Early and Periodic Screening Diagnostic and Treatment

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Early and Periodic Screening Diagnostic and
Treatment

• EPSDT myths, legends and truths
• Jeffery Thompson, MD MPH
• Washington State Medicaid

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EPSDT The Legend

• The findings of this Task Force are dramatic
  evidence that poverty is still with us, still
  exacting its price in spoiled lives and failed
  expectations. For entirely too many Americans the
  promise of American life is not being kept. I
  wish to see an America in which no young person,
  whatever the circumstances, shall reach the age
  of 21 without the health, education, and skills
  that will give him an opportunity to be an
  effective citizen and a self-supporting
  individual.
• Lyndon B.Johnson, January 5, 1964

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One-Third of a Nation A Report on Young Men
Found Unqualified for Military Service
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EPSDT the truth

• EPSDT is a federal Medicaid program and
  comprehensive service for those under 21
• OBRA 89 impact
• Annual reporting
• Periodic schedules
• Lead Screening
• Medically necessary services

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EPSDT the plan

• Periodic and "as needed" screening services that
  include Unclothed physical examination
• Comprehensive health and developmental history
  (including assessment of both physical and mental
  health development)
• Immunizations recommended by the CDC advisory
  committee on immunization practices (ACIP)
• Health education and anticipatory guidance

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EPSDT the services

• Necessary health care diagnosis services,
  treatment, and other measures classified as
  medical assistance to correct or ameliorate
  defects and physical and mental health conditions
  discovered by screening services, whether or not
  such services are covered under the state medical
  assistance plan

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EPSDT and Medical Necessity

•  "Medically necessary" is a term for describing
  requested service which is reasonably calculated
  to prevent, diagnose, correct, cure, alleviate or
  prevent worsening of conditions in the client
  that endanger life, or cause suffering or pain,
  or result in an illness or infirmity, or threaten
  to cause or aggravate a handicap, or cause
  physical deformity or malfunction. There is no
  other equally effective, more conservative or
  substantially less costly course of treatment
  available or suitable for the client requesting
  the service. For the purpose of this section,
  "course of treatment" may include mere
  observation or, where appropriate, no treatment
  at all.

WAC388-500-0005
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Define Reasonably Calculated
Hierarchy of Evidence

• "Evidence-based" -- The ordered and explicit use
  of the best evidence available

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Cadillac's vs. Chevy's What is the Grade?
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WAC388-501-0165
Less Risk, Less Cost Next Step in Reasonable
Care
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GRADE A Solid evidence that this technology
has good value

• EXAMPLE Vaccinations under the Federal VAC
• Gets an A for having good studies and evidence
• Reduces Mortality and Morbidity
• Gardasil (Vaccination for HPV and prevention of
  cervical cancer)

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GRADE B Solid evidence that this technology
has good value

• EXAMPLE Use of Botox in Spasm
• Gets an B for lower extremities and assisting
  walking
• There is however, little or poor evidence to
  support use in arm and to control excessive saliva

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GRADE B/C/D Reasonable evidence and data points
in direction of value
EXAMPLE Bariatric surgery in 2003 got a D
but in 2004 it gets a B

• Surgery gets a B for diabetics who are obese
  (BMI gt35) and
• a D for other co-morbid conditions (WAC
  388-551-1600 or http//www.hta.hca.wa.gov/)
• Approval rates dropped (95 to 67) ,
• Costs are down (36,000 to 17,000 per case)
  ,
• Mortality and serious complications are
  reduced (0 in 2005)
• Expected annual savings and clinical outcomes
  are better
• Pediatric Bariatric Surgery in 2007 got a
  D from the community Health Technology
  Assessment Committee
• 18-21 y/o only the band and lt18 y/o requests
  will be looked individually and if no studies
  get a D for experimental and investigational

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GRADE D EXAMPLE Disabling idiopathic generalized
dystonia
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Combining EBM and Risk/Safety Management
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EPSDT The Myth

• Decision making should be case by case
• Use your medical necessity language
• Look to see if the request is safe and
  non-experimental
• Carefully consider broad non-cover or limitations
  in benefit design for those lt21 y/o
• Everyone gets everything when requested under an
  EPSDT exam - is a myth

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Questions?