Good Coverage, Poor Access

Consider the following case study:

A 4 year old boy, Andy, has just qualified for coverage through a regional TennCare MCO. He presents to the local health department for an EPSDT (well child checkup) exam.

What is Covered

An EPSDT must include all the following services:

• Screening Services -- Screening services must include all of the following services:
  1. Comprehensive health and developmental history
  2. Comprehensive unclothed physical exam
  3. Appropriate immunizations
  4. Laboratory tests
  5. Lead Toxicity Screening
• Health Education Vision Services
• Dental Services
• Hearing Services
• Other Necessary Health Care - States must provide other necessary health care, diagnosis services, treatment, and other measures described in section 1905(a) of the Act to correct or ameliorate defects, and physical and mental illnesses and conditions discovered by the screening services.

Results

During the EPSDT, the examiner finds the following:

• A developmental screening tool shows a "refer" score; mother notes concerns about aggressive behavior and speech delay.
• Mother wants to know if there's anything that can be done for fecal soiling.
• BMI is at the 97 %ile for age and sex
• He has significant tooth decay
• He is noted to have end-expiratory wheezing
• He has some curvature of the spine with R shoulder higher than the L shoulder

What's Next?

The examiner needs to make some followup plans for Andy's health, but encounters the following problems:

• Medical issues (asthma, constipation): Local family physicians do not accept TennCare or do not feel comfortable dealing with complex pediatric issues. Andy's mother will instead go to the local hospital's ER if these problems flare up, even though it is much more cost-effective to treat them in a private physician's office.
• Specialist issues (scoliosis): The closest in-network pediatric orthopaedist is over 100 miles away; mother can't afford gasoline and time off work.
• Dental issues (caries): He'll need sedation for dental work, which local TennCare dentists do not provide.
• Behavioral issues: There is a 6 month waiting list for new appointments at the community mental health center. By contrast, patients with commercial insurance are being offered appointments within 2 weeks at a private child psychiatry practice.

Summary

This vignette is regrettably all too common in Cumberland County. Andy has COVERAGE, but not ACCESS.

His EPSDT screen and all its elements are covered benefits from TennCare. Andy's mother will not have to pay out of pocket for these important preventive services.

Andy is having difficulty getting access to the follow-up services you've identified.

Access means Andy will get timely, local, and child-appropriate services.