1. Effective Use of Medicaid to Support EHDI Programs Peggy McManus Maternal and Child Health Policy Research Center Karl White National Center for Hearing Assessment and Management Janet Farrell Massachusetts State EDHI Program

2. 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.

3. 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

4. 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

5. 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?

6. 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

7. 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

8. 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

9. 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

10. Information and Education Examined state EPSDT strategies for using effective educational strategies in working with PCPs, families, hospitals, HCOs, and local health departments PCPs No magic bullets or single approaches Very little done so far on follow-up Important to have good, actionable data about how PCPs perform Evidence-based data also important Newsletters that profile promising practices useful

11. Information and Education PCPs (continued): Ongoing training of residents helps CME necessary, but not sufficient More needed to target PCPs in rural areas, with small numbers of children in practice

12. 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

13. 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

14. Information and Education Use of popular media helpful Critical 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

15. 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

16. 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

17. 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 causeseducation & training, reimbursement, other Streamline & integrate hearing follow-up services with CM, EI, WIC, 1-800#, EPSDT outreach

18. Quality and Financial Incentives Examined opportunities for incorporating quality incentives from Healthy People 2010 Examined Medicaid reimbursement levels

19. 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

20. Quality Incentives NICHQs 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

21. 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 Theyre not doing this work for the financial rewards, but for the benefits of the children.

22. Reimbursement Incentives Ha, ha, ha. Stand in line. State Medicaid and public health funding is already stretched to its limits Important to piggyback with existing EPSDT administrative outreach efforts Through Medicaids administrative match, possibly some potential for funding follow-up activities

23. 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

24. 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

25. 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

26. Collaboration Examples: MD- a portion of EHDI coordinators 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

27. 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)

28. Massachusetts Prenatal Care 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

29. 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

30. 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

31. 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

32. 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

33. 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

34. 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