The Early Periodic Screening, Diagnosis, and Treatment Program [EPSDT] : Status of Progress and Implementation in 51 States and Territories Albert Chang, MD, MPH Hyman Goldstein, PhD Kent Thomas, BA Helen M. Wallace, MD, MPH

INTRODUCTION The 1967 Amendments to Title 19 (Medicaid) of the Social Security Act specifically directed states with Medicaid programs to implement the Early and Periodic Screening, Diagnosis, and Treatment (EPSDT) program. An esti- mated 12 million children and youth were eligible for EPSDT, making it the single largest public program of preventive health care for children and youth in the United States.’ The goals set for EPSDT were high: to improve children’s health; to promote preventive medicine; to search out eligible children; to inform and encourage participa- tion in the program; and to require state programs to arrange for screening, referral, diagnosis and treatment.’

The status of implementation of EPSDT in 54 states and territories was studied in 1972: Results showed that many states were providing EPSDT services only to eligible preschool children and not to eligible school-age children and youth. A number of states also had not yet implemented an EPSDT program.

This study was done to resurvey the 54 states and territories in 1976 in order to determine the progress toward implementa- tion of EPSDT on a nationwide basis and to determine the extent of implementation in each state. Specific objectives of this study were to determine: ( I ) the state agency with overall responsibility for EPSDT, (2) the setting of standards and guidelines under EPSDT, (3) the participation of health consultants and other health agencies, (4) the proportion of the eligible population that has been served, ( 5 ) expenditures in EPSDT, (6) content and extent of services, (7) the types of providers and an assessment of their partici- pation, and finally (8) the problems in EPSDT programs and recommendations to deal with these problems.

METHOD OF STUDY A nine-page study* was developed, pre-

tested, and mailed with a cover letter to the 54 state and territory** agency directors named by the Regional Office EPSDT Coordinator, Department of Health, Education, and Welfare, as most directly responsible for the overall state administration of EPSDT. Additional data on state EPSDT programs were obtained from the national office of the Medical Services Administration, Social and Rehabilitative Services, Department of HEW.

STUDY FINDINGS

Responses by States and Territories After the initial mailing in the summer of

1976 and two follow-up mailings in the fall of 1976, 52 study forms were returned for a response rate of 96.3%. This included 49 states and 3 territories. Because one state response*** indicated that it had not yet implemented an EPSDT program, this study will be based on the data reported by the 51 states and territories that currently report having an EPSDT program.

State Agency Responsible for the EPSDT Program

The responsibility for the overall state EPSDT Program was in a welfare or social services agency (Department of Welfare, Department of Social Services, Department of Human Services, and Department of Human Resources) in 33 states; and in a health agency (Department of Health, De- partment of Health and Welfare, and Department of Health and Social Services) in

**The 50 states, District of Columbia, Puerto Rico, the Virgin Islands, and Guam.

*Available on request.

***Arizona

17 states. In the remaining state, a separate Medicaid Commission was responsible for EPSDT.

Establishment of Standards and Guidelines in State EPSDT Programs

Health professionals outside of the state agency were involved in setting the standards and guidelines for the EPSDT Programs established in 44 statss: 36 states had the participation of the state chapter of the American Academy of Pediatrics, and 28 states had the participation of the State Medical Society. Three states had not established standards and guidelines, and four states did not provide this information.

Health Consultants in State EPSDT Programs

Forty-nine states had a variety of health consultants serving in the EPSDT programs: pediatricians (27), other types of physicians (29), nurses (27), social workers (29), and nutritionists (10). Nineteen states mentioned other health consultants such as dentists, audiologists, psychologists and optometrists. Most states reported more than one type of health consultant. The remaining two states reported that their EPSDT Programs did not have health consultants. Children knefited in 1975

The 5 1 states reported a total of 9,771,683 children and youth eligible for EPSDT in 1975. Of those eligible, 1,813,886 (18.6%) received screening services. The percent screened varied from a low of 1 Vo to a high of 80Vo of the state’s eligible children and youth.

The 49 states which had referral informa- tion reported that 799,886 children and youth were referred, or 46.9% of the 1,705,250 children and youth screened by these states. The remaining two states did not provide

454 THE JOURNAL OF SCHOOL HEALTH OCTOBER 1979

referral information. As to diagnosis and treatment statistics,

very little information is available since only 5 statcs were able to report the total number of children and youth screened, referred, diagnosed, and treated in the state EPSDT program. The rest of the states had not developed data linkage systems and could not report this inforpation.

Expenditures in 1975 number of children and youth served cannot report the expenditures in 1975.

Forty-one states reported a total of $38,921,416 spent for screening of 1,399,990 children and youth. The average cost per Content of State EPSDT PrWnms child screened using these figures is $27.80. The state EPSDT Programs included It is not possible to calculate the cost per child health screening tests, immunizations, well- screened, referred, diagnosed and treated child health supervision and dental care because the five states that can report the services. The tests and services provided are

TABLE 1

Screening Tests and P reven t ive Heal th Se rv ices Included i n EPSDT and Other Pub l i c Programs (51 responding s t a t e s )

Test o r s e r v i c e

Screening Tests

Developmental Vision Hearing Hct . /Hgb . Tubercul in S i c k l e C e l l Blood P res su re U r i n a l y s i s Lead Poisoning Urine Cu l tu re

Immunizations

DPT P o l i o Mea s 1 es Rubel la Mumps

Well Chi ld Supervis ion

Heal th Appra l sa l ( i nc lud i n g h i s t o r y and phys ica l exam.)

Height & Weight Inspec t ion f o r

Ears, Nose & Throat Exam. Immunization Assessment Heart Exam. N u t r i t i o n Counsel l ing

An t i c ipa to ry Guidance Sa fe ty 6 Accident Pre-

ven t ion I n s t r u c t i o n

Phys ica l Defects

and Education

I Dental Care

Cleaning and Prophylaxis Top ica l App l i ca t ion

F i l l i n g Ex t rac t ion Dental Hygiene Education P r o s t h e s i s Orthodont ic Care

of F luo r ide

I

Included in EPSDT

48 47 47 47 44 43 43 39 38 28

46 46 46 46 16

48 48

48 48 48 44

38 29

22

35

35 34 34 31 30 19

Included i n o t h e r p u b l i c

program

1 3 4 7

2 2 2 2 1

1 1

1 1 1 1

5 14

10

14

1 3 1 5 1 5 15 1 7 16

Not ‘ included i n EPSDT nor o t h e r pub l i c program

Ouestion n o t answered

2 2 2 2 2 4 3 8 4

11

2 2 2 2

34

2 2

2 2 2 5

4 7

11

2

3 2 2 4 3 7

OCTOBER 1979 THE JOURNAL OF SCHOOL HEALTH 455

listed in Table I . * In a few states, some of these screening tests are provided under the auspices of Crippled Children’s Services, Maternal and Child Health Services, Title 19 or other public programs.

Thirty-four states reported that at least one new health test was introduced by EPSDT. Among the new health tests introduced were: hearing testing (lo), dental screening (lo), vision testing (9), immunization ( I ) , develop-

*A few states also provided the following tests: speech testing, testing for venereal dis- ease, and testing for ova and parasites.

mental assessment ( I ) , and speech testing (1). Three states reported that the entire preven- tive health service package for children and youth was a new service. Seventeen states reported that no new health tests were introduced by EPSDT.

Henlth Care Providers Table 2 shows the types of health providers

participating in each state EPSDT Program and the state agency’s subjective assessment of their participation.

In states indicating participation, the following types of providers were ranked

high in the list of “good” participants: hospitals, Crippled Children’s Programs, pediatricians, maternal and child health clinics, neighborhood health centers, dental clinics, well-child conferences, child develop- ment clinics, group practices, and general practitioners.

Significnnt Problems

The following problems were cited by at least 10 states: insufficient primary provider participation (20). under-utilization of EPSDT services (la), poor coordination in

TABLE 2

Major Types of P rov ide r s i n S t a t e EPSDT Programs (51 responding s t a t e s )

P a r t i c i p a t i o n

P rov ide r s ~

P e d i a t r i c i a n s General P r a c t i t i o n e r s

Group P r a c t i c e s Dental C l i n i c s Hosp i t a l s

Crippled Ch i ld ren ’ s

Neighborhood Heal th

Children & Youth P r o j e c t s Maternal and Child

Heal th C l i n i c s Well Child Conferences

Day Care Centers ( i n c l . Heads t a r t )

Osteopaths Materni ty and In fan t

Family Planning C l i n i c s School Heal th Se rv ices Child Development C l i n i c s Materni ty C l i n i c s Mental Re ta rda t ion

C l i n i c s

Heal th Maintenance Organizat ions

Nursery Schools Ch i rop rac to r s

Programs

Centers

Care P r o j e c t s

- Yes

47 46

43 41 40

40

38

37

35 34

34

34

31

30 26 26 21

21

20 12

6 -

- No -

3 3

5 8

1 0

9

1 0 1 2

1 3

14

13

14

18 17 23 21 26

26

26 34 42 -

No answer

1

2

3 2

1

2

3 2

3

3

4

3

2

4 2 4 4

4

5 5 3

Note: Totals may no t add up t o 100% due t o rounding.

I f P rov ide r P a r t i c i p a t i n g , Sub jec t ive Asseuement of P rov ide r P a r t i c i p a t i o n by Percent of States

- Good - 72.3

56.5

58.1 63.4 75.0

80.0

65.8 54.1

68.6 61.8

50.0

47.1

51.6 46.6 42.3 61.5 38.1

47.6

45.0 25.0 16.7 -

- F a i r

10.6

17.4 20.9

17.1 15.0

7.5

15.8 24.3

1 7 . 1 23.5

32.4

29.4

25.8

23.3 34.6 11.5 14.3

14.3

20.0 41.7 16.7

-

-

Poor

4.3 8.7

2.3 2.4

-

-

2.5

- - - -

- 2.9

- -

3.8

3.8 4.8

4.8

10.0 8.3 - -

Unable :o comment

12.8

15.2

13.9 14.6 10.0

10.0

18.4 21.6

11.4

14.7

17.6

11.8

19.4 30.0

15.4 23.1

43.0

33.3

20.0 25.0 66.7

Unspecified

456 THE JOURNAL OF SCHOOL HEALTH OCTOBER 1979

public agencies (IZ), high rate of broken appointments (1 l), and insufficient outreach activities (10). Other problems cited by the states were: inadequate follow-up activities (7), insufficient specialist participation (6), insufficient staff in agency (6), insufficient preparation of staff in agency (6) and difficulty in complying with Federal require- ments (6).

Recommendations The following recommendations for im-

proving the state EPSDT programs were cited by at least 10 states: increase health education and utilization by eligible families (14), increase knowledge of and participation in EPSDT by health providers (12), improve coordination among public agencies (12). increase outreach activities (lo), and increase staff in agency (10). Other recommendations cited by the states were: improve follow-up activities (9), increase funding for program (7), increase knowledge of EPSDT in staff of public agencies (6), increase dental provider participation (3), and improve transportation arrangements for eligible families (3).

DISCLJSSJON

Since an earlier study of state EPSDT programs in 1972: some progress has taken place in the implementation of EPSDT in the 5 I states and territories reported in this study. By 1974, all of these states and territories had initiated an EPSDT Program for eligible children and youth. In the majority of states, standards and guidelines for EPSDT have been established with participation of inter- disciplinary health consultants and input from organized health organizations such as state chapters of the American Academy of Pediatrics and state medical societies. The content of the state EPSDT programs includes standard health screening tests, immunizations. well-child health supervision and dental care services. Thirty-four states report that at least one new health test was introduced by the EPSDT Program.

There still exist, however, significant problem areas in these state EPSDT pro- grams. For example, three states had not yet established health standards and guidelines; and in two states, there were no health consultants involved in the EPSDT program.

The major problem is that less than 20% of eligible children and youth have actually received these preventive health services. This fact alone, almost 10 years after the enactment of the EPSDT Legislation, has made it a prime target of criticism by Congress,’ by health professionals,’ by the press? by child advocacy groups: and by the mass media.’

What accounts for these problem areas as well as the low participation of health providerg? Foltz has accurately identified three “constraints” on the nationwide imple-

mentation of the EPSDT Program: 1) federal inability to enforce its laws and regulations, 2) states’ inability to develop adequate management and management information systems, and 3) lack of consensus among professionals as to what constitutes appropri- ate preventive pediatric care for children.’ Evidence for (1) above is the half-hearted commitment and effort by both the federal administration and the state governments which led to the long-delayed and feeble implementation of state programs, some starting as late as 1974.6 (Legislation was in 1967 and implementation was scheduled for July 1, 1969.) The second constraint is also apparent. With few exceptions,lO*” states were not able to screen many children nor to document the number and follow-up of health conditions detected. States, therefore, cannot provide accountability for their efforts, limited as they are. The third “constraint” probably carries greater impli- cations than what first might appear. Although it can be said that most health professionals would agree on the value of preventive health services for children, honest difference of opinion exists, on the what, when, how and where these services should be provided. Thus, questions have arisen, for example, on the indication for routine tuberculin testing” or urine testing.13 As to schedule and frequency of preventive visits, even the most recent edition of the American Academy of Pediatrics’ StandaM of Child Health Care l4 does not give a recommended schedule and frequency and states “the optimal number of visits or preventive procedures for all children or their parents is at present impossible to establish”.

The above “constraints” would easily hinder the best intentioned efforts to provide preventive health services on a nationwide basis for needy children and youth. In addition, at least three other significant limitations exist in the national EPSDT program: (1) it is a program for only a segment of the poor children and youth population; (2) there is not enough money to fund the services it is committed to provide, and (3) there have never existed any specific, measurable objectives related to program goals. From its inception, EPSDT in serving only Medicaid children and youth, was judged as not helpful to a11 needy children and youth, ie, those who were poor and needy but not covered by Medicaid. In subsequent years, as the realization was made that many “non-poor children also needed preventive health services, this categorical element of the EPSDT Program has been criticized. The financial limitations are also severe. Although it is true that the imple- mentation of the EPSDT Program took place at a time when both the federal and state administrations were experiencing financial retrenchment,” the costs of EPSDT services

were much higher than originally estimated. Using the figure of $27.80 average cost per child screened calculated from data provided in this survey, it would cost at least $278 million to screen the approximate 10 million eligible children and youth. This would not include, however, the additional costs of referral, treatment and follow-up for selected children and youth. The lack of specific measurable objectives in the EPSDT Pro- gram has prevented any valid program evaluation of the national program. Thus, just as proponents of EPSDT can point out that large numbers of children and youth are beginning to receive preventive health ser- vices, detractors can claim that only a small minority of the eligible population are receiving services that they are entitled to. This lack of measurable objectives appears to be common in Federal programs of this magnitude.16

At the time of this review (May 1979), several legislative initiatives under the name of the Child Health Assessment Program (CHAP) have been proposed to revitalize a much weakened national EPSDT Program. ” Although under this proposal more funds will be allocated and eligibility would be extended to more children, major deficiencies would still persist. Thus, under CHAP, outreach efforts would still be limited. few provisions are made to increase participation of addi- tional health providers and many needy children from poor and near-poor families would still not be served. One would hope that these efforts to improve and strengthen the EPSDT Program will be adopted at the national level. These well-intentioned steps, however, should not blind us to the fact that preventive health services for children and youth will not be universally adopted until scientific knowledge strengthens their validity and until national health policy assigns them as priorities for all children and youth.

This study was supported by Grant No. MC-R-060208-03-0 from the Maternal and Child Health Service, Office of Clinical Services, U.S. Department of Health, Educa- tion, and Welfare, Rockville, Maryland.

REFERENCES

1. Newman HN: Child Health Services Under Medicaid: Concentrating efforts where they count. Paper presented at the National Health Foundation Conference, March 12- 13, 1974, Boston, Massachusetts. 2. Dixon MS: EPSDT (Early and Periodic

Screening, Diagnosis, and Treatment Pro- gram). Pediatrics 54244-90, 1974.

3. Wallace HM, Goldstein H, Oglesby AC: The health and medical care of children under Title 19 (Medicaid). Amer J Pub HIth 64:501-506, 1974.

OCTOBER 1979 THE JOURNAL OF SCHOOL HEALTH 457

1-please affix addross label here:

2-and indicate correction here:

Name

Titl.

Address

city State zip - 3-mail to: American School Health Association

National Office Building P.O. Box 708 Kent, Ohio 44240

4. US. Congress: Department of Health, Education and Wecfare’s Administration of Health Programs: Shortchanging Children. Report by the Subcommittee on Oversight and Investigations of the Committee on Interstate and Foreign Commerce, Septem- ber, 1976.

5. American Academy of Pediatrics: U.S. to increase funding, scope of EPSDT program. News and Comments, May 1977.

6. Iglehart JK: Health report. National Journal Reports, June 29, 1974.

7. Children’s Defense Fund: EPSDT: Does It Spell Health Care for Poor Children? Washington D.C., 1977.

8. American Broadcasting Company: Children: A Case of Neglect. Broadcast on July 17, 1974.

9. Foltz AM: Constraints on EPSDT policy. Paper presented to the Association for Teachers of Maternal and Child Health, April 5, 1978, Washington D.C.

10. Wiygub FM, Cobb AB, Beeb TW: Health Screening for Medicaid Eligible Chil- dren in Mississippi: Results of the First Three years of Screening. J Miss State Med Assoc

11. Kirk TR, Rice G, Allen PM: EPSDT - One quarter million screening in Michigan. Amer J Pub Hlth 66:5:482-484, 1976.

12. Edwards PQ: Tuberculin testing of children. Pediatrics 54:628-30, 1974.

13. Gutgesell M: Practicality of screening urinalyses in asymptomatic children in a primary care setting. Pediatrics 62: 103-05, 1978. 14. American Academy o f Pediatrics:

Standards of Child Health Care, Third Edition, 1977.

IS. Shenkin BN: Politics and the health of children. Medical Care 14:884-6, 1976. 16. Wholey JS, Nay JN, Scanlon JW: If

You Don’t Care Where You Get To, Then It Doesn’t Matter Which Way You Go. Publications Office, The Urban Institute, 2100 M Street, N.W., Washington D.C. 20037.

17. U.S. Congress: Child Health Assess- ment Act, H R. 6706- S 1392,95th Congress, 1977.

14:281-283, 1973.

Albert Chang. MD, MPH (Corresponding author) is Assistant Professor, Helen M. Wallace, MD, MPH is professor, Hyman Goldstein, PhD is lecturer and Research Biostatistician and Kent Thomas are all in the Department of Social and Administrative Health Sciences, School of Public Health, Universily of California, Berkeley, CA 94720.

458 THE JOURNAL OF SCHOOL HEALTH OCTOBER 1979