Last month, an inspector general report out of the Department of Health and Human Services recommended that Medicaid data can be used “to identify instances of potential child abuse or neglect.” The topline numbers in the report would suggest some merit to the idea, but details in the bowels of the appendices call the whole thing into question.
The researchers audited Medicaid claims with diagnosis codes that may relate to injuries borne of maltreatment for 29,534 children receiving services at the emergency room. Using a random sample of 100 children, the report estimates that nearly 15% of the potential abuse and neglect “were not reported to CPS,” or child protective services. Of the 100 cases in the random sample, 13 involved no referral to CPS.
From this, the IG draws two conclusions:
- The federal Centers for Medicare and Medicaid (CMS) should inform states that a data analysis of Medicaid claims is a useful way to conduct quality assurance on mandatory reporting of maltreatment by doctors, who along with school staff are expected by every state to refer any concerns to state hotlines.
- Determine whether CMS should strengthen federal requirements around mandatory reporting when it comes to Medicaid-enrolled children.
CMS concurred with the idea of a review of federal requirements, but disagreed with issuing guidance to states. Youth Services Insider asked the Administration for Children and Families – the federal agency that oversees child welfare – for its reaction. It had none.
As mentioned, if more than one in every 10 possible abuse or neglect cases was not being referred by emergency room doctors, that would be alarming. But a review of the 13 cases in the appendix suggest, in our humble opinion, that this report found quite the opposite.
Readers can see lengthier descriptions of those cases on page 39 of the report, but here is a quick breakdown of the salient details:
1. A 17-year-old allegedly raped by her 20-year-old boyfriend; law enforcement investigated.
2. A 3-year-old allegedly touched by a 13-year-old family friend; law enforcement and the area child advocacy center contacted.
3. A 15-year-old assaulted outside home, with no indication it was by a family member. Not reported to any officials.
4. A 16-year-old who ran away and was allegedly trafficked; law enforcement involved.
5. A 14-year-old was sexually assaulted on a walk home from school; law enforcement involved.
6. A 12-year-old beat up at school. Not reported to any officials.
7. A 12-year-old beat up outside an apartment building, not by family members; not reported to any officials.
8. A 3-year-old in a car accident while not in a car seat, where dad had a seizure and crashed; law enforcement investigated and dad had licensed suspended.
9. A 16-year-old youth in foster care who alleged she had been raped; the foster parent didn’t believe her and took her to the hospital. Law enforcement was contacted.
10. A 15-year-old and several siblings came to a hospital because parents suspected their aunt had drugged and possibly sexually abused them; law enforcement contacted.
11. A 9-year-old brought in by mom who feared a sexual assault had occurred outside the home; the physical exam was normal, and law enforcement was contacted.
12. A 10-year-old was brought in by mom who suspected abuse involving another boy in the neighborhood. She didn’t agree to a forensic investigation of her child; not reported to any officials.
13. A 3-year-old brought by a mom who suspected that a friend’s child had abused the girl. The exam was normal; not reported to any officials.
Given that the purpose of CPS is to look into abuse or neglect by the people who are caregivers to the children, there is one that may be warranted a call to the hotline. You could make a case that the aunt suspected of drugging several nieces and nephews should get a look by maltreatment investigators; she served in a temporary caregiver role, might interact with them again, and perhaps has children of her own in her house.
But that actually might have happened, because law enforcement was called about this incident. And it is not clear if this assessment by the inspector general would unearth it if the police later referred this to CPS to look into the aunt.
Turning to the other 12 cases, seven were referred to law enforcement. Three of the cases where police were not called involved adolescents who were allegedly beaten up at school or in the neighborhood.
So by Youth Services Insider’s count, one case out of the 100-case sample involved a case that should have generated a CPS report, and did not. And even in that case, law enforcement might have made that report later depending on what they found out. So either this sample found 99% fidelity to mandated reporting, or 100%.
That doesn’t necessarily mean that using Medicaid claim studies as quality control is a terrible idea – though the use of a strategy that would only review the cases of poor children and parents might not be a great look for a system often accused of mistaking poverty for neglect. But the report’s use of this random sample to project a high miss rate on mandatory reporting of abuse or neglect does not pass muster.