GAO To CMS: Set Goals, Measure Progress on EPSDT (Do Better)

Another day, another area where CMS could be spending its valuable resources to fulfill Medicaid’s mission to provide health care to low-income Americans, including and especially children.

The Government Accountability Office (GAO), Congress’s watchdog for federal agencies, has some ideas. Regular Say Ahhh! readers know the great potential of Medicaid’s pediatric benefit, called EPSDT. Medicaid beneficiaries under age 21 must receive all early screenings, needed diagnostic assessments and any resulting medically necessary treatment (The too-often overlooked ‘T’ in EPSDT) to prevent or address conditions or delays.

GAO’s new report, released publicly last month, reviews the extent to which children in Medicaid get services they need. As CMS put it in their 2014 EPSDT guide for states, to ensure all children get the care they need when they need it: right care, right time, right setting.

The title of the new report says it all: Additional CMS Data and Oversight Needed to Help Ensure Children Receive Recommended Screenings

Using CMS-416 data (limited though it is), GAO offers additional detail on some themes we already know:

Not all children in Medicaid are getting required preventive screens. In 2017, 60 percent of children nationally received at least one well-child screening during the year. Only three states – Hawaii, Iowa, and Louisiana – were meeting CMS’s 1990 target that 80 percent of children in Medicaid receive at least one well-child screening annually. (And, of course, for the very young infants and toddlers, once a year doesn’t cut it!)

More kids are getting preventive dental services, but growth is inconsistent across states. In 2017, nearly half of children received preventive dental—48 percent, up from 42 percent in 2017. But this falls short of CMS goal of a 10 percentage point increase over five years (2011-2015). Nine states did meet this 10 percent target between 2011 – 2017: Florida, Idaho, Indiana, Iowa, Montana, Ohio, Pennsylvania, Texas, and Wisconsin. But 12 states showed a decrease or no change during this period.

Despite collecting data, we have no useful information on blood lead screenings. Says GAO in its report summary “Data on blood lead screenings is incomplete, so nobody knows how many young children were screened.” OK…

GAO argues CMS has not regularly or systematically assessed the usefulness of state-reported data, assisted states in efforts to improve rates of things like well-child screenings, set and communicated EPSDT performance targets for states, or consistently evaluated state performance using the CMS-416 or Child Core Set measures.

For example, on the high-profile issue of blood lead screenings, in 2016 CMS clarified Medicaid’s lead screening policy to states, but since then has taken no additional steps to help states as they seek to determine children with dangerous levels of exposure within Medicaid are identified and treated. The report highlights Nebraska and New Jersey among states that took matters into their own hands, creating registries or databases that track blood lead screening regardless of payor.

CMS contends the new, long-awaited T-MSIS data reporting system and state scorecards will help propel this work, though as of the beginning of 2019, “T-MSIS data were not being used to create the CMS-416, Child Core Set, or the scorecard.” (p. 12)

So, what does GAO recommend? CMS should:

  • Set clear goals and performance targets for key measures and communicate them to states
  • Regularly assess the usefulness and relevance of EPSDT performance measures, adding or revising them if they aren’t helpful to inform progress
  • Help states take actions to improve performance
  • Establish and set milestones on a time frame for when T-MSIS will be able to generate state-reported data to streamline and improve state reporting.

To be fair, responsibility for meeting EPSDT’s potential for every child doesn’t solely reside with this Administration—states share it— but they certainly set the tone. Yet CMS instead seems laser-focused on finding ways to purge eligible children and their families from the rolls, rather than ensuring Medicaid is working FOR them. Its time federal Medicaid leaders got their priorities straight. Generations of children depend on strong leadership from the top.

Elisabeth Wright Burak is a Senior Fellow at the Georgetown University McCourt School of Public Policy’s Center for Children and Families.