Medicaid Preventive Services: Concerted Efforts Needed to Ensure Beneficiaries Receive Services
Released: 2009-09-14T00:00:00

Letter

Background

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.

State Medicaid Programs Must Cover Comprehensive Health Check Ups for Children

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.

State Medicaid Programs Are Not Required to Cover Preventive Services for Adults

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.

National Surveys Show That Certain Health Conditions Are Prevalent among Children and Adults in Medicaid, and Receipt of Recommended Preventive Services Varies Widely

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.

For Medicaid Children, Obesity Is a Health Condition of Great Concern: Nearly One in Five Examined Were Obese

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.

Among Medicaid Children, Almost Half Did Not Receive a Well-Child Check Up during a 2-Year Period

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.

Among Medicaid Adults, Nearly 6 in 10 Had One or More Health Conditions that Could Be Identified or Managed by Preventive Services

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.

Medicaid Adults’ Receipt of Recommended Preventive Services Varied Widely by Service

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.

For Children in Medicaid, Most State Medicaid Programs Reported Monitoring and Promoting the Provision of Preventive Services

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.

Most State Medicaid Programs Reported Monitoring and Setting Goals for Medicaid Children’s Utilization of Preventive Services

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.

Most State Medicaid Programs Reported Multiple Initiatives Aimed at Improving Provision of Preventive Services for Children in Medicaid and Viewed Certain Initiatives as Successful

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.

For Adults, Most State Medicaid Programs Reported Covering Some but Not All Recommended Preventive Services

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.

CMS Oversight of the Provision of Preventive Services Primarily Focuses on Children’s Services, and Gaps in Oversight Remain

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.

For Children in Medicaid, CMS Oversight Focuses Largely on Collecting State EPSDT Reports; CMS Reviews Few EPSDT Programs, Including Those with Low Participant Ratios

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.

For Adults in Medicaid, CMS Has Recognized the Value of Preventive Services and Provided Oversight by Issuing Some Related Guidance for State Medicaid Programs

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.

Conclusions

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.

Recommendations for Executive Action

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.

Agency Comments

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.

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Appendix I: NHANES Analysis

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.

Appendix II: MEPS and NHIS Analyses

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.

Appendix III: State Medicaid Director Survey Results

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.

Appendix IV: Comments from the Department of Health and Human Services

Appendix V: GAO Contact and Staff Acknowledgments

Staff Acknowledgments

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.

Related GAO Products

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.