Effective Use of Medicaid to Support EHDI Programs

Peggy McManusMaternal and Child Health Policy Research Center

Karl WhiteNational Center for Hearing Assessment and Management

Janet FarrellMassachusetts State EDHI Program

Faculty Disclosure Information

In the past 12 months, we have not had a significant financial interest or other relationship with the manufacturers of products or providers of the services that will be discussed in our presentation

This presentation will not include discussion of pharmaceuticals or devices that have not been approved by the FDA nor will the presentation discuss unapproved or "off-label" uses of pharmaceuticals or devices.

Medicaid is the largest single insurer of children in the United States (30% of all children are enrolled in Medicaid and 40% of all births are paid by Medicaid)

Medicaid reimbursement polices and practices significantly affect policies and practices of private health insurers

EPSDT (Early and Periodic Screening, Diagnosis, and Treatment) is a required part of Medicaid that provides preventive health care (and where needed) treatment services to children

Assessing Current Practices

15 state email survey, conducted by MCH Policy Research Center, January – March 2005

Examined Fee for Service (FFS) policies for a comprehensive set of hearing services

Obtained 2005 fees and compared them to 2000 fees collected by MCHPRC in previous study

Research Questions

1. Do states have reimbursable codes for a comprehensive set of hearing services?

2. What are average payment amounts, range of payments, & fee distribution in 2005?

3. What changes in reimbursement have states made since 2000?

4. How do state Medicaid fees compare to Medicare fees?

Strategic Directions Meeting

July 12 & 13, 2005 in Salt Lake Cite 10 states participated (State EDHI coordinator and

State EPSDT Director)

Each state developed a written action plan focused on using EPSDT to improve EHDI services for children

Overview

Strategic Directions for Medicaid and EPSDT►Hearing Standards and Policies►Information and Education►Quality and Financial Incentives►Collaboration with EHDI Programs

Lengthy interviews conducted with 10 state EPSDT directors ---CO, IL, IA, MA, NC, NH, UT

Based on interview form developed with assistance from NCHAM and State EDHI directors

Standards and Policies

Examined state EPSDT policies for hearing screening and follow-up

Stated EPSDT hearing standards mostly based on AAP preventative care guidelines

EPSDT standards focus almost exclusively on screening, not referral and follow-up

JCIH guidelines seldom referenced

Standards and Policies

States have organized mechanism for regularly updating EPSDT with input from other state agencies and key stakeholder groups

Effective ways of implementing new standards – work closely with state AAP chapters

Hospital involvement also critical State universal newborn hearing screening

laws- key in facilitating adoption of standards More attention needed to address a follow-up

of failed screens

Information and Education

Examined state EPSDT strategies for using effective educational strategies in working with PCP’s, families, hospitals, HCO’s, and local health departments

PCP’s ►No magic bullets or single approaches ►Very little done so far on follow-up ►Important to have good, actionable data

about how PCP’s perform ►Evidence-based data also important ►Newsletters that profile promising practices useful

Information and Education

PCP’s (continued): ►Ongoing training of residents helps

►CME necessary, but not sufficient

►More needed to target PCP’s in rural

areas, with small numbers of children

in practice

Information and Education

Families:►Work with existing family networks

►More education needed on follow-up, especially with families whose children have complex health care needs

►Follow-up telephone calls & face-to-face meetings work best

Information and Education

Hospitals►State EHDI efforts, especially involving on-site work,

critical in implementing universal newborn hearing screening

►Funding hearing aid loaner programs important

►Need to target small, rural hospitals and move beyond screening

►Perinatal conferences important

►Also, having short educational videos about hearing screening for use by hospitals important

Information and Education

Use of popular media helpfulCritical to have a “why” piece –

explaining why both screening & follow-up are necessary

Informing families about standard of care is important and can positively influence parent demand for services

Information and Education

Local Health Departments►EPSDT outreach workers have critical

role to play, but few have focused on hearing

►Important to link with home visiting, case management, disease

management, & other initiatives involving LHDs

►Regular training opportunities for LHDs, with CME important

Information and Education

Hard-to-reach groups►EPSDT outreach workers have critical

role to play►Home visiting & case management

programs reach high-risk groups, though hearing follow-up seldom addressed

►More attention to cultural competence to reduce families’ delays in seeking follow-up

►Translation & transportation support

Information and Education

Overarching Comments►Comprehensive strategy needed, promoted through

various channels (e.g. immunization)

►Have a simple, consistent message – 1/3/6

►Involve key groups at outset

►Address shortage of audiologists, including

causes—education & training, reimbursement, other

►Streamline & integrate hearing follow-up services

with CM, EI, WIC, 1-800#, EPSDT outreach

Quality and Financial Incentives

Examined opportunities for incorporating quality incentives from Healthy People 2010

Examined Medicaid reimbursement levels

Quality Incentives

Few EPSDT programs use or are aware of Health People 2010 hearing objectives

Most Medicaid quality standards from NCQA (HEDIS), AAP

Use of quality indicators (e.g., 1/3/6) could be an effective strategy

Important to have actionable data for use by providers

Comparative state data also helpful

Quality Incentives

NICHQ’s model of collaborating with practices, conducting chart reviews, identifying improvement strategies, and providing feedback (e.g. lead, immunization)

Need to make sure hearing screening and follow-up is incorporated into EPSDT evaluations. Records could be tagged for follow-up

Quality Incentives

Consider a GPRA project (e.g. immunization) CMS could set a standard (e.g. dental care) Maintain close link with public health Issue certificates of excellence to providers

scoring 95% or higher Acknowledge the good work of providers

“They’re not doing this work for the financial rewards, but for the benefits of the children.”

Reimbursement Incentives

“Ha, ha, ha. Stand in line.”State Medicaid and public health funding

is already stretched to its limitsImportant to piggyback with existing

EPSDT administrative outreach effortsThrough Medicaid’s administrative

match, possibly some potential for funding follow-up activities

Reimbursement Incentives

To claim administrative match requires financial support from other state agencies- good luck!

To justify payment changes, evidence of cost savings needed

Professional organizations & provider groups need to advocate for rate increases showing costs not being met and access adversely affected

Reimbursement Incentives

Also, comparative state fee data useful – no one wants to be lowest

See examples from dental care. Also, incentives used successfully with EPSDT visit rates, immunizations, and lead screening

Examine hospital payment mechanisms to assess where to place incentive

Consider outside foundation and community funds

Collaboration

Examined new and existing opportunities to promote collaboration

Consider roles and responsibilities for state EHDI programs to play with Medicaid and participating MCOs and other providers

Already a great deal of collaboration between Medicaid and EHDI programs, mostly around newborn screening

Meetings at least quarterly help, involving Medicaid and other key stakeholders

Written interagency agreements useful in promoting accountability

Collaboration

Examples: MD- a portion of EHDI coordinator’s time/salary is dedicated to working with Medicaid

IL: “Think Tank Day” on newborn hearing projects for coming year; developed education, referral, and follow-up document; grand rounds training with AAP; newborn screening advisory group; now working on parent website

MA Statistics

80,000 births annually >99% hearing screening rate

universal at all birthing facilities follow-up occurs on all referrals at the state level

Did not pass, missed, home births, and resident births born out of state)

<1.5% refer rate

200 children diagnosed with hearing loss after referral from newborn hearing screening

(estimated data from the Childhood Hearing Data System)

Massachusetts PrenatalCare Payment Source

28.9% publicly insured (MassHealth, CommonHealth, Medicaid Managed Care, Healthy

Start, Medicare and Free Care)

Medicaid covered 1 out of every 4 women 70% privately insured 0.7% self-paid for prenatal care 0.4% other

Massachusetts Department of Public Health, Massachusetts Births 2003

EPSDT and EHDI

Attended national meeting Developed a workplan

who is responsible, what needs to happen, start and end dates, obstacles and resources

Began a schedule of regular meetings with both programs

Collaborated with internal and external partners

Workplan Activities

Updated EPSDT Policy Manual expanded section on hearing assessment information on risk indicators for hearing loss

Updated periodicity schedule for MA Health Quality Partners (MHPQ) intended for quality practice recommendations endorsed by many of the major insurers in the state

Outreach to Medicaid Managed Care Organizations (MCOs)

Developed newborn hearing screening training for MCOs

Presented at the MCH/MCO Workgroup Meeting provided resources

Included the DPH, School Health Vision Screening Initiative and Women, Infants and Children (WIC) Program in training

Addressed opportunities for future collaboration

Training for Audiological Diagnostic Centers

EPSDT Reimbursement: hearing aids and hearing

related services Provided contact information: MassHealth

prior approval, MCOs customer assistance Developed list of questions about prior

approval issues Follow-up meeting planned with prior approval

staff from MassHealth

Head Start Training

Met with EPSDT and Head Start to discuss hearing and vision screening issues

Developed module for “best practices” training for early childhood vision and hearing screening and EPSDT

audience: Head Start Health Services Managers and Child Care Consultants, School Health Nurses

exceeded capacity of 100 for the training

Next Steps

Explore opportunities to work with cochlear implant programs in MA

MCO newsletters Explore feasibility of utilizing MassHealth data to

improve follow-up Analyze Family Satisfaction Survey results to

assess differences in responses for publicly insured families

Develop strategies to recognize MassHealth providers that dispense hearing aids to children