The Effect of Foster Care Policy on EPSDT Visits

Angela B. Snyder, Ph.D., M.P.H.Glenn M. Landers M.B.A., M.H.A.

Mei Zhou, M.S.

Motivation

• Children entering foster care are often in poor health

• Most foster care children are eligible for Medicaid• Standards of care developed jointly by the Child

Welfare League of America (CWLA) and the American Academy of Pediatrics (AAP)

• The implementation of foster care policies vary by state– States have not taken full advantage of EPSDT services– ACF (2005) reports that only 20 states provided adequate

services to meet children’s physical health needs

• Few states consistently measure the impact of foster care policies

Previous Research

• Before entering foster care: inadequate routine medical care/preventive care (Curtis, 1999; Simms, 1989)

• 1/3 of foster care children living in NYC, LA, and Philadelphia did not receive proper immunizations and 12% received no routine care (GAO, 1995)

• Few studies compare health care utilization of foster care children with those not in foster care

Previous Research

• Rosenbach, Lewis & Quinn (2000) found that for 2 (CA & PA) out of 3 states (CA, PA, FL) children in foster care were more likely than other Medicaid children to have a preventive check-up; in all states, foster care children had higher rates of dental visits.

• Bilaver & colleagues (1999) found three times greater odds of receiving a Medicheck screen, including EPSDT services for foster care

children compared to other Medicaid children.

Background

• Benefits of this study:– More recent data, – Ability to use several comparison groups of

children enrolled in Medicaid, – Ability to use multivariate methods to focus

on preventive/EPSDT services, – A unique state with low Medicaid managed

care penetration at the time of the study.

Research Questions

• Does the Georgia DFCS policy requiring an EPSDT screen and comprehensive exam within ten days of foster care placement and ongoing care consistent with AAP guidelines increase the utilization of preventive care services (both medical and dental) among foster children compared with other Georgia children on Medicaid?

• If so, by how much?

Data/Methods• Retrospective cohort study using 2005 Georgia

Medicaid claims data• Study group (N=12,735)

– Children 3 to 18 years of age, – Ever eligible for benefits in 2005 via foster

care • Comparison groups:

– Adoption assistance (N=12,034),– Supplemental Security Income (N=38,096),

and – Income-eligible (N=772,752)

Methods

• Category of Medicaid eligibility was determined hierarchically in the following order: foster care, adoption assistance, SSI, and finally income-eligible.

• Children receiving adoption assistance (84%) and SSI (76%) were more likely to be continuously enrolled for the entire year.

39%41%

20%

Continuously enrolledEntered Foster Care 2005Left Foster Care in 2005

Methods

• Logistic regression is used to estimate the likelihood of an annual EPSDT visit and at least one dental visit by eligibility group.

• Control variables include: age, gender, race, rural/urban residence, months of enrollment during 2005, and health status (as measured by annual Medicaid expenditures) for the EPSDT model only.

Descriptive Results

• All groups about 50% male with the exception of SSI (65%)

• Foster Care children evenly split on race: there were more non-white children in the other groups

• Foster Care and adoption assistance: about half children lived in urban areas, income-eligible and SSI children were 66% and 65% urban respectively

• Mean age of foster care children 10, 11 for AA and SSI, 9.5 for income-eligible children.

Descriptive Results

• Health Status/Utilization-- Average Medicaid expenditure per child– Foster Care: $6,433– Adoption Assistance: $2,209– Income-eligible: $1,037– SSI: $6,072

ResultsPreventive Visits by Medicaid Eligibility

47%

24% 26% 26%

69%

55%49% 47%

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

Foster Care Adoption Assistance Income Eligible SSI

Eligibility Group

Having at least one EP SDT visit Having at least one dental visit

Results

• Compared to children in the adoption assistance (odds ratio [OR], 1.62), SSI (OR, 2.15), and income-eligible (OR, 1.5) Medicaid groups, foster care children were more likely to receive an annual EPSDT screening when controlling for other variables.

• Foster care children were over two times more likely than children receiving adoption assistance (OR, 2.04), SSI (OR, 2.85) and income-eligible Medicaid (OR, 2.03) to have a dental visit during the same year.

Implications

• Georgia foster care policy requiring a Health Check within 10 days of placement into the foster care system and annual check-ups consistent with pediatric guidelines is effective at significantly increasing EPSDT visits for foster care children compared to other children receiving Medicaid.

• The policy requiring a visual inspection of the mouth and appropriate referral to a dental provider is also effective at increasing dental visits.

• State policy makers might consider additional monitoring of children receiving adoption assistance to further improve the utilization of preventive care by this vulnerable group.

Limitations• Unable to capture utilization of preventive care

for privately-insured children in foster care or adoption assistance who may be covered through their foster/adoptive parents.

• Only a proxy measure of health status for EPSDT model.

• Medicaid eligibility data may be biased in identifying foster care children who are more likely to receive services (Rubin et al., 2005)

Future Research

• Future research is planned linking Medicaid claims data to child welfare administrative data for information on foster care placement and more accurate reporting on entrance into foster care and Medicaid service receipt.

• Many states are moving foster care children from FFS to Medicaid managed care; the impact of this change on receipt of preventive services should be evaluated.