This is the accessible text file for GAO report number GAO-09-578
entitled 'Medicaid Preventive Services: Concerted Efforts Needed to
Ensure Beneficiaries Receive Services' which was released on
September 14, 2009.
This text file was formatted by the U.S. Government Accountability
Office (GAO) to be accessible to users with visual impairments, as part
of a longer term project to improve GAO products' accessibility. Every
attempt has been made to maintain the structural and data integrity of
the original printed product. Accessibility features, such as text
descriptions of tables, consecutively numbered footnotes placed at the
end of the file, and the text of agency comment letters, are provided
but may not exactly duplicate the presentation or format of the printed
version. The portable document format (PDF) file is an exact electronic
replica of the printed version. We welcome your feedback. Please E-mail
your comments regarding the contents or accessibility features of this
document to Webmaster@gao.gov.
This is a work of the U.S. government and is not subject to copyright
protection in the United States. It may be reproduced and distributed
in its entirety without further permission from GAO. Because this work
may contain copyrighted images or other material, permission from the
copyright holder may be necessary if you wish to reproduce this
material separately.
Report to the Chairman, Committee on Finance, U.S. Senate:
United States Government Accountability Office:
GAO:
August 2009:
Medicaid Preventive Services:
Concerted Efforts Needed to Ensure Beneficiaries Receive Services:
GAO-09-578:
GAO Highlights:
Highlights of GAO-09-578, a report to the Chairman, Committee on
Finance, U.S. Senate.
Why GAO Did This Study:
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.
What GAO Found:
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.
What GAO Recommends:
GAO recommends that CMS (1) ensure that state Early and Periodic
Screening, Diagnostic, and Treatment (EPSDT) programs are regularly
reviewed, and (2) expedite its 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 services, for
adults. CMS concurred with GAO’s recommendations.
View [hyperlink, http://www.gao.gov/products/GAO-09-578] or key
components. For more information, contact Alicia Puente Cackley at
(202) 512-7114 or cackleya@gao.gov.
[End of section]
Contents:
Letter:
Results in Brief:
Background:
National Surveys Show That Certain Health Conditions Are Prevalent
among Children and Adults in Medicaid, and Receipt of Recommended
Preventive Services Varies Widely:
For Children in Medicaid, Most State Medicaid Programs Reported
Monitoring and Promoting the Provision of Preventive Services:
For Adults, Most State Medicaid Programs Reported Covering Some but Not
All Recommended Preventive Services:
CMS Oversight of the Provision of Preventive Services Primarily Focuses
on Children's Services, and Gaps in Oversight Remain:
Conclusions:
Recommendations for Executive Action:
Agency Comments:
Appendix I: NHANES Analysis:
Appendix II: MEPS and NHIS Analyses:
Appendix III: State Medicaid Director Survey Results:
Appendix IV: Comments from the Department of Health and Human Services:
Appendix V: GAO Contact and Staff Acknowledgments:
Related GAO Products:
Tables:
Table 1: Estimated Percentage of Children Aged 2 through 20 with
Certain Health Conditions, by Health Insurance Status:
Table 2: Estimated Percentage of Obese Children Aged 2 through 20 Who
Had Not Been Previously Diagnosed as Overweight, by Health Insurance
Status:
Table 3: Estimated Percentage of Adults Aged 21 through 64 with Certain
Health Conditions, by Health Insurance Status:
Table 4: Of Adults Aged 21 through 64 Found to Have Health Conditions:
Estimated Percentage Who Had Not Been Diagnosed by a Health Care
Professional, by Health Insurance Status:
Table 5: Estimated Percentage of Children Who Received a Well-Child
Check Up During a 2-Year Period, by Health Insurance Status:
Table 6: Estimated Percentage of Children Who Received Certain
Preventive Services, by Health Insurance Status:
Table 7: Estimated Percentage of Adults Who Received Certain Preventive
Services, by Health Insurance Status:
Table 8: Number of State Medicaid Programs Reporting Covering Certain
Preventive Services:
Table 9: Number of State Medicaid Programs Reporting Covering Services
to Manage Identified Health Conditions:
Table 10: Information State Medicaid Programs Reported Reviewing to
Monitor Utilization of Preventive Services:
Table 11: Number of State Medicaid Programs Reporting Monitoring
Utilization of Specific Services for Adults and Children in Medicaid,
by Service Delivery Model:
Table 12: Reasons Reported by State Medicaid Programs for Not
Monitoring Utilization of Covered Preventive Services for Children,
Beyond Federally Required Monitoring:
Table 13: Reasons Reported by State Medicaid Programs for Not
Monitoring Utilization of Covered Preventive Services for Adults:
Table 14: Number of State Medicaid Programs Reporting Utilization Goals
for Certain Preventive Services for Children, and Whether Goals Were
Being Met, by Service Delivery Model:
Table 15: Number of State Medicaid Programs Reporting Utilization Goals
for Certain Preventive Services for Adults, and Whether Goals Were
Being Met, by Service Delivery Model:
Table 16: Number of State Medicaid Programs Reporting Certain Barriers
to Meeting Utilization Goals:
Table 17: Initiatives State Medicaid Programs Reported Having
Implemented that Pertain to Either Managed Care or Fee-For-Service
Delivery Systems:
Table 18: Number of State Medicaid Programs Reporting that Implemented
Initiatives Had or Had Not Improved Provider Participation or Provision
of Preventive Services:
Table 19: Number of State Medicaid Programs Reporting Certain
Initiatives Designed to Increase Medicaid Children's and Adults' Use of
Preventive Services Since 2004, by Service Delivery Model:
Table 20: Number of State Medicaid Programs Reporting Certain Efforts
Geared Specifically Toward Diagnosing and Treating Obesity, and
Complications Related to Obesity, by Service Delivery Model:
Figures:
Figure 1: Estimated Percentage of Children in Medicaid Aged 2 through
20 Who Were Obese Compared to the National Goal for 2010:
Figure 2: Estimated Percentage of Children in Medicaid Who Did and Did
Not Receive a Well-Child Check Up during a 2-Year Period, by Age:
Figure 3: Estimated Prevalence of Certain Health Conditions among
Adults Aged 21 through 64, by Health Insurance Status:
Figure 4: Estimated Percentage of Adults Aged 21 through 64 in Medicaid
with Health Conditions Who Reported Their Conditions Had or Had Not
Been Diagnosed:
Figure 5: Estimated Receipt of Certain Recommended Preventive Services
among Adults in Medicaid:
Figure 6: Number of State Medicaid Programs Reporting that They
Monitored Children's Utilization of Specific Preventive Services:
Figure 7: Number of State Medicaid Programs that Reported Covering
Certain Recommended Preventive Services for Adults and Health Risk
Assessments or Well-Adult Check Ups:
Figure 8: Variation in State Medicaid Programs' Fiscal Year 2007
Participant Ratios:
Abbreviations:
ACIP: Advisory Committee on Immunization Practices:
AHRQ: Agency for Healthcare Research and Quality:
BMI: body mass index:
CDC: Centers for Disease Control and Prevention:
CMS: Centers for Medicare & Medicaid Services:
EPSDT: Early and Periodic Screening, Diagnostic, and Treatment:
FFS: fee-for-service:
HHS: Department of Health and Human Services:
MCO: managed care organization:
MEPS: Medical Expenditure Panel Survey:
mg/dL: milligrams per deciliter:
mmHg: millimeters of mercury:
NHANES: National Health and Nutrition Examination Survey:
NHIS: National Health Interview Survey:
OBRA 89: Omnibus Budget Reconciliation Act of 1989:
CHIP: State Children's Health Insurance Program:
SMDL: State Medicaid Director Letter:
USPSTF: United States Preventive Services Task Force:
[End of section]
United States Government Accountability Office:
Washington, DC 20548:
August 14, 2009:
The Honorable Max Baucus:
Chairman:
Committee on Finance:
United States Senate:
Dear Mr. Chairman:
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.[Footnote 1] 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.[Footnote 2] For adults aged 21 and older in Medicaid,
coverage of preventive services is generally not required.[Footnote 3]
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.[Footnote 4] 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.[Footnote 5] 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.[Footnote 6]
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,[Footnote 7] 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.[Footnote 8] For adults,[Footnote 9] we estimated the
prevalence of certain health conditions that can be identified or
managed by USPSTF recommended preventive services[Footnote 10] and were
prevalent enough to examine reliably: high blood pressure, high
cholesterol, obesity, and diabetes.[Footnote 11] 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).[Footnote 12] For children,[Footnote 13] 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:[Footnote 14] blood pressure
tests, cholesterol tests, cervical cancer screening,[Footnote 15]
mammography, colorectal cancer screening, diet and exercise counseling,
and influenza immunizations.[Footnote 16] 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).[Footnote 17]
For both adults and children, we analyzed data for the Medicaid and
privately insured populations.[Footnote 18]
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).
[Footnote 19] 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:[Footnote 20] 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.[Footnote 21] 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.[Footnote 22] 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.[Footnote 23]
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.
Results in Brief:
National survey 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
that adults' receipt of preventive services varies widely depending on
the service. According to estimates based on analyses of NHANES, MEPS,
and NHIS data:
* Medicaid children under age 21 are at risk of having certain health
conditions and many are not receiving well-child check ups. NHANES
examination data from 1999 through 2006 suggest that nearly one in five
Medicaid children aged 2 through 20 (an estimated 18 percent) were
obese, and about half of these children, or their parents, reported
that they had not previously been diagnosed as overweight. Compared to
privately insured children, a higher percentage of Medicaid children
were obese. Other health conditions of concern were less common than
obesity but still prevalent: an estimated 4 percent of Medicaid
children aged 8 through 20 had high blood pressure, and an estimated 10
percent of Medicaid children aged 6 through 20 had high cholesterol.
Furthermore, MEPS data from 2003 through 2006 suggest that Medicaid
children often do not receive well-child check ups--an estimated 41
percent of children in Medicaid did not receive a well-child check up
during a 2-year period.
* Medicaid adults are also an at-risk population--more than half have
one or more of the health conditions reviewed--and their receipt of
preventive services varies widely depending on the service. NHANES data
from 1999 through 2006 suggest that nearly 6 in 10 Medicaid adults aged
21 through 64 (an estimated 57 percent) were obese or had high blood
pressure, high cholesterol, diabetes, or a combination of these health
conditions; Medicaid adults also had higher rates of obesity and
diabetes than adults with private health coverage. With regard to the
receipt of preventive services, national data showed mixed results.
MEPS data from 2003 through 2006 suggest that Medicaid adults' reported
rates of receipt of recommended preventive services varied
substantially by service: for example, an estimated 93 percent of
Medicaid adults received a blood pressure test during the 2 years prior
to the survey, while an estimated 41 percent of Medicaid adults of the
age for whom a colorectal cancer screening was recommended ever
received one. Compared to adults with private insurance, a lower
percentage of adults covered by Medicaid received preventive services.
For children in Medicaid, who generally are entitled to coverage of
EPSDT services, most states reported in our survey that they monitored
and set goals for children's utilization of preventive services, and
had undertaken initiatives to promote the provision of preventive
services to children. Nine states reported that they did not monitor
children's utilization of specific preventive services such as well-
child check ups. States more frequently monitored and set goals for
utilization of services for children receiving services from managed
care organizations than for children in fee-for-service. Most states
reported implementing, since 2004, multiple initiatives to improve the
provision of preventive services.
For adults in Medicaid, for whom coverage of preventive services is
generally not required, most state Medicaid programs reported covering
some but not all of the preventive services we asked about on our
survey. Of the eight recommended preventive 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 other services were reported as
covered by three-quarters or more of the states. The two remaining
recommended preventive services were covered by a minority of states:
less than one-third reported covering intensive counseling to manage
obesity and intensive counseling to manage high cholesterol. Thirty-
nine states reported covering well-adult check ups or health risk
assessments for adults, which provide an opportunity for delivering
recommended preventive services such as blood pressure tests and
obesity screenings.
For children in Medicaid, CMS oversees the provision of services by
collecting and publishing state EPSDT reports and conducting occasional
reviews of state programs, but gaps in oversight remain. For adults in
Medicaid, CMS oversight is more limited. For children:
* CMS collects reports from states on the provision of EPSDT services;
reports from fiscal year 2000 through 2007 show that most states are
not achieving CMS's 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. State reports for 2007 showed that, on average, 58 percent of
Medicaid children received at least one EPSDT well-child check up for
which they were eligible; rates in individual states varied from 25 to
79 percent.
* CMS also oversees states' EPSDT programs through occasional reviews
of individual state programs, but conducts few such reviews. CMS's
reviews examine different aspects of these programs, including how
states ensure that beneficiaries have access to and information about
EPSDT well-child check ups and other services. The reviews have
identified problems with service delivery and other aspects of EPSDT
programs, and have required corrective action or recommended specific
improvements. CMS conducted only 11 EPSDT program reviews between April
2001 and June 2009, including few reviews of programs with low reported
rates of provision of EPSDT services. CMS does not have formal criteria
or time frames for reviewing individual EPSDT programs. Instead,
according to CMS officials, ESPDT reviews are performed at the
discretion of CMS regional offices.
* CMS provides other guidance to states on EPSDT, such as through the
published State Medicaid Manual, and officials have recognized the need
for--but not yet begun drafting--additional guidance on EPSDT coverage
of obesity screening and services to manage childhood obesity. A 2006
study raised concerns that Medicaid providers may not be aware of to
what extent obesity services were covered or reimbursed under EPSDT,
and that states' provider manuals did not often explain this coverage.
In response, CMS officials said they intend to develop new guidance for
states on this topic, but as of the time of our review had not done so.
For adults, CMS has recognized the value of preventive services by
providing some related guidance to states. However, the guidance has
not included the recommended preventive services that we examined.
To improve the extent to which children in Medicaid receive EPSDT
services for which they are eligible, we are recommending that CMS
ensure that state EPSDT programs are regularly reviewed. To support
states' efforts to cover appropriate preventive services, we are
recommending that CMS expedite its 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.
In commenting on a draft of this report, CMS concurred with both of our
recommendations, and commented that the agency recognizes the need for
and the value of preventive services. In response to our recommendation
that CMS expedite its effort to provide guidance on coverage of obesity-
related services for Medicaid children, CMS committed to providing this
guidance by the end of 2009. CMS also commented that it 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. We incorporated technical comments from
CMS as appropriate.
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.[Footnote 24] 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.[Footnote 25] 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.[Footnote 26] 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,[Footnote 27] 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.
[Footnote 28] 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.
[Footnote 29] 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
figure 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.[Footnote 30]
Among privately insured children, an estimated 14 percent were obese.
Figure 1: Estimated Percentage of Children in Medicaid Aged 2 through
20 Who Were Obese Compared to the National Goal for 2010:
[Refer to PDF for image: vertical bar graph]
Age: 2-11;
Percent obese: 15%.
Age: 12-20;
Percent obese: 22%.
Age: all ages;
Percent obese: 18%.
Healthy People 2010 goal for all children: 5%.
Source: GAO analysis of 1999 through 2006 NHANES data and Healthy
People 2010 target goals.
Note: The NHANES data for children in Medicaid also include children in
CHIP, which we estimate to be about 16 percent of the total during 1999
through 2006. The Healthy People 2010 target goal is for 5 percent or
less of all children to be overweight or obese.
[End of figure]
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.[Footnote 31] 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,[Footnote 32] 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.[Footnote 33] 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 figure 2). In comparison, the estimated proportions of privately
insured children who had received a well-child check up were generally
similar.
Figure 2: Estimated Percentage of Children in Medicaid Who Did and Did
Not Receive a Well-Child Check Up during a 2-Year Period, by Age:
[Refer to PDF for image: stacked vertical bar graph]
Ages: 2-4;
Did receive a well-child check up: 78%;
Did not receive a well-child check up: 22%.
Ages: 5-7;
Did receive a well-child check up: 60%;
Did not receive a well-child check up: 40%.
Ages: 8-10;
Did receive a well-child check up: 52%;
Did not receive a well-child check up: 48%.
Ages: 11-13;
Did receive a well-child check up: 60%;
Did not receive a well-child check up: 40%.
Ages: 14-16;
Did receive a well-child check up: 51%;
Did not receive a well-child check up: 49%.
Ages: 17-20;
Did receive a well-child check up: 46%;
Did not receive a well-child check up: 54%.
Ages: All ages;
Did receive a well-child check up: 59%;
Did not receive a well-child check up: 41%.
Source: GAO analysis of 2003 through 2006 MEPS data.
Note: The MEPS data for children in Medicaid also include children in
CHIP, which we estimate to be about 18 percent of the total during 2003
through 2006. MEPS collects information for each person in the
household based on information provided by one adult member of the
household.
[End of figure]
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.[Footnote 34] 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.[Footnote 35] 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.
[Footnote 36] Obesity was the most common of these health conditions;
an estimated 42 percent of adults in Medicaid aged 21 through 64 were
obese (see figure 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 figure 3).
Figure 3: Estimated Prevalence of Certain Health Conditions among
Adults Aged 21 through 64, by Health Insurance Status:
[Refer to PDF for image: multiple vertical bar graph]
Condition: Obesity[A];
Privately insured adults aged 21 through 64: 32%;
Medicaid adults aged 21 through 64: 42%.
Condition: High blood pressure;
Privately insured adults aged 21 through 64: 23%;
Medicaid adults aged 21 through 64: 27%.
Condition: High cholesterol;
Privately insured adults aged 21 through 64: 16%;
Medicaid adults aged 21 through 64: 19%.
Condition: Diabetes[A];
Privately insured adults aged 21 through 64: 7%;
Medicaid adults aged 21 through 64: 13%.
Condition: One or more of these conditions:
Privately insured adults aged 21 through 64: 53%;
Medicaid adults aged 21 through 64: 57%.
Source: GAO analysis of 1999 through 2006 NHANES data.
Note: We also estimated the prevalence of these health conditions after
adjusting for age differences between these two health insurance
groups. After adjusting for age, the prevalence differences between the
two insurance groups widened by a few percentage points for each health
condition we analyzed--the percentage of privately insured adults with
each condition was about 1 to 2 percentage points lower, and the
percentage of Medicaid adults with each condition was about 1 to 4
percentage points higher.
[A] Differences in rates of obesity and diabetes between health
insurance groups were statistically significant at the 95 percent
confidence level.
[End of figure]
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.[Footnote 37] 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 figure 4). These estimates were
similar to those of privately insured adults.
Figure 4: Estimated Percentage of Adults Aged 21 through 64 in Medicaid
with Health Conditions Who Reported Their Conditions Had or Had Not
Been Diagnosed:
[Refer to PDF for image: stacked vertical bar graph]
Condition: Obesity;
Reported had been previously diagnosed: 65%;
Reported had not been previously diagnosed: 35%.
Condition: High blood pressure;
Reported had been previously diagnosed: 75%;
Reported had not been previously diagnosed: 25%.
Condition: High cholesterol;
Reported had been previously diagnosed: 65%;
Reported had not been previously diagnosed: 35%.
Condition: Diabetes;
Reported had been previously diagnosed: 83%;
Reported had not been previously diagnosed: 17%.
Condition: One or more of these conditions;
Reported had been previously diagnosed: 60%;
Reported had not been previously diagnosed: 40%.
Source: GAO analysis of 1999 through 2006 NHANES data.
[End of figure]
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.[Footnote 38] Similarly, estimates
based on NHIS data suggest that only 33 percent of adults in Medicaid
aged 21 through 64 with high blood pressure[Footnote 39] had received a
screening test for diabetes within the past 3 years[Footnote 40] (see
figure 5).
Figure 5: Estimated Receipt of Certain Recommended Preventive Services
among Adults in Medicaid:
[Refer to PDF for image: horizontal bar graph]
Service: Blood pressure test (within 2 years);
Percent: 93%.
Service: Cervical cancer screen (within 3 years);
Percent: 90%.
Service: Cholesterol test (within 5 years);
Percent: 77%.
Service: Mammogram (within 2 years);
Percent: 66%.
Service: Diet or exercise advice (ever);
Percent: 64%.
Service: Colorectal cancer screen (ever);
Percent: 41%.
Service: Influenza immunization (within 1 year);
Percent: 37%.
Service: Diabetes screen (within 3 years);
Percent: 33%.
Source: GAO analysis of 2003 through 2006 MEPS data and 2006 NHIS data.
[End of figure]
Notes: Analyses were restricted to those adults aged 21 through 64 that
fit the age, gender, or health risk factor criteria for each
recommended service (for example, analysis of receipt of mammograms was
restricted to women aged 40 through 64; see appendix II for more
information). Results for all services except diabetes screening were
based on 2003 through 2006 MEPS data; the result for diabetes screening
was based on 2006 NHIS data.
[End of figure]
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.[Footnote 41]
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 figure 6).
Figure 6: Number of State Medicaid Programs Reporting that They
Monitored Children's Utilization of Specific Preventive Services:
[Refer to PDF for image: horizontal bar graph]
Service: Well-child check up or health risk assessment;
Number of state Medicaid programs: 42%.
Service: Number or receipt of any preventive service;
Number of state Medicaid programs: 40%.
Service: Cervical cancer screen;
Number of state Medicaid programs: 20%.
Service: Diabetes screen;
Number of state Medicaid programs: 18%.
Service: Cholesterol test;
Number of state Medicaid programs: 12%.
Service: Obesity screen;
Number of state Medicaid programs: 11%.
Service: Blood pressure test;
Number of state Medicaid programs: 10%.
Source: GAO analysis of survey of state Medicaid directors, conducted
between October 2008 and February 2009.
[End of figure]
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.[Footnote 42] 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.
[Footnote 43] 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.[Footnote
44] 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.[Footnote 45]
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.[Footnote 46] 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 figure 7).[Footnote
47] 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.)
Figure 7: Number of State Medicaid Programs that Reported Covering
Certain Recommended Preventive Services for Adults and Health Risk
Assessments or Well-Adult Check Ups:
[Refer to PDF for image: horizontal bar graph]
Service: Cervical cancer screen for women aged 21–64;
Number of state Medicaid programs: 49%.
Service: Mammography for women aged 40–64;
Number of state Medicaid programs: 48%.
Service: Colorectal cancer screen for adults aged 50–64;
Number of state Medicaid programs: 47%.
Service: Influenza immunization for adults aged 50–64;
Number of state Medicaid programs: 46%.
Service: Diabetes screen for adults with high blood pressure aged 21–
64;
Number of state Medicaid programs: 43%.
Service: Well-adult check up or health risk assessment for adults aged
21–64;
Number of state Medicaid programs: 39%.
Service: Cholesterol test for men aged 35–64 and adults aged 21–64 with
risk factors for heart disease;
Number of state Medicaid programs: 39%.
Service: Intensive counseling to manage high cholesterol for adults
aged 21–64;
Number of state Medicaid programs: 14%.
Service: Intensive counseling to manage obesity for adults aged 21–64;
Number of state Medicaid programs: 13%.
Source: GAO analysis of survey of state Medicaid directors, conducted
between October 2008 and February 2009.
Notes: Well-adult check ups or health risk assessments for adults,
while not explicitly recommended by the USPSTF, provide an opportunity
for delivering recommended preventive services such as blood pressure
tests and obesity screenings. Figure numbers do not include states that
reported that a service was covered under managed care but not under
fee-for-service.
[End of figure]
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.[Footnote 48] 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.[Footnote 49] 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,[Footnote 50] 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.[Footnote 51]
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.[Footnote 52] Individual states reported ratios ranging
from 25 to 79 percent, and 11 states had ratios under 50 percent (see
figure 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.
Figure 8: Variation in State Medicaid Programs' Fiscal Year 2007
Participant Ratios:
[Refer to PDF for image: vertical bar graph]
Participant ratio: 0-9%;
Number of state Medicaid programs: 0.
Participant ratio: 10-19%;
Number of state Medicaid programs: 0.
Participant ratio: 20-29%;
Number of state Medicaid programs: 1%.
Participant ratio: 30-39%;
Number of state Medicaid programs: 1%.
Participant ratio: 40-49%;
Number of state Medicaid programs: 9%.
Participant ratio: 50-59%;
Number of state Medicaid programs: 19%.
Participant ratio: 60-69%;
Number of state Medicaid programs: 16%.
Participant ratio: 70-79%;
Number of state Medicaid programs: 4%.
Participant ratio: 80-89%;
Number of state Medicaid programs: 0.
Participant ratio: 90-100%;
Number of state Medicaid programs: 0.
Source: GAO analysis of 2007 CMS 416 reports.
Notes: The participant ratio reflects the percentage of children who
received at least one EPSDT well-child check up or service that they
should have received during the year--CMS's goal for the participant
ratio is 80 percent. Only 50 states are shown because 1 state reported
a participant ratio of greater than 100 percent; as noted earlier, CMS
officials told us that this ratio cannot be correct.
[End of figure]
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.[Footnote 53] 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[Footnote 54]--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.
[Footnote 55] 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.
[Footnote 56] 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.[Footnote 57] 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.[Footnote 58] 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 appendix 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 [hyperlink,
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.
Sincerely yours,
Signed by:
Alicia Puente Cackley:
Director, Health Care:
[End of section]
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.[Footnote 59] 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.[Footnote 60]
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.[Footnote 61]
* 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.[Footnote 62] 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.[Footnote 63] 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.
[Footnote 64]
Table 1: Estimated Percentage of Children Aged 2 through 20 with
Certain Health Conditions, by Health Insurance Status:
Obesity: all children (2-20): Private insurance;
95 percent confidence interval: Percentage: 14.23[A];
95 percent confidence interval: Lower bound: 12.88;
95 percent confidence interval: Upper bound: 15.59.
Obesity: all children (2-20): Medicaid;
95 percent confidence interval: Percentage: 17.77[A];
95 percent confidence interval: Lower bound: 15.63;
95 percent confidence interval: Upper bound: 19.90.
Obesity: children (2-11): Private insurance;
95 percent confidence interval: Percentage: 12.62[A];
95 percent confidence interval: Lower bound: 10.99;
95 percent confidence interval: Upper bound: 14.25.
Obesity: children (2-11): Medicaid;
95 percent confidence interval: Percentage: 15.47[A];
95 percent confidence interval: Lower bound: 13.15;
95 percent confidence interval: Upper bound: 17.79.
Obesity: children (12-20): Private insurance;
95 percent confidence interval: Percentage: 15.84[A];
95 percent confidence interval: Lower bound: 14.13;
95 percent confidence interval: Upper bound: 17.55.
Obesity: children (12-20): Medicaid;
95 percent confidence interval: Percentage: 22.08[A];
95 percent confidence interval: Lower bound: 18.62;
95 percent confidence interval: Upper bound: 25.53.
High blood pressure: all children (8-20): Private insurance;
95 percent confidence interval: Percentage: 3.05;
95 percent confidence interval: Lower bound: 2.42;
95 percent confidence interval: Upper bound: 3.68.
High blood pressure: all children (8-20): Medicaid;
95 percent confidence interval: Percentage: 4.38;
95 percent confidence interval: Lower bound: 2.81;
95 percent confidence interval: Upper bound: 5.96.
High blood pressure: children (8-11): Private insurance;
95 percent confidence interval: Percentage: 3.40;
95 percent confidence interval: Lower bound: 2.23;
95 percent confidence interval: Upper bound: 4.56.
High blood pressure: children (8-11): Medicaid;
95 percent confidence interval: Percentage: 5.48;
95 percent confidence interval: Lower bound: 2.77;
95 percent confidence interval: Upper bound: 8.19.
High blood pressure: children (12-20): Private insurance;
95 percent confidence interval: Percentage: 2.90;
95 percent confidence interval: Lower bound: 2.18;
95 percent confidence interval: Upper bound: 3.62.
High blood pressure: children (12-20): Medicaid;
95 percent confidence interval: Percentage: 3.63;
95 percent confidence interval: Lower bound: 2.17;
95 percent confidence interval: Upper bound: 5.09.
High blood cholesterol: all children (6-20): Private insurance;
95 percent confidence interval: Percentage: 10.91;
95 percent confidence interval: Lower bound: 9.82;
95 percent confidence interval: Upper bound: 12.00.
High blood cholesterol: all children (6-20): Medicaid;
95 percent confidence interval: Percentage: 9.80;
95 percent confidence interval: Lower bound: 8.02;
95 percent confidence interval: Upper bound: 11.57.
High blood cholesterol: children (6-11): Private insurance;
95 percent confidence interval: Percentage: 11.13;
95 percent confidence interval: Lower bound: 9.36;
95 percent confidence interval: Upper bound: 12.89.
High blood cholesterol: children (6-11): Medicaid;
95 percent confidence interval: Percentage: 10.06;
95 percent confidence interval: Lower bound: 7.11;
95 percent confidence interval: Upper bound: 13.00.
High blood cholesterol: children (12-20): Private insurance;
95 percent confidence interval: Percentage: 10.78;
95 percent confidence interval: Lower bound: 9.17;
95 percent confidence interval: Upper bound: 12.39.
High blood cholesterol: children (12-20): Medicaid;
95 percent confidence interval: Percentage: 9.54;
95 percent confidence interval: Lower bound: 7.71;
95 percent confidence interval: Upper bound: 11.37.
Source: GAO analysis of 1999 through 2006 NHANES data.
Notes: The Medicaid category included some children enrolled in CHIP.
Of the total Medicaid and CHIP population of children, about 16 percent
were enrolled in CHIP during the 1999 through 2006 period. Obesity for
children aged 2 through 19 was defined as having a BMI equal to or
greater than 95th percentile of age and sex-specific BMI, based on CDC
growth charts for the United States. Obesity for children aged 20 was
defined as having a BMI of 30 or higher. Girls who were pregnant were
not included in the obesity analysis. NHANES measured blood pressure up
to four times during its physical examination. For our analysis, we
calculated the average of the blood pressure measurements and defined
high blood pressure in children aged 8 through 17 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. For children aged
18 through 20 we defined high blood pressure as having an average
systolic blood pressure reading of 140 mmHg or higher or having an
average diastolic blood pressure of 90 mmHg or higher. Blood pressure
was not measured in children younger than age 8. High blood cholesterol
in children aged 6 through 20 was defined as equal to or greater than
200 mg/dL. Blood cholesterol was not measured in children younger than
age 6 in the 2004 through 2005 NHANES or in children younger than age 3
in the 1999 through 2004 NHANES.
[A] The difference between the percentage for children covered by
Medicaid compared to the percentage for children covered by private
insurance is statistically significant at the 95 percent confidence
level.
[End of table]
Table 2: Estimated Percentage of Obese Children Aged 2 through 20 Who
Had Not Been Previously Diagnosed as Overweight, by Health Insurance
Status:
All children (2-20): Private insurance;
95 percent confidence interval: Percentage: 65.39[A];
95 percent confidence interval: Lower bound: 61.49;
95 percent confidence interval: Upper bound: 69.30.
All children (2-20): Medicaid;
95 percent confidence interval: Percentage: 54.18[A];
95 percent confidence interval: Lower bound: 48.09;
95 percent confidence interval: Upper bound: 60.26.
Children 2-11: Private insurance;
95 percent confidence interval: Percentage: 76.02[A];
95 percent confidence interval: Lower bound: 71.32;
95 percent confidence interval: Upper bound: 80.72.
Children 2-11: Medicaid;
95 percent confidence interval: Percentage: 58.44[A];
95 percent confidence interval: Lower bound: 50.95;
95 percent confidence interval: Upper bound: 65.93.
Children 12-20: Private insurance;
95 percent confidence interval: Percentage: 56.97;
95 percent confidence interval: Lower bound: 51.79;
95 percent confidence interval: Upper bound: 62.15.
Children 12-20: Medicaid;
95 percent confidence interval: Percentage: 48.57;
95 percent confidence interval: Lower bound: 39.16;
95 percent confidence interval: Upper bound: 57.99.
Source: GAO analysis of 1999 through 2006 NHANES data.
Notes: The Medicaid category included some children enrolled in CHIP.
Of the total Medicaid and CHIP population of children, about 16 percent
were enrolled in CHIP during the 1999 through 2006 period. Parents of
children aged 2 through 11 years were asked, "Has a doctor or health
professional ever told you that [child] was overweight?" Parents of
those aged 12 through 15 years were asked, "Has a doctor or health
professional ever told [child] that he/she was overweight?" Those aged
16 through 20 years were asked, "Has a doctor or health professional
ever told you that you were overweight?" Obesity for children aged 2
through 19 was defined as having a BMI equal to or greater than 95th
percentile of age and sex-specific BMI, based on CDC growth charts for
the United States. Obesity for children age 20 was defined as having a
BMI of 30 or higher. Girls who were pregnant were not included in the
analysis.
[A] The difference between the percentage for children covered by
Medicaid compared to the percentage for children covered by private
insurance is statistically significant at the 95 percent confidence
level.
[End of table]
Table 3: Estimated Percentage of Adults Aged 21 through 64 with Certain
Health Conditions, by Health Insurance Status:
Obesity: Private insurance;
95 percent confidence interval: Percentage: 31.95[A];
95 percent confidence interval: Lower bound: 30.18;
95 percent confidence interval: Upper bound: 33.72.
Obesity: Medicaid;
95 percent confidence interval: Percentage: 41.96[A];
95 percent confidence interval: Lower bound: 36.99;
95 percent confidence interval: Upper bound: 46.93.
High blood pressure: Private insurance;
95 percent confidence interval: Percentage: 23.21;
95 percent confidence interval: Lower bound: 21.84;
95 percent confidence interval: Upper bound: 24.57.
High blood pressure: Medicaid;
95 percent confidence interval: Percentage: 26.68;
95 percent confidence interval: Lower bound: 22.78;
95 percent confidence interval: Upper bound: 30.58.
High blood cholesterol: Private insurance;
95 percent confidence interval: Percentage: 16.31;
95 percent confidence interval: Lower bound: 15.19;
95 percent confidence interval: Upper bound: 17.42.
High blood cholesterol: Medicaid;
95 percent confidence interval: Percentage: 18.87;
95 percent confidence interval: Lower bound: 15.14;
95 percent confidence interval: Upper bound: 22.60.
Diabetes: Private insurance;
95 percent confidence interval: Percentage: 7.28[A];
95 percent confidence interval: Lower bound: 6.13;
95 percent confidence interval: Upper bound: 8.43.
Diabetes: Medicaid;
95 percent confidence interval: Percentage: 12.62[A];
95 percent confidence interval: Lower bound: 8.43;
95 percent confidence interval: Upper bound: 16.82.
One or more of the above conditions: Private insurance;
95 percent confidence interval: Percentage: 52.91;
95 percent confidence interval: Lower bound: 50.56;
95 percent confidence interval: Upper bound: 55.26.
One or more of the above conditions: Medicaid;
95 percent confidence interval: Percentage: 57.00;
95 percent confidence interval: Lower bound: 49.67;
95 percent confidence interval: Upper bound: 64.33.
Source: GAO analysis of 1999 through 2006 NHANES data.
Notes: Obesity for adults was defined as BMI of 30 or higher (pregnant
women were not included in the obesity analysis). NHANES measured blood
pressure up to four times during its physical examination. For our
analysis, we calculated the average of the blood pressure measurements
and applied CDC's definition of high blood pressure for adults as
having an average systolic blood pressure reading of 140 mmHg or
higher, or having an average diastolic blood pressure reading of 90
mmHg or higher. Following CDC, we additionally included adults taking
blood pressure lowering medication in this category. We also used CDC's
definitions of the other health conditions examined. High total blood
cholesterol for adults was defined as 240 mg/dL or more. Diabetes for
adults was defined as fasting plasma glucose of 126 mg/dL or more, or
previously diagnosed with diabetes. Examination sampling weights were
used for analyses of obesity, blood pressure, and blood cholesterol.
Diabetes subsample weights were used for analyses of diabetes and one
or more conditions. We also estimated the prevalence of these health
conditions after adjusting for age differences between these two health
insurance groups. After adjusting for age, the prevalence differences
between the two insurance groups widened by a few percentage points for
each health condition we analyzed--the percentage of privately insured
adults with each condition was about 1 to 2 percentage points lower,
and the percentage of Medicaid adults with each condition was about 1
to 4 percentage points higher.
[A] The difference between the percentage for adults covered by
Medicaid compared to the percentage for adults covered by private
insurance is statistically significant at the 95 percent confidence
level.
[End of table]
Table 4: Of Adults Aged 21 through 64 Found to Have Health Conditions:
Estimated Percentage Who Had Not Been Diagnosed by a Health Care
Professional, by Health Insurance Status:
Obesity: Private insurance;
95 percent confidence interval: Percentage: 30.18;
95 percent confidence interval: Lower bound: 28.39;
95 percent confidence interval: Upper bound: 31.97.
Obesity: Medicaid;
95 percent confidence interval: Percentage: 34.90;
95 percent confidence interval: Lower bound: 28.00;
95 percent confidence interval: Upper bound: 41.79.
High blood pressure: Private insurance;
95 percent confidence interval: Percentage: 26.31;
95 percent confidence interval: Lower bound: 23.50;
95 percent confidence interval: Upper bound: 29.11.
High blood pressure: Medicaid;
95 percent confidence interval: Percentage: 24.60;
95 percent confidence interval: Lower bound: 15.14;
95 percent confidence interval: Upper bound: 34.05.
High blood cholesterol: Private insurance;
95 percent confidence interval: Percentage: 36.36;
95 percent confidence interval: Lower bound: 32.75;
95 percent confidence interval: Upper bound: 39.97.
High blood cholesterol: Medicaid;
95 percent confidence interval: Percentage: 34.64;
95 percent confidence interval: Lower bound: 23.77;
95 percent confidence interval: Upper bound: 45.51.
Diabetes: Private insurance;
95 percent confidence interval: Percentage: 23.71;
95 percent confidence interval: Lower bound: 17.56;
95 percent confidence interval: Upper bound: 29.86.
Diabetes: Medicaid;
95 percent confidence interval: Percentage: 16.71;
95 percent confidence interval: Lower bound: 6.50;
95 percent confidence interval: Upper bound: 26.91.
One or more of the above conditions: Private insurance;
95 percent confidence interval: Percentage: 35.49;
95 percent confidence interval: Lower bound: 32.97;
95 percent confidence interval: Upper bound: 38.02.
One or more of the above conditions: Medicaid;
95 percent confidence interval: Percentage: 39.60;
95 percent confidence interval: Lower bound: 32.57;
95 percent confidence interval: Upper bound: 46.63.
Source: GAO analysis of 1999 through 2006 NHANES data.
Notes: Obesity for adults was defined as BMI of 30 or higher (pregnant
women were not included in the obesity analysis). NHANES measured blood
pressure up to four times during its physical examination. For our
analysis, we calculated the average of the blood pressure measurements
and applied CDC's definition of high blood pressure for adults as
having an average systolic blood pressure reading of 140 mmHg or
higher, or having an average diastolic blood pressure reading of 90
mmHg or higher. Following CDC, we additionally included adults taking
blood pressure lowering medication in this category. We also used CDC's
definitions of the other health conditions examined. High total blood
cholesterol for adults was defined as 240 mg/dL or more. Diabetes for
adults was defined as fasting plasma glucose of 126 mg/dL or more, or
previously diagnosed with diabetes. Adults were asked if they had ever
been told by a health care professional that they were overweight or
had high blood pressure, high cholesterol, or diabetes. Examination
sampling weights were used for analyses of obesity, blood pressure, and
blood cholesterol. Diabetes subsample weights were used for analyses of
diabetes and one or more conditions. No differences between health
insurance groups were statistically significant at the 95 percent
confidence level.
[End of table]
[End of section]
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.[Footnote 65] As with the National Health and Nutrition
Examination Survey (NHANES) data described in appendix I, we analyzed
results for children under age 21[Footnote 66] 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.[Footnote 67] 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.[Footnote 68] 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[Footnote 69] (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.[Footnote 70] 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.
Table 5: Estimated Percentage of Children Who Received a Well-Child
Check Up During a 2-Year Period, by Health Insurance Status:
All children (2-20): Private insurance;
95 percent confidence interval: Percentage: 63.66;
95 percent confidence interval: Lower bound: 60.65;
95 percent confidence interval: Upper bound: 66.67.
All children (2-20): Medicaid;
95 percent confidence interval: Percentage: 59.25;
95 percent confidence interval: Lower bound: 55.50;
95 percent confidence interval: Upper bound: 63.01.
Children 2-4: Private insurance;
95 percent confidence interval: Percentage: 86.65[A];
95 percent confidence interval: Lower bound: 82.63;
95 percent confidence interval: Upper bound: 90.67.
Children 2-4: Medicaid;
95 percent confidence interval: Percentage: 77.54[A];
95 percent confidence interval: Lower bound: 71.45;
95 percent confidence interval: Upper bound: 83.64.
Children 5-7: Private insurance;
95 percent confidence interval: Percentage: 70.02[A];
95 percent confidence interval: Lower bound: 64.52;
95 percent confidence interval: Upper bound: 75.51.
Children 5-7: Medicaid;
95 percent confidence interval: Percentage: 59.81[A];
95 percent confidence interval: Lower bound: 53.15;
95 percent confidence interval: Upper bound: 66.48.
Children 8-10: Private insurance;
95 percent confidence interval: Percentage: 53.03;
95 percent confidence interval: Lower bound: 46.52;
95 percent confidence interval: Upper bound: 59.53.
Children 8-10: Medicaid;
95 percent confidence interval: Percentage: 52.02;
95 percent confidence interval: Lower bound: 44.43;
95 percent confidence interval: Upper bound: 59.61.
Children 11-13: Private insurance;
95 percent confidence interval: Percentage: 59.99;
95 percent confidence interval: Lower bound: 53.03;
95 percent confidence interval: Upper bound: 66.95.
Children 11-13: Medicaid;
95 percent confidence interval: Percentage: 59.63;
95 percent confidence interval: Lower bound: 51.35;
95 percent confidence interval: Upper bound: 67.92.
Children 14-16: Private insurance;
95 percent confidence interval: Percentage: 65.17;
95 percent confidence interval: Lower bound: 58.53;
95 percent confidence interval: Upper bound: 71.82.
Children 14-16: Medicaid;
95 percent confidence interval: Percentage: 51.49;
95 percent confidence interval: Lower bound: 44.30;
95 percent confidence interval: Upper bound: 58.68.
Children 17-20: Private insurance;
95 percent confidence interval: Percentage: 53.06;
95 percent confidence interval: Lower bound: 47.18;
95 percent confidence interval: Upper bound: 58.95.
Children 17-20: Medicaid;
95 percent confidence interval: Percentage: 45.92;
95 percent confidence interval: Lower bound: 37.15;
95 percent confidence interval: Upper bound: 54.68.
Source: GAO analysis of 2003 through 2006 MEPS data.
Notes: The Medicaid category included some children enrolled in CHIP.
Of the total Medicaid and CHIP population of children, about 18 percent
were enrolled in CHIP during the 2003 through 2006 period. Age ranges
refer to children's ages at the end of the 2-year period analyzed. The
pooled set of 2-year periods analyzed were calendar years 2003 through
2004, 2004 through 2005, and 2005 through 2006. Medical visits were
considered well-child check ups if the reason given for the visit was
either a well-child check up, a general examination, or shots and
immunizations.
[A] The difference between the percentage for children covered by
Medicaid compared to the percentage for children covered by private
insurance is statistically significant at the 95 percent confidence
level.
[End of table]
Table 6: Estimated Percentage of Children Who Received Certain
Preventive Services, by Health Insurance Status:
Blood pressure test, within 2 years: Children aged 2-20: Private
insurance;
95 percent confidence interval: Percentage: 68.48[A];
95 percent confidence interval: Lower bound: 66.97;
95 percent confidence interval: Upper bound: 69.99.
Blood pressure test, within 2 years: Children aged 2-20: Medicaid;
95 percent confidence interval: Percentage: 63.03[A];
95 percent confidence interval: Lower bound: 61.33;
95 percent confidence interval: Upper bound: 64.72.
Diet or exercise advice, within 2 years: Children aged 2-17: Private
insurance;
95 percent confidence interval: Percentage: 53.95;
95 percent confidence interval: Lower bound: 52.16;
95 percent confidence interval: Upper bound: 55.74.
Diet or exercise advice, within 2 years: Children aged 2-17: Medicaid;
95 percent confidence interval: Percentage: 52.27;
95 percent confidence interval: Lower bound: 50.59;
95 percent confidence interval: Upper bound: 53.94.
Height and weight measured, within 2 years, Children aged 2-17: Private
insurance;
95 percent confidence interval: Percentage: 90.36[A];
95 percent confidence interval: Lower bound: 89.23;
95 percent confidence interval: Upper bound: 91.50.
Height and weight measured, within 2 years, Children aged 2-17:
Medicaid;
95 percent confidence interval: Percentage: 88.16[A];
95 percent confidence interval: Lower bound: 87.05;
95 percent confidence interval: Upper bound: 89.28.
Source: GAO analysis of 2003 through 2006 MEPS data.
Note: The Medicaid category included some children enrolled in CHIP. Of
the total Medicaid and CHIP population of children, about 18 percent
were enrolled in CHIP during the 2003 through 2006 period.
[A] The difference between the percentage for children covered by
Medicaid compared to the percentage for children covered by private
insurance is statistically significant at the 95 percent confidence
level.
[End of table]
Table 7: Estimated Percentage of Adults Who Received Certain Preventive
Services, by Health Insurance Status:
Blood pressure test, within 2 years, Men and women aged 21-64: Private
insurance;
95 percent confidence interval: Percentage: 92.58;
95 percent confidence interval: Lower bound: 92.19;
95 percent confidence interval: Upper bound: 92.97.
Blood pressure test, within 2 years, Men and women aged 21-64:
Medicaid;
95 percent confidence interval: Percentage: 92.79;
95 percent confidence interval: Lower bound: 91.67;
95 percent confidence interval: Upper bound: 93.91.
Cholesterol test, within 5 years, Men aged 35-64; men and women aged 21-
64 with risk factors for heart disease[A]: Private insurance;
95 percent confidence interval: Percentage: 85.34[D];
95 percent confidence interval: Lower bound: 84.57;
95 percent confidence interval: Upper bound: 86.11.
Cholesterol test, within 5 years, Men aged 35-64; men and women aged 21-
64 with risk factors for heart disease[A]: Medicaid;
95 percent confidence interval: Percentage: 76.89[D];
95 percent confidence interval: Lower bound: 74.96;
95 percent confidence interval: Upper bound: 78.82.
Cervical cancer screen, within 3 years[B], Women aged 21-64, no
hysterectomy: Private insurance;
95 percent confidence interval: Percentage: 92.18[D];
95 percent confidence interval: Lower bound: 91.55;
95 percent confidence interval: Upper bound: 92.80.
Cervical cancer screen, within 3 years[B], Women aged 21-64, no
hysterectomy: Medicaid;
95 percent confidence interval: Percentage: 90.22[D];
95 percent confidence interval: Lower bound: 88.59;
95 percent confidence interval: Upper bound: 91.85.
Mammogram, within 2 years, Women aged 40-64: Private insurance;
95 percent confidence interval: Percentage: 80.09[D];
95 percent confidence interval: Lower bound: 79.09;
95 percent confidence interval: Upper bound: 81.10.
Mammogram, within 2 years, Women aged 40-64: Medicaid;
95 percent confidence interval: Percentage: 65.87[D];
95 percent confidence interval: Lower bound: 2.52;
95 percent confidence interval: Upper bound: 69.21.
Colorectal cancer screen, ever, Men and women aged 50-64: Private
insurance;
95 percent confidence interval: Percentage: 56.21[D];
95 percent confidence interval: Lower bound: 54.79;
95 percent confidence interval: Upper bound: 57.63.
Colorectal cancer screen, ever, Men and women aged 50-64: Medicaid;
95 percent confidence interval: Percentage: 41.23[D];
95 percent confidence interval: Lower bound: 37.01;
95 percent confidence interval: Upper bound: 45.44.
Influenza immunization, within 1 year, Men and women aged 50-64:
Private insurance;
95 percent confidence interval: Percentage: 36.66;
95 percent confidence interval: Lower bound: 35.45;
95 percent confidence interval: Upper bound: 37.87.
Influenza immunization, within 1 year, Men and women aged 50-64:
Medicaid;
95 percent confidence interval: Percentage: 37.17;
95 percent confidence interval: Lower bound: 33.43;
95 percent confidence interval: Upper bound: 40.92.
Diet or exercise advice, ever, Obese men and women aged 21-64[C]:
Private insurance;
95 percent confidence interval: Percentage: 65.65;
95 percent confidence interval: Lower bound: 64.51;
95 percent confidence interval: Upper bound: 66.79.
Diet or exercise advice, ever, Obese men and women aged 21-64[C]:
Medicaid;
95 percent confidence interval: Percentage: 63.65;
95 percent confidence interval: Lower bound: 60.76;
95 percent confidence interval: Upper bound: 66.54.
Diabetes screen, within 3 years, Men and women aged 21-64 with high
blood pressure, not previously diagnosed with diabetes: Private
insurance;
95 percent confidence interval: Percentage: 45.56[D];
95 percent confidence interval: Lower bound: 42.99;
95 percent confidence interval: Upper bound: 48.14.
Diabetes screen, within 3 years, Men and women aged 21-64 with high
blood pressure, not previously diagnosed with diabetes: Medicaid
95 percent confidence interval: Percentage: 32.57[D];
95 percent confidence interval: Lower bound: 26.23;
95 percent confidence interval: Upper bound: 38.90.
Source: GAO analysis of 2003 through 2006 MEPS and 2006 NHIS data.
Notes: Preventive services other than diabetes screening were examined
using 2003 through 2006 MEPS data. Diabetes screening was examined
using 2006 NHIS data. Populations analyzed for each preventive service
were based on USPSTF recommendations as of March 2009; these
recommendations had been in effect as of 2003 or earlier.
[A] Risk factors for heart disease were based on available self
reported health conditions of MEPS participants--high blood pressure,
height and weight corresponding to a BMI of 30 or higher, and diabetes.
[B] MEPS questions use the term Pap test to refer to a cervical cancer
screen.
[C] Obesity was defined as having a BMI of 30 or higher.
[D] The difference between the percentage for adults covered by
Medicaid compared to the percentage for adults covered by private
insurance is statistically significant at the 95 percent confidence
level.
[End of table]
[End of section]
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.[Footnote 71] 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.
Table 8: Number of State Medicaid Programs Reporting Covering Certain
Preventive Services:
Service: Cervical cancer screening for women aged 21-64[A];
Number of states: 49.
Service: Mammography for women aged 40-64;
Number of states: 48.
Service: Colorectal cancer screening for adults aged 50-64[A];
Number of states: 47.
Service: Influenza vaccine for adults aged 50-64[B];
Number of states: 46.
Service: Diabetes screening for adults aged 21-64 with high blood
pressure[C];
Number of states: 43.
Service: Well-adult check up or health risk assessment for adults aged
21-64[D];
Number of states: 39.
Service: Cholesterol test for men aged 35-64 and adults aged 21-64 with
risk factors for heart disease[C];
Number of states: 39.
Service: Intensive counseling to manage high cholesterol for adults
aged 21-64;
Number of states: 14.
Service: Intensive counseling to manage obesity for adults aged 21-64;
Number of states: 13.
Source: GAO analysis of survey of state Medicaid directors, conducted
between October 2008 and February 2009.
[A] One other state Medicaid program reported that this service was not
covered under FFS but was covered by MCOs.
[B] Two other state Medicaid programs reported that this service was
not covered under FFS but was covered by MCOs.
[C] Three other state Medicaid programs reported that this service was
not covered under FFS but was covered by MCOs.
[D] Well-adult check ups or health risk assessments for adults, while
not explicitly recommended by the USPSTF, provide an opportunity for
delivering recommended preventive services such as blood pressure tests
and obesity screenings. Four other state Medicaid programs reported
that this service was not covered under FFS but was covered by MCOs.
[End of table]
Table 9: Number of State Medicaid Programs Reporting Covering Services
to Manage Identified Health Conditions:
Service: High blood pressure;
Nutrition assessment and counseling: 16 (31%);
Condition-specific intensive counseling: 14 (27%);
Medication: 42 (82%);
Equipment for monitoring and control: 16 (31%);
Other: 6 (12%);
None of these are covered: 5 (10%).
Service: High cholesterol;
Nutrition assessment and counseling: 17 (33%);
Condition-specific intensive counseling: 14 (27%);
Medication: 42 (82%);
Equipment for monitoring and control: 4 (8%);
Other: 6 (12%);
None of these are covered: 6 (12%).
Service: Diabetes;
Nutrition assessment and counseling: 25 (49%);
Condition-specific intensive counseling: 21 (41%);
Medication: 43 (84%);
Equipment for monitoring and control: 35 (69%);
Other: 7 (14%);
None of these are covered: 3 (6%).
Service: Obesity;
Nutrition assessment and counseling: 16 (31%);
Condition-specific intensive counseling: 13 (25%);
Medication: 17 (33%);
Equipment for monitoring and control: 4 (8%);
Other: 14 (27%);
None of these are covered: 11 (22%).
Source: GAO analysis of survey of state Medicaid directors, conducted
between October 2008 and February 2009.
[End of table]
Table 10: Information State Medicaid Programs Reported Reviewing to
Monitor Utilization of Preventive Services:
Type of information: CMS 416 reports;
Number of states reviewing information: 45 (88%).
Type of information: Healthcare Effectiveness Data and Information Set
(HEDIS) or HEDIS-like data;
Number of states reviewing information: 44 (86%).
Type of information: External quality review reports;
Number of states reviewing information: 40 (78%).
Type of information: Fee-for-service claims or encounter data;
Number of states reviewing information: 38 (75%).
Type of information: Consumer Assessment of Healthcare Providers and
Systems data;
Number of states reviewing information: 36 (71%).
Type of information: Encounter data required to be provided by MCOs;
Number of states reviewing information: 34 (67%).
Type of information: Contract deliverables of a Primary Care Case
Manager or Administrative Services Organization;
Number of states reviewing information: 14 (27%).
Type of information: Other[A];
Number of states reviewing information: 12 (24%).
Source: GAO analysis of survey of state Medicaid directors, conducted
between October 2008 and February 2009.
[A] Other information state Medicaid programs reported reviewing to
monitor utilization of preventive services included vaccine and lead
screening claims and pay for performance data. One state reported that
they did not review information to monitor utilization of preventive
services.
[End of table]
Table 11: Number of State Medicaid Programs Reporting Monitoring
Utilization of Specific Services for Adults and Children in Medicaid,
by Service Delivery Model:
Service: Total number or receipt of any preventive service;
Children in MCOs[A]: 32 (86%);
Adults in MCOs[B]: 22 (59%);
Children in FFS[C]: 26 (55%);
Adults in FFS[D]: 17 (35%).
Service: Well-child or well-adult check up;
Children in MCOs[A]: 33 (89%);
Adults in MCOs[B]: 11 (41%);
Children in FFS[C]: 26 (55%);
Adults in FFS[D]: 6 (20%).
Service: Health risk assessment;
Children in MCOs[A]: 15 (41%);
Adults in MCOs[B]: 11 (65%);
Children in FFS[C]: 9 (19%);
Adults in FFS[D]: 5 (21%).
Service: Blood pressure test;
Children in MCOs[A]: 10 (27%);
Adults in MCOs[B]: 15 (44%);
Children in FFS[C]: 1 (2%);
Adults in FFS[D]: 4 (8%).
Service: Obesity screening;
Children in MCOs[A]: 11 (30%);
Adults in MCOs[B]: 6 (18%);
Children in FFS[C]: 2 (4%);
Adults in FFS[D]: 3 (6%).
Service: Cholesterol test;
Children in MCOs[A]: 10 (27%);
Adults in MCOs[B]: 21 (66%);
Children in FFS[C]: 4 (9%);
Adults in FFS[D]: 9 (25%).
Service: Diabetes screening;
Children in MCOs[A]: 14 (38%);
Adults in MCOs[B]: 24 (67%);
Children in FFS[C]: 7 (15%);
Adults in FFS[D]: 10 (25%).
Service: Cervical cancer screening;
Children in MCOs[A]: 15 (41%);
Adults in MCOs[B]: 26 (70%);
Children in FFS[C]: 11 (23%);
Adults in FFS[D]: 15 (33%).
Service: Influenza immunization;
Children in MCOs[A]: [Empty];
Adults in MCOs[B]: 9 (26%);
Children in FFS[C]: [Empty];
Adults in FFS[D]: 10 (23%).
Service: Mammography;
Children in MCOs[A]: [Empty];
Adults in MCOs[B]: 24 (67%);
Children in FFS[C]: [Empty];
Adults in FFS[D]: 15 (33%).
Service: Colorectal cancer screening:
Children in MCOs[A]: [Empty];
Adults in MCOs[B]: 12 (33%);
Children in FFS[C]: [Empty];
Adults in FFS[D]: 10 (23%).
Source: GAO analysis of survey of state Medicaid directors, conducted
between October 2008 and February 2009.
Notes: Children were defined as Medicaid beneficiaries under age 21.
Adults were defined as Medicaid beneficiaries aged 21 through 64.
[A] Limited to states that contract with MCOs to deliver services to
some or all Medicaid children.
[B] Limited to states that contract with MCOs to deliver services to
some or all Medicaid adults and that reported covering the service.
[C] Limited to states that use FFS to deliver services to some or all
Medicaid children.
[D] Limited to states that use FFS to deliver services to some or all
Medicaid adults and that reported covering the service.
[End of table]
Table 12: Reasons Reported by State Medicaid Programs for Not
Monitoring Utilization of Covered Preventive Services for Children,
Beyond Federally Required Monitoring:
Reason: Administrative burden;
Number of states that cited reason: 21 (41%).
Reason: Technology challenges;
Number of states that cited reason: 20 (39%)
Reason: Other[A];
Number of states that cited reason: 17 (33%).
Reason: Data are unavailable;
Number of states that cited reason: 15 (29%).
Reason: Too expensive;
Number of states that cited reason: 9 (18%).
Reason: Not a top priority;
Number of states that cited reason: 7 (14%).
Source: GAO analysis of survey of state Medicaid directors, conducted
between October 2008 and February 2009.
Note: Children were defined as Medicaid beneficiaries under age 21.
[A] Other reasons state Medicaid programs reported for not monitoring
utilization of preventive services included inadequate staff resources
to monitor utilization of preventive services, providers are not
required to submit clinical information which would be necessary to
monitor utilization of preventive services, and MCOs have incomplete
data or are not required to monitor utilization.
[End of table]
Table 13: Reasons Reported by State Medicaid Programs for Not
Monitoring Utilization of Covered Preventive Services for Adults:
Reason: Administrative burden;
Number of states that cited reason: 27 (53%).
Reason: Technology challenges;
Number of states that cited reason: 22 (43%)
Reason: Other[A];
Number of states that cited reason: 17 (33%).
Reason: Data are unavailable;
Number of states that cited reason: 15 (29%).
Reason: Do not cover services, therefore do not monitor;
Number of states that cited reason: 12 (24%).
Reason: Not a top priority;
Number of states that cited reason: 11 (21%).
Reason: Too expensive;
Number of states that cited reason: 9 (18%).
Source: GAO analysis of survey of state Medicaid directors, conducted
between October 2008 and February 2009.
Note: Adults were defined as Medicaid beneficiaries aged 21 through 64.
[A] Other reasons state Medicaid programs reported for not monitoring
utilization of covered preventive services for adults included
inadequate staff resources to monitor utilization of preventive
services and that providers are not required to submit clinical
information which would be necessary to monitor utilization of
preventive services.
[End of table]
Table 14: Number of State Medicaid Programs Reporting Utilization Goals
for Certain Preventive Services for Children, and Whether Goals Were
Being Met, by Service Delivery Model:
Service: Total number or receipt of any preventive service;
MCO goals[A]: 19 (51%);
MCO goals: meeting goals[B]: 15 (79%);
FFS goals[C]: 11 (23%);
FFS goals: meeting goals[D]: 6 (55%).
Service: Well-child or well-adult check up;
MCO goals[A]: 25 (68%);
MCO goals: meeting goals[B]: 17 (68%);
FFS goals[C]: 16 (34%);
FFS goals: meeting goals[D]: 6 (38%).
Service: Health risk assessment;
MCO goals[A]: 7 (19%);
MCO goals: meeting goals[B]: 6 (86%);
FFS goals[C]: 5 (11%);
FFS goals: meeting goals[D]: 2 (40%).
Service: Blood pressure test;
MCO goals[A]: 4 (11%);
MCO goals: meeting goals[B]: 3 (75%);
FFS goals[C]: 3 (6%);
FFS goals: meeting goals[D]: 2 (67%).
Service: Obesity screening;
MCO goals[A]: 4 (11%);
MCO goals: meeting goals[B]: 3 (75%);
FFS goals[C]: 2 (4%);
FFS goals: meeting goals[D]: 1 (50%).
Service: Cholesterol test;
MCO goals[A]: 6 (16%);
MCO goals: meeting goals[B]: 5 (83%);
FFS goals[C]: 1 (2%);
FFS goals: meeting goals[D]: 1 (100%).
Service: Diabetes screening;
MCO goals[A]: 7 (19%);
MCO goals: meeting goals[B]: 5 (71%);
FFS goals[C]: 1 (2%);
FFS goals: meeting goals[D]: 1 (100%).
Service: Cervical cancer screening;
MCO goals[A]: 9 (24%);
MCO goals: meeting goals[B]: 5 (56%);
FFS goals[C]: 2 (4%);
FFS goals: meeting goals[D]: 0 (0%).
Source: GAO analysis of survey of state Medicaid directors, conducted
between October 2008 and February 2009.
Note: Children were defined as Medicaid beneficiaries under age 21.
[A] Limited to states that contract with MCOs to deliver services to
some or all Medicaid children.
[B] Limited to states that contract with MCOs to deliver services to
some or all Medicaid children and that reported setting goals for MCOs.
[C] Limited to states that use FFS for some or all Medicaid children.
[D] Limited to states that use FFS for some or all Medicaid children,
and that reported setting goals for FFS.
[End of table]
Table 15: Number of State Medicaid Programs Reporting Utilization Goals
for Certain Preventive Services for Adults, and Whether Goals Were
Being Met, by Service Delivery Model:
Service: Total number or receipt of any preventive service;
MCO goals[A]: 16 (43%);
MCO goals: meeting goals[B]: 12 (75%);
FFS goals[C]: 2 (4%);
FFS goals: meeting goals[D]: 0 (0%).
Service: Well-child or well-adult check up;
MCO goals[A]: 11 (32%);
MCO goals: meeting goals[B]: 9 (82%);
FFS goals[C]: 2 (6%);
FFS goals: meeting goals[D]: 0 (0%).
Service: Health risk assessment;
MCO goals[A]: 7 (25%);
MCO goals: meeting goals[B]: 5 (71%);
FFS goals[C]: 2 (7%);
FFS goals: meeting goals[D]: 1 (50%).
Service: Blood pressure test;
MCO goals[A]: 9 (26%);
MCO goals: meeting goals[B]: 7 (78%);
FFS goals[C]: 1 (3%);
FFS goals: meeting goals[D]: 1 (100%).
Service: Obesity screening;
MCO goals[A]: 2 (6%);
MCO goals: meeting goals[B]: 2 (100%);
FFS goals[C]: 0 (0%);
FFS goals: meeting goals[D]: 0 (0%).
Service: Cholesterol test;
MCO goals[A]: 12 (38%);
MCO goals: meeting goals[B]: 9 (75%);
FFS goals[C]: 4 (11%);
FFS goals: meeting goals[D]: 2 (5%).
Service: Diabetes screening;
MCO goals[A]: 14 (39%);
MCO goals: meeting goals[B]: 10 (71%);
FFS goals[C]: 4 (10%);
FFS goals: meeting goals[D]: 1 (25%).
Service: Cervical cancer screening:
MCO goals[A]: 15 (41%);
MCO goals: meeting goals[B]: 11 (73%);
FFS goals[C]: 4 (9%);
FFS goals: meeting goals[D]: 0 (0%).
Service: Influenza immunization;
MCO goals[A]: 3 (9%);
MCO goals: meeting goals[B]: 2 (67%);
FFS goals[C]: 5 (12%);
FFS goals: meeting goals[D]: 4 (80%).
Service: Mammography;
MCO goals[A]: 16 (44%);
MCO goals: meeting goals[B]: 1 (69%);
FFS goals[C]: 5 (11%);
FFS goals: meeting goals[D]: 1 (20%).
Service: Colorectal cancer screening;
MCO goals[A]: 6 (17%);
MCO goals: meeting goals[B]: 4 (67%);
FFS goals[C]: 1 (2%);
FFS goals: meeting goals[D]: 0 (0%).
Source: GAO analysis of survey of state Medicaid directors, conducted
between October 2008 and February 2009.
Notes: Limited to states that reported covering the service for adults.
Adults were defined as Medicaid beneficiaries aged 21 through 64.
[A] Limited to states that contract with MCOs to deliver services to
some or all Medicaid adults.
[B] Limited to states that contract with MCOs to deliver services to
some or all Medicaid adults and that reported setting goals for MCOs.
[C] Limited to states that use FFS for some or all Medicaid adults.
[D] Limited to states that use FFS for some or all Medicaid adults, and
that reported setting goals for FFS.
[End of table]
Table 16: Number of State Medicaid Programs Reporting Certain Barriers
to Meeting Utilization Goals:
Barrier: Other[A];
Number of states that cited barrier: 34 (67%).
Barrier: Beneficiaries not concerned with preventive services:
Number of states that cited barrier: 16 (31%)
Barrier: Beneficiaries missing appointments: 13 (25%).
Number of states that cited barrier:
Barrier: Beneficiaries not able to get to appointments;
Number of states that cited barrier: 6 (12%).
Barrier: Insufficient state resources to raise payment rates to
increase provider participation in Medicaid;
Number of states that cited barrier: 5 (10%).
Barrier: There is not an adequate number of providers in general (to
serve both Medicaid and non-Medicaid populations);
Number of states that cited barrier: 3 (6%).
Barrier: There is not an adequate number of providers to serve the
Medicaid population;
Number of states that cited barrier: 2 (4%).
Barrier: Insufficient state legislative support to provide support
services that would make it easier for beneficiaries to access
services;
Number of states that cited barrier: 1 (2%).
Barrier: Insufficient state legislative support to increase coverage of
services;
Number of states that cited barrier: 0 (0%).
Source: GAO analysis of survey of state Medicaid directors, conducted
between October 2008 and February 2009.
[A] Other reported barriers included problems with provider performance
and incorrect billing by providers.
[End of table]
Table 17: Initiatives State Medicaid Programs Reported Having
Implemented that Pertain to Either Managed Care or Fee-For-Service
Delivery Systems:
Initiative: Increase payment rates for office visits and/or specific
preventive services;
Targeted to pediatric providers: 37 (73%);
Targeted to providers of adult services: 31 (61%);
Not applicable: 10 (20%).
Initiative: Streamline provider enrollment process;
Targeted to pediatric providers: 20 (39%);
Targeted to providers of adult services: 20 (39%);
Not applicable: 23 (45%).
Initiative: Streamline payment processing (including electronic
billing);
Targeted to pediatric providers: 29 (57%);
Targeted to providers of adult services: 30 (59%);
Not applicable: 16 (31%).
Initiative: Offer electronic health records;
Targeted to pediatric providers: 7 (14%);
Targeted to providers of adult services: 7 (14%);
Not applicable: 37 (73%).
Initiative: Utilize provider pay for performance program(s);
Targeted to pediatric providers: 16 (31%);
Targeted to providers of adult services: 14 (27%);
Not applicable: 27 (53%).
Initiative: Utilize health plan pay for performance program(s);
Targeted to pediatric providers: 20 (39%);
Targeted to providers of adult services: 20 (39%);
Not applicable: 24 (47%).
Initiative: Start a provider advisory panel;
Targeted to pediatric providers: 29 (57%);
Targeted to providers of adult services: 23 (45%);
Not applicable: 18 (35%).
Initiative: Educate providers about covered preventive services;
Targeted to pediatric providers: 42 (82%);
Targeted to providers of adult services: 30 (59%);
Not applicable: 9 (18%).
Initiative: Hire a primary care case management vendor or an
administrative services organization;
Targeted to pediatric providers: 15 (29%);
Targeted to providers of adult services: 17 (33%);
Not applicable: 27 (53%).
Initiative: Encourage providers to perform health risk assessments;
Targeted to pediatric providers: 20 (39%);
Targeted to providers of adult services: 16 (31%);
Not applicable: 26 (51%).
Initiative: Other initiative(s) to increase provider participation[A];
Targeted to pediatric providers: 15 (29%);
Targeted to providers of adult services: 11 (22%);
Not applicable: 24 (47%).
Initiative: Other initiative(s) to increase provision of preventive
services[B];
Targeted to pediatric providers: 19 (37%);
Targeted to providers of adult services: 12 (24%);
Not applicable: 22 (43%).
Source: GAO analysis of survey of state Medicaid directors, conducted
between October 2008 and February 2009.
[A] Other reported initiatives to increase provider participation
included forming relationships with provider associations or sending
mailings to providers and EPSDT beneficiaries regarding lead screening
and well check ups.
[B] Other reported initiatives to increase provision of preventive
services included financial incentives for providers and MCOs that
provide preventive services and pay for performance measures.
[End of table]
Table 18: Number of State Medicaid Programs Reporting that Implemented
Initiatives Had or Had Not Improved Provider Participation or Provision
of Preventive Services:
Implemented Initiative: Increase payment rates for office visits and/or
specific preventive services;
Major improvement: 3 (8%);
Minor improvement: 14 (37%);
No improvement: 4 (11%);
Don't know: 15 (39%).
Implemented Initiative: Streamline provider enrollment process;
Major improvement: 0 (0%);
Minor improvement: 7 (35%);
No improvement: 2 (10%);
Don't know: 9 (45%).
Implemented Initiative: Streamline payment processing (including
electronic billing);
Major improvement: 5 (17%);
Minor improvement: 6 (20%);
No improvement: 2 (7%);
Don't know: 11 (37%).
Implemented Initiative: Offer electronic health records;
Major improvement: 0 (0%);
Minor improvement: 0 (0%);
No improvement: 1 (14%);
Don't know: 6 (86%).
Implemented Initiative: Utilize provider pay for performance
program(s);
Major improvement: 2 (11%);
Minor improvement: 8 (42%);
No improvement: 1 (5%);
Don't know: 7 (37%).
Implemented Initiative: Utilize health plan pay for performance
program(s);
Major improvement: 6 (29%);
Minor improvement: 5 (24%);
No improvement: 2 (10%);
Don't know: 6 (29%).
Implemented Initiative: Start a provider advisory panel:
Major improvement: 3 (10%);
Minor improvement: 8 (28%);
No improvement: 3 (10%);
Don't know: 13 (45%).
Implemented Initiative: Educate providers about covered preventive
services;
Major improvement: 3 (7%);
Minor improvement: 16 (38%);
No improvement: 0 (0%);
Don't know: 20 (48%).
Implemented Initiative: Hire a primary care case management vendor or
an administrative services organization;
Major improvement: 6 (35%);
Minor improvement: 2 (12%);
No improvement: 1 (6%);
Don't know: 6 (35%).
Implemented Initiative: Encourage providers to perform health risk
assessments;
Major improvement: 3 (15%);
Minor improvement: 6 (30%);
No improvement: 1 (5%);
Don't know: 8 (40%).
Implemented Initiative: Other initiative(s) to increase provider
participation;
Major improvement: 1 (7%);
Minor improvement: 4 (27%);
No improvement: 0 (0%);
Don't know: 5 (33%).
Implemented Initiative: Other initiative(s) to increase provision of
preventive services;
Major improvement: 3 (15%);
Minor improvement: 2 (10%);
No improvement: 0 (0%);
Don't know: 7 (35%).
Source: GAO analysis of survey of state Medicaid directors, conducted
between October 2008 and February 2009.
Note: Limited to states that reported having implemented the
initiative.
[End of table]
Table 19: Number of State Medicaid Programs Reporting Certain
Initiatives Designed to Increase Medicaid Children's and Adults' Use of
Preventive Services Since 2004, by Service Delivery Model:
Initiative: Encourage use of preventive services through direct
outreach (e.g., phone, mail);
Targeted to children in MCOs[A]: 31 (84%);
Targeted to adults in MCOs[B]: 22 (59%);
Targeted to children in FFS[C]: 32 (68%);
Targeted to adults in FFS[D]: 19 (40%).
Initiative: Encourage use of preventive services through nonmonetary
incentives;
Targeted to children in MCOs[A]: 24 (65%);
Targeted to adults in MCOs[B]: 18 (49%);
Targeted to children in FFS[C]: 5 (11%);
Targeted to adults in FFS[D]: 4 (8%).
Initiative: Encourage use of preventive services through monetary
incentives;
Targeted to children in MCOs[A]: 17 (46%);
Targeted to adults in MCOs[B]: 16 (43%);
Targeted to children in FFS[C]: 9 (19%);
Targeted to adults in FFS[D]: 8 (17%).
Initiative: Encourage use of preventive services by reducing cost
sharing;
Targeted to children in MCOs[A]: 4 (11%);
Targeted to adults in MCOs[B]: 4 (11%);
Targeted to children in FFS[C]: 3 (6%);
Targeted to adults in FFS[D]: 2 (4%).
Initiative: Promote medical home initiatives;
Targeted to children in MCOs[A]: 25 (68%);
Targeted to adults in MCOs[B]: 23 (62%);
Targeted to children in FFS[C]: 25 (53%);
Targeted to adults in FFS[D]: 23 (48%).
Initiative: Publicize or encourage/require health plans to publicize
availability of preventive services for Medicaid beneficiaries;
Targeted to children in MCOs[A]: 26 (70%);
Targeted to adults in MCOs[B]: 22 (59%);
Targeted to children in FFS[C]: 15 (32%);
Targeted to adults in FFS[D]: 8 (17%).
Initiative: Provide case management services to follow up with
beneficiaries after an initial diagnosis;
Targeted to children in MCOs[A]: 25 (68%);
Targeted to adults in MCOs[B]: 22 (59%);
Targeted to children in FFS[C]: 16 (34%);
Targeted to adults in FFS[D]: 18 (38%).
Initiative: Provide disease management programs;
Targeted to children in MCOs[A]: 30 (81%);
Targeted to adults in MCOs[B]: 32 (86%);
Targeted to children in FFS[C]: 21 (45%);
Targeted to adults in FFS[D]: 28 (58%).
Initiative: Promote healthy lifestyle choices such as exercise,
nutrition, and tobacco cessation;
Targeted to children in MCOs[A]: 30 (81%);
Targeted to adults in MCOs[B]: 30 (81%);
Targeted to children in FFS[C]: 23 (49%);
Targeted to adults in FFS[D]: 26 (54%).
Initiative: Expand coverage of preventive services;
Targeted to children in MCOs[A]: 9 (24%);
Targeted to adults in MCOs[B]: 9 (24%);
Targeted to children in FFS[C]: 7 (15%);
Targeted to adults in FFS[D]: 11 (23%).
Initiative: Provide scheduling assistance;
Targeted to children in MCOs[A]: 22 (59%);
Targeted to adults in MCOs[B]: 17 (46%);
Targeted to children in FFS[C]: 13 (28%);
Targeted to adults in FFS[D]: 10 (21%).
Initiative: Provide childcare;
Targeted to children in MCOs[A]: 1 (3%);
Targeted to adults in MCOs[B]: 2 (5%);
Targeted to children in FFS[C]: 0 (0%);
Targeted to adults in FFS[D]: 0 (0%).
Initiative: Encourage doctors to provide evening appointments;
Targeted to children in MCOs[A]: 18 (49%);
Targeted to adults in MCOs[B]: 17 (46%);
Targeted to children in FFS[C]: 11 (23%);
Targeted to adults in FFS[D]: 10 (21%).
Initiative: Other[E];
Targeted to children in MCOs[A]: 4 (11%);
Targeted to adults in MCOs[B]: 5 (14%);
Targeted to children in FFS[C]: 0 (0%);
Targeted to adults in FFS[D]: 1 (2%).
Source: GAO analysis of survey of state Medicaid directors, conducted
between October 2008 and February 2009.
Notes: Children were defined as Medicaid beneficiaries under age 21.
Adults were defined as Medicaid beneficiaries aged 21 through 64.
[A] Limited to states that contract with MCOs to deliver services to
some or all Medicaid children.
[B] Limited to states that contract with MCOs to deliver services to
some or all Medicaid adults.
[C] Limited to states that use FFS to deliver services to some or all
Medicaid children.
[D] Limited to states that use FFS to deliver services to some or all
Medicaid adults.
[E] Other reported initiatives included translation services, pay for
performance, and child care for pregnant women.
[End of table]
Table 20: Number of State Medicaid Programs Reporting Certain Efforts
Geared Specifically Toward Diagnosing and Treating Obesity, and
Complications Related to Obesity, by Service Delivery Model:
Effort: Promote weight reduction programs for Medicaid beneficiaries;
Targeted to children in MCOs[A]: 13 (35%);
Targeted to adults in MCOs[B]: 11 (30%);
Targeted to children in FFS[C]: 4 (9%);
Targeted to adults in FFS[D]: 3 (6%).
Effort: Promote childhood obesity programs for Medicaid beneficiaries
(either within specific counties or regions or throughout the state);
Targeted to children in MCOs[A]: 23 (62%);
Targeted to adults in MCOs[B]: 3 (8%);
Targeted to children in FFS[C]: 8 (17%);
Targeted to adults in FFS[D]: 3 (6%).
Effort: Educate providers to perform obesity screenings on Medicaid
beneficiaries;
Targeted to children in MCOs[A]: 26 (70%);
Targeted to adults in MCOs[B]: 14 (38%);
Targeted to children in FFS[C]: 12 (26%);
Targeted to adults in FFS[D]: 7 (15%).
Effort: Educate providers to offer obesity counseling as needed to
Medicaid beneficiaries;
Targeted to children in MCOs[A]: 23 (62%);
Targeted to adults in MCOs[B]: 13 (35%);
Targeted to children in FFS[C]: 9 (19%);
Targeted to adults in FFS[D]: 6 (13%).
Effort: Provide reimbursement information for nutrition assessment and
counseling for obese adults in documentation for providers;
Targeted to children in MCOs[A]: 9 (24%);
Targeted to adults in MCOs[B]: 11 (30%);
Targeted to children in FFS[C]: 7 (15%);
Targeted to adults in FFS[D]: 10 (21%).
Effort: Provide reimbursement information for nutrition assessment and
counseling for overweight children in documentation for providers;
Targeted to children in MCOs[A]: 13 (35%);
Targeted to adults in MCOs[B]: 7 (19%);
Targeted to children in FFS[C]: 9 (19%);
Targeted to adults in FFS[D]: 1 (2%).
Effort: Promote family-based obesity initiatives;
Targeted to children in MCOs[A]: 9 (24%);
Targeted to adults in MCOs[B]: 5 (14%);
Targeted to children in FFS[C]: 3 (6%);
Targeted to adults in FFS[D]: 3 (6%).
Effort: Other[E];
Targeted to children in MCOs[A]: 4 (11%);
Targeted to adults in MCOs[B]: 2 (5%);
Targeted to children in FFS[C]: 1 (2%);
Targeted to adults in FFS[D]: 1 (2%).
Source: GAO analysis of survey of state Medicaid directors, conducted
between October 2008 and February 2009.
Notes: Children were defined as Medicaid beneficiaries under age 21.
Adults were defined as Medicaid beneficiaries aged 21 through 64.
[A] Limited to states that contract with MCOs to deliver services to
some or all Medicaid children.
[B] Limited to states that contract with MCOs to deliver services to
some or all Medicaid adults.
[C] Limited to states that use FFS to deliver services to some or all
Medicaid children.
[D] Limited to states that use FFS to deliver services to some or all
Medicaid adults.
[E] Other initiatives included development of body mass index
performance measures and statewide public health initiatives that
include, but are not limited to the Medicaid population.
[End of table]
[End of section]
Appendix IV: Comments from the Department of Health and Human Services:
Department Of Health & Human Services:
Office Of The Secretary:
Assistant Secretary For Legislation:
Washington, DC 2020:
July 13, 2009:
Alicia Puente Cackley:
Director, Health Care:
U.S. Government Accountability Office:
441 G Street N.W.
Washington, DC 20548:
Dear Ms. Cackley:
Enclosed are comments on the U.S. Government Accountability Office's
(GAO) report entitled: "Medicaid Preventive Services: Concerted Efforts
Needed to Ensure Beneficiaries Receive Services" (GAO-09-578).
The Department appreciates the opportunity to review this report before
its publication.
Sincerely,
Signed by:
Barbara Pisaro Clark:
Acting Assistant Secretary for Legislation:
Attachment:
[End of letter]
Department Of Health & Human Services:
Administrator:
Centers for Medicare & Medicaid Services:
Washington, DC 20201:
Date: July 19. 2009
To: Alicia Puente Cackley:
Director, Health Care:
Government Accountability Office:
From: [Signed by] Charlene Frizzera:
Acting Administrator:
Subject: Government Accountability Office (GAO) Draft Report: Medicaid
Preventive Services: Concerted Efforts Needed to Ensure Beneficiaries
Receive Services (GAO-09-578):
Thank you for the opportunity to review and comment on the GAO Draft
Report entitled: "Medicaid Preventive Services: Concerted Efforts
Needed to Ensure Beneficiaries Receive Services" (GAO-09-578). The
report was prepared at the request of Senator Max Battens. The purpose
of the report was to examine the extent to which:
1) Children and adults in Medicaid have certain conditions that can be
identified or managed by preventive services (utilizing data from the
Department of Health and Human Services' (HHS) National Health and
Nutrition Examination Survey);
2) State Medicaid programs monitor and promote the provision of
preventive services for children in Medicaid, for whom coverage of
Early and Periodic Screening, Diagnostic and Treatment (EPSDT) services
is generally required (utilizing survey responses from 51 State
Medicaid Directors-including Washington, DC);
3) State Medicaid programs cover recommended preventive services for
adults in Medicaid, for whom coverage of preventive services is
generally not required (utilizing available data from the Medical
Expenditure Panel Survey administered by the Agency for Healthcare
Research and Quality); and;
4) The Centers for Medicare & Medicaid Services (CMS) oversees the
provision of preventive services for children and adults in Medicaid
(through interviews of CMS officials at the Central and Regional
Offices, and through review of ESPDT reports).
In the Draft Report, the GAO recommends that CMS:
(1) Ensure that state Early and Periodic Screening, Diagnostic and
Treatment (EPSDT) programs arc regularly reviewed; and;
(2) Expedite its 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 Response to Recommendation 1:
We concur. CMS recognizes the need for and the value of preventive
services for children as well as for adults. The law is particularly
strong with respect to children under the EPSDT provisions which
require all Medicaid children have access to preventive services. We
believe that the low well-child visit rates observed are unacceptable
given the importance of preventive services for children and the
requirements of the law. As noted in the report, CMS has established
the goal of ensuring that each state provide EPSDT well-child check ups
to at least 80 percent of Medicaid children in the State based on the
State's periodicity schedule, but the data show, and our reviews
confirm, that we are far from achieving that goal.
The CMS has recently conducted an internal review of policies and
policy guidance, procedures and oversight efforts. We will augment this
review by consulting with States, maternal and child health experts and
children's advocates for the purpose of developing a comprehensive
workplan to provide updated guidance and training for State Medicaid
programs, to review and revise the CMS 416 reporting form, and to
establish a regular schedule for reviewing State policy and
implementation efforts. CMS is committed to begin releasing guidance to
States through State Medicaid Director Letters and to establish a
training program and protocol for the state reviews and technical
assistance by the end of the year. We also intend to identify and share
best practices, including current State initiatives to assure children
with preventive care through a medical home and successful State
efforts to reduce coverage gaps and "churning" among eligible children
that can undermine efforts to assure that children receive preventive
services consistent with the State's periodicity schedule.
Pursuant to the Children's Health Insurance Program Act of 2009
(CHIPRA, Public Law 111-3), CMS has also undertaken a new initiative to
establish quality measures, and we believe these measures and the
subsequent State reporting under this measures can enhance performance
under EPSDT, including with respect to dental and obesity-related
services. The new quality measures are being developed with the Agency
for Health Care Quality, in consultation from other agencies within
HHS, States and outside organizations with particular expertise in
these matters. One consideration is whether to integrate State
reporting under these measures (which is voluntary) with the mandatory
reporting under EPSDT. The CHIPRA quality initiative also relates
closely to initiatives to improve quality of care through reporting
opportunities that will evolve through adoption and enhancement of
electronic health records under the American Recovery and Reinvestment
Act of 2009 (Public Law 111-5).
CMS Response to Recommendation 2:
We concur. CHIPRA includes a provision for a childhood obesity
demonstration program, although it did not include appropriated funding
for the demonstration. HHS, under the leadership of the Surgeon
General's office and with support from CMS, is developing the
demonstration proposal as required under CHIPRA. CMS is pursuing a
number of options to obtain funding for this important demonstration.
As mentioned in the report, CMS has recognized the need for guidance to
State Medicaid programs on coverage of obesity-related services for
children. CMS is committed to providing this guidance to States through
a State Medicaid Directors letter by the end of this calendar year.
The CMS has been involved in several initiatives regarding childhood
obesity at the national level. It has participated in the Surgeon
General's Childhood Overweight and Obesity Prevention Council, which
began in November 2007, and the Children's Obesity Action Network,
which addresses issues related to payment policy and health care
disparities. CMS has also supported the work of the National Committee
for Quality Assurance on the development of two new Healthcare
Effectiveness Data and Information Set (HEDIS) measures that address
obesity. CMS will work with States to promote awareness of these new
measures and encourage States to consider utilizing them as part of
their Medicaid Quality Improvement Strategies.
Summary:
In response to this report, CMS plans to issue a State Medicaid
Director letter that will work toward ensuring that children receive
preventive services through the EPSDT program, and remind States of the
80 percent goal for well-child visits. It will also remind States of
the importance of ensuring that children receive a comprehensive well-
child visit and the importance of providing preventive services to
adults. The CMS EPSDT workgroup is also working on State guidance on
EPSDT monitoring, assessment, and reporting and will continue to work
on enhancing CMS assessment of EPSDT services. We hope that these
efforts will help us target initiatives that will improve the quality
of care for children receiving ESPDT services.
As described here, CMS has a number of initiatives underway, both short
and long-term, to improve the EPSDT program, and to increase services
related to obesity. This report has provided additional information
useful to those planning efforts. CMS is committed to ensuring that all
Medicaid children receive all appropriate services under the EPSDT
program. CMS also identified and submits a few technical comments for
consideration.
[End of section]
Appendix V: GAO Contact and Staff Acknowledgments:
GAO Contact:
Alicia Puente Cackley, (202) 512-7114 or cackleya@gao.gov:
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.
[End of section]
Related GAO Products:
Medicaid: Extent of Dental Disease in Children Has Not Decreased, and
Millions Are Estimated to Have Untreated Tooth Decay. [hyperlink,
http://www.gao.gov/products/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. [hyperlink,
http://www.gao.gov/products/GAO-08-50]. Washington, D.C.: November 26,
2007.
Medicaid: Concerns Remain about Sufficiency of Data for Oversight of
Children's Dental Services. [hyperlink,
http://www.gao.gov/products/GAO-07-826T]. Washington, D.C.: May 2,
2007.
Childhood Obesity: Factors Affecting Physical Activity. [hyperlink,
http://www.gao.gov/products/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. [hyperlink,
http://www.gao.gov/products/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. [hyperlink,
http://www.gao.gov/products/GAO-05-44R]. Washington, D.C.: December 8,
2004.
Medicare Preventive Services: Most Beneficiaries Receive Some but Not
All Recommended Preventive Services. [hyperlink,
http://www.gao.gov/products/GAO-04-1004T]. Washington, D.C.: September
21, 2004.
Medicaid and SCHIP: States Use Varying Approaches to Monitor Children's
Access to Care. [hyperlink, http://www.gao.gov/products/GAO-03-222].
Washington, D.C.: January 14, 2003.
Medicare: Most Beneficiaries Receive Some but Not All Recommended
Preventive Services. [hyperlink,
http://www.gao.gov/products/GAO-03-958]. Washington, D.C.: September 8,
2003.
Medicare: Use of Preventive Services Is Growing but Varies Widely.
[hyperlink, http://www.gao.gov/products/GAO-02-777T]. Washington, D.C.:
May 23, 2002.
Medicare: Beneficiary Use of Clinical Preventive Services. [hyperlink,
http://www.gao.gov/products/GAO-02-422]. Washington, D.C.: April 10,
2002.
Medicaid: Stronger Efforts Needed to Ensure Children's Access to Health
Screening Services. [hyperlink,
http://www.gao.gov/products/GAO-01-749]. Washington, D.C.: July 13,
2001.
Lead Poisoning: Federal Health Care Programs Are Not Effectively
Reaching At-Risk Children. [hyperlink,
http://www.gao.gov/products/HEHS-99-18]. Washington, D.C.: January 15,
1999.
Medicaid Managed Care: Challenge of Holding Plans Accountable Requires
Greater State Effort. [hyperlink,
http://www.gao.gov/products/GAO/HEHS-97-86]. Washington, D.C.: May 16,
1997.
Medicare: Provision of Key Preventive Diabetes Services Falls Short of
Recommended Levels. [hyperlink,
http://www.gao.gov/products/T-HEHS-97-113]. Washington, D.C.: April 11,
1997.
[End of section]
Footnotes:
[1] States may provide Medicaid services, including preventive
services, to children and adults through different service delivery and
financing systems such as fee-for-service and managed care. In a
traditional fee-for-service delivery system, the Medicaid program
reimburses providers directly and on a retrospective basis for each
service delivered. Under a capitated managed care model, states
contract with a managed care organization and prospectively pay the
organization a fixed monthly fee per patient to provide or arrange for
most health services. Managed care delivery systems are subject to
specific federal requirements related to Medicaid enrollees and
services.
[2] For purposes of this report we refer to these EPSDT screening
services as an EPSDT well-child check up. States are also required to
cover other EPSDT services, defined as vision services, dental
services, hearing services, and services necessary to correct or
improve health conditions discovered through screenings, regardless of
whether these services are typically covered by the state's Medicaid
plan for other beneficiaries. 42 U.S.C. § 1396d(r). In this report, we
collectively refer to EPSDT well-child check ups and these other
services as EPSDT services. In 2001, we found problems with children
not receiving EPSDT services; see Medicaid: Stronger Efforts Needed to
Ensure Children's Access to Health Screening Services, GAO-01-749
(Washington, D.C.: July 13, 2001). A list of related GAO products can
be found at the end of this report.
[3] Although states are generally not required to cover preventive
services for adult Medicaid beneficiaries, according to CMS officials
there are circumstances when states must cover medically necessary
preventive services for adult Medicaid beneficiaries who have been
diagnosed with or show symptoms of a disease.
[4] State Medicaid programs must provide EPSDT services at intervals
that meet reasonable standards of medical and dental practice as
determined by the state and as medically necessary. Accordingly, states
adopt their own periodicity schedules, which include age-specific
timetables that identify when EPSDT well-child check ups and other
services should occur. CMS's 80 percent goal includes only children who
should receive an initial or periodic screening service, termed well-
child check up for purposes of this report, in a given year; therefore,
it incorporates the fact that the interval of well-child check ups for
some children may be greater than a year.
[5] The USPSTF considers evidence from studies that assess the effects
of preventive services on health outcomes, and recommends that health
care providers offer or provide services for which (1) there is high
certainty that the net benefit is substantial ("A" recommendation) or
(2) there is high certainty that the net benefit is moderate or there
is moderate certainty that the net benefit is moderate to substantial
("B" recommendation). An analysis guided by the National Commission on
Prevention Priorities of the cost effectiveness of 25 USPSTF
recommended preventive services concluded that many are cost effective,
and some are cost saving. See Michael V. Maciosek, Ashley B. Coffield,
Nichol M. Edwards, Thomas J. Flottemesch, Michael J. Goodman, Leif I.
Solberg, "Priorities among Effective Clinical Preventive Services:
Results of a Systematic Review and Analysis," American Journal of
Preventive Medicine, vol. 31, no. 1 (2006).
[6] Medicare covers defined preventive services such as colorectal
cancer screening tests, screening mammography, and diabetes screening
tests, and more recently, the Medicare Improvements for Patients and
Providers Act of 2008 authorized the Secretary of HHS to expand
Medicare coverage to additional preventive services recommended by the
USPSTF, under certain circumstances. Pub. L. No. 110-275, § 101, 122
Stat. 2494, 2496-97 (2008) (codified, as amended, at 42 U.S.C. §
1395x(s)(2)(BB)).
[7] Our figures for Medicaid children include children enrolled in the
State Children's Health Insurance Program (CHIP), because NHANES data
from 1999 through 2004 contain a single category that combines Medicaid
and CHIP beneficiaries (NHANES data for 2005 through 2006 contain
separate categories for Medicaid and CHIP beneficiaries, but we grouped
them for comparability with the earlier survey years). CHIP provides
health care coverage to children in low-income families who are not
eligible for traditional Medicaid programs. States may implement CHIP
programs by expanding their existing Medicaid programs, establishing
separate child health programs, or a combination of both. States with
Medicaid expansion programs must provide to CHIP beneficiaries all
benefits that are available to the traditional Medicaid population.
CHIP enrollment in fiscal year 2006 was 6.6 million children. Of the
total Medicaid and CHIP population of children, about 16 percent were
enrolled in CHIP during the 1999 through 2006 period.
[8] Diabetes was not prevalent enough among children to examine
reliably using NHANES data. We excluded children's oral health from our
scope because of recent related work; see Medicaid: Extent of Dental
Disease in Children Has Not Decreased, and Millions Are Estimated to
Have Untreated Tooth Decay, [hyperlink,
http://www.gao.gov/products/GAO-08-1121] (Washington, D.C.: September
23, 2008). Our scope also excluded certain immunizations, blood lead
levels, and tobacco exposure and use.
[9] Our figures for Medicaid adults could also include some adults
enrolled in CHIP (in 2007, GAO reported that in June 2006, about
349,000 adults were enrolled in CHIP; see State Children's Health
Insurance Program: Program Structure, Enrollment and Expenditure
Experiences, and Outreach Approaches for States That Cover Adults,
[hyperlink, http://www.gao.gov/products/GAO-08-50] (Washington, D.C.:
November 26, 2007)). Our figures for adults do not include adults
enrolled in both Medicare and Medicaid, and are limited to adults aged
21 through 64.
[10] The USPSTF assesses scientific evidence regarding the
effectiveness of a broad range of preventive services to address
clinical categories such as cancer, heart and vascular diseases,
infectious diseases, injury and violence, and metabolic, nutritional,
and endocrine conditions. USPSTF recommendations for adult preventive
services that were in effect as of March 2009 included blood pressure
tests for all adults; cholesterol tests for men aged 35 and older and
adults aged 20 and older with risk factors for coronary heart disease;
obesity screening for all adults, including intensive counseling and
behavioral interventions to promote sustained weight loss for obese
adults; intensive diet counseling for adults with high cholesterol;
diabetes screening for adults with high blood pressure; cervical cancer
screening for sexually active women; mammography for women aged 40 and
older; and colorectal cancer screening for adults aged 50 through 75.
The USPSTF also recognizes the importance of immunizations in primary
disease prevention, but does not review new evidence on immunizations
in order not to duplicate the work of the CDC's Advisory Committee on
Immunization Practices (ACIP). ACIP recommends influenza immunization
for adults aged 50 and older. For purposes of this report, the term
recommended preventive services refers to USPSTF and ACIP recommended
services.
[11] Other conditions, such as sexually transmitted diseases, were not
prevalent enough to examine reliably among adults in Medicaid using
NHANES data.
[12] The 2003 through 2006 period for the MEPS data differed from the
1999 through 2006 period for the NHANES data. NHANES includes a smaller
number of participants than MEPS, and it was necessary to group data
from NHANES surveys conducted during 1999 through 2006 in order to
include a sufficient number of survey participants to assess reliably
health conditions in the Medicaid population. It was not possible to
use the same time frame for the MEPS analysis, because MEPS did not
include certain questions we examined prior to 2001.
[13] Similar to NHANES, the Medicaid category in the MEPS data included
children enrolled in CHIP. Of the total Medicaid and CHIP population,
about 18 percent were enrolled in CHIP during the 2003 through 2006
period.
[14] USPSTF and ACIP recommendations for the services we analyzed were
in place as of the survey years used in our MEPS analysis. We limited
our analyses to the age and risk groups that USPSTF and ACIP
recommended should receive the services.
[15] In this report, we use the term cervical cancer screening to refer
to a Pap test, also called a Pap smear.
[16] Our scope did not include smoking cessation services. Some of the
questions we analyzed did not fully measure USPSTF-recommended
preventive services, but provide information related to them. For
example, the USPSTF recommends that obese adults receive intensive
obesity counseling, whereas MEPS participants were asked if they
received any type of diet or exercise advice from a doctor or health
care professional. See appendix II for further discussion of the extent
to which the available measures capture the USPSTF recommendations.
[17] MEPS interviews from 2003 through 2006 included a section on
diabetes, but did not include a question on screening tests for
diabetes. The USPSTF recommendation for diabetes testing was in place
as of 2003.
[18] Individuals were categorized based on their health insurance
status at one point in time, and health insurance status was not
necessarily constant during the time periods over which we examined
their receipt of services. Our analysis shows whether individuals
enrolled in Medicaid and private insurance at a given point of time
were in need of preventive services. When we compared our analysis of
well-child check ups to an analysis that only included children who
were consistently enrolled in Medicaid and private insurance during the
entire period we examined, we did not find significant differences in
results.
[19] For purposes of this report, we refer to the District of Columbia
as a state.
[20] On our survey, we asked about recommended preventive services for
which related national data were available.
[21] According to CMS and state officials, obesity screening and blood
pressure tests are often not billed separately from well-adult check
ups or health risks assessments.
[22] One CMS region had only one state with a managed care contract,
and we excluded one contract from another state from our review because
the contract was no longer in effect.
[23] See [hyperlink, http://www.gao.gov/products/GAO-08-1121].
[24] 42 U.S.C. §§ 1396a(a)(10)(A), 1396d(a)(4)(B). Absent additional
CMS approval, state Medicaid programs must cover EPSDT services for
individuals under age 21 who are eligible for Medicaid under
categorically needy categories.
[25] EPSDT services, in addition to well-child check ups, include:
vision services, including diagnosis and treatment for vision defects
such as eyeglasses; dental services, including relief of pain and
infections, restoration of teeth, and maintenance of dental health;
hearing services, including diagnosis, and treatment for defects in
hearing such as hearing aids; and services necessary to correct or
improve health conditions discovered through screenings, regardless of
whether these services are typically covered by the state's Medicaid
plan for other beneficiaries. See 42 U.S.C. § 1396d(r).
[26] 42 U.S.C. §§ 1396d(a)(4)(B), 1396d(r).
[27] Pub. L. No. 101-239, § 6403, 103 Stat. 2106, 2262-64 (1989)
(codified, as amended, at 42 U.S.C. § 1396d(r)(5)).
[28] Beginning in 1990, OBRA 89 required state Medicaid programs to
annually report to the Secretary of HHS information on EPSDT services
including the number of children provided EPSDT screenings, the number
of children referred for corrective treatment as a result of the
screenings, the number of children receiving dental services, and the
states' results in meeting annual goals for children's receipt of EPSDT
services established by HHS. Pub. L. No. 101-239, § 6403, 103 Stat.
2106, 2262-64 (1989) (codified, as amended, at 42 U.S.C. §
1396a(a)(43)).
[29] Obesity in children aged 2 through 19 was defined as having a 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 greater than or equal to 30. Girls
who were pregnant were not included in the analysis.
[30] See appendix I for more information on how NHANES collected this
information.
[31] These age ranges differ because NHANES surveys did not examine
blood pressure in children younger than 8 or cholesterol in children
younger than 6 during all survey years we analyzed (prior to the 2005-
2006 survey, cholesterol was examined in children aged 3 and older).
NHANES measured blood pressure up to four times during its physical
examination. For our analysis, we calculated the average of the blood
pressure measurements and defined high blood pressure for children aged
8 through 17 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; for children aged 18 through 20, we defined high blood
pressure as having an average systolic blood pressure of 140
millimeters of mercury (mmHg) or higher, or having an average diastolic
blood pressure of 90 mmHg or higher. High total blood cholesterol for
children aged 6 through 20 was defined as greater than or equal to 200
milligrams per deciliter (mg/dL). NHANES interviews did not determine
whether children younger than 16 had been previously diagnosed with
high blood pressure or whether children younger than 20 had been
previously diagnosed with high cholesterol.
[32] State ESPDT periodicity schedules for fiscal year 2006 generally
included 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. Five state periodicity schedules specified an interval
greater than 2 years for some children aged 6 through 20.
[33] This measure of well-child check ups was not restricted to EPSDT
well-child check ups. See appendix II for more information on how well-
child check ups were measured.
[34] MEPS did not collect comparable information on diet or exercise
advice or height and weight measurement for individuals older than 17.
[35] MEPS asked about height and weight measurement separately, so the
two measurements may not have been done at the same time (as necessary
to calculate BMI to screen for obesity). It is unclear why a larger
proportion of children reportedly had their height and weight measured
compared to the proportions who received well-child check ups or other
specific preventive services, but it is possible that height and weight
measurement could be more likely to occur during sick visits to the
doctor or at school.
[36] NHANES measured blood pressure up to four times during its
physical examination. For our analysis, we calculated the average of
the blood pressure measurements and applied CDC's definition of high
blood pressure: a patient's having an average systolic blood pressure
of 140 mmHg or higher, or having an average diastolic blood pressure of
90 mmHg or higher. Following CDC, we additionally included adults
taking blood pressure lowering medication in this category. We also
used CDC definitions for the other health conditions we analyzed.
Obesity for adults was defined as BMI greater than or equal to 30
(pregnant women were not included in the obesity figures). High total
blood cholesterol for adults was defined as 240 mg/dL or more. Diabetes
for adults was defined as fasting plasma glucose of 126 mg/dL or more
or having been previously diagnosed with diabetes.
[37] Adults were asked during the NHANES interview if they had ever
been told by a health care professional that they were overweight, or
had high blood pressure, high cholesterol, or diabetes.
[38] Colorectal cancer screening tests included sigmoidoscopy,
colonoscopy, or stool tests.
[39] As of March 2009, USPSTF recommended screening only adults with
high blood pressure for diabetes.
[40] Diabetes screening questions were not included in MEPS from 2003
through 2006, but were included in the 2006 NHIS; adults who had not
previously been diagnosed with diabetes were asked if they had been
tested for high blood sugar or diabetes in the past 3 years.
[41] States are required to collect data and report to CMS on EPSDT
services such as well-child check ups, but according to officials
states are not required to use these data as part of any monitoring
efforts.
[42] The survey asked if state Medicaid programs had established
utilization goals other than the federal 80 percent goal, but did not
ask what the specific utilization goals were.
[43] The survey defined managed care to include capitated managed care
arrangements only. Administrative arrangements such as Primary Care
Case Management, Disease Management, and Administrative Services
Organizations were defined as fee-for-service.
[44] Of the 51 state Medicaid programs, 4 reported exclusively using
managed care to provide services to children and 14 reported
exclusively using a fee-for-service system to provide services to
children. The remaining 33 reported using a combination of managed care
and fee-for-service delivery systems to provide services to Medicaid
children in the state.
[45] Three programs reported that increasing payment rates for
pediatric providers had not resulted in improvement; two reported that
starting a provider advisory panel had not resulted in improvement; and
one reported that streamlining payment processing had not resulted in
improvement. No programs reported that educating providers about
coverage had not resulted in improvement.
[46] Some state Medicaid programs reported that certain preventive
services were not covered under their fee-for-service program but were
covered by the states' Medicaid managed care organization(s)--services
covered under managed care but not fee-for-service are not included in
this discussion, but are noted in table 8 in appendix III.
[47] Seventeen other states that did not report covering intensive
counseling for obese adults did report covering other services that,
while not explicitly recommended by the USPSTF, are aimed at managing
obesity--such as obesity medication or nutrition assessment and
counseling. A minority of states reported additional efforts
specifically aimed at addressing adult obesity. For example, 15 states
reported promoting weight reduction programs for adult beneficiaries,
and 17 reported educating providers to conduct obesity counseling for
adults in Medicaid as needed. Thirty states that did not report
covering intensive counseling for adults with high cholesterol reported
covering medication or a nutrition assessment and counseling for adults
with high cholesterol.
[48] 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 the contract provisions we
identified to provide a description of such provisions.
[49] See [hyperlink, http://www.gao.gov/products/GAO-01-749].
[50] See [hyperlink, http://www.gao.gov/products/GAO-01-749].
[51] See Medicaid: Concerns Remain about Sufficiency of Data for
Oversight of Children's Dental Services, [hyperlink,
http://www.gao.gov/products/GAO-07-826T] (Washington, D.C.: May 2,
2007).
[52] One state reported a ratio of greater than 100 percent, which
would imply that more children received a check up than were expected
to receive a check up. We did not include this state's ratio in this
discussion; according to CMS officials, ratios greater than 100 percent
could not be correct.
[53] See [hyperlink, http://www.gao.gov/products/GAO-01-749].
[54] Under federal law, state Medicaid programs must inform all
eligible Medicaid beneficiaries under age 21 of the availability of
EPSDT services and the need for age-appropriate immunizations. State
Medicaid programs also must provide EPSDT screening services when
requested and arrange for necessary corrective treatment for conditions
identified during screenings. 42 U.S.C. § 1396a(a)(43).
[55] In 2007 through 2008, CMS conducted 17 reviews that were
specifically focused on EPSDT dental services for children. These
reviews have resulted in numerous recommendations to states, with
regard to issues such as providing information about the importance and
availability of dental services, reimbursing pediatricians and other
non-dentists who provide oral health services, and establishing
incentives to encourage dental students to practice in areas of need.
[56] Similarly, 30 states reported participant ratios below 50 percent
on at least one of their CMS 416 reports for fiscal years 2000 through
2007; 6 of these 30 had their EPSDT program reviewed.
[57] See "Policy Brief: Strategies for Improving Access to
Comprehensive Obesity Prevention and Treatment Services for Medicaid-
Enrolled Children." Sara Wilensky, Ramona Wittington, and Sara
Rosenbaum. School of Public Health and Health Services, Department of
Health Policy, George Washington University, October 2006.
[58] Through the SMDLs, CMS provides states with guidance and
clarification on current information pertaining to Medicaid policy,
Medicaid data issues, and CHIP issues.
[59] Health insurance status of children was reported by an adult in
the household. Survey participants who reported both Medicaid and
private insurance were included in the private insurance category.
Survey participants who reported both Medicaid and Medicare insurance
coverage were not included in the analysis.
[60] The NHANES category for adults could also include some adults
enrolled in CHIP. In 2007, GAO reported that in June 2006, there were
349,000 adults enrolled in CHIP. See GAO, State Children's Health
Insurance Program: Program Structure, Enrollment and Expenditure
Experiences, and Outreach Approaches for States That Cover Adults,
[hyperlink, http://www.gao.gov/products/GAO-08-50] (Washington, D.C.:
Nov. 26, 2007).
[61] Parents of overweight children aged 2 through 11 years were asked,
"Has a doctor or health professional ever told you that [child] was
overweight?" Parents of those aged 12 through 15 years were asked, "Has
a doctor or health professional ever told [child] that he/she was
overweight?" Those aged 16 through 20 years were asked, "Has a doctor
or health professional ever told you that you were overweight?"
Information was not collected from children under age 16 or their
parents regarding whether they had been told by a health care
professional about the child's high blood pressure. Information was not
collected from children under age 20 or their parents regarding whether
they had been told by a health care professional about the child's high
cholesterol.
[62] The systolic and diastolic blood pressure averages were calculated
as described in the NHANES documentation: If only one blood pressure
reading was obtained, that reading is the average. If there is more
than one blood pressure reading, the first reading is always excluded
from the average. If only two blood pressure readings were obtained,
the second blood pressure reading is the average. If all diastolic
readings were zero, then the average would be zero. Exception: If there
is one diastolic reading of zero and one (or more) with a number above
zero, the diastolic reading with zero is not used to calculate the
diastolic average. If two out of three diastolic readings are zero, the
one diastolic reading that is not zero is used to calculate the
diastolic average.
[63] NHANES surveys examined cholesterol in children aged 3 and older
prior to the 2005 survey and in children aged 6 and older in 2006. We
therefore only used data for children aged 6 through 20 in our
analysis.
[64] For adults, we also estimated the percentages after adjusting for
age differences between the two health insurance groups. After
adjusting for age, the prevalence differences between the two insurance
groups widened by a few percentage points for each health condition we
analyzed--the percentage of privately insured adults with each
condition was about 1 to 2 percentage points lower, and the percentage
of Medicaid adults with each condition was about 1 to 4 percentage
points higher.
[65] MEPS interviews from 2003 through 2006 included a section on
diabetes, but did not include a question on screening tests for
diabetes.
[66] Information was not always available on receipt of services for
children younger than 2 or older than 17.
[67] Individuals were categorized based on their health insurance
status at one point in time, and health insurance status was not
necessarily constant during the time periods over which we examined
their receipt of services. Our analysis shows whether individuals
enrolled in Medicaid and private insurance at a given point of time
were in need of preventive services. When we compared our analysis of
well-child check ups to an analysis that only included children who
were consistently enrolled in Medicaid and private insurance during the
entire period we examined, we did not find significant differences in
results.
[68] Separate questions were asked for children 2 through 17 and
individuals aged 18 and older. We combined responses for children aged
2 through 17 with responses for those aged 18 through 20.
[69] The United States Preventive Services Task Force (USPSTF) assesses
scientific evidence regarding the effectiveness of a broad range of
preventive services to address clinical categories such as cancer,
heart and vascular diseases, infectious diseases, injury and violence,
and metabolic, nutritional, and endocrine conditions. USPSTF
recommendations for adult preventive services that were in effect as of
March 2009 included: blood pressure tests for all adults; cholesterol
tests for men aged 35 and older and adults aged 20 and older with risk
factors for coronary heart disease; obesity screening for all adults,
including intensive counseling and behavioral interventions to promote
sustained weight loss for obese adults; intensive diet counseling for
adults with high cholesterol; diabetes screening for adults with high
blood pressure; cervical cancer screening for sexually active women;
mammography for women aged 40 and older; and colorectal cancer
screening for adults aged 50 through 75. The USPSTF also recognizes the
importance of immunizations in primary disease prevention, but does not
review new evidence on immunizations in order not to duplicate the work
of the CDC's Advisory Committee on Immunization Practices (ACIP). ACIP
recommends influenza immunization for adults aged 50 and older.
[70] In this report, we use the term cervical cancer screening to refer
to a Pap test. MEPS questions used the term Pap test.
[71] Monitoring questions regarding certain preventive services (for
example, colorectal cancer screening) were not applicable for children.
[End of section]
GAO's Mission:
The Government Accountability Office, the audit, evaluation and
investigative arm of Congress, exists to support Congress in meeting
its constitutional responsibilities and to help improve the performance
and accountability of the federal government for the American people.
GAO examines the use of public funds; evaluates federal programs and
policies; and provides analyses, recommendations, and other assistance
to help Congress make informed oversight, policy, and funding
decisions. GAO's commitment to good government is reflected in its core
values of accountability, integrity, and reliability.
Obtaining Copies of GAO Reports and Testimony:
The fastest and easiest way to obtain copies of GAO documents at no
cost is through GAO's Web site [hyperlink, http://www.gao.gov]. Each
weekday, GAO posts newly released reports, testimony, and
correspondence on its Web site. To have GAO e-mail you a list of newly
posted products every afternoon, go to [hyperlink, http://www.gao.gov]
and select "E-mail Updates."
Order by Phone:
The price of each GAO publication reflects GAO’s actual cost of
production and distribution and depends on the number of pages in the
publication and whether the publication is printed in color or black and
white. Pricing and ordering information is posted on GAO’s Web site,
[hyperlink, http://www.gao.gov/ordering.htm].
Place orders by calling (202) 512-6000, toll free (866) 801-7077, or
TDD (202) 512-2537.
Orders may be paid for using American Express, Discover Card,
MasterCard, Visa, check, or money order. Call for additional
information.
To Report Fraud, Waste, and Abuse in Federal Programs:
Contact:
Web site: [hyperlink, http://www.gao.gov/fraudnet/fraudnet.htm]:
E-mail: fraudnet@gao.gov:
Automated answering system: (800) 424-5454 or (202) 512-7470:
Congressional Relations:
Ralph Dawn, Managing Director, dawnr@gao.gov:
(202) 512-4400:
U.S. Government Accountability Office:
441 G Street NW, Room 7125:
Washington, D.C. 20548:
Public Affairs:
Chuck Young, Managing Director, youngc1@gao.gov:
(202) 512-4800:
U.S. Government Accountability Office:
441 G Street NW, Room 7149:
Washington, D.C. 20548: