Improving Access to Healthcare through Patient Advocacy:

Understanding EPSDTEarly and Periodic Screening,

Diagnosis, and Treatment AKA Healthchek

Dawn Bolyard, APN, Mercy Children’s Hospital Children’s Pulmonary Center

Robert Cole, Esq., Advocates for Basic Legal Equality, Inc.

Ramalinga Reddy, MD, Mercy Children’s Hospital Children’s Pulmonary Center

Date: December 7, 2011

Training Objectives

Understand EPSDT (Healthchek in Ohio)

Understand differences in services available to children under EPSDT and adults under Medicaid

Apply standard to a case presentation

Identify tools to advocate for healthcare coverage to children under EPSDT

What is Advocacy?

Action by a physician to promote those social, economic, educational, and political changes that ameliorate the suffering and threats to human health and well-being that he or she identifies through his or her professional work and expertise.

M.A. Earnest, S.L. Wong, and S.G. Frederico, “Perspective: Physician Advocacy: What is It and How Do We Do It?” Academic Medicine, 85 no. 1 (2010).

Advocacy as a Means to Improve Health

Basic Tenets of Advocacy

All people have worth and dignity.

Advocacy efforts must be sensitive and responsive to the unique needs of individuals from diverse ethnic, racial, and cultural backgrounds.

Advocacy should include collaboration with patients and encouragement of self-advocacy whenever practicable.

Physicians as Advocates: Review of Physician Advocacy Tools

Make a telephone call or write a letter to a landlord, agency caseworker, or school.

Help de-stigmatize the use of government benefits by encouraging patients to apply.

Encourage families to save all documents: rent receipts, letters, notices of denial, appeals, etc. for their records.

Encourage families to reapply or file an appeal.

Advocate for patients by speaking up on their behalf to policymakers at the county, state, and federal levels.

What is EPSDT?

EPSDT is Early and Periodic Screening, Diagnosis, and Treatment

If a child is under age 21 and on Medicaid, the child’s Medicaid coverage is governed by federal EPSDT standards

In Ohio we call EPSDT Healthchek

Promotes preventative health care by

providing for early and regular

medical and dental screenings.

Provides medically necessary health

care to correct or ameliorate a

defect, physical or mental illness, or

a condition [health problem]

identified through a screening.

WHY HEALTHCHEK/EPSDT IS IMPORTANT

HEALTHCHEK/EPSDT OVERVIEW

Early and Periodic Screening, Diagnosis, and Treatment (EPSDT) defined by federal law and includes:

Periodic Screening Services

Vision Services

Dental Services

Hearing Services

Other Necessary Health Care

Additional EPSDT Covered Services:

Rehabilitative services for developmental disabilities

Mental health and substance abuse services

Medical and adaptive equipment

Transportation

In-home nursing, personal care, and specialized therapies

Out-of-home residential, facility and hospital services

Other medically necessary care

EPSDT CRITERIA

Must be listed in the federal law at 42 U.S.C. § 1396d(a) [1905(a) of the Social Security Act].

Must be medically necessary "to correct or ameliorate a defect, physical or mental illness, or a condition [health problem] identified by screening”.

EPSDT CRITERIA CON’T.

“Ameliorate” means to: improve or maintain the recipient’s health in the best condition possible, compensate for a health problem, prevent it from worsening, or prevent the development of additional health problems.

EPSDT CRITERIA CON’T.

Must be determined to be medical in nature.

Must be generally recognized as an accepted method of medical practice or treatment.

Must not be experimental, investigational.

Must be safe.

Must be effective.

EPSDT FEATURES

No Waiting List for EPSDT Services

No Monetary Cap on the Total Cost of EPSDT services

No Upper Limit on the Number of Hours under EPSDT

No Limit on the Number of EPSDT Visits to a Physician, Therapist, Dentist or Other Licensed Clinician

EPSDT FEATURES CON’T.

No Set List that Specifies When or What EPSDT Services or Equipment May Be Covered

No Co-payment or Other Cost to the Recipient Coverage for Services that Are Never Covered for Recipients 21 Years of Age and Older

Coverage for Services Not Listed in the Ohio State Medicaid Plan

IMPORTANT POINTS ABOUT EPSDT

The full array of EPSDT services must be coverable within the scope of those listed in the federal law at 42 U.S.C. § 1396d(a) [1905(a) of the Social Security Act].

EPSDT requires Medicaid to cover these services if they are medically necessary to correct or ameliorate a defect, physical or mental illness, or a condition [health problem].

IMPORTANT POINTS ABOUT EPSDT CON’T.

EPSDT services do not have to be services that are covered under the Ohio State Medicaid Plan or under any of the Division of Medical Assistance’s (DMA) clinical coverage policies or service definitions or billing codes.

IMPORTANT POINTS ABOUT EPSDT CON’T.

EPSDT covers short-term and longer services as long as the requested services will correct or ameliorate the child's condition. For example, a service must be covered under EPSDT if it is necessary for immediate relief (e.g., pain medication). Treatment need not ameliorate the child's condition taken as a whole, but need only be medically necessary to ameliorate one of the child's diagnoses or medical conditions.

CASE Study: The RSV Prophylaxis Controversy

2006 AAP Guidelines 28 weeks and under and less than a

year at start of season

Chronic lung or Significant Cardiac disease and less than 2 at season start

29 – 31 / 6 weeks and less than 6 months at season start.

32 to 35 / 6 weeks less than 6 months with 2 risk factors Daycare School age sibs

2009 AAP Guidelines No change for 28 weeks, chronic lung,

cardiac or 29 to 31 / 6 weeks infants.

Definition of 35 weeks changed to 34 / 6. no dosing after 34 / 6.

Eligibility now less than 3 months at season start,

one of two risk factors

dosing truncated to max. of 3 doses before the age of 3 months.

The Controversy The Fall out

Many experts voiced their opposition to the new guidelines

NMA Pediatric Pulmonologist Pediatricians Nurse Practitioners Premie Parents Groups

Insurance companies followed the new guidelines

Practitioners left in a quandary about how to access care for their patients.

Increased Disparity for some patients who needed prophylaxis but where not able to access care.

New guidelines did not follow the science that was currently known about prophylaxis against RSV .

Went against FDA package insert recommendations for dosing

Changed the definition of gestational age going against the AAP’s own premature infant experts recommendations.

Ignored current research about 32 to 35 week infants

Case Study

NM was a 33 week premature infant born in Sept. 2010 Home at 37 weeks on an apnea monitor, cafcit, dx with bpd, Was dosed with Synagis before discharge in mid October Home is with Mom, Great Grand Pa, aunts, uncles and cousin several who are school age and one who is a year old and who had severe RSV disease in his first year of life requiring intubation. NM will attend day care for church services 4 hours a week.He has been approved for two more Synagis injections. This will mean that prophylaxis will end in Dec. during the middle of RSV season.

What can you do?

History

Denial was based on 2009 guidelines of truncated dosing.

Peer to peer communication was also denied.

What is the next step?

What would you like to know?

An appeal for additional dosing was made to his insurer and was denied.

Conclusion of case

MLP was involved in the case

presented in Court using EPSDT

Dosing for the remainder of the season was obtained for the child.

What can a Physician do?

Follow the appeals process Document reasons for not following established guidelines, offer

current research Use strong language and hold individual accountable for their

denial. (what is your name so that your denial can be documented in the chart.)

When needed use your resources. MLP Research associates

Resources

United Way 211

Legal Aid Line for LAWO and ABLE 1-888-534-1432 / www.legalaidline.org

Partner sites may refer the patient directly to the MLPC

www.medical-legalpartnership.org