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.

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.

Status Legend:

Review Pending-GAO has not yet assessed implementation status.

Open-Actions to satisfy the intent of the recommendation have not been taken or are being planned, or actions that partially satisfy the intent of the recommendation have been taken.

Closed-implemented-Actions that satisfy the intent of the recommendation have been taken.

Closed-not implemented-While the intent of the recommendation has not been satisfied, time or circumstances have rendered the recommendation invalid.

• Review Pending
• Open
• Closed - implemented
• Closed - not implemented

Recommendations for Executive Action

Recommendation: To improve the provision of preventive services to the Medicaid population, the Administrator of CMS should ensure that state Early and Periodic Screening, Diagnostic, and Treatment (EPSDT) programs are regularly reviewed to identify gaps in provision of EPSDT services to children and to identify needed improvements.

Agency Affected: Department of Health and Human Services: Centers for Medicare and Medicaid Services

Status: Open

Comments: In December 2010, CMS formed a National EPSDT Improvement Workgroup comprised of federal staff and more than 30 external experts representing States, providers, academicians and advocates. CMS has held two in-person meetings of the entire Workgroup (December 2010 and May 2011). In addition, subgroups meet regularly by phone examining gaps and possible solutions in four areas: data collection, reporting and analysis; integrated care; behavioral health; and outreach and awreness. By late 2012 the subgroups are expected to share suggestions with CMS about ways for CMS to support clarity and improvement of service delivery at the State level, to reduce the burden of reporting for States, and to improve CMS oversight of State performance. As part of this project, CMS is finalizing a contract to survey State EPSDT performance to identify State-specific gaps and opportunities for improvement. In the interim, CMS has held three trainings on EPSDT topics for Regional CMS Office staff: EPSDT 101 (August 2010); the CMS-416 (October 2010); and long-term care services and waivers (March 2011). CMS also hosts monthly EPSDT calls for Regional Office staff to provide a forum for continuous learning and improvement. CMS is currently focusing particular attention on the specific EPSDT benefit of dental care. In April 2011, the CMS Oral Health Survey was published online to support the new oral health GPRA goal to increase children's access to preventive dental care (http://www.cms.gov/MedicaidDentalCoverage/Downloads/5_CMSDentalStrategy04112011.pdf).On February 24, 2012, CMS said they'd established a contract with NORC at the University of Chicago that commenced on September 7, 2011. NORC, along with subcontractors George Washington University and the National Academy for State Health Policy, are working with CMS to support the National EPSDT Improvement Workgroup. Examples of the work NORC is engaged in are: in-depth analyses of EPSDT in nine States (focused especially on outreach and awareness, data collection and reporting for accountability, behavioral and mental health services, and integrated care approaches); a literature review of EPSDT-related studies and reports; and an environmental scan of available information, by State, on a variety of EPSDT topics and questions. Further deliverables are expected by September 2012. In addition, CMS has completed the first-ever quality assurance review of CMS 416 data submitted by States. They developed a set of criteria to identify

Recommendation: To improve the provision of preventive services to the Medicaid population, the Administrator of CMS should 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 Affected: Department of Health and Human Services: Centers for Medicare and Medicaid Services

Status: Closed - Implemented

Comments: On July 12, 2010, CMS noted that they plan to release a letter to State Health Officials in the near future specifically addressing the issue of obesity services and coverage under the Medicaid/Early and Periodic Screening, Diagnostic, and Treatment (EPSDT) program. They said that they currently have a draft of the letter, and that it should be issued by mid-November 2010.