Health Conditions, Utilization, and Expenditures of Children in Foster Care. Utilization of Health Care Services

09/19/1999

Previous studies have shown that children in foster care utilize more mental health services, on average, than do other children covered by Medicaid (Takayama et al. 1994; Halfon et al. 1992(b), 1995). Studies have differed in their findings as to whether children in foster care utilize more physical health services. For example, Chernoff et al. (1994) and Halfon et al. (1995) found that foster children had higher health care costs than other children, whereas Takayama et al. (1994) found that they did not.

This section explores patterns of health care utilization among foster care children and children in other categories of Medicaid eligibility. Utilization is measured in two ways: first, in terms of initial access to care (initial entry into the health care system); and, second, in terms of the intensity of use. The access to care measures reflect the percentage of children with one or more inpatient stays or one or more visits of a particular type, while the intensity measures capture the number of inpatient days or outpatient visits per 1,000 children. We analyze patterns of mental health and substance abuse treatment separately, given the importance of this type of care for the foster care population. The utilization measures were defined in Chapter II (Table II.5).

1. Access to Care and Intensity of Use

a. Inpatient Care

Children in foster care had above-average rates of hospitalization compared to the general population of Medicaid children (Table III.15 and Figure III.7). Among the three states, foster care children in Florida were slightly more likely to have a stay (4.1 percent in Florida versus 3.2 percent in the other two states). As expected, SSI children had the highest likelihood of a hospital stay (7 to 12 percent in 1994), and correspondingly, the number of hospital days per 1,000 children was dramatically higher among SSI children than foster care children, ranging from three times higher in Pennsylvania to 14 times higher in California. Compared to the AFDC children, those in foster care were more likely to be admitted to the hospital and they had two to three times more inpatient days per 1,000 children. Children receiving adoption assistance had by far the lowest rate of inpatient use.(13)

 

Table III.15: Health Care Utilization Among Children in Foster Care and Other Categories of Medicaid Eligibility, 1994. 

Figure III.7: Variations in Health Care Utilization, by Category of medicaid Eligibility, 1994.

Figure III.7 (Continued).

 

b. Outpatient Provider Visits

We observed considerable variation in patterns of outpatient provider visits, both across states and among groups of Medicaid children within each state. Over 80 percent of the foster care children in Florida and Pennsylvania had at least one provider visit in 1994 (excluding visits to emergency rooms), compared to 65 percent in California. Nationally, 74 percent of children had at least one ambulatory medical care visit in 1996 (McCormick et al. 2000), suggesting that utilization by foster care children in California was lower than the national average for all children.(14)

Not only was the likelihood of a provider visit among foster care children lower in California than in the other two states, but it was also lower relative to the AFDC and SSI children within that state (71 and 77 percent, respectively). On the other hand, foster care children in California had a higher intensity of provider contact than AFDC children (as measured by visits per 1,000 children), signifying that once they were in the system, they received more care. Nevertheless, these comparisons echo the conclusions of a task force in California, which cited the lack of a "system of health care for foster children, but rather an unplanned, often uncoordinated set of services" (California State University 1998).

In Florida, we found that the rate of provider visits among foster care children was higher than that of SSI children (85 percent versus 78 percent) and moreover, the intensity of visits was higher (14,400 versus 12,200 per 1,000). In Pennsylvania, the likelihood of a visit was relatively comparable (83 percent versus 86 percent), but SSI children had more visits (22,700 versus 15,600 per 1,000). Not surprisingly, in both states foster care children had substantially higher utilization than AFDC children (averaging three times more visits per 1,000 children).

c. Emergency Room Utilization

Between one-fourth and one-third of all foster care children visited an emergency room (ER) at least once in 1994. Nationally, the self-reported rate was much lower, at 13 percent overall, and 15.5 percent among those with public insurance coverage (McCormick et al. 2000). Across all three states, foster care children were less likely than SSI children to use the ER. The patterns of ER use varied, however, relative to the AFDC population. The likelihood of an ER visit among foster care children was similar to that of AFDC children in California (28-29 percent), slightly higher in Florida (25 percent versus 22 percent), and quite a bit lower in Pennsylvania (34 percent versus 42 percent). Indeed, in Pennsylvania, the number of ER visits per 1,000 children was one-third lower among foster care children than AFDC children. It is unclear what is driving these variations in patterns of ER use across states and among populations within states.

d. Prescribed Drugs

We found that one-half to two-thirds of foster care children had one or more prescriptions in 1994, with the lowest rate observed in California (51 percent). The rate in the general population nationally was 55 percent in 1996, so foster care children in California were below the national rate (McCormick et al. 2000).

Not surprisingly, across all three states SSI children were more likely than foster care children to receive one or more prescribed drugs. We were surprised, however, to find that in two states  California and Pennsylvania  the AFDC population also had higher prescription drug utilization than the foster care population. We would expect these differences to be driven by case mix (such as differences in the prevalence of otitis media or asthma), but we were not able to explore what drugs or diagnoses account for the variation.

e. Preventive Care

Turning now to preventive checkups, foster care children in Pennsylvania had the highest rate of preventive care (41 percent), compared to 35 percent in California and 28 percent in Florida. Indeed, in Florida, the rate was similarly low across all categories of Medicaid eligibility. In the other two states, foster care children had the highest levels of preventive care compared to children in other groups. In California, for example, one-third of the foster care children but only one-fourth of the SSI children had a preventive visit in 1994.

Despite somewhat more favorable levels of preventive care among foster care children in two of the three states, it is nevertheless apparent that many foster care children do not receive routine check-ups in a given year, despite the recommendations for preventive health examinations every six months for infants and preschoolers in foster care, and annual exams thereafter (CWLA 1988).(15)

f. Dental Care

Foster care children were more likely to receive dental care than any other group of Medicaid children. Sixty percent of the foster care children in Pennsylvania and 44-45 percent in California and Florida had at least one dental visit in 1994, compared to 28-38 percent in the AFDC population and 31-35 percent in the SSI population. Moreover, the number of visits per 1,000 foster care children exceeded the number for the other groups, especially in Pennsylvania. In general, the level of dental care observed in the foster care population was comparable to that observed in the general population, with about 43 percent of all children nationally having at least one dental visit in 1996 (McCormick et al. 2000). Other Medicaid children, however, used dental care at rates well below the national average.

2. Utilization of Mental Health and Substance Abuse Services

The likelihood of receiving mental health or substance abuse treatment services varied substantially among foster care children in the three states, ranging from a low of 23 percent in California to a high of 38 percent in Florida, with Pennsylvania in the middle at 33 percent (Table III.16 and Figure III.8).(16) Few foster care children were hospitalized for mental health or substance abuse treatment (only 1.7 to 2.9 percent). Most received treatment on an outpatient basis.

Table III.16: Utilization of Mental Health and Substance Abuse Treatment Services, by Category of Medicaid Eligibility, 1994.

Figure III.8:
Variations in Use of Mental Health/Substance Abuse Services, by Category of Medicaid Eligibility, 1994

Figure III.8: Variations in Use of Mental Health/Substance Abuse Services, by Category of Medicaid Eligibility, 1994.

Source: HCFA State Medicaid Research Files.

Among foster care children receiving any services, there was wide variation across states in the average number of services. For example, in Pennsylvania, foster care children averaged nearly 22 visits per user, versus 18 in Florida, and only 6 in California. (17) Thus, not only did foster care children in California have the lowest likelihood of a visit, but those who entered treatment also had fewer visits. In contrast, utilization was highest in Pennsylvania, both in terms of the likelihood of entering treatment and the number of visits once children were in treatment. This pattern is consistent with results on the higher frequency of mental conditions among foster care children in Pennsylvania than in California, as classified in the CDPS (recall Table III.9). What is not clear, however, is whether the level of use is commensurate with clinical need, and moreover, whether children in California are more likely to have an undiagnosed mental health condition due to barriers to care.

How do patterns of use among foster care children compare to those among children in other categories of Medicaid eligibility? As expected, based on our previous analysis of health conditions in the Medicaid population, foster care children had not only the highest likelihood of a visit, but in some cases, a higher intensity as well. In California, for example, 6 percent of AFDC children and 15 percent of SSI children received treatment, compared to 23 percent of the foster care population. Thus, even though the likelihood of use among foster care children was lower in California than in the other two states, it was nevertheless higher than comparison groups within the state. We see an even more substantial difference in Florida, where the likelihood of any mental health or substance abuse treatment was more than two times higher among foster care children than SSI children, and more than 12 times higher than AFDC children.

In general, the intensity of outpatient treatment (captured by the average number of visits per user) was higher among foster care children than among those in the other groups. In Florida, for example, foster care children averaged 18 visits per user, compared to 12 visits among SSI children, and 7 visits among AFDC children. On the other hand, in Pennsylvania, it would appear that once children entered the treatment system, there was a relatively small difference in the number of visits they received (22 visits, foster care children; 20 visits, SSI children; 19 visits, adoption assistance children).

Although foster care children were more likely to be admitted for inpatient treatment in all three states, the average length of stay was typically greater among SSI children than foster care children. This pattern was most pronounced in California, where SSI children averaged 57 days and foster care children averaged 17 days. This is largely a function of a few outlier cases in the SSI population that influence group averages.

3. Variations Within the Foster Care Population

Tables 17A, 17B, and 17C show patterns of health care utilization among foster care children by selected demographic characteristics and Tables 18A, 18B, and 18C show patterns of mental health and substance abuse treatment.

 

Table III.17A:
Variations in Health Care Utilization Among Children in Foster Care,
by Demographic Characteristics:
California, 1994
  Inpatient Care Outpatient Provider Visits Emergency Room Visits Percent with a prescribed drug Percent with a preventive visit Dental Visits(1)
Percent with a stay Days per 1,000 children Percent with a visit Visits per 1,000 children Percent with a visit Visits per 1,000 children Percent with a visit Visits per 1,000 children
Total 3.2 440 65.0 5,699 27.5 844 51.2 34.5 45.3 1,060
Age
Less than 1 10.2 4,043 35.3 4,419 14.8 947 27.1 27.7 NA NA
1 to 4 5.6 801 62.9 5,079 30.6 1,041 55.7 46.5 35.6 658
5 to 9 1.8 128 69.1 4,621 24.8 613 54.4 38.2 46.6 978
10 to 14 1.4 128 69.8 6,105 26.5 684 51.7 31.7 50.8 1,145
15 to 18 2.2 224 65.7 7,229 30.7 1,019 48.9 23.7 41.5 1,159
Length of Medicaid Eligibility
1 to 5 months 2.0 919 29.2 4,113 8.1 590 15.0 11.9 10.9 744
6 to 11 months 4.4 919 60.5 5,356 26.7 894 45.2 30.7 36.1 1,001
12 months 3.2 325 73.4 5,839 31.7 847 60.1 40.1 53.0 1,082
Type of Health Condition
No condition 1.2 110 50.8 2,741 17.4 425 36.9 27.1 35.6 851
Any condition 7.7 1,059 95.6 11,248 49.3 1,631 81.9 50.5 64.5 1,424
Physical condition only 13.5 1,982 95.7 9,243 57.6 2,070 84.7 55.3 60.0 1,298
Mental condition only 1.0 59 93.5 10,528 34.0 830 73.6 43.9 64.0 1,421
Both physical and mental conditions 7.0 833 99.4 17,284 60.1 2,148 92.0 51.6 72.9 1,635
SSI Eligibility Status
SSI eligibility 8.0 2,936 89.0 12,215 49.2 2,218 78.4 41.4 59.2 1,229
No SSI eligibility 3.1 393 64.6 5,577 27.2 818 50.7 34.4 45.1 1,056
Type of Foster Care Assistance
Title IV-E Assistance 3.6 458 70.3 5,775 30.2 884 56.8 39.7 51.0 1,116
No Title IV-E Assistance 2.4 390 53.3 5,498 21.5 736 38.7 23.0 34.5 927
SOURCE:  HCFA State Medicaid Research Files.
NA = Not Applicable.
(1)  Dental visits are calculated for children age 4 and over.

 

Table III.17B:
Variations in Health Care Utilization Among Children in Foster Care,
by Demographic Characteristics:
Florida, 1994
  Inpatient Care Outpatient Provider Visits Emergency Room Visits Percent with a prescribed drug Percent with a preventive visit Dental Visits(1)
Percent with a stay Days per 1,000 children Percent with a visit Visits per 1,000 children Percent with a visit Visits per 1,000 children Percent with a visit Visits per 1,000 children
Total 4.1 475 84.6 14,443 25.0 476 67.9 27.6 44.0 1,000
Age
Less than 1 21.5 6,462 76.7 12,096 23.0 682 61.6 59.5 NA NA
1 to 4 6.6 614 89.6 11,722 29.7 564 83.0 60.3 15.7 159
5 to 9 1.8 218 84.5 12,519 16.7 249 67.4 37.8 46.8 957
10 to 14 1.4 156 84.7 17,675 22.2 369 60.7 29.0 47.7 1,117
15 to 18 2.9 176 80.9 16,495 31.8 721 60.9 16.9 39.4 1,018
Length of Medicaid Eligibility
1 to 5 months 3.4 1,331 48.7 8,921 9.0 444 28.8 17.2 6.7 377
6 to 11 months 6.6 1,362 80.6 11,031 25.4 552 61.5 35.0 22.0 511
12 months 3.5 268 91.5 15,341 27.5 463 75.9 41.4 43.6 844
SSI Eligibility Status
SSI eligibility 10.0 1,957 93.5 25,631 38.3 890 88.6 36.8 35.8 818
No SSI eligibility 4.0 446 84.5 14,218 24.8 468 67.5 37.5 35.4 775
Type of Foster Care Assistance
Title IV-E Assistance 4.4 534 86.7 13,923 25.3 467 70.3 41.8 35.7 752
No Title IV-E Assistance 3.5 368 81.0 15,393 24.7 493 63.7 29.9 34.8 820
SOURCE:  HCFA State Medicaid Research Files.
NA = Not Applicable.
(1)  Dental visits are calculated for children age 4 and over.

 

Table III.17C:
Variations in Health Care Utilization Among Children in Foster Care,
by Demographic Characteristics:
Pennsylvania, 1994
  Inpatient Care Outpatient Provider Visits Emergency Room Visits Percent with a prescribed drug Percent with a preventive visit Dental Visits(1)
Percent with a stay Days per 1,000 children Percent with a visit Visits per 1,000 children Percent with a visit Visits per 1,000 children Percent with a visit Visits per 1,000 children
Total 3.2 343 83.0 15,570 33.8 745 67.6 40.5 60.3 1,421
Age
Less than 1 18.0 3,864 88.6 11,994 37.4 1,425 75.7 70.4 NA NA
1 to 4 7.1 885 92.2 10,986 40.2 849 83.5 63.5 62.1 1,055
5 to 9 2.2 173 90.8 17,213 27.7 481 71.9 46.2 68.2 1,295
10 to 14 1.8 143 88.6 21,488 34.6 664 67.9 40.9 68.9 1,575
15 to 18 1.8 131 71.8 13,486 33.3 867 57.9 25.6 51.8 1,448
Length of Medicaid Eligibility
1 to 5 months 1.1 305 37.5 5,832 9.6 490 22.7 12.7 15.3 896
6 to 11 months 3.2 432 74.2 9,873 29.9 740 57.3 31.2 47.0 1,269
12 months 3.5 329 91.8 16,961 38.4 756 76.8 46.9 70.6 1,469
Type of Health Condition
No condition 0.7 24 72.3 7,177 24.3 484 55.3 30.8 51.6 1,261
Any condition 6.8 737 98.2 25,950 47.4 1,068 85.1 54.3 73.1 1,621
Physical condition only 11.3 1,236 98.0 15,743 50.7 1,192 86.9 56.8 69.5 1,524
Mental condition only 0.7 46 97.8 30,719 37.5 725 78.6 48.6 73.6 1,652
Both physical and mental conditions 8.9 975 99.6 38,990 59.3 1,455 94.0 60.1 77.4 1,706
SSI Eligibility Status
SSI eligibility 8.7 1,727 95.7 33,760 56.1 1,368 88.0 57.7 68.5 1,540
No SSI eligibility 3.1 305 82.6 15,066 33.3 728 67.1 40.1 60.1 1,423
Type of Foster Care Assistance
Title IV-E Assistance 3.7 384 88.3 15,996 36.7 767 73.0 44.9 65.7 1,540
No Title IV-E Assistance 1.9 206 69.2 14,157 26.5 675 53.6 29.1 48.3 1,417
SOURCE:  HCFA State Medicaid Research Files.
NA = Not Applicable.
(1)  Dental visits are calculated for children age 4 and over.

 

a. Variations by Age

The relationship between age and health care utilization is far from consistent across the various measures of utilization. In general, inpatient use declined with age, although in California and Florida, inpatient rates rose in adolescence.(18) Like the general population of children (McCormick et al. 2000), infants had the highest rate of inpatient use.

The level of outpatient provider visits was highly variable across states. In general, the highest visit rates were among foster care children ages 10 to 14 and 15 to 18, but the number of visits per 1,000 in California was always well below that in the other two states. These data highlight the extensive health care needs of foster care children during the preteen and teenage years.

Patterns of emergency room utilization were more similar across states, with foster care children ages 1 to 4 and 15 to 18 having the highest rates in all three states. (This is consistent with national patterns as well.) Although one in three adolescents in foster care used emergency room services in 1994, the visit rates were highly variable across states: 1,019 visits per 1,000 adolescents in California, versus 721 per 1,000 in Florida, and 867 per 1,000 in Pennsylvania. Among preschool children, 30 to 40 percent had at least one emergency room visit and the number of visits ranged from 564 to 1,041 per 1,000. In general, foster care children in California, regardless of age, had higher levels of emergency room use than those in the other two states, perhaps compensating for the lower level of other provider visits in that state.

The next three measures of utilization  prescribed drug use, preventive care, and dental care  were highest among preschool children and declined with age. For preventive care, in particular, adolescents had the lowest level of use. One in four adolescents in California and Pennsylvania and only one in six in Florida had a preventive visit in 1994. Clearly, this does not conform to the CWLA/AAP standards, which recommend annual health exams for children in foster care (CWLA 1988; AAP 1994).

Utilization of mental health and substance abuse treatment services generally increased with age (Table III.18A, 18B, and 18C). This was particularly true for inpatient care, where admission rates were highest among those ages 10 to 14 and 15 to 18. The likelihood of an outpatient visit and the average number of outpatient visits per user also was highest in these two age groups, except in Pennsylvania, where children ages 5 to 9 had a higher level of use than the 15- to 18-year-olds. This might be a function of the greater emphasis in Pennsylvania on health screenings and assessments through the early and periodic screening, diagnosis, and treatment (EPSDT) program in Pennsylvania. (Section G discusses variations in expenditures for EPSDT services across states.)

Table III.18A: Variations in Mental Health and Substance Abuse (MH/SA) Treatment Among Foster Care Children, by Demographic Characteristics: California, 1994.

Table III.18B: Variations in Mental Health and Substance Abuse (MH/SA) Treatment Among Foster Care Children, by Demographic Characteristics: Florida, 1994.

Table III.18C: Variations in Mental Health and Substance Abuse (MH/SA) Treatment Among Foster Care Children, by Demographic Characteristics: Pennsylvania, 1994.

b. Variations by Length of Medicaid Eligibility

In general, health care utilization increased with length of Medicaid eligibility, such that foster care children enrolled for the full 12 months had higher levels of use than those who were enrolled for only part of the year. This was particularly true for provider visits, where the likelihood of a visit as well as the number of visits per 1,000 children was dramatically higher for those enrolled the full year. (The visit rate was adjusted for the number of months of coverage, to control statistically for the number of months of coverage.) As shown in Table III.17B, for example, 49 percent of foster care children in Florida who were enrolled 1 to 5 months had one or more provider visits, compared to 80 percent of those enrolled 6 to 11 months, and 92 percent of those enrolled the full year. Likewise, the number of visits ranged from 8,900 per 1,000 (1 to 5 months of enrollment) to 15,300 per 1,000 (12 months of enrollment). Similar disparities were observed for utilization of preventive care, dental care, and use of prescribed drugs. For example, 23 percent of foster care children in Pennsylvania who were enrolled 1 to 5 months had a prescribed drug in 1994, versus 57 percent of those enrolled 6 to 11 months, and 77 percent of those enrolled all 12 months (Table III.17C).

The one exception to this pattern was the use of inpatient services, where children enrolled the full year tended to have lower levels of inpatient use than those enrolled part of the year. As an example, foster care children in California who were enrolled the full year had one-third fewer days per 1,000 than those enrolled part of the year (Table III.17A). One possible explanation is that hospitalization may be the direct cause or immediate consequence of foster care placement, resulting in higher hospitalization rates at the beginning of the foster care placement.(19) Indeed, children with no Medicaid coverage prior to their foster care placement had nearly a threefold higher likelihood of being hospitalized within two months of placement than those who had been enrolled in Medicaid prior to placement. This is discussed below in the analysis of patterns of use before and after foster care placement.

As shown in Tables III.18A, 18B, and 18C, the likelihood of mental health or substance abuse treatment was dramatically higher among foster care children enrolled the full year. Similarly, the number of visits per user and average length of stay was longer among those enrolled the full year. This could signify a lag in initiating a treatment plan for children newly placed in foster care, or it could reflect case mix differences. (As was shown on Table III.14, foster care children enrolled the full year were more likely to have mental conditions  either alone or in combination with physical conditions  than children enrolled part of the year.) In any event, such disparities raise concerns that the clinical needs of children in foster care are not being met during the early stages of placement. At a minimum, prevention and evaluation services are recommended to ease the transition into foster care and to identify emotional and behavioral problems (Schneiderman et al. 1998).

c. Variations by Type of Health Condition

As might be expected, foster care children with none of the specified CDPS conditions had lower levels of utilization than those with one or more conditions. This relationship held for all of the utilization measures shown in Tables III.17A, 17B, and 17C and III.18A, 18B, 18C. The observed differentials  especially for inpatient care, outpatient provider visits, emergency room visits, and prescribed drugs  are consistent with the higher medical needs among those with one or more chronic conditions. Nevertheless, the lower levels of use of preventive care and dental care among children with no chronic or disabling conditions suggest that these children are not receiving the recommended routine care (CWLA 1988; AAP 1994). It is likely that this group of children is less connected to the health care system, and therefore less likely to receive routine care. Indeed, it is possible that some of these children have undiagnosed conditions due to infrequent contact with the health care system. This group of children should be the target of outreach to ensure that they are receiving the necessary preventive care, and that physical or mental health conditions are being diagnosed and treated.

Virtually all foster care children with a CDPS condition had one or more provider contacts during 1994; the likelihood of a visit exceeded 90 percent across all three groups of children with a CDPS condition. Nevertheless, we observed substantial differentials in utilization patterns among those with a CDPS condition. For example, children with physical conditions only had the highest inpatient rates, while those with both physical and mental conditions had by far the highest provider visit rates. In general, those with mental conditions only had the lowest levels of inpatient care, emergency room services, prescribed drugs, and preventive care. Additionally, those with physical conditions only were least likely to receive dental care. Disparities across groups do not automatically signify that certain groups of foster care children are underutilizing services or that other groups are overutilizing services. Nevertheless, lower levels of preventive and dental care among certain children suggests a barrier to obtaining routine care.

As expected, children with mental conditions  either alone or in combination with physical conditions  were the most likely to receive mental health or substance abuse services (Tables III.18A-C). In California, for example, 69 percent of those with a mental condition only and 76 percent of those with both mental and physical conditions  versus only 23 percent of those with a physical condition only  received at least one mental health or substance abuse service. Children with both mental and physical conditions had by far the highest rate of inpatient mental health/substance abuse treatment. While these comparisons make intuitive sense, they nevertheless raise two questions: First, are certain children with mental health or substance abuse conditions falling through the cracks and not receiving mental health or substance abuse treatment? And second, are children with physical conditions receiving adequate mental health services following their transition to foster care?

d. Variations by SSI Eligibility Status

Next, we compared utilization patterns between children who were and were not eligible for SSI. Foster care children who are also eligible for SSI are expected to be more vulnerable than those who are not eligible for SSI benefits.(20) Foster care children who were also eligible for SSI had higher utilization across the board than those who were not eligible for SSI (Tables III.17A-C). This pattern held for mental health and substance abuse services as well (Table III.18A-C). Across all three states, the number of provider visits per 1,000 foster care children on SSI was double that of children not on SSI, while the number of inpatient days per 1,000 was four to seven times higher among foster care children receiving SSI benefits. In general, preventive and dental use also was higher among the foster care children receiving SSI (except in Florida). This differential in the use of well child care may be a result of the connectedness of SSI children to the health care system due to their higher health care needs.

e. Variations by Title IV-E Status

In general, foster care children whose Medicaid eligibility was through Title IV-E had higher levels of utilization, although patterns varied slightly across states. One consistent finding is that Title IV-E foster care children had higher levels of preventive care. In addition, although the likelihood of a provider contact was higher among Title IV-E children, the number of visits per 1,000 tended to be quite similar between the two groups of children. It is not clear why we observed such differences but they are likely to be a function of underlying case mix variations. (As was shown in Table III.14, Title IV-E children were more likely than non-Title-IV-E children to have physical conditions.) Patterns of mental health and substance abuse treatment were fairly similar between the two groups, except in Florida, where non-Title IV-E children were more likely than Title IV-E children to receive treatment.

4. Analysis of Utilization Before and After Foster Care Placement

In addition to looking at annual utilization patterns, we explored patterns of use before and after foster care placement. There is considerable concern among policymakers that children do not receive adequate care once they are placed in a foster care setting. Health care needs are often overlooked, accurate health history information is often not available, and caseworkers may not understand the Medicaid system (Rawlings-Sekunda 1999).

The CWLA developed a set of guidelines for health services for children in foster care (CWLA 1988).(21) According to these guidelines, children in foster care should receive the following screening, assessment, and treatment services:

  • Immediate health screening. This should be performed prior to placement, if possible, or within 24 hours after placement to identify health problems that may affect placement or that require immediate attention. The evaluation should include a comprehensive health, nutrition, and developmental assessment; complete physical examination; screening for vision, hearing, and dental status; and a mental health screening.
  • Comprehensive health assessment. This should be performed within 30 days of placement. The assessment should include tests for anemia, tuberculosis, and developmental delays, as well as a complete blood count and urinalysis. Tests for sickle cell anemia, lead poisoning, HIV infections, hepatitis B, and other communicable diseases should be performed as needed. Immunizations and medications should be provided as necessary. A dental examination should be performed.
  • Comprehensive mental health assessment. This should be performed within 30 days of placement by a qualified mental health practitioner.
  • Ongoing primary care. This should include preventive care, following the AAP periodicity schedule or the state Medicaid agency's EPSDT schedule.
  • Mental health services. These services should be made available to all children in placement, and should include psychiatric services and psychological testing.
  • Specialized health services. These services include 24-hour emergency care, referrals for specialized health consultations, and other specialized services, including services for learning disabilities, hearing or vision impairment, orthodontia, plastic surgery, and speech and language problems.
  • Transportation services. These services should ensure access to health care.
  • Case management services. These services should facilitate continuity and coordination of care.

We analyzed how frequently children placed in foster care received these services, and whether the likelihood of that happening varied depending on whether the child had Medicaid coverage through another eligibility category at the time of placement.

To conduct this analysis, we identified a subset of children who were placed in foster care from January through October 1995 (1994 in Pennsylvania), who had no other period of foster care eligibility in the previous 12 months, and who remained enrolled in Medicaid for two months following the month of initial foster care eligibility. The number of children included in this analysis, including the percent with prior Medicaid coverage, was as follows:

State Number of Children
Included in Analysis
Percent with Prior
Medicaid Eligibility
California 24,983 54.7
Florida 3,512 71.7
Pennsylvania 7,190 68.6

To assess whether children received health care services on a timely basis  in accordance with the CWLA guidelines  we examined utilization during the post-placement periods. We recognized, however, that states may lag in designating foster care as the reason for eligibility for those children who were already enrolled in Medicaid. Therefore, we also included a two-month window for utilization prior to the designation of foster care eligibility. We created "windows" for analyzing utilization one and two months prior to foster care eligibility (for those with prior Medicaid coverage), during the month of initial foster care eligibility, and during the two months following. The CWLA guidelines stipulate windows for receipt of certain services, for example, within 24 hours or 30 days of placement. Because the SMRF file indicates only the month in which eligibility began, we were required to use broad windows to examine utilization patterns.

Tables III.19A, 19B, and 19C present the results of this analysis. The tables show, for each measure, the utilization patterns before and after foster care placement. The two pre-placement windows include those children with prior Medicaid eligibility and are designed to be cumulative, showing the percent of children with utilization in the two months prior to placement (as reflected in the Medicaid eligibility record) and then the subset of those who had use in the one month prior to placement. In the post-placement period, we show the percent with use during the month that placement began, and the cumulative effect over time (that is, one and two months after the initial placement). As an example, in California, about one-third of the children had a provider visit during the month foster care eligibility began; two full months after the foster care placement, 54 percent of those with prior Medicaid coverage, but 60 percent of those with no prior Medicaid coverage had at least one visit (Table III.19A). The average number of visits per user was similar between the two groups during the post-placement period.

The use of inpatient care in the pre- and post-placement period varied across the three states (Tables III.19A-C). In California and Florida, foster care children with no prior Medicaid coverage were more likely to be hospitalized during the month of placement, compared to foster care children with prior coverage. The differential persisted over the two-month post-placement period. As mentioned earlier, hospitalization is often the impetus for obtaining Medicaid coverage.

 

Table III.19A:
Patterns of Utilization Before and After Foster Care (FC) Eligibility Began,
by Prior Medicaid Coverage Status:
California
Utilization Measure Utilization Before Foster Care Eligibility Began Utilization After Foster Care Eligibility Began
Within Two Months Before Within One Month Before During Month Eligibility Began Within One Month After Within Two Months After
Percent with an inpatient stay
Medicaid coverage before FC placement 1.3 0.6 0.7 1.0 1.3
No Medicaid coverage before FC placement - - 1.5 2.5 3.2
Percent with a provider visit
Medicaid coverage before FC placement 39.2 28.8 32.7 46.3 53.7
No Medicaid coverage before FC placement - - 31.1 51.0 60.4
Average number of visits per user
Medicaid coverage before FC placement 2.4 1.9 1.9 2.7 3.3
No Medicaid coverage before FC placement - - 1.8 2.6 3.4
Percent with a preventive visit
Medicaid coverage before FC placement 15.6 9.5 10.0 18.2 23.7
No Medicaid coverage before FC placement - - 12.3 24.2 33.0
Percent with an emergency room visit
Medicaid coverage before FC placement 13.4 8.0 7.6 11.8 15.5
No Medicaid coverage before FC placement - - 4.2 10.6 15.5
Percent with a dental visit
Medicaid coverage before FC placement 9.1 5.9 8.3 16.0 21.0
No Medicaid coverage before FC placement - - 6.0 11.4 15.6
Percent with a mental health/substance abuse service
Medicaid coverage before FC placement 5.9 4.1 6.3 10.1 12.8
No Medicaid coverage before FC placement - - 4.6 10.4 14.3
Percent with case management service
Medicaid coverage before FC placement # # # # #
No Medicaid coverage before FC placement - - 0.0 # #
Percent with transportation service
Medicaid coverage before FC placement 0.9 0.4 0.4 0.7 0.8
No Medicaid coverage before FC placement - - 0.0 # #
Percent with lab/x-ray service
Medicaid coverage before FC placement 15.8 9.9 11.5 18.3 22.8
No Medicaid coverage before FC placement - - 11.0 20.3 26.7
Source:  HCFA State Medicaid Research Files.
Note:  Numbers may not sum to total due to rounding.
#  Less than 0.05.

 

Table III.19B:
Patterns of Utilization Before and After Foster Care (FC) Eligibility Began,
by Prior Medicaid Coverage Status:
Florida
Utilization Measure Utilization Before Foster Care Eligibility Began Utilization After Foster Care Eligibility Began
Within Two Months Before Within One Month Before During Month Eligibility Began Within One Month After Within Two Months After
Percent with an inpatient stay
Medicaid coverage before FC placement 1.9 0.9 0.4 0.6 0.8
No Medicaid coverage before FC placement - - 1.0 1.5 2.0
Percent with a provider visit
Medicaid coverage before FC placement 39.7 27.2 25.4 33.9 39.6
No Medicaid coverage before FC placement - - 23.0 37.0 44.1
Average number of visits per user
Medicaid coverage before FC placement 2.7 2.1 2.0 2.7 3.3
No Medicaid coverage before FC placement - - 1.4 2.2 2.8
Percent with a preventive visit
Medicaid coverage before FC placement 17.5 9.2 7.2 11.6 14.5
No Medicaid coverage before FC placement - - 11.8 17.7 20.6
Percent with an emergency room visit
Medicaid coverage before FC placement 6.5 3.2 2.5 4.3 6.0
No Medicaid coverage before FC placement - - 2.2 5.0 8.0
Percent with a dental visit
Medicaid coverage before FC placement 5.4 3.4 3.7 6.3 8.9
No Medicaid coverage before FC placement - - 1.0 3.9 7.4
Percent with a mental health/substance abuse service
Medicaid coverage before FC placement 4.1 2.6 2.2 2.7 3.1
No Medicaid coverage before FC placement - - 0.7 1.5 2.2
Percent with case management service
Medicaid coverage before FC placement 14.3 12.0 12.0 15.4 18.0
No Medicaid coverage before FC placement - - 4.8 8.7 10.8
Percent with transportation service
Medicaid coverage before FC placement # 0.0 # 0.1 0.1
No Medicaid coverage before FC placement - - 0.0 0.1 0.1
Percent with lab/x-ray service
Medicaid coverage before FC placement 18.5 10.4 8.9 14.4 19.1
No Medicaid coverage before FC placement - - 13.8 21.6 26.0
Source:  HCFA State Medicaid Research Files.
Note:  Numbers may not sum to total due to rounding.
#  Less than 0.05.

 

Table III.19C:
Patterns of Utilization Before and After Foster Care (FC) Eligibility Began,
by Prior Medicaid Coverage Status:
Pennsylvania
Utilization Measure Utilization Before Foster Care Eligibility Began Utilization After Foster Care Eligibility Began
Within Two Months Before Within One Month Before During Month Eligibility Began Within One Month After Within Two Months After
Percent with an inpatient stay
Medicaid coverage before FC placement 2.0 1.4 0.4 0.8 1.1
No Medicaid coverage before FC placement - - 0.4 0.9 1.2
Percent with a provider visit
Medicaid coverage before FC placement 36.2 28.7 33.6 45.2 50.9
No Medicaid coverage before FC placement - - 20.1 39.1 51.2
Average number of visits per user
Medicaid coverage before FC placement 3.8 2.7 2.8 4.3 5.9
No Medicaid coverage before FC placement - - 1.8 2.8 3.8
Percent with a preventive visit
Medicaid coverage before FC placement 10.8 8.4 10.7 16.7 20.4
No Medicaid coverage before FC placement - - 5.5 12.9 19.4
Percent with an emergency room visit
Medicaid coverage before FC placement 13.3 7.9 5.6 8.8 11.8
No Medicaid coverage before FC placement - - 2.9 6.3 9.6
Percent with a dental visit
Medicaid coverage before FC placement 6.9 5.1 9.5 17.3 22.6
No Medicaid coverage before FC placement - - 2.8 10.5 19.6
Percent with a mental health/substance abuse service
Medicaid coverage before FC placement 11.7 9.0 9.3 12.7 15.4
No Medicaid coverage before FC placement - - 7.4 12.7 17.0
Percent with case management service
Medicaid coverage before FC placement 0.0 0.0 0.0 0.0 0.0
No Medicaid coverage before FC placement - - 0.0 0.0 0.0
Percent with transportation service
Medicaid coverage before FC placement 1.4 0.9 0.5 0.6 1.1
No Medicaid coverage before FC placement - - 0.3 0.5 0.7
Percent with lab/x-ray service
Medicaid coverage before FC placement 15.0 10.2 11.3 16.7 21.9
No Medicaid coverage before FC placement - - 8.2 16.3 20.9
Source:  HCFA State Medicaid Research Files.
Note:  Numbers may not sum to total due to rounding.
#  Less than 0.05.

We would expect almost all children to have had at least one Medicaid-paid provider visit within the two months following foster care placement. (22) This was not the case, however. The highest rates were observed in California, with 54 to 60 percent having a visit, followed by Pennsylvania (51 percent), and lastly, Florida (40 to 44 percent). Only about one-fifth to one-third had a visit during the month of foster care placement. The average number of visits, among those with at least one visit, ranged from 2.8 to 5.9 by two months post-placement. Interestingly, foster care children in California had the highest likelihood of a provider visit within the first two months of placement, despite overall lower levels of utilization on an annual basis (recall Table III.15). The rate of preventive care  which includes health screenings and assessments  was less than 10 percent during the month of foster care placement. Interestingly, however, the rates in California and Florida were higher among those children with no prior coverage than among those with previous Medicaid coverage, suggesting that providers were more likely to perform assessments on those who were newly enrolled. However, combining the five-month window surrounding the foster care placement for those with prior Medicaid coverage, eliminates the difference, with 35 percent of children having a preventive visit during that period (data not shown). What is not clear is whether some children receive the assessments in the pre-placement period, which is recommended, or whether the dates of placement on the eligibility files are incorrect so that some of the utilization appearing on the claims file before placement is actually occurring after placement. What is clear from these data is that few children were receiving comprehensive assessments reimbursed by Medicaid within the two-month post-placement period.

Although the CWLA guidelines suggest that laboratory tests and x-rays should be performed during the initial assessments, only 20 to 27 of children percent of children had such a claim during the two-month post-placement period. It is possible that such tests were performed in public health clinics and not billed to Medicaid, but this cannot be determined from the available data.

Mental health services were provided to relatively few children following a foster care placement. Only about one in six children received such services in California and Pennsylvania, and only 2 to 3 percent in Florida. It is possible that these services were being provided through the state mental health system and not reimbursed by Medicaid during the initial placement period, but nevertheless, the rates are quite a bit lower than would be expected. It is also possible that evaluations of mental health status were performed in conjunction with a general preventive exam, rather than through a separate mental health evaluation. Dental visit rates were uniformly higher than visits for mental health and substance abuse related services.

The CWLA guidelines mention the need for specialized health services, including 24-hour emergency treatment. In California and Florida, patterns of emergency room use following placement were similar between children with and without prior Medicaid coverage, whereas in Pennsylvania, children with prior Medicaid coverage were slightly more likely to use the emergency room than those with no prior coverage.

Certain services recommended in the CWLA guidelines, especially case management and transportation, were never or only rarely paid for by Medicaid. Case management services were paid through Medicaid only in Florida, with 11 to 18 percent receiving these services in the two-month, post-placement period. Interestingly, those with prior Medicaid coverage were more likely to receive such services through Medicaid, perhaps because they were already linked to a case manager through another program. Transportation services were almost never paid for by Medicaid. That is not to say that families were not receiving these services through another system (such as child welfare), but Medicaid was not the reimbursement mechanism.

The primary observation from this analysis is that few children were receiving services that conform to the CWLA guidelines (to the extent that we have been able to operationalize the standards using claims data). The CWLA guidelines were published in 1988 and these data are from 1994. It seems clear that foster care children were not receiving services at the level envisioned by the guidelines. What cannot be discerned without more recent data is whether the situation has improved in the six years since this study period. Further analysis of more recent claims data would be required. Analysis of medical records also would be desirable, to overcome the coding limitations of administrative data (such as uncertainties concerning the initial date of the foster care placement, limited information on types of health screenings and assessments, and lack of data on referrals for specialty care). Such an analysis would also reveal whether children were receiving services prior to Medicaid coverage or through systems of care not reimbursed by Medicaid (such as public health, mental health, schools, or child welfare).