which are, according to CMS officials, implemented  at a state’s discretion—have included actions such as assessing potential  impediments to timely access to EPSDT services, ensuring that providers  are aware of how to access current data in order to monitor their efforts,  and developing a state standard for timely access to services. For example,  one review found that providers seemed confused about the health plans’  requirements for prior authorization and specialty referrals; CMS  recommended that the state assess whether the providers’ understanding  of prior authorization procedures was impeding timely access to EPSDT  services and, if so, ensure that training was provided to correct the  misunderstanding.
Corrective action plans—upon which states must act, according to CMS  officials—have included requirements for states to improve the process of  informing beneficiaries, providers, and community partners about the  support services available through Medicaid and how to access them, to  develop an appropriate methodology to report data for the CMS 416, and  to identify and implement strategies to increase vaccination of children  against pneumonia.
Best practices that reviews have identified have included a statewide  EPSDT outreach effort to ensure that beneficiaries are aware of the  availability of Medicaid services, a dance program that addresses  childhood obesity, and the provision of Medicaid instructions and written  materials in a patient’s primary language.
With the exception of reviews specifically focused on dental services, CMS  conducted only 11 EPSDT program reviews between April 2001 and June  2009, and few states with low participant ratios had been reviewed. For  example, eight states reported participant ratios below 50 percent on all of  their annual CMS 416 reports from fiscal years 2000 through 2007. Of those  eight states, six had not had their EPSDT programs reviewed by CMS  between April 2001 and June 2009. Although CMS has developed an  EPSDT review guide to promote consistency, according to CMS officials  there is no CMS directive or requirement for the CMS regional offices to  perform these reviews, and CMS has not established criteria or a schedule  for performing regular reviews.
CMS oversight of preventive services for children in Medicaid also  includes providing policy guidance to state Medicaid programs, such as  through its State Medicaid Manual and other guidance; for example, CMS  officials reported that they intend to draft guidance for states on coverage  of obesity services as part of EPSDT services, but as of the time of our  review had not done so. A 2006 study raised concerns that Medicaid  providers may not be aware to what extent obesity services were covered  or reimbursed under EPSDT, and that states’ provider manuals did not  often explain this coverage. For example, the study found that state  Medicaid manuals did not specifically discuss coverage of nutritional  counseling, and that states may not have been correctly compensating  providers whose practices emphasized appropriate obesity interventions.  The study recommended that states take several steps, including clarifying  the proper coding and payment procedures for obesity prevention and  treatment services. As of the time of our review, CMS officials told us  that they intend to draft policy guidance to address these concerns and  that the guidance would suggest methods for reporting and charging for  obesity-related services, but that they had not yet begun drafting this  guidance.
section_title: For Adults in Medicaid, CMS Has Recognized the Value of Preventive Services and Provided Oversight by Issuing Some Related Guidance for State Medicaid Programs
paragraphs: Unlike CMS’s oversight of children’s EPSDT services, CMS is not required  to collect utilization data from states on adults’ receipt of services and— according to officials—does not conduct program reviews as it does for  EPSDT services for children in Medicaid. CMS has, however, issued  guidance for state Medicaid programs through State Medicaid Director  Letters (SMDL) on topics relevant to adult preventive services. For  example, one letter issued in 2004 provided guidance on how states could  cover certain services, known as disease management services, to manage  chronic health conditions such as diabetes in their Medicaid programs and  discussed how new disease management models could be implemented by  states. As of March 2009, CMS had not issued similar coverage guidance on  other recommended preventive services we reviewed for adults, such as  obesity screening and intensive counseling.
Although CMS has issued some guidance through SMDLs, several state  Medicaid programs expressed that additional guidance could be helpful. In  response to an open-ended survey question on support state Medicaid  programs would like from CMS related to preventive services, 12 states  reported they would like more technical assistance and guidance from  CMS. For example, one state reported that the state would like  clarification of restrictions to coverage of preventive services and another  reported it would like advice on how to monitor improvements in  utilization of preventive services. In addition, four states expressed  interest in CMS sharing best practices of other states. As of March 2009,  there were 24 promising practices for Medicaid and CHIP on the CMS Web  site; 8 of these pertained to preventive services for adults.
section_title: Conclusions
paragraphs: The prevalence of obesity and other health conditions among Medicaid  beneficiaries nationally suggests that more can and should be done to  ensure this vulnerable population receives recommended preventive  services. Although Medicaid children generally are entitled to coverage of  EPSDT services that may identify and address health conditions such as  obesity, both national survey data and states’ 416 reports to CMS suggest  that children’s receipt of EPSDT services is well below national goals.  Further, providers may not understand that services to screen for and  manage obesity are covered under EPSDT. State-specific reviews of  EPSDT programs have helped identify needed improvements but too few  have been done. For adults, states’ coverage of preventive services  generally is not required, but USPSTF recommends certain preventive  services for specific ages and risk groups, and such services can be  covered by Medicaid if states choose to do so. National survey  examination data suggest that the provision of recommended services  could benefit adults in Medicaid, as 6 in 10 adults in Medicaid have one or  more potentially preventable health conditions.
States and CMS have acted in recent years to improve the provision and  monitoring of preventive services for the Medicaid population. CMS  intends to develop policy guidance for obesity services for Medicaid  children under EPSDT, though as of the time of our review, had not done  so. However, gaps in provision of services remain. An estimated 41 percent  of Medicaid children aged 2 through 20 participating in a nationally  representative survey had not received a well-child check up during a   2-year period, and receipt of recommended preventive services in the adult  Medicaid population varied widely, depending on the service. Improved  access to preventive services for Medicaid beneficiaries will take a  concerted effort by the federal government and states.
section_title: Recommendations for Executive Action
paragraphs: To improve the provision of preventive services to the Medicaid  population, we recommend that the Administrator of CMS take the  following two actions:    Ensure that state EPSDT programs are regularly reviewed to identify gaps  in provision of EPSDT services to children and to identify needed  improvements.
Expedite current efforts to provide policy guidance on coverage of  obesity-related services for Medicaid children, and consider the need to  provide similar guidance regarding coverage of obesity screening and  counseling, and other recommended preventive services, for adults.
section_title: Agency Comments
paragraphs: We provided a draft of this report to HHS for comment, and CMS  responded on behalf of HHS. (See app. IV.) CMS concurred with both of  our recommendations, and commented that the agency recognizes the  need for and the value of preventive services, and will remind states of the  importance of ensuring that children receive a comprehensive well-child  check up, and of the importance of providing preventive services to adults.
CMS agreed with our recommendation that the agency ensure state  EPSDT programs are regularly reviewed. CMS committed to establishing a  training program and protocol for the state reviews and technical  assistance by the end of the year and also commented that it intends to  conduct related efforts, including developing a comprehensive work plan  to establish a regular schedule for reviewing state policy and  implementation efforts and reviewing and revising the CMS 416.
CMS also agreed with our recommendation that the agency expedite  efforts to provide guidance to states on coverage of obesity-related  services for Medicaid children, and consider the need to provide similar  guidance regarding coverage of obesity screening and counseling, and  other recommended preventive services, for adults. CMS committed to  providing guidance on obesity-related services for children through an  SMDL by the end of the calendar year. CMS also highlighted the agency’s  involvement in several initiatives related to childhood obesity at the  national level and the agency’s support of the development of new  Healthcare Effectiveness Data and Information Set measures that address  obesity.
CMS also provided technical comments, which we incorporated as  appropriate.
As agreed with your office, unless you publicly announce the contents of  this report earlier, we plan no further distribution until 30 days from the  report date. At that time, we will send copies of this report to the Secretary  of HHS and other interested parties. In addition, the report will be  available at no charge on GAO’s Web site at http://www.gao.gov. If you or  your staff members have any questions about this report, please contact  me at (202) 512-7114 or cackleya@gao.gov. Contact points for our Offices  of Congressional Relations and Public Affairs may be found on the last  page of this report. GAO staff members who made major contributions to  this report are listed in appendix V.
section_title: Appendix I: NHANES Analysis
paragraphs: The National Health and Nutrition Examination Survey (NHANES),  conducted multiple times since the early 1960s by the Department of  Health and Human Services’s (HHS) National Center for Health Statistics  of the Centers for Disease Control and Prevention (CDC), is designed to  provide nationally representative estimates of the health and nutrition  status of the noninstitutionalized civilian population of the United States.  NHANES provides information on civilians of all ages. Prior to 1999, three  periodic surveys were conducted. Since 1999, NHANES has been  conducted annually. For this study, we examined data from 1999 through  2006 on children aged 2 through 20 and adults aged 21 through 64. We  grouped NHANES data from 1999 through 2006 in order to include a  sufficient number of survey participants to provide a reliable basis for  assessing the extent of health conditions in the Medicaid population. To  assess the reliability of NHANES data, we interviewed knowledgeable  officials, reviewed relevant documentation, and compared the results of  our analyses to published data. We determined that the NHANES data  were sufficiently reliable for the purposes of our engagement.
Our analysis of NHANES data focused on physical examinations and  laboratory tests for a variety of health conditions. As part of an overall  physical examination of survey participants, trained medical personnel  generally obtain a blood sample and administer laboratory tests such as  measurement of total blood cholesterol and glucose levels, obtain height  and weight measurements, and conduct three or four blood pressure  readings. To analyze these data, we considered two categories of survey  participants based on their health insurance status at the time of the  survey, as reported during the interview section of the survey: Medicaid  beneficiaries and the privately insured. We do not present results for the  uninsured, those with other forms of government health insurance, such  as Medicare (we excluded adults enrolled in both Medicare and Medicaid),  and those who provided no information on their health insurance status.  For the 1999 through 2004 period, the NHANES Medicaid category for  children includes some children enrolled in the State Children’s Health  Insurance Program (CHIP). In the 2005 through 2006 NHANES data,  children enrolled in CHIP can be differentiated from children enrolled in  Medicaid, but we grouped these children together for consistency with the  previous time period. We estimate that about 84 percent of these children  were enrolled in Medicaid with the remainder enrolled in CHIP between  1999 and 2006.
For children, we used the NHANES data to estimate the percentage who  were obese, the percentage with high blood pressure, the percentage with  high blood cholesterol, and the percentage of obese children who had not  been diagnosed as overweight (see tables 1 and 2).
Obesity. NHANES data included measures of the height and weight of  children aged 2 through 20. Obesity in children aged 2 through 19 was  defined as having a body mass index (BMI) equal to or greater than 95th  percentile of age and sex-specific BMI, based on CDC growth charts for  the United States; obesity in children age 20 was defined as having a BMI  of 30 or higher. Girls who were pregnant were not included in the obesity  analysis. Children or their parents were also asked if the child had been  diagnosed as overweight prior to participating in the survey.
High Blood Pressure. NHANES data included up to four blood pressure  readings for children aged 8 through 20. We calculated average systolic  and diastolic blood pressure based on the second, third, and fourth  readings. High blood pressure in children aged 8 through 17 was defined  as equal to or greater than 95th percentile of age, height, and sex-specific  average systolic or diastolic blood pressure, based on blood pressure  tables from HHS’s National Heart, Lung, and Blood Institute. High blood  pressure in children aged 18 through 20 was defined as having an average  systolic blood pressure reading of 140 millimeters of mercury (mmHg) or  higher, or having an average diastolic blood pressure of 90 mmHg or  higher.
High Blood Cholesterol. NHANES data included measures of total blood  cholesterol in children aged 6 through 20. High total blood cholesterol in  children aged 6 through 20 was defined as greater than or equal to 200  milligrams per deciliter (mg/dL).
For adults aged 21 through 64, we used NHANES data to estimate the  percentage who were obese, the percentage with high blood pressure, the  percentage with high blood cholesterol, the percentage with diabetes, and  the percentage with a combination of these conditions. We used CDC  definitions of these health conditions. Of adults with each of these  conditions, we also estimated the percentage who reported that their  condition had not been diagnosed by a health care professional prior to  the survey (see tables 3 and 4).
Obesity. NHANES examinations of adults included height and weight  measurements. Obesity for adults was defined as having a BMI of 30 or  higher (pregnant women were not included in the obesity analysis).
High Blood Pressure. NHANES examinations of adults included up to  four blood pressure readings. Average systolic and diastolic blood  pressure readings were calculated as described for children (see footnote  62). High blood pressure for adults was defined as having an average  systolic blood pressure reading of 140 mmHg or higher, having an average  diastolic blood pressure reading of 90 mmHg or higher, or taking blood  pressure lowering medication.
High Blood Cholesterol. NHANES laboratory tests for adults included  measurement of blood cholesterol. High total blood cholesterol for adults  was defined as 240 mg/dL or more.
Diabetes. A subsample of NHANES participants, those whose  examination was scheduled in the morning, were asked to fast prior to  having their blood drawn. Laboratory tests for this subsample of NHANES  participants included measurement of fasting plasma glucose. Diabetes for  adults was defined as fasting plasma glucose of 126 mg/dL or more, or  having previously been diagnosed with diabetes.
For all estimated percentages for children and adults, we calculated a  lower and upper bound at the 95 percent confidence level (there is a 95  percent probability that the actual percentage falls within the lower and  upper bounds), of beneficiaries in each of the two insurance categories  using raw data and the appropriate sampling weights and survey design  variables. We used the standard errors of the estimates to calculate  whether any differences between the two insurance groups were  statistically significant at the 95 percent confidence level.
section_title: Appendix II: MEPS and NHIS Analyses
paragraphs: The Medical Expenditure Panel Survey (MEPS), administered by the  Department of Health and Human Services’s (HHS) Agency for Healthcare  Research and Quality (AHRQ), collects data on the use of specific health  services. We analyzed results from the MEPS household component,  which collects data from a sample of families and individuals in selected  communities across the United States, drawn from a nationally  representative subsample of households that participated in the prior  year’s National Health Interview Survey (NHIS, a survey conducted by the  National Center for Health Statistics at the Centers for Disease Control  and Prevention (CDC)). We pooled MEPS data from multiple years to yield  sample sizes large enough to generate reliable estimates for the Medicaid  subpopulation. Our analysis was based on data from surveys conducted in  2003 through 2006, the most recent data available. We supplemented our  MEPS analysis with analysis of data from the 2006 NHIS survey, which  covered a question of interest that was not available in MEPS. It was  possible to use one year of the NHIS data because the sample size is larger  than MEPS. To determine the reliability of the MEPS and NHIS data, we  spoke with knowledgeable agency officials and reviewed related  documentation and compared our results to published data. We  determined that the MEPS and NHIS data were sufficiently reliable for the  purposes of our engagement.
The MEPS household interviews feature several rounds of interviewing  covering 2 full calendar years. MEPS is continuously fielded; each year a  new sample of households is introduced into the study. MEPS collects  information for each person in the household based on information  provided by one adult member of the household. This information includes  demographic characteristics, self-reported health conditions, reasons for  medical visits, use of medical services including preventive services, and  health insurance coverage. We analyzed responses to MEPS questions  about children’s medical visits and children’s and adults’ receipt of  preventive services. NHIS collects information about demographic  characteristics, health conditions, use of medical services, and health  insurance coverage. We analyzed responses to an NHIS question on adults’  receipt of a diabetes screening test. As with the National Health and  Nutrition Examination Survey (NHANES) data described in appendix I, we  analyzed results for children under age 21 and adults aged 21 through 64,  divided into two categories on the basis of their health insurance status.  Unless noted, we used age and insurance status variables that were  measured during the same interview as the questions about preventive  services. Similar to NHANES, the Medicaid category in MEPS included  children enrolled in the State Children’s Health Insurance Program  (CHIP). We estimate that 82 percent were enrolled in Medicaid with the  remainder enrolled in CHIP between 2003 and 2006. Our NHIS analysis  was limited to adults.
For children, we analyzed data for several different MEPS questions to  examine children’s receipt of well-child check ups and specific preventive  services (see tables 5 and 6).
Well-Child Check Up. The MEPS survey included questions about office  based and outpatient medical visits for children aged 0 through 20. We  considered a medical visit to be a well-child check up if the visit was in  person and if the respondent reported that the reason for the visit was  either: a well-child check up, a general examination, or shots and  immunizations. Using sampling weights, for each health insurance  category, we estimated the percentage of children aged 2 through 20 at the  end of the survey’s 2-year period who had received one or more well-child  check ups during the survey’s 2-year period. We used insurance status  variables that were measured at the end of the survey’s 2-year period. We  used MEPS longitudinal weights to facilitate this analysis of medical visits  that occurred during the 2-year survey period. The pooled 2-year survey  periods analyzed were 2003 through 2004, 2004 through 2005, and 2005  through 2006.
Blood Pressure Test. MEPS included questions about whether children  aged 2 through 20 had their blood pressure measured by a doctor or health  care professional, and if so, how long ago. Using sampling weights, we  estimated the percentage of children in each health insurance category  that had their blood pressure measured during the 2 years prior to the  question being asked.
Diet or Exercise Advice. MEPS included questions about whether  children aged 2 through 17 had (1) received advice about eating healthy  from a doctor or health care professional, and if so, how long ago, and (2)  received advice about exercise, sports, or physically active hobbies from a  doctor or health care professional, and if so, how long ago. Using sampling  weights, we estimated the percentage of children in each health insurance  category that had received advice about either a healthy diet or exercise,  during the 2 years prior to the question being asked.
Height and Weight Measurement. MEPS included questions about  whether children aged 0 through 17 had (1) had their height measured by a  doctor or health care professional, and if so how long ago; and (2) had  their weight measured by a doctor or health care professional, and if so,  how long ago. Using sampling weights, we estimated the percentage of  children in each health insurance category that had both their height and  their weight measured during the two years prior to the question being  asked. Height and weight were not necessarily measured at the same time,  and these measurements did not necessarily take place in the context of a  body mass index (BMI) calculation or obesity screening.
For adults aged 21 through 64, we analyzed data for several different  MEPS questions that related to receipt of recommended preventive  services (see table 7). It was not possible to determine whether  respondents received these services for screening purposes, as  recommended by the United States Preventive Services Task Force  (USPSTF), as opposed to receiving them for purposes of diagnosing a  suspected health condition. Nevertheless, the estimates are useful in  indicating the maximum percentages of adults who may have received  certain recommended preventive services. For example, if 40 percent of  adults aged 50 through 64 reported receiving a colorectal cancer  screening, some may have received the screen for diagnostic purposes  after experiencing symptoms of colorectal cancer. Regardless, in this  example, 60 percent of adults in this age range—for whom colorectal  cancer screening is recommended by the USPSTF—did not receive a  colorectal cancer screening for any reason.
Blood Pressure Test. MEPS included questions about whether adults  had their blood pressure measured by a doctor or health care professional,  and if so, how long ago. Using sampling weights, we estimated the  percentage of adults aged 21 through 64 in each health insurance category  who reported that they had their blood pressure measured during the   2 years prior to the question being asked.
Cholesterol Test. MEPS included questions about whether adults had  their cholesterol tested by a doctor or health care professional, and if so,  how long ago. Using sampling weights, we estimated the percentage of  adults in each health insurance category for whom a cholesterol test was  recommended, who reported that they had their cholesterol tested during  the five years prior to the question being asked. USPSTF recommends  cholesterol tests for men aged 35 and older, and men and women aged 20  and older with health conditions that are risk factors for heart disease. We  used available information about risk factors for heart disease that was  self-reported by survey participants to determine whether a cholesterol  test was recommended on this basis; these risk factors were diabetes, high  blood pressure, or BMI greater than or equal to 30.
Mammogram. MEPS included questions about whether women had a  mammogram, and if so, how long ago. Using sampling weights, we  estimated the percentage of women aged 40 through 64 in each health  insurance category who reported that they had a mammogram during the   2 years prior to the question being asked.
Cervical Cancer Screening. MEPS included questions about whether  women had a cervical cancer screening, and if so, how long ago. Using  sampling weights, we estimated the percentage of women aged 21 through  64 in each health insurance category who had not reported having a  hysterectomy and who reported that they had a cervical cancer screening  during the 3 years prior to the question being asked.
Colorectal Cancer Screening. MEPS included questions about whether  adults had a colonoscopy, a sigmoidoscopy, or a stool test, and if so, how  long ago. Using sampling weights, we estimated the percentage of adults  aged 50 through 64 in each health insurance category who reported that  they had ever had one of these tests.
Influenza Immunization. MEPS included questions about whether  adults had received a flu shot, and if so, how long ago. Using sampling  weights, we estimated the percentage of adults aged 50 through 64 in each  health insurance category who reported that they had a flu shot during the  year prior to the question being asked.
Diet or Exercise Advice. MEPS included questions about whether adults  had received advice from a doctor or health care professional to (1) eat  fewer high fat or high cholesterol foods, or (2) exercise more. Using  sampling weights, we estimated the percentage of adults aged 21 through  64 in each health insurance category, whose self reported height and  weight corresponded to a BMI of 30 or higher, who reported that they had  ever received either diet or exercise advice. This type of advice does not  fulfill the USPSTF recommendation that obese adults receive sustained  intensive obesity counseling, but it provides an indicator of the maximum  proportion of adults who could have received such counseling.
Diabetes Screening. MEPS interviews from 2003 through 2006 did not  ask about adults’ receipt of diabetes screening tests, but the 2006 NHIS  did; adults who had not previously been diagnosed with diabetes were  asked if they had been tested for high blood sugar or diabetes in the last 3  years. Using NHIS sampling weights, we estimated the percentage of  adults aged 21 through 64 in each health insurance category, who reported  having high blood pressure and who reported that they had received a  screening test for diabetes during the 3 years prior to answering the  question. USPSTF recommends diabetes screening for adults with high  blood pressure.
For all estimated percentages for children and adults, we calculated a  lower and upper bound at the 95 percent confidence level using the  appropriate sampling weights and survey design variables. We used the  standard errors of the estimates to calculate if any differences between the  insurance groups were statistically significant at the 95 percent confidence  level.
section_title: Appendix III: State Medicaid Director Survey Results
paragraphs: To gather information about state Medicaid programs’ coverage, oversight,  and promotion of preventive services, we surveyed 51 state Medicaid  directors (in the 50 states and the District of Columbia). The survey was  conducted from October 29, 2008, through February 6, 2009. It included  questions on the coverage of preventive services for adults, the methods  used for oversight of preventive services for children and adults, including  monitoring of utilization of specific services, utilization goals, including  whether or not goals were being met, state promotion efforts and specific  initiatives aimed at preventive services, and the federal support provided  to state Medicaid programs for the provision of preventive services. Many  of the survey questions asked state Medicaid directors to consider specific  Medicaid populations such as children in Medicaid under age 21 or adults  in Medicaid age 21 and over, or beneficiaries enrolled in managed care  organizations (MCO) or fee-for-service (FFS). We developed the content of  the survey based on interviews with officials from the Centers for  Medicare & Medicaid Services (CMS) and state Medicaid programs, and a  review of documents from CMS and external reports. Some content and  changes were made after pre-testing with state Medicaid programs.
Many of our survey questions focused on specific preventive services. For  example, the survey included questions about states’ coverage for adults,  and monitoring for adults and children, of several specific preventive  services including well-child and well-adult check ups, health risk  assessments, diabetes screening, cholesterol tests, cervical cancer  screening, mammography, colorectal cancer screening, and influenza  immunization. We asked about these specific preventive services because  they were related to recommended preventive services and to the services  we examined in our analysis of Medical Expenditure Panel Survey (MEPS)  and National Health Interview Survey (NHIS) data (see appendix II). We  did not ask about coverage of services for children because the children’s  Early and Periodic Screening, Diagnostic, and Treatment (EPSDT) benefit  is required to be covered under Medicaid.
To establish the reliability of our survey data, we spoke with  knowledgeable agency officials in developing the survey, pre-tested the  survey questions, and followed up with state Medicaid officials to achieve  a 100 percent response rate. Survey responses were submitted  electronically. In a few cases, when states gave responses that were  unclear or signaled the question was not completed, we followed up with  states to clarify their responses in order to ensure that their responses  contained the most accurate and current information available. We  determined that the data submitted by states were sufficiently reliable for  the purposes of our engagement.
section_title: Appendix IV: Comments from the Department of Health and Human Services
section_title: Appendix V: GAO Contact and Staff Acknowledgments
subsections: section_title: Staff Acknowledgments
paragraphs: In addition to the individual named above, Katherine M. Iritani, Acting  Director; Emily Beller; Susannah Bloch; Elizabeth Deyo; Erin Henderson;  Martha Kelly; Teresa Tam; and Hemi Tewarson made key contributions to  this report.
section_title: Related GAO Products
paragraphs: Medicaid: Extent of Dental Disease in Children Has Not Decreased, and  Millions Are Estimated to Have Untreated Tooth Decay. GAO-08-1121.  Washington, D.C.: September 23, 2008.
State Children’s Health Insurance Program: Program Structure,  Enrollment and Expenditure Experiences, and Outreach Approaches for  States That Cover Adults. GAO-08-50. Washington, D.C.: November 26,  2007.
Medicaid: Concerns Remain about Sufficiency of Data for Oversight of  Children’s Dental Services. GAO-07-826T. Washington, D.C.: May 2, 2007.
Childhood Obesity: Factors Affecting Physical Activity. GAO-07-260R.  Washington, D.C.: December 6, 2006.
Childhood Obesity: Most Experts Identified Physical Activity and the  Use of Best Practices as Key to Successful Programs. GAO-06-127R.  Washington, D.C.: October 7, 2005.
Medicaid Managed Care: Access and Quality Requirements Specific to  Low-Income and Other Special Needs Enrollees. GAO-05-44R.  Washington, D.C.: December 8, 2004.
Medicare Preventive Services: Most Beneficiaries Receive Some but Not  All Recommended Preventive Services. GAO-04-1004T. Washington, D.C.:  September 21, 2004.
Medicaid and SCHIP: States Use Varying Approaches to Monitor  Children’s Access to Care. GAO-03-222. Washington, D.C.: January 14,  2003.
Medicare: Most Beneficiaries Receive Some but Not All Recommended  Preventive Services. GAO-03-958. Washington, D.C.: September 8, 2003.
Medicare: Use of Preventive Services Is Growing but Varies Widely.  GAO-02-777T. Washington, D.C.: May 23, 2002.
Medicare: Beneficiary Use of Clinical Preventive Services. GAO-02-422.  Washington, D.C.: April 10, 2002.
Medicaid: Stronger Efforts Needed to Ensure Children’s Access to Health  Screening Services. GAO-01-749. Washington, D.C.: July 13, 2001.
Lead Poisoning: Federal Health Care Programs Are Not Effectively  Reaching At-Risk Children. HEHS-99-18. Washington, D.C.:   January 15, 1999.
Medicaid Managed Care: Challenge of Holding Plans Accountable  Requires Greater State Effort. GAO/HEHS-97-86. Washington, D.C.:   May 16, 1997.
Medicare: Provision of Key Preventive Diabetes Services Falls Short of  Recommended Levels. T-HEHS-97-113. Washington, D.C.: April 11, 1997.