Quality Management Performance Measures for Acute-care Contractors Measurement Period Ending September 30, 2003 Prepared by the Division of Health Care Management December 2004 Anthony D. Rodgers Director, AHCCCS TABLE OF CONTENTS OVERVIEW ......................................................................................................... 1 RESULTS Children’s Access to Primary Care Practitioners ................................................. 4 Adults’ Access to Preventive/Ambulatory Health Services ................................ 15 Breast Cancer Screening ..................................................................................... 19 Cervical Cancer Screening .................................................................................. 21 Timeliness of Prenatal Care ................................................................................ 23 DISCUSSION ..................................................................................................... 25 REFERENCES ................................................................................................... 26 APPENDIX Methodology and Technical Specifications ....................................................... 27 i OVERVIEW of time with one Contractor. Thus, members included in the results of each measure represent only a portion of AHCCCS members, rather than the entire acute-care population. This report includes information on performance measures for preventive health care services provided to members enrolled with acute-care health plans that contract with the Arizona Health Care Cost Containment System (AHCCCS). These members are eligible for AHCCCS under Medicaid or the State Children’s Health Insurance Program (SCHIP), known as KidsCare. This report includes data for the contract year ending September 30, 2003 (some measures count health services provided in a previous contract year). Results are reported in aggregate by Maricopa, Pima and the combined rural counties, and by individual Contractor. The report also indicates whether an increase or decrease in a rate is statistically significant; that is, whether the change is not merely due to chance. Where available, national averages for Medicaid managed care plans reported by NCQA are compared with AHCCCS overall rates. The report includes data from seven publicly and privately operated health plans (known as Contractors). In addition, data for the Comprehensive Medical and Dental Program (CMDP), a health plan operated by the Arizona Department of Economic Security (DES) for children and adolescents in foster care, is reported for one measure. Data Sources and Quality AHCCCS uses a statewide, automated managed care data system known as the Prepaid Medical Management Information System (PMMIS). Members included in the denominator for each measure are selected from the Recipient Subsystem of PMMIS. The results reported here should be viewed as indicators of utilization of services, rather than absolute rates for how successfully AHCCCS and/or its Contractors provide care. Many factors affect whether AHCCCS members use services. By analyzing trends over time, AHCCCS and its Contractors can identify areas for improvement and implement interventions to increase access to, and use of, services. Numerators, and therefore rates, for each measure are based on AHCCCS encounter data; i.e., records of medically necessary services provided and the related claims paid by Contractors. AHCCCS conducts data validation studies to evaluate the completeness, accuracy and timeliness of encounter data. From the latest data validation results, it is estimated that overall encounter data is approximately 85 percent accurate. Through ongoing review and analysis of encounter submission trends and data quality, AHCCCS develops ways to continually improve the accuracy of encounter data. Methodology AHCCCS used the Health Plan Employer Data and Information Set (HEDIS®) as a guide in determining the methodology for these measures. Developed and maintained by the National Committee for Quality Assurance (NCQA), HEDIS is the most widely used set of performance measures in the managed care industry. One of the criteria for selecting members to be included in the analyses is that they be continuously enrolled for a minimum period 1 Access to PCPs – Medicaid Members, declined slightly. Another measure, Timeliness of Prenatal Care, is based on new methodology and is being reported by AHCCCS for the first time. It should be noted that data collection issues related to one Contractor may have affected its rates for some measures. Problems with Maricopa Health Plan’s claims processing system have resulted in a major lag in submitting encounter data to AHCCCS during CYE 2003, and the likelihood that the plan’s rates are artificially low. However, it does not appear that Maricopa Health Plan’s rates had a substantial effect on AHCCCS overall rates because the health plan represents a relatively small percentage of the acute-care population. Maricopa Health Plan has taken actions to correct its encounter-submission problems. When analyzed by area, rates for all measures were highest in Pima County. For some measures, AHCCCS rates were higher than the most recent national HEDIS means (averages) reported by NCQA for Medicaid health plans. As in years past, the AHCCCS rates for Children’s Access to PCPs among members in two age groups, 1 year and 2 through 6 years, was better than the NCQA means for those groups. This was true of both Medicaid-eligible members and KidsCare members. Rotation of Measures In 2000, NCQA began to “rotate” reporting of measures, and AHCCCS adopted a similar rotation schedule in 2003. This rotation schedule alternates most measures on a biennial basis, allowing Contractors an “intervention year” between measures; thus, providing adequate time to focus activities on improving specific rates. The AHCCCS rate for Adults’ Access to Preventive/Ambulatory Health Services for members ages 21 to 44 years is slightly under the NCQA mean, but the AHCCCS rate for members 45 to 64 years exceeds the NCQA average. Three measures are reported annually. These include Children’s Access to Primary Care Practitioners (PCPs) – Medicaid Members, Children’s Access to PCPs – KidsCare Members, and Adults’ Access to Preventive/Ambulatory Health Services. However, the AHCCCS rate for Cervical Cancer Screening is well below the HEDIS mean, despite a significant improvement in the AHCCCS rate. Individual Contractor performance varied widely. One Contractor, Mercy Care Plan, met or exceeded the AHCCCS Minimum Performance Standard in five of six measures. Three Contractors – Health Choice Arizona, Pima Health System and University Family Care – met or exceeded the minimum standard in four measures. Three other Contractors – Arizona Physicians IPA, Maricopa Health Plan and Phoenix Health Plan/Community Connection – met or exceeded the minimum standard in only two measures. CMDP exceeded the minimum standard for its measure, Children’s Access to PCPs – Medicaid Members. Highlights of the Data Results of the six AHCCCS acute-care measures reported here were mixed in the most recent period. Three measures showed no statistically significant change: • Children’s Access to PCPs – KidsCare Members, • Adults’ Access to Preventive/Ambulatory Health Services, and • Breast Cancer Screening. One measure, Cervical Cancer Screening, improved and one measure, Children’s 2 Performance Improvement AHCCCS will require corrective action plans from Contractors that did not meet the Minimum Performance Standard for any measure, or that showed statistically significant declines in their rates, even if they met the minimum standard. Contractors that fail to show improvement may be subject to sanctions in the future. AHCCCS will continue to provide technical assistance, such as identifying new interventions or enhancements to existing efforts, to help Contractors improve their performance. This data also may be used in developing future Performance Improvement Projects by Contractors. It should be noted that, as of October 1, 2003, Care 1st Healthplan of Arizona has contracted with AHCCCS to provide services to Medicaid and KidsCare members. However, the health plan did not have enough members who met the continuous enrollment criteria to be included in this report. Feedback For questions or comments about this report, please contact: Rochelle Tigner Quality Improvement Manager Division of Health Care Management Clinical Quality Management, MD 6500 701 E. Jefferson St. Phoenix, AZ 85034 (602) 417-4683 rttigner@ahcccs.state.az.us 3 Children’s Access to Primary Care Practitioners (Medicaid and KidsCare) should strive for the AHCCCS Goal of 80 percent. Children’s access to primary care services is critical in helping to prevent the premature onset of disease and disability. Lack of access to primary care practitioners (PCPs) may result in unnecessary .1,2 hospitalizations. National Comparisons The National Committee for Quality Assurance (NCQA) has reported national averages for Medicaid health plans by age group for Children’s Access to PCPs. In calendar year 2002, the most recent year for which national data are available, the averages were: 1 year 90.9 percent 2 through 6 years 79.9 percent 7 through 11 years 80.2 percent PCPs can address physical, nutritional, developmental and behavioral health needs, and make referrals to specialists or to services such as nutritional support and parenting classes. If members are receiving these general health care services through a PCP, they likely have access to other levels of the health care system. NCQA did not report an average for children 12 through 20 years old. Indicator Description Two separate indicators measured the percentage of children and adolescents who: • were 1 through 20 years of age if eligible under Medicaid, or 1 through 18 years of age if eligible under KidsCare, at the end of the measurement period (October 1, 2002, through September 30, 2003), • were continuously enrolled with one acute-care Contractor during the measurement period, • had no more than one break in enrollment, not exceeding 31 days, and • had one or more visits with PCPs, including pediatricians, general or family practice physicians, internal medicine physicians, physician’s assistants, nurse practitioners or obstetrician/gynecologists, during the measurement period. Current Results and Trends Children’s Access to PCPs – Medicaid AHCCCS overall rates for Medicaid-eligible children were: 96.5 percent for members 1 year old, 83.3 percent for members 2 through 6 years, 66.9 percent for members 7 through 11 years, and 67.7 percent for members 12 through 20 years (Table 1). The AHCCCS total rate was 75.7 percent, a decline from the previous measurement period, when the rate was 76.6 percent (p<.001). Total rates by Contractor ranged from 52.7 percent to 80.7 percent. Five of eight Contractors met or exceeded the AHCCCS Minimum Performance Standard and one exceeded the AHCCCS Goal. Performance Goals AHCCCS has adopted a Minimum Performance Standard that Contractors achieve a rate of 77 percent for both measures. If Contractors have already achieved this rate for either group, they Rates for Medicaid-eligible children were higher in Pima County and the combined rural counties, at 78.6 percent and 77.9 percent, respectively. The rate for Maricopa County was 73.5 percent. 4 Children’s Access to PCPs – KidsCare Overall rates for KidsCare members were 95.1 percent for members 1 year old, 87.3 percent for members 2 through 6 years, 73.7 percent for members 7 through 11 years, and 74.1 percent for members 12 through 18 (Table 2). The AHCCCS total rate for KidsCare members was 77.7 percent, compared with 78.4 percent in the previous measurement period. However, the change was not statistically significant (p=.089). Total rates by Contractor ranged from 54.5 percent to 81.7 percent. Six of seven Contractors met or exceeded the AHCCCS Minimum Performance Standard and four met or exceeded the AHCCCS Goal. Rates for KidsCare members were highest in Pima County, at 80.4 percent, followed by the combined rural counties and Maricopa County, at 77.9 percent and 76.6 percent, respectively The AHCCCS overall rate for children’s access to PCPs among Medicaid-eligible members has remained above 70 percent since 1998, and was at its highest point in CYE 2002, at approximately 77 percent. The overall rate among KidsCare members was 60 percent in 1999, when the rate for this group was first measured, and reached the highest point in the current measurement period. Fig. 1: Children’s Access to PCPs, 1998-2003 100% 90% 80% 70% 60% 50% 40% 30% 20% Medicaid KidsCare 5 Table 1 Arizona Health Care Cost Containment System CHILDREN'S ACCESS TO PRIMARY CARE PRACTITIONERS BY CONTRACTOR MEMBERS ELIGIBLE UNDER MEDICAID Measurement Period October 1, 2002, to September 30, 2003 Age Number of Members Number with >1 Visits Percent with >1 Visits Relative Percent Change from Previous Period 1 2 3-6 7-11 12-20 Total 472 383 1,494 1,614 2,113 6,076 460 367 1,284 1,213 1,581 4,905 97.5% 95.8% 85.9% 75.2% 74.8% 80.7% -0.1% p=.927 Universtiy Family Care 1 2 3-6 7-11 12-20 Total 473 378 1,267 1,530 1,710 5,358 458 361 1,095 1,131 1,284 4,329 96.8% 95.5% 86.4% 73.9% 75.1% 80.8% Pima Health System * 1 2 3-6 7-11 12-20 Total 424 314 842 1,049 1,348 3,977 406 297 712 767 975 3,157 95.8% 94.6% 84.6% 73.1% 72.3% 79.4% 0.6% p.=633 1 2 3-6 7-11 12-20 Total 365 240 675 917 1,072 3,269 355 231 544 686 764 2,580 97.3% 96.3% 80.6% 74.8% 71.3% 78.9% Contractor University Family Care * Pima Health System * Indicates the Contractor met or exceeded the AHCCCS Minimum Performance Standard. Shaded rows show totals and percentages from the previous measurement period. Statistically significant changes from the previous period are highlighted in yellow. 6 Statistical Significance Table 1 Arizona Health Care Cost Containment System CHILDREN'S ACCESS TO PRIMARY CARE PRACTITIONERS BY CONTRACTOR MEMBERS ELIGIBLE UNDER MEDICAID Measurement Period October 1, 2002, to September 30, 2003 Contractor Mercy Care Plan * Mercy Care Plan CMDP * CMDP Age Number of Members Number with >1 Visits Percent with >1 Visits Relative Percent Change from Previous Period 1 2 3-6 7-11 12-20 Total 6,426 4,948 15,044 14,458 16,733 57,609 6,230 4,618 12,553 10,262 11,943 45,606 96.9% 93.3% 83.4% 71.0% 71.4% 79.2% 1.2% p<.001 1 2 3-6 7-11 12-20 Total 1 2 3-6 7-11 12-20 Total 5,986 3,786 12,350 11,984 12,965 47,071 245 216 629 678 1,678 3,446 5,766 3,475 10,103 8,277 9,196 36,817 228 189 532 517 1,261 2,727 96.3% 91.8% 81.8% 69.1% 70.9% 78.2% 93.1% 87.5% 84.6% 76.3% 75.1% 79.1% -5.4% p<.001 1 2 3-6 7-11 12-20 Total 205 177 539 625 1,506 3,052 198 161 476 489 1,230 2,554 96.6% 91.0% 88.3% 78.2% 81.7% 83.7% * Indicates the Contractor met or exceeded the AHCCCS Minimum Performance Standard. Shaded rows show totals and percentages from the previous measurement period. Statistically significant changes from the previous period are highlighted in yellow. 7 Statistical Significance Table 1 Arizona Health Care Cost Containment System CHILDREN'S ACCESS TO PRIMARY CARE PRACTITIONERS BY CONTRACTOR MEMBERS ELIGIBLE UNDER MEDICAID Measurement Period October 1, 2002, to September 30, 2003 Age Number of Members Number with >1 Visits Percent with >1 Visits Relative Percent Change from Previous Period 1 2 3-6 7-11 12-20 Total 2,228 1,726 5,294 4,696 4,838 18,782 2,148 1,598 4,393 3,097 3,253 14,489 96.4% 92.6% 83.0% 65.9% 67.2% 77.1% 2.2% p<.001 Health Choice AZ 1 2 3-6 7-11 12-20 Total 2,159 1,527 4,468 4,098 3,856 16,108 2,066 1,403 3,519 2,653 2,512 12,153 95.7% 91.9% 78.8% 64.7% 65.1% 75.4% AZ Physicians IPA 1 2 3-6 7-11 12-20 Total 6,529 5,152 18,798 19,979 23,088 73,546 6,302 4,737 15,457 13,707 15,877 56,080 96.5% 91.9% 82.2% 68.6% 68.8% 76.3% -1.0% p=.001 AZ Physicians IPA 1 2 3-6 7-11 12-20 Total 6,230 4,580 16,391 17,678 18,633 63,512 6,008 4,202 13,424 12,264 13,004 48,902 96.4% 91.7% 81.9% 69.4% 69.8% 77.0% Contractor Health Choice AZ * * Indicates the Contractor met or exceeded the AHCCCS Minimum Performance Standard. Shaded rows show totals and percentages from the previous measurement period. Statistically significant changes from the previous period are highlighted in yellow. 8 Statistical Significance Table 1 Arizona Health Care Cost Containment System CHILDREN'S ACCESS TO PRIMARY CARE PRACTITIONERS BY CONTRACTOR MEMBERS ELIGIBLE UNDER MEDICAID Measurement Period October 1, 2002, to September 30, 2003 Age Number of Members Number with >1 Visits Percent with >1 Visits Relative Percent Change from Previous Period 1 2 3-6 7-11 12-20 Total 2,663 1,833 6,394 6,006 6,315 23,211 2,587 1,688 5,105 3,883 4,116 17,379 97.1% 92.1% 79.8% 64.7% 65.2% 74.9% -1.3% p=.018 Phoenix Health Plan/CC 1 2 3-6 7-11 12-20 Total 2,243 1,538 5,373 5,005 5,176 19,335 2,154 1,408 4,341 3,316 3,450 14,669 96.0% 91.5% 80.8% 66.3% 66.7% 75.9% Maricopa Health Plan 1 2 3-6 7-11 12-20 Total 1,372 1,147 3,462 3,507 3,583 13,071 1,277 939 1,963 1,321 1,388 6,888 93.1% 81.9% 56.7% 37.7% 38.7% 52.7% -20.2% p<.001 Maricopa Health Plan 1 2 3-6 7-11 12-20 Total 1,387 915 3,014 3,092 2,880 11,288 1,324 800 2,167 1,653 1,513 7,457 95.5% 87.4% 71.9% 53.5% 52.5% 66.1% Contractor Phoenix Health Plan/CC * Indicates the Contractor met or exceeded the AHCCCS Minimum Performance Standard. Shaded rows show totals and percentages from the previous measurement period. Statistically significant changes from the previous period are highlighted in yellow. 9 Statistical Significance Table 1 Arizona Health Care Cost Containment System CHILDREN'S ACCESS TO PRIMARY CARE PRACTITIONERS BY CONTRACTOR MEMBERS ELIGIBLE UNDER MEDICAID Measurement Period October 1, 2002, to September 30, 2003 Contractor TOTAL TOTAL Age Number of Members Number with >1 Visits Percent with >1 Visits Relative Percent Change from Previous Period 1 2 3-6 7-11 12-20 Total 20,359 15,719 51,957 51,987 59,696 199,718 19,638 14,433 41,999 34,767 40,394 151,231 96.5% 91.8% 80.8% 66.9% 67.7% 75.7% -1.2% 1 2 3-6 7-11 12-20 Total 19,048 13,141 44,077 44,929 47,798 168,993 18,329 12,041 35,669 30,469 32,953 129,461 96.2% 91.6% 80.9% 67.8% 68.9% 76.6% * Indicates the Contractor met or exceeded the AHCCCS Minimum Performance Standard. Shaded rows show totals and percentages from the previous measurement period. Statistically significant changes from the previous period are highlighted in yellow. 10 Statistical Significance p<.001 Table 2 Arizona Health Care Cost Containment System CHILDREN'S ACCESS TO PRIMARY CARE PRACTITIONERS BY CONTRACTOR MEMBERS ELIGIBLE UNDER KIDSCARE Measurement Period October 1, 2002, to September 30, 2003 Relative Percent Contractor Age Number of Members Number with >1 Visits Percent with >1 Visits Change from Previous Period Statistical Significance 1.7% p=.335 -0.7% p=.752 Health Choice AZ * 1 2 3-6 7-11 12-18 Total 12 88 390 550 489 1,529 12 83 354 423 377 1,249 100.0% 94.3% 90.8% 76.9% 77.1% 81.7% Health Choice AZ 1 2 3-6 7-11 12-18 Total 35 141 408 564 459 1,607 34 134 351 425 347 1,291 97.1% 95.0% 86.0% 75.4% 75.6% 80.3% University Family Care * 1 2 3-6 7-11 12-18 Total 5 37 113 277 401 833 5 36 95 222 322 680 100.0% 97.3% 84.1% 80.1% 80.3% 81.6% 1 2 3-6 7-11 12-18 Total 11 43 120 280 390 844 11 42 107 230 304 694 100.0% 0.0% 89.2% 82.1% 77.9% 82.2% University Family Care * Indicates the Contractor met or exceeded the AHCCCS Minimum Performance Standard. Shaded rows show totals and percentages from the previous measurement period. Statistically significant changes from the previous period are highlighted in yellow. 11 Table 2 Arizona Health Care Cost Containment System CHILDREN'S ACCESS TO PRIMARY CARE PRACTITIONERS BY CONTRACTOR MEMBERS ELIGIBLE UNDER KIDSCARE Measurement Period October 1, 2002, to September 30, 2003 Relative Percent Number of Members Number with >1 Visits Percent with >1 Visits Change from Previous Period Statistical Significance 1 2 3-6 7-11 12-18 Total 70 336 1,215 2,060 2,018 5,699 66 314 1,060 1,590 1,597 4,627 94.3% 93.5% 87.2% 77.2% 79.1% 81.2% 1.8% p=.063 Mercy Care Plan 1 2 3-6 7-11 12-18 Total 76 314 1,120 1,947 1,891 5,348 72 296 972 1,511 1,416 4,267 94.7% 94.3% 86.8% 77.6% 74.9% 79.8% Pima Health System * 1 2 3-6 7-11 12-18 Total 2 20 34 109 126 291 2 20 33 80 97 232 100.0% 100.0% 97.1% 73.4% 77.0% 79.7% -4.0% p=.318 1 2 3-6 7-11 12-18 Total 2 14 38 105 95 254 2 14 34 85 76 211 0.0% 100.0% 0.0% 81.0% 80.0% 83.1% Contractor Mercy Care Plan * Pima Health System Age * Indicates the Contractor met or exceeded the AHCCCS Minimum Performance Standard. Shaded rows show totals and percentages from the previous measurement period. Statistically significant changes from the previous period are highlighted in yellow. 12 Table 2 Arizona Health Care Cost Containment System CHILDREN'S ACCESS TO PRIMARY CARE PRACTITIONERS BY CONTRACTOR MEMBERS ELIGIBLE UNDER KIDSCARE Measurement Period October 1, 2002, to September 30, 2003 Relative Percent Number of Members Number with >1 Visits Percent with >1 Visits Change from Previous Period Statistical Significance 1 2 3-6 7-11 12-18 Total 79 320 1,344 2,704 2,928 7,375 75 303 1,171 2,002 2,162 5,713 94.9% 94.7% 87.1% 74.0% 73.8% 77.5% -0.4% p=.669 AZ Physicians IPA 1 2 3-6 7-11 12-18 Total 114 381 1,439 2,801 2,867 7,602 113 356 1,257 2,077 2,108 5,911 99.1% 93.4% 87.4% 74.2% 73.5% 77.8% Phoenix Health Plan/CC * 1 2 3-6 7-11 12-18 Total 40 146 650 942 771 2,549 37 135 559 687 537 1,955 92.5% 92.5% 86.0% 72.9% 69.6% 76.7% -2.4% p=.107 1 2 3-6 7-11 12-18 Total 38 153 594 910 694 2,389 38 145 523 669 503 1,878 100.0% 94.8% 88.0% 73.5% 72.5% 78.6% Contractor AZ Physicians IPA * Phoenix Health Plan/CC Age * Indicates the Contractor met or exceeded the AHCCCS Minimum Performance Standard. Shaded rows show totals and percentages from the previous measurement period. Statistically significant changes from the previous period are highlighted in yellow. 13 Table 2 Arizona Health Care Cost Containment System CHILDREN'S ACCESS TO PRIMARY CARE PRACTITIONERS BY CONTRACTOR MEMBERS ELIGIBLE UNDER KIDSCARE Measurement Period October 1, 2002, to September 30, 2003 Relative Percent Number of Members Number with >1 Visits Percent with >1 Visits Change from Previous Period Statistical Significance 1 2 3-6 7-11 12-18 Total 16 88 294 435 305 1,138 16 73 192 214 125 620 100.0% 83.0% 65.3% 49.2% 41.0% 54.5% -20.9% p<.001 Maricopa Health Plan 1 2 3-6 7-11 12-18 Total 22 84 314 458 281 1,159 21 72 261 282 162 798 95.5% 85.7% 83.1% 61.6% 57.7% 68.9% TOTAL 1 2 3-6 7-11 12-18 Total 224 1,035 4,040 7,077 7,038 19,414 213 964 3,464 5,218 5,217 15,076 95.1% 93.1% 85.7% 73.7% 74.1% 77.7% -0.9% p=.089 1 2 3-6 7-11 12-18 Total 298 1,130 4,033 7,065 6,677 19,203 291 1,059 3,505 5,279 4,916 15,050 97.7% 93.7% 86.9% 74.7% 73.6% 78.4% Contractor Maricopa Health Plan TOTAL Age * Indicates the Contractor met or exceeded the AHCCCS Minimum Performance Standard. Shaded rows show totals and percentages from the previous measurement period. Statistically significant changes from the previous period are highlighted in yellow. 14 Adults’ Access to Preventive/Ambulatory Health Services Three behaviors – tobacco use, poor nutrition and lack of physical activity – are major contributors to this country’s leading killers, cardiovascular disease and cancer. These behaviors often worsen the complications of chronic diseases, such as diabetes, and increase the risk of developing other serious illnesses.3 achieved this rate, they should strive for an AHCCCS-established Goal of 80 percent. National Comparisons The National Committee for Quality Assurance (NCQA) has reported national averages for Medicaid health plans by age group for this measure. In calendar year 2002, the most recent year for which national data are available, the rates were: 20 to 44 years 75.3 percent 45 to 64 years 81.6 percent Access to routine ambulatory medical services for adults is essential to the early diagnosis and treatment of diseases. Regular health care visits also provide opportunities for clinicians to educate and counsel patients on smoking cessation, diet, exercise and other healthy behaviors. Current Results and Trend Overall, AHCCCS rates were 74.1 percent for members 21 to 44 years and 82.1 percent for members 45 to 64 years. The AHCCCS total rate remained unchanged from the previous measurement period, at 76.2 percent. Total rates by Contractor ranged from 63.2 percent to 78.4 percent. One of seven Contractors met the AHCCCS Minimum Performance Standard (Table 3). Indicator Description The indicator for this measure was the percentage of members who: • were ages 21 through 64 years at the end of the measurement period (October 1, 2002, through September 30, 2003), • were continuously enrolled with one acute-care Contractor during the measurement period, • had no more than one break in enrollment, not exceeding 31 days, and • had at least one preventive/ambulatory visit during the measurement period, including encounters with primary care physicians, specialists, physician’s assistants, nurse practitioners, ophthalmologists and optometrists. The overall rate for this measure slightly higher in Pima County, at percent, compared with the combined counties and Maricopa County, at percent and 75.5 percent, respectively. was 77.6 rural 76.4 The AHCCCS overall rate for this measure was at its highest point in CYE 1999, at 78.7 percent, and has declined slightly since then. Fig. 2: Adults’ Access to Care, 1998-2003 Results were analyzed by two age groups: 21 through 44 and 45 through 64 years. 100% 80% Performance Goals AHCCCS has adopted a Minimum Performance Standard that Contractors achieve a total rate of at least 78 percent for this indicator. If Contractors have already 60% 40% 20% 0% 1998 15 1999 2000 2001 2002 2003 Table 3 Arizona Health Care Cost Containment System ADULTS' ACCESS TO PREVENTIVE/AMBULATORY HEALTH SERVICES BY CONTRACTOR Measurement Period: October 1, 2002, through September 30, 2003 Contractor Mercy Care Plan * Mercy Care Plan University Family Care University Family Care AZ Physicians IPA AZ Physicians IPA Ages Number of Members Number with >1 Visits 21-44 22,474 17,136 76.2% 45-64 8,007 6,774 84.6% Total 30,481 23,910 78.4% 21-44 16,416 12,518 76.3% 45-64 5,311 4,450 83.8% Total 21,727 16,968 78.1% 21-44 2,486 1,854 74.6% 45-64 1,111 916 82.4% Total 3,597 2,770 77.0% 21-44 1,918 1,488 77.6% 45-64 786 647 82.3% Total 2,704 2,135 79.0% 21-44 28,821 21,374 74.2% 45-64 10,214 8,414 82.4% Total 39,035 29,788 76.3% 21-44 21,979 16,332 74.3% 45-64 7,145 5,940 83.1% Total 29,124 22,272 76.5% * Indicates the Contractor met or exceeded the AHCCCS Minimum Performance Standard. Shaded rows show totals and percentages from the previous measurement period. Statistically significant changes from the previous period are highlighted in yellow. 16 Percent with >1 Visits Relative Percent Change from Previous Period Statistical Significance 0.4% p=.345 -2.5% p=.065 -0.2% p=.622 Table 3 Arizona Health Care Cost Containment System ADULTS' ACCESS TO PREVENTIVE/AMBULATORY HEALTH SERVICES BY CONTRACTOR Measurement Period: October 1, 2002, through September 30, 2003 Contractor Health Choice AZ Health Choice AZ Pima Health System Pima Health System Phoenix Health Plan/CC Phoenix Health Plan/CC Ages Number of Members Number with >1 Visits 21-44 6,443 4,796 74.4% 45-64 2,159 1,740 80.6% Total 8,602 6,536 76.0% 21-44 4,918 3,544 72.1% 45-64 1,660 1,297 78.1% Total 6,578 4,841 73.6% 21-44 1,692 1,245 73.6% 45-64 724 589 81.4% Total 2,416 1,834 75.9% 21-44 1,221 875 71.7% 45-64 558 454 81.4% Total 1,779 1,329 74.7% 21-44 7,121 5,267 74.0% 45-64 2,440 1,962 80.4% Total 9,561 7,229 75.6% 21-44 5,451 4,040 74.1% 45-64 1,902 1,557 81.9% Total 7,353 5,597 76.1% * Indicates the Contractor met or exceeded the AHCCCS Minimum Performance Standard. Shaded rows show totals and percentages from the previous measurement period. Statistically significant changes from the previous period are highlighted in yellow. 17 Percent with >1 Visits Relative Percent Change from Previous Period Statistical Significance 3.2% p=.001 1.6% p=.370 -0.7% p=.443 Table 3 Arizona Health Care Cost Containment System ADULTS' ACCESS TO PREVENTIVE/AMBULATORY HEALTH SERVICES BY CONTRACTOR Measurement Period: October 1, 2002, through September 30, 2003 Contractor Maricopa Health Plan Maricopa Health Plan TOTAL TOTAL Ages Number of Members Number with >1 Visits 21-44 3,220 1,873 58.2% 45-64 1,703 1,236 72.6% Total 4,923 3,109 63.2% 21-44 2,470 1,643 66.5% 45-64 1,436 1,118 77.9% Total 3,906 2,761 70.7% 21-44 72,257 53,545 74.1% 45-64 26,358 21,631 82.1% Total 98,615 75,176 76.2% 21-44 54,373 40,440 74.4% 45-64 18,798 15,463 82.3% Total 73,171 55,903 76.4% * Indicates the Contractor met or exceeded the AHCCCS Minimum Performance Standard. Shaded rows show totals and percentages from the previous measurement period. Statistically significant changes from the previous period are highlighted in yellow. 18 Percent with >1 Visits Relative Percent Change from Previous Period Statistical Significance -10.7% p<.001 -0.2% p=.416 Breast Cancer Screening In the last decade, the overall death rate from female breast cancer declined from 23 deaths per 100,000 women in 1990 to 18.8 deaths per 100,000 in 1998. However, the rates of decline for Hispanic and black women were lower than for white, nonHispanic women, and the rates for Asians, Pacific Islanders, American Indians and Alaska Natives were virtually unchanged.4 achieve a rate of at least 55 percent for this measure. If Contractors have already achieved this rate, they should strive for the AHCCCS Goal of 60 percent. Breast cancer is the second most commonly diagnosed cancer among women, after skin cancer.5 The Centers for Disease Control and Prevention estimates that 216,000 new cases of invasive breast cancer will occur in the United States this year, and more than 40,000 women will die of the disease.5,6 Data from the Arizona Department of Health Services indicates that approximately 670 women in 7 the state died of breast cancer in 2003. Current Results and Trend The AHCCCS overall rate for the current measurement period was unchanged from the previous period, at 54.6 percent. Individual Contractor rates ranged from 51.3 percent to 62.2 percent. Four of seven Contractors met or exceeded the AHCCCS Minimum Performance Standard and two exceeded the AHCCCS Goal (Table 4). National Comparison NCQA has reported a national average of 55.9 percent for Medicaid health plans for this measure in calendar year 2003. Rates were higher in Pima County and the combined rural counties, at 58.1 percent and 57 percent, respectively. The rate for Maricopa County was 51.2 percent. Screening mammography is an important tool in the early detection of breast cancer. Studies have demonstrated that screening mammography may reduces mortality from 8,9 the disease by up to 30 percent. The AHCCCS overall rate for breast cancer screening has increased from 49.7 percent in CYE 1995, and was at its highest point in CYE 1998, at 57.3 percent. Indicator Description The indicator for this measure was the percentage of women who: • were ages 52 through 64 years as of September 30, 2003, • were continuously enrolled with one Contractor for two years (October 1, 2001, through September 30, 2003), • had no more than one break in enrollment, not exceeding 31 days per year, and • had a mammogram in the two-year period. Fig. 3: Breast Cancer Screening, 1995-2003 70% 60% 50% 40% 30% 20% 10% 1995 Performance Goals AHCCCS has adopted a Minimum Performance Standard that Contractors 19 1996 1997 1998 1999 2000 2001 2003 Table 4 Arizona Health Care Cost Containment System BREAST CANCER SCREENING RATES BY CONTRACTOR Measurement Period October 1, 2001, through September 30, 2003 Relative Percent Change From Number of Members Number Screened Percent Screened Previous Period Pima Health System * 225 140 62.2% -5.6% Statistical Significance p=.454 Pima Health System 170 112 65.9% Maricopa Health Plan * 470 283 60.2% 16.8% p=.009 Maricopa Health Plan 423 218 51.5% University Family Care * 271 159 58.7% 1.5% p=.863 University Family Care 166 96 57.8% Mercy Care Plan * 1,759 973 55.3% -2.4% p=.476 Mercy Care Plan 1,133 642 56.7% AZ Physicians IPA 2,250 1,196 53.2% -0.5% p=.866 AZ Physicians IPA 1,529 817 53.4% Health Choice AZ 466 239 51.3% -5.1% p=.426 Health Choice AZ 370 200 54.1% Phoenix Health Plan/CC 591 303 51.3% -9.0% p=.094 Phoenix Health Plan/CC 506 285 56.3% TOTAL 6,032 3,293 54.6% -1.0% p=.571 TOTAL 4,297 2,370 55.2% Contractor * Indicates the Contractor met or exceeded the AHCCCS Minimum Performance Standard. Shaded rows show totals and percentages from the previous measurement period. Statistically significant changes from the previous period are highlighted in yellow. 20 Cervical Cancer Screening According to the American Cancer Society, an estimated 10,520 new cases of invasive cervical cancer will be diagnosed in 2004, and nearly 4,000 women will die of the disease.6 Many of these deaths could be prevented with timely screening. Performance Goals AHCCCS has adopted a Minimum Performance Standard that Contractors achieve a rate of at least 57 percent for this measure. If Contractors have already achieved this rate, they should strive for an AHCCCSestablished Goal of 60 percent. Since the introduction of the Papanicolaou (Pap) test, death from cervical cancer has declined by 70 percent. The Pap test can detect human papillomavirus (HPV) infection and precancerous conditions. Treatment of these problems can stop cervical cancer before it fully develops.10,11 National Comparison NCQA has reported a national average of 64.0 percent for Medicaid health plans for this measure in calendar year 2003. Current Results and Trend The AHCCCS overall rate for the current measurement period increased to 53.2 percent from 50.5 percent in the previous period (p<.001). Individual Contractor rates ranged from 44.1 percent to 57.6 percent. One of seven Contractors met the AHCCCS Minimum Performance Standard; however, four others showed statistically significant increases (Table 5). The American College of Obstetricians and Gynecologists, the American Cancer Society and the U.S. Preventive Services Task Force recommend that women have a Pap test and pelvic examination when they become sexually active or at age 18, whichever occurs first. Annual Pap tests are recommended until three consecutive Pap tests are interpreted as being normal. Following this, Pap tests can be performed every three years, at the discretion of a woman’s health care provider. Rates were slightly higher in Pima County, at 55.5 percent, compared with 53.0 percent in Maricopa County and 52.0 percent in the combined rural counties. Indicator Description This indicator for this measure was the percentage of members who: • were ages 16 through 64 years as of October 1, 2002, • were continuously enrolled with one Contractor during a one-year period (October 1, 2002, through September 30, 2003), • had no more than one break in enrollment, not exceeding 31 days, and • had at least one Pap test within a threeyear period (October 1, 2000, through September 30, 2003). The AHCCCS overall rate for cervical cancer screening has decreased from approximately 57.2 percent in CYE 1999. Fig. 4: Cervical Cancer Screening, 1999-2003 70% 60% 50% 40% 30% 20% 10% 1999 21 2000 2001 2003 Table 5 Arizona Health Care Cost Containment System CERVICAL CANCER SCREENING RATES BY CONTRACTOR Measurement Period: October 1, 2000, through September 30, 2003 Percent Screened Relative Percent Change From Previous Period Statistical Significance 4,682 57.6% 8.4% p<.001 3,725 1,977 53.1% Mercy Care Plan 28,833 16,259 56.4% -0.6% p=.565 Mercy Care Plan 11,583 6,569 56.7% University Family Care 3,588 1,981 55.2% 9.9% p<.001 University Family Care 1,585 796 50.2% AZ Physicians IPA 36,224 19,034 52.5% 8.7% p<.001 AZ Physicians IPA 15,812 7,644 48.3% Pima Health System 2,459 1,281 52.1% 13.9% p<.001 Pima Health System 1,141 522 45.7% Phoenix Health Plan /CC 9,158 4,234 46.2% -3.6% p=.066 Phoenix Health Plan /CC 4,070 1,952 48.0% Maricopa Health Plan 4,682 2,066 44.1% 18.4% p<.001 Maricopa Health Plan 2,471 921 37.3% TOTAL 93,079 49,537 53.2% 5.5% p<.001 TOTAL 40,387 20,381 50.5% Number of Members Number Screened Health Choice AZ * 8,135 Health Choice AZ Contractor * Indicates the Contractor met or exceeded the AHCCCS Minimum Performance Standard. Shaded rows show totals and percentages from the previous measurement period. Statistically significant changes from the previous period are highlighted in yellow. 22 Timeliness of Prenatal Care Women who receive early and ongoing prenatal care are more likely to have better pregnancy outcomes than women who receive little or no prenatal care.12,13,14,15 achieve a rate of at least 59 percent for this measure. If Contractors have already achieved this rate, they should strive for the AHCCCS Goal of 65 percent. Adverse outcomes such as low birth weight, preterm delivery and cognitive impairment of newborns can be prevented by modifying maternal behaviors.16 Prenatal care affords physicians and other health care practitioners opportunities to address risk factors such as smoking, alcohol use and improper diet, as well as treat medical complications that can negatively affect the health of mother and baby. In addition, prenatal care provides opportunities to educate pregnant women, especially firsttime mothers, on childbirth and infant care. National Comparison NCQA has reported a national average of 76.5 percent for Medicaid health plans for this measure in calendar year 2003. Current Results The AHCCCS overall rate for the current measurement period was 73.7 percent. All eight Contractors met the AHCCCS Minimum Performance Standard for this measure and six met the AHCCCS Goal (Table 6). Rates were slightly higher in Pima County, at 74.6 percent, compared with 73.2 percent in Maricopa County and 71.4 percent in the combined rural counties. Arizona continues to lag behind the national average for women receiving prenatal care in the first trimester. In 2003, 75.5 percent of all Arizona women who had live births started prenatal care in the first trimester, compared with 83.8 percent nationally.17 AHCCCS further analyzed rates by the length of time women were enrolled. The rate of women who were continuously enrolled with a Contractor and had a prenatal care visit in the first trimester was 86.5 percent. Among women who were enrolled later in pregnancy or had gaps in enrollment, the rate of prenatal visits within 42 days of enrollment was 68.5 percent. Indicator Description The indicator for this measure was the percentage of women who: • had a live birth during the measurement period (October 1, 2002, through September 30, 2003). • were continuously enrolled with the same acute-care Contractor for 43 days or more prior to delivery, and • had a prenatal care visit during their first trimester of pregnancy or within 42 days of enrollment, depending on the date of enrollment with the Contractor and any gaps in enrollment during the pregnancy. This is the first year AHCCCS has measured timeliness of prenatal care using the current methodology, so comparisons with previous rates cannot be made. Performance Goals AHCCCS has adopted a Minimum Performance Standard that Contractors 23 Table 6 Arizona Health Care Cost Containment System TIMELINESS OF PRENATAL CARE Measurement Period: October 1, 2002, through September 30, 2003 Visits within Contractor Visits within 42 days the First Trimester Members With Visits Percent Members of Enrollment With Visits Percent Total Members With Visits Percent Mercy Care Plan * 2,731 2,447 89.6% 6,106 4,741 77.6% 8,837 7,188 81.3% AZ Physicians IPA * 2,367 2,080 87.9% 6,441 4,308 66.9% 8,808 6,388 72.5% University Family Care * 234 201 85.9% 499 309 61.9% 733 510 69.6% Health Choice AZ * 838 706 84.2% 1,883 1,135 60.3% 2,721 1,841 67.7% Phoenix Health Plan/CC * 777 631 81.2% 1,999 1,196 59.8% 2,776 1,827 65.8% 150 115 7,212 105 70 6,240 70.0% 60.9% 86.5% 409 442 17,779 232 256 12,177 56.7% 57.9% 68.5% 559 557 24,991 337 326 18,417 60.3% 58.5% 73.7% Maricopa Health Plan * Pima Health System * TOTAL * Indicates the Contractor met or exceeded the AHCCCS Minimum Performance Standard. 24 DISCUSSION The data reported here indicate that children – especially those in the youngest age groups – and adults enrolled with AHCCCS have a high degree of access to the health care system. However, many adults are reluctant to use preventive services. This may be due to lack of knowledge or confusion about what services or tests are needed and when, language barriers, cultural beliefs, and skepticism about the effectiveness of prevention.18 Pima Health System, which had the highest rates of breast cancer screening in the last two measurement periods, has combined personal outreach and education for a variety of ages and health needs when case managers make home visits to families with newborns. Since several family members may be enrolled with the health plan, they check to see if other members of the household are due for preventive visits and use the opportunity to encourage them to receive services. Case managers may assist in making appointments for family members who are enrolled in the health plan and arranging for transportation. For example, a significant percentage of women responding to a recent National Cancer Institute survey said that they did not have a mammogram because they did not know they needed one or their doctor had not recommended one.19 Women of certain racial or ethnic groups may be reluctant to obtain mammograms or Pap tests because of embarrassment about reproductive health issues and fatalistic attitudes that an individual can do little to alter the future, or they may believe that the needs of the group are more important than their own needs.20,21 Provider-focused Strategies Some strategies to improve rates of preventive care are aimed at providers. At a minimum, most Contractors periodically send providers lists of members who are due or overdue for a particular service. Other provider interventions include distributing profiles to individual practitioners that show their rates for a particular service compared with their peers, recognition of providers who meet certain quality criteria, and “pay-forperformance” arrangements that reward providers with the highest rates. Several Contractors are using or considering these mechanisms for improvement. Overcoming Barriers to Care Routine reminders that it’s time for members to get a particular service may not be enough to improve rates of preventive health services. For instance, AHCCCS Contractors should emphasize how the benefits of mammography in detecting cancer early outweigh the discomfort and any perceived risks associated with the procedure. They also should remind women who have no special risk factors for breast cancer that they need regular mammograms to detect possible tumors. These strategies may be tied together. Feedback in the form of provider profiles helps physicians, hospitals and other providers improve their performance. Health plans may recognize providers that perform at a certain level; e.g. in provider or member information materials, and those that meet specific criteria may receive extra payment. Personal outreach coupled with culturally relevant education materials may be effective in improving rates of breast and cervical cancer screening, especially among some racial or ethnic groups. Conclusion AHCCCS will continue to work with Contractors, especially those with the lowest rates, and their actions to improve performance for these measures. 25 REFERENCES 10 1 American Cancer Society. What causes cancer of the cervix: Can it be prevented? Available at: http://www.cancer.org/eprise/main/docroot/CRI/ content/CRI_2_2_2X. Accessed November 20, 2002. 11 Taber’s cyclopedic medical dictionary: Ed. 19, F.A. Davis Co., Philadelphia, 2001. 12 Greenberg RS: The impact of prenatal care in different social groups. Am J Obstet Gyn. April 1, 1983. 13 Leveno KJ, et al: Prenatal care and the low birth weight infant, Obstet Gyn. November 1985. 14 National Center for Health Statistics. 1996 final natality data, prepared by the March of Dimes Perinatal Data Center. 1998 15 Kirkman-Liff B: Analysis of prenatal care in Arizona, Arizona State University School of Health Administration and Policy; December 1993. 16 Centers for Disease Control and Prevention. Surveillance Summaries, July 2, 2004. MMWR 2004:53(SS-4). 17 Arizona Department of Health Services. Natality: Maternal characteristics and newborns’ health. Arizona Health Status and Vital Statistics 2003. Available at: http://www.azdhs.gov/plan/report/ahs/ahs2003/t oc03.htm. Accessed November 9, 2004. 18 U.S. Department of Health and Human Services. Healthy People 2010, 2nd ed. Washington, D.C.: U.S. Government Printing Office, November 2000. 19 National Cancer Institute. Breast cancer screening physician data query (PDQ®), 2001. Available at: http://www.cancer.gov/cancer_information/pdq. Accessed May 2, 2002. 20 Alarcon M. Breast and cervical cancer among Latino women. National Council of La Raza, Washington, D.C. 1998. 21 Transcultural Nursing. Basic concepts and case studies: Asian community. Available at: http://www.culturediversity.org/asia.htm#Pain. Accessed April 9, 2003. U.S. Department of Health and Human Services. Healthy people 2000 objectives. Washington, D.C.: U.S. Government Printing Office, November 1990. 2 Arizona Maternal and Child Health Committee. Maternal and Child Health Needs Assessment, Arizona 2000. Phoenix, Arizona: Arizona Department of Health Services, April 2001. 3 Arizona Department of Health Services, Office of Epidemiology and Statistics. 2001 behavioral risk factors of Arizona adults. Phoenix, Arizona. Arizona Department of Health Services, 2002. 4 Keppel KG, Pearcy JN, Wagener DK. Trends in racial and ethnic-specific rates for health status indicators: United States, 1990-1998. Healthy people statistical notes, no. 23. Hyattsville, Maryland: National Center for Health Statistics. January 2002. 5 Centers for Disease Control and Prevention. National breast and cervical cancer early detection program: Breast cancer and mammography information. Available at: http://www.cdc.gov/cancer/nbccedp/info-bc.htm. Accessed November 3, 2004. 6 Centers for Disease Control and Prevention. National breast and cervical cancer early detection program: 2004/2005 fact sheet. Available at: http://www.cdc.gov/cancer/nbccedp/about2004.ht m#facts. Accessed November 3, 2004. 7 Arizona Department of Health Services. Arizona health status and vital statistics 2003 report. Available at: http://www.azdhs.gov/plan/report/ahs/ahs2003/t oc03.htm. Accessed November 9, 2004. 8 Agency for Healthcare Research and Quality. Breast cancer screening: summary of the evidence. Available at: http://www.ahcpr.gov/clinic/3rduspstf/breastcan cer/bcscrnsum1.htm. Accessed November 10, 2004. 9 National Cancer Institute. Summary of evidence: screening by mammography. Available at: http://www.cancer.gov/cancertopics/pdq/screeni ng/breast/HealthProfessional/page1. Accessed November 10, 2004. 26 APPENDIX Methodology and Technical Specifications for Acute-care Performance Measures For Measurement Periods Ending September 30, 2003 I. CHILDREN'S ACCESS TO PRIMARY CARE PRACTITIONERS (MEDICAID AND KIDSCARE MEMBERS) Population Members were selected from the acute-care population only. Sample Frame AHCCCS used the Health Plan Employer Data and Information Set (HEDIS®), 2002 version, as a guide in developing the methodology for this measure. Enrollment criteria Acute-care members who: • were ages 1 through 20 years if eligible under the Medicaid program or 1 through 18 years old if eligible under the KidsCare program, • were continuously enrolled with the same acute-care Contractor during the measurement period, and • had no more than one break in enrollment, not to exceed 31 days in the contract year Service selection criteria Acute-care members who: • met the enrollment criteria and • had at least one visit with a health plan PCP during the measurement period. Sample Selection All members who met the sample frame criteria were included in this measure. Population Stratification The sample frame was stratified for both the Medicaid and KidsCare populations by: • Maricopa, Pima and Rural counties, and • acute-care Contractor or the Comprehensive Medical and Dental Program (CMDP) managed by the Department of Economic Security (DES). Population Exclusions This measure did not include children who were enrolled in Arizona Long-term Care System (ALTCS), the Division of Developmental Disabilities (DDD) managed by the Department of Economic Security (DES), Indian Health Services (IHS), Emergency Services Program (ESP) and Fee For Service (FFS). In addition, this measure excluded any members who also were Medicare recipients. 27 Data Sources • Recipient enrollment data were used to identify members who met the denominator criteria. • Encounter data were used to identify the number of members who had PCP visits. Data Collection The Information Services Division (ISD) of AHCCCS extracted administrative data from the Prepaid Medical Management Information System (PMMIS). No outside data were collected. Data Validation Data validation was performed to ensure that all data received from the Information Services Division (ISD) were from the appropriate service records and met this measure’s service selection criteria, and that all recipients selected met the proper enrollment criteria. The Data Analysis and Research Unit (DA&R) in the Division of Health Care Management (DHCM) developed a Quality Control (QC) process based on the measure methodology. DA&R verified that members selected met the sample frame criteria. The QC report provided by ISD was used to complete data validation. Denominator The number of members who met the sample frame criteria for enrollment Numerator The number of members who met the sample frame criteria for service selection Comparative Analysis For the Medicaid and KidsCare populations separately: • the total rate for all Contractors was compared to the total for the previous measurement period. • totals for Maricopa, Pima and the combined rural counties were compared to each other and to totals for the previous measurement period. • individual Contractor rates were compared to their rates for the previous year. • individual Contractor rates were compared to the AHCCCS Minimum Performance Standard and Goal. • if available, the total rate for all Contractors was compared to the national average for this measure as reported by the National Committee for Quality Assurance (NCQA). Deviations from HEDIS This measure differs from HEDIS 2002 in the following areas: • the HEDIS measure includes only members ages 1 through 11 years. The AHCCCS measure includes ages 1 through 20 for the Medicaid population and ages 1 through 18 for the KidsCare population. • The HEDIS measure uses a one-year enrollment for ages 1-6 years and two-year enrollment period for members ages 7 through 11 years. AHCCCS used the one-year enrollment period for all ages. • The HEDIS measure includes PCP visits in the two-year enrollment period for ages 7 through 11 years. AHCCCS selected services in the one-year measurement period only. 28 • • • The AHCCCS measure uses CPT codes 99384, 99385, 99394 and 99395 to collect preventive medicine visits by members 12 and older. HEDIS does not use these codes because members older than 11 are not included in the measure. The HEDIS measures uses codes 99341 to 99350 for services provided in a private residence. The AHCCCS measure uses only codes 99341 to 99345 for these services. AHCCCS uses Evaluation and Management codes in conjunction with ICD-9 diagnosis codes to identify some PCP visits. HEDIS used both the CPT and ICD-9 codes independently to identify visits. Recipient Subsystem Requirements • Members must have been 1 through 20 years of age, or 1 through 18 years of age if eligible under KidsCare, as of September 30 of the measurement period. • Members must have been continuously enrolled during the measurement period and on September 30 of the measurement period. • Members must have been enrolled with the same acute-care, capitated Contractor for the entire measurement period. • Prior Period Coverage (PPC) was not considered part of continuous enrollment and was treated as a break in acute enrollment. • A member with one single enrollment gap, not to exceed 31 days, was considered to have continuous enrollment and was included in the population; however, the gap could not occur at the beginning or the end of the continuous enrollment period. • Change of county-service-area with the same Contractor without any gap of enrollment was not considered a break in enrollment. • For those members who stayed with the same Contractor but moved to a different county during the measurement period, the member was assigned to the last county of residence. • Any enrollment that changed from an acute-care Contractor to a Contractor for the Arizona Long Term Care System (ALTCS) and back to an acute-care Contractor within 31 days was treated as a break in acute enrollment instead of enrollment with more than one capitated Contractor during the measurement period. • Any member enrolled with the following Contractors was excluded: 000850 - State Emergency Services 000950 - Federal Emergency Services 000960 - Family Planning Services 003335 - Permanent Fee-For-Service 008690 - Temporary Fee-For-Service 010174 - Maricopa LTC, Residual 010182 - Pima LTC, Residual 999998 - Indian Health Services 888886 - Fee-For-Service LTC, residual 079873 - DHS 110007 - DES/DDD 550005 - DES/VD • Members with rate codes 45XX were excluded. • Members with Medicare Part A and/or Part B during the measurement period were excluded. Note: A data file containing the information for each member was created and used to identify services received. 29 Encounter Subsystem Requirements Utilizing data from the Recipient Subsystem: • All encounters selected (Form 1500 and UB 82/92) for the numerator were based on the service selection criteria listed below. • Encounters were included if the begin-date of service fell within the measurement period. • Encounters from the Arizona Department of Health Services/Children’s Rehabilitative Services (CRS) and ADHS/Behavioral Health Services (BHS) who also were enrolled with another Contractor were included in the other Contractor’s data. • All services for the member were reported under the member’s last county of residence in the measurement period. • The selected encounters were sorted by member primary ID. • All members from the denominator who did not meet the selection criteria and who had encounters matching the service exclusionary criteria listed below were excluded from the numerator. Service Selection Criteria CPT-4 Codes for Preventive Medicine Services (UB82/92 or HCFA 1500) 99381 - 99385 New Patient (ages 1 - 39 years) 99391 - 99395 Established Patient (ages 1 - 39 years) 99401 - 99404 Preventive medicine, individual counseling 99411 - 99412 Preventive medicine, group counseling 99420 Administration and interpretation of health risk assessment instrument 99429 Unlisted preventive medicine service The following CPT-4 codes were used in conjunction with ICD-9 codes CPT-4 Codes for Evaluation and Management (UB82/92 or HCFA 1500) 99201 - 99205 New Patient 99211 - 99215 Established patient 99241 - 99245 Office or other outpatient consultations 99341 - 99345 Home services 99499 Unlisted evaluation and management service In Conjunction with ICD-9 Diagnosis Codes: V20.2 Routine infant or child health check V70.0 Routine general medical examination at health care facility V70.3 Other general medical examination V70.5 - V70.6 Health examination V70.7 Examination for normal comparison or control in clinical research V70.8 - V70.9 Other specified and unspecified general medical examination. 30 Exclusions Form Type = “I” Form type = “O” with revenue code = 450 ( Emergency Room) Form Type = “A” with place of service = 23= (Emergency Room), 21= (Inpatient Hospital). If principal/first-listed diagnosis codes ICD-9 290-316 If principal/first-listed diagnosis codes ICD-9 960-979 with a secondary diagnosis of chemical dependency codes ICD-9-CM 303.xx and 304.xx. CPT Procedure Codes 90801-90899 OR ICD-9 Procedure Codes 94.26, 94.27, and 94.6 In conjunction with the following ICD-9 Diagnosis Codes: V20.2 Routine infant or child health check V70.0 Routine general medical examination at health care facility. V70.3 Other general medical examination V70.5 - V70.6 Health examination V70.7 Examination for normal comparison or control in clinical research V70.8 - V70.9 Other specified and unspecified general medical examination. 31 II. ADULTS' ACCESS TO PREVENTIVE/AMBULATORY CARE SERVICES Population Members were selected from the acute-care population only. Sample Frame AHCCCS used the Health Plan Employer Data and Information Set (HEDIS®), 2002 version, as a guide in developing the methodology for this measure. Enrollment criteria The enrollment criteria for sample frame included acute-care members who: • were ages 21 through 64 years, • were continuously enrolled with the same acute-care Contractor during the measurement period, and • had no more than one break in enrollment, not to exceed 31 days in the contract year Prior period coverage (PPC) was not considered part of continuous enrollment and was treated as a break in acute enrollment. • • • • Service selection criteria The service selection criteria for sample frame included acute-care members who: met the enrollment criteria and had at least one preventive or ambulatory care visit during the measurement period Sample Selection All members who met the sample frame criteria were included in this measure. Population Stratification The sample frame was stratified by: • Maricopa, Pima and Rural counties, and • acute-care Contractor or the Comprehensive Medical and Dental Program (CMDP) managed by the Department of Economic Security (DES). Population Exclusions This measure did not include members enrolled in the Arizona Long-term Care System (ALTCS), the Division of Developmental Disabilities (DDD) managed by the Department of Economic Security (DES), Indian Health Services (IHS), Emergency Services Program (ESP) and Fee For Service (FFS). In addition, this measure excluded any members who also were Medicare recipients. Data Sources • Recipient enrollment data were used to identify members who met the denominator criteria. • Encounter data were used to identify the number of members who received preventive or ambulatory care visits. 32 Data Collection The Information Services Division (ISD) of AHCCCS extracted administrative data from the Prepaid Medical Management Information System (PMMIS). There was no outside data collected. Data Validation Data validation was performed to ensure that all data received from the Information Services Division (ISD) were from the appropriate service records and met this measure’s service selection criteria, and that all recipients selected met the proper enrollment criteria. The Data Analysis and Research Unit (DA&R) in the Division of Health Care Management (DHCM) developed a Quality Control (QC) process based on the measure methodology. DA&R verified that the members selected met the sample frame criteria. The QC report provided by ISD was used to complete data validation. Denominator The number of members who met the sample frame criteria for enrollment Numerator The number of members who met the sample frame criteria for service selection. Note: A member was included in the numerator only once under the number of visits received. Comparative Analysis • The total rate for all Contractors was compared to the total for the previous measurement period. • Totals for Maricopa, Pima and the combined rural counties were compared to each other and to totals for the previous measurement period. • Individual Contractor rates were compared to their rates for the previous year. • Individual Contractor rates were compared to the AHCCCS Minimum Performance Standard and Goal. • If available, the total rate for all Contractors was compared to the national average for this measure as reported by the National Committee for Quality Assurance (NCQA). Deviations from HEDIS This measure differs from HEDIS 2002 in the following area: • The HEDIS measure includes members who are age 20 years and older. The AHCCCS measure includes only members 21 through 64 years. • AHCCCS used Revenue codes 770 (General Classification/Preventive Care Services), 771 (Vaccine Administration) and 779 (Other Preventive Care Services) to identify preventive/ambulatory care visits. HEDIS does not use these codes. 33 Recipient Subsystem Requirements: • Members selected must have been 21 through 64 years old as of September 30 of the measurement period. • Members must have been continuously enrolled during the measurement period and as of September 30 of the measurement period. • Members must have been enrolled with one acute-care, capitated Contractor for the entire measurement period. • Prior Period Coverage (PPC) was not considered part of continuous enrollment and was treated as a break in acute enrollment. • A member with one single enrollment gap per contract year, not exceeding 31 days, was considered to have continuous enrollment and was included in the population. • A change of county-service-area with the same Contractor without any gap in enrollment was not considered a break in enrollment. • For those members who stayed with the same Contractor but moved to a different county during the reporting period, the member was assigned to the last county of residence. • Any enrollment that changed from an acute-care Contractor to a Contractor for the Arizona Long Term Care System (ALTCS) and back to an acute-care Contractor within 31 days was treated as a break in acute enrollment instead of enrollment with more than one Contractor during the measurement period. • Any member enrolled with the following Contractors was excluded: 000850 – State Emergency Services 000950 – Federal Emergency Services 000960 – Family Planning Services 003335 – Permanent Fee-For-Service 008690 – Temporary Fee-For-Service 010174 – Maricopa LTC, Residual 010182 – Pima LTC, Residual 999998 – Indian Health Services 888886 – Fee-For-Service LTC, Residual 079873 – DHS 110007 – DES/DDD 550005 – DES/VD • • Members with Medicare Part A and/or Part B during the measurement period were excluded. Members with rate codes 45XX and 46XX were excluded. Note: A data file was created containing the information for each member that was to be used to identify the services received. Encounter Subsystem Requirements: Utilizing data from Recipient Subsystem: • All encounters (using Form 1500 and UB 82/92) for the selected members were based on the service selection criteria listed below. • Encounters were included if the begin-date of service fell within the measurement period. • Encounters from the Arizona Department of Health Services (ADHS)/Behavioral Health Services (BHS) were excluded. • All services for the member were reported under the member’s last county of residence in the measurement period. • All selected encounters were sorted by members’ primary identification numbers. • All members from the denominator who did not meet the selection criteria and who had encounters matching the service exclusionary criteria listed below were excluded from the numerator. 34 Service Selection Criteria CPT-4 Codes for Preventive Medicine Services (UB82/92 or HCFA 1500) 99385 – 99387 New Patient 99395 – 99397 Established Patient 99401 – 99404 Preventive medicine, individual counseling 99411 – 99412 Preventive medicine, group counseling 99420 Administration and interpretation of health risk assessment instrument 99429 Unlisted preventive medicine service OR CPT-4 Codes for Evaluation and Management (UB82/92 or HCFA 1500) 99201 – 99205 New Patient 99211 – 99215 Established patient 99241 – 99245 Office or other outpatient consultations 99301 – 99303 Comprehensive nursing facility assessments 99311 – 99313 Subsequent nursing facility care 99321 – 99323 Domiciliary, rest home, or custodial care services, new patient 99331 – 99333 Domiciliary, rest home, or custodial care services, established patient 99341 – 99350 Home services 99499 Unlisted evaluation and management service OR CPT-4 Codes for Ophthalmology and Optometry (UB82/92 or HCFA 1500) 92002 – 92004 General ophthalmological services, new patient 92012 – 92014 General ophthalmological services, established patient OR Revenue Codes(UB 82/92) 510 Clinic 511 Chronic pain clinic 514 OB/GYN clinic 516 Urgent clinic 517 Family clinic 519 Other clinic 520 Freestanding clinic 521 Rural clinic 522 Rural / home 523 Family practice clinic 526 Freestanding urgent care clinic 35 529 530 531 539 770 771 779 982 983 Other freestanding clinic Osteopath services Osteopath Rx Other Osteopath services General Classification/Preventative Care Services Vaccine Administration Other Preventative Care Services Professional fees, outpatient services Professional fees, clinic Exclusions Form Type = “I” Form type = “O” with revenue code = 450 (Emergency Room) Form Type = “A” with place of service = 23= (Emergency Room), 21= (Inpatient Hospital). If principal/first-listed diagnosis codes ICD-9 290-316 If principal/first-listed diagnosis codes ICD-9 960-979 with a secondary diagnosis of chemical dependency codes ICD-9-CM 303.xx and 304.xx. CPT Procedure Codes 90801-90899 OR ICD-9 Procedure Codes 94.26, 94.27, and 94.6 In conjunction with the following ICD-9 Diagnosis Codes: V20.2 Routine infant or child health check V70.0 Routine general medical examination at health care facility. V70.3 Other general medical examination V70.5 - V70.6 Health examination V70.7 Examination for normal comparison or control in clinical research V70.8 - V70.9 Other specified and unspecified general medical examination. 36 III. BREAST CANCER SCREENING Population All members selected were from the acute-care population exclusively. Sample Frame AHCCCS used the Health Plan Employer Data and Information Set (HEDIS®), 2002 version, as a guide in developing the methodology for this measure. Enrollment criteria Acute-care members who: • were ages 52 to 64 years old at the end of the measurement period, • were continuously enrolled with one acute-care Contractor for two years, and • had no more than one break in enrollment, not exceeding 31 days, per year. Prior Period Coverage (PPC) was not considered part of continuous enrollment and was treated as a break in acute enrollment. Service selection criteria Acute-care members who: • met the enrollment criteria and • had a mammogram within the two-year measurement period. Sample Selection All members who met the sample frame criteria were included in this measure. Population Stratification The sample frame was stratified by: • Maricopa, Pima and the combined rural counties, and • acute-care Contractor. Population Exclusions This measure did not include members enrolled in the Arizona Long Term Care system (ALTCS) or the fee-for-service program (i.e., Indian Health Services and Emergency Services Program). In addition, this measure excluded any members who also were Medicare recipients. Data Sources • Recipient enrollment data were used to identify members who met the denominator criteria. • Encounter data were used to identify the number of members who received mammograms. Data Collection The Information Services Division (ISD) of AHCCCS extracted administrative data from the Prepaid Medical Management Information System (PMMIS). No outside data were collected. 37 Data Validation Data validation was performed to ensure that all data received from the Information Services Division (ISD) were from the appropriate service records and met this measure’s service selection criteria, and that all recipients selected met the proper enrollment criteria. The Data Analysis and Research Unit (DA&R) in the Division of Health Care Management (DHCM) developed a Quality Control (QC) process based on the measure methodology. DA&R verified that the members selected met the sample frame criteria. The QC report provided by ISD was used to complete data validation. Denominator The number of members who met the sample frame criteria for enrollment Numerator The number of members in the sample frame who met the criteria for service selection Comparative Analysis • The total for all Contractors was compared to results for the previous measurement period. • The average results for Maricopa, Pima and the combined rural counties were compared to each other and to results for the previous measurement period. • Individual Contractor rates were compared to their rates for the previous year. • Individual Contractor rates were compared to the AHCCCS Minimum Performance Standard and AHCCCS goal. • If available, the total rate for all Contractors was compared to the national average for this measure as reported by the National Committee for Quality Assurance (NCQA). Deviations from HEDIS This measure differs from HEDIS 2002 in the following area: • HEDIS criteria include searching for evidence of a bilateral mastectomy as far back as possible in the patient’s history, through either administrative data or medical record review. AHCCCS only searched for evidence of a bilateral mastectomy during the measurement period. Recipient Subsystem Requirements • Only female members were selected. • Members selected must have been 52 through 64 years old as of September 30 of the measurement period. • Members must have been continuously enrolled during the measurement period, and as of September 30 of the measurement period. • Members selected must have been enrolled with one acute-care Contractor for the entire measurement period. • Prior Period Coverage (PPC) was not considered as part of continuous enrollment and was treated as a break in acute enrollment. • A member with one single enrollment gap, not exceeding 31 days per contract year, was considered to have continuous enrollment and was included in the sample frame. 38 • • • • • • A change of county service area while enrolled with the same Contractor without any gap of enrollment was not considered a break in enrollment. For those members who stayed with the same acute-care Contractor but moved to a different county during the measurement period, the member was assigned to the last county of residence. Any enrollment that changed from an acute-care Contractor to a Contractor for the Arizona Long Term Care System (ALTCS) and back to an acute-care Contractor within 31 days was treated as a break in acute enrollment instead of enrollment with more than one Contractor during the measurement period. Members enrolled with the following Contractors were not selected: 000850 - State Emergency Services 000950 - Federal Emergency Services 000960 - Family Planning Services 003335 - Permanent Fee-For-Service 008690 - Temporary Fee-For-Service 010174 - Maricopa LTC, Residual 010182 - Pima LTC, Residual 999998 - Indian Health Services 888886 - Fee-For-Service LTC, residual 079873 - DHS 110007 - DES/DDD 550005 - DES/VD Members with Medicare Part A and/or Part B during the measurement period were excluded. Members with rate codes 45XX and 46XX were excluded. Note: A data file containing the information for each member was created and used to identify the services received. Encounter Subsystem Requirements Utilizing data from Recipient Subsystem: • All encounters selected (using Form 1500 or UB 82/92) for the selected members were based on the service selection criteria listed below. • Encounters were included if the begin-date of service fell within the measurement period. • Encounters from the ADHS/Behavioral Health Services (BHS) were excluded. • All services for the member were reported under the member’s last county of residence in the measurement period. • The selected encounters were sorted by members’ primary identification numbers. • All members from the denominator who did not meet the selection criteria and who had encounters matching the service exclusionary criteria listed below were excluded from the numerator. Service Selection Criteria CPT-4 Procedure Codes (HCFA 1500 or UB 82/92) 76090 Mammography – unilateral 76091 Mammography – bilateral 76092 Screening mammography, bilateral OR 39 ICD-9 Diagnostic Codes (HCFA 1500 or UB 82/92) V76.11 Screening mammogram for high-risk patient V76.12 Other screening mammogram OR ICD-9 Procedure Codes (UB 82/92) 87.36 Xerography of breast 87.37 Other mammography OR Revenue Codes (UB 82/92) 401 Mammography 403 Screen mammography Service Exclusionary Criteria ICD-9 Procedure Codes (UB 82/92) 85.44 Bilateral extended simple mastectomy 85.46 Bilateral radical mastectomy 85.48 Bilateral extended radical mastectomy OR CPT-4 Procedure Codes (HCFA 1500 or UB 82/92) 19200 Mastectomy, radical, including pectoral muscles, an axillary lymph nodes 19220 Mastectomy, radical, including pectoral muscles, axillary and internal mammary lymph nodes 19240 Mastectomy, modified radical, including axillary lymph nodes with or without pectoralis minor muscle, but excluding pectoralis major muscle In conjunction with modifier code: 50 Bilateral procedure 40 IV. CERVICAL CANCER SCREENING Population Members were selected from the acute-care population exclusively. Sample Frame AHCCCS used the Health Plan Employer Data and Information Set (HEDIS®), 2002 version, as a guide in developing the methodology for this measure. Enrollment criteria Acute-care members who: • were ages 16 to 64 at the end of the measurement period, • were continuously enrolled with one acute-care Contractor during the measurement period, and • had no more than one break in enrollment, not exceeding 31 days, during the measurement period Prior Period Coverage (PPC) was not considered part of continuous enrollment and was treated as a break in acute enrollment. Service selection criteria Acute-care members who: • met the enrollment criteria and • who received one or more Pap tests within the measurement period or two previous years Sample Selection All members who met the sample frame were included in this measure. Population Stratification The sample frame was stratified by: • Maricopa, Pima and the combined rural counties, and • acute-care Contractor. Population Exclusions This measure did not include members enrolled in KidsCare, the Arizona Long Term Care system (ALTCS), or the fee-for-service program (i.e., Indian Health Services and Emergency Services Program). In addition, this measure excluded any members who also were Medicare recipients. Members who had a hysterectomy with no residual cervix during the measurement period also were excluded. Data Sources Recipient enrollment data were used to identify members who met the denominator criteria. • Encounter data were used to identify the number of members who received a Pap test. • 41 Data Collection The Information Services Division (ISD) of AHCCCS extracted administrative data from the Prepaid Medical Management Information System (PMMIS). No outside data were collected. Data Validation Data validation was performed to ensure that all data received from the Information Services Division (ISD) were from the appropriate service records and met this measure’s service selection criteria, and that all recipients selected met the proper enrollment criteria. The Data Analysis and Research Unit (DA&R) in the Division of Health Care Management (DHCM) developed a Quality Control (QC) process based on the measure methodology. DA&R verified that the members selected met the sample frame criteria. The QC report provided by ISD was used to complete data validation. Denominator The number members who met the sample frame criteria for enrollment Numerator The number of members in the sample frame who met the criteria for service selection Comparative Analysis • The total for all Contractors was compared to results for the previous measurement period. • The average results for Maricopa, Pima and the combined rural counties were compared to each other and to results for the previous measurement period. • Individual Contractor rates were compared to their rates for the previous year. • Individual Contractor rates were compared to the AHCCCS Minimum Performance Standard and AHCCCS goal. • If available, the total rate for all Contractors was compared to the national average for this measure as reported by the National Committee for Quality Assurance (NCQA). Deviations from HEDIS This measure differs from HEDIS 2002 in the following areas: • The HEDIS measure uses the age range 21 through 69 years. The AHCCCS measure used the age range 16 through 64 years. • The AHCCCS measure used additional HCPCS codes P3000, P3001 and Q0091, and revenue code 311. • The AHCCCS measure used additional CPT codes 88143, 88144, 88145, 88147, 88148, 88153, 88154, 88164, 88165, 88166, and 88167. • The HEDIS measure gives Contractors the option of using cervical cancer screening exclusionary codes for those women identified as having had a hysterectomy with no residual cervix at any time. The AHCCCS measure only included the exclusionary codes if they occurred during the measurement period. 42 Recipient Subsystem Requirements • Only female members were selected. • Members selected must have been 16 through 64 years old as of September 30 of the measurement period. • Members selected must have been continuously enrolled during the measurement period and as of September 30 of the measurement period. • Members selected must have been enrolled with one acute-care Contractor for the entire measurement year. • Prior Period Coverage (PPC) was not considered as part of continuous enrollment and was treated as a break in acute enrollment. • A member with one single enrollment gap, not exceeding 31 days, was considered to have continuous enrollment and was included in the sample frame. • A change of county service area while enrolled with the same acute-care Contractor without any gap of enrollment was not considered a break in enrollment. • For those members who stayed with the same acute-care Contractor but moved to a different county during the measurement period, the member was assigned to the last county of residence. • The member’s enrollment-begin date was the beginning date of the measurement period. The enrollment-end date was the ending date of the measurement period. If the allowable gap appeared at the beginning of the measurement period, then the member’s enrollment begindate was the first enrollment date after the gap. • Because only acute-care Contractors were evaluated, any enrollment that changed from an acute- care Contractor to a Contractor for the Arizona Long Term Care System (ALTCS) and back to an acute-care Contractor within 31 days was treated as a break in acute enrollment instead of enrollment with more than one Contractor during the measurement period. • Members enrolled with the following Contractors were not selected: 000850 - State Emergency Services 000950 - Federal Emergency Services 000960 - Family Planning Services 003335 - Permanent Fee-For-Service 008690 - Temporary Fee-For-Service 010174 - Maricopa LTC, Residual 010182 - Pima LTC, Residual 999998 - Indian Health Services 888886 - Fee-For-Service LTC, residual 079873 - DHS 110007 - DES/DDD 550005 - DES/VD • • Members with Medicare Part A and/or Part B during the measurement period were excluded. Members with rate codes 45XX and 46XX were excluded. Note: A data file containing the information for each member was created and used to identify the services received. Encounter Subsystem Requirements Utilizing data from Recipient Subsystem: • All encounters selected (Form 1500 and UB 82/92) for the selected members were based on the service selection criteria listed below. • Encounters were included if the begin-date of service fell within the measurement period. 43 • • • • Encounters from the Arizona Department of Health Services/Children’s Rehabilitative Services (CRS) and ADHS/Behavioral Health Services (BHS) were excluded. Children receiving services through CRS or BHS who also were enrolled with another Contractor were included in the other Contractor’s data. All services for the member were reported under the member’s last county of residence in the measurement period. The selected encounters were sorted by member primary ID. All members from the denominator who did not meet the selection criteria and who had encounters matching the service exclusionary criteria listed below were excluded from the numerator. Service Selection Criteria CPT-4 codes (UB82/92 or HCFA 1500) 88141 Cytopathology, cervical or vaginal, requiring interpretation by physician 88142 Cytopathology, cervical or vaginal, collected in preservative fluid, manual screening 88143 Cytopathology, cervical or vaginal, collected in preservative fluid, manual screening and rescreening 88144 Cytopathology, cervical or vaginal, collected in preservative fluid, manual screening and computer-assisted rescreening 88145 Cytopathology, cervical or vaginal, collected in preservative fluid, manual screening and computer-assisted rescreening using cell selection 88147 Cytopathology smears, cervical or vaginal; screening by automated system under physician supervision 88148 Cytopathology smears, cervical or vaginal; screening by automated system under physician supervision, with manual rescreening 88150 Cytopathology, slides, cervical or vaginal, manual screening 88151 Cytopathology, slides, cervical or vaginal 88152 Cytopathology, slides, cervical or vaginal, manual screening and computerassisted rescreening 88153 Cytopathology, slides, cervical or vaginal, manual screening and rescreening 88154 Cytopathology, slides, cervical or vaginal, manual screening and computer-assisted rescreening using cell selection 88155 Cytopathology, slides, cervical or vaginal, definitive hormonal evaluation 88156 Cytopathology, slides, cervical or vaginal 88157 Cytopathology, slides, cervical or vaginal 88158 Cytopathology, slides, cervical or vaginal, with manual screening 88164 Cytopathology, slides, cervical or vaginal (the Bethesda System), manual screening 88165 Cytopathology, slides, cervical or vaginal (the Bethesda System), manual screening and rescreening 88166 Cytopathology, slides, cervical or vaginal (the Bethesda System), manual screening and computer-assisted rescreening 44 88167 Cytopathology, slides, cervical or vaginal (the Bethesda System), manual screening and computer-assisted rescreening using cell selection OR HCPCS Codes (UB82/92 or HCFA 1500): P3000 Screening Papanicolaou smear, cervical or vaginal P3001 Screening Papanicolaou smear, cervical or vaginal Q0091 Screening Papanicolaou smear; obtaining, preparing and conveyance G0141 Screening cytopathology smears, cervical or vaginal, performed by automated system, manual rescreening G0143 Screening cytopathology smears, cervical or vaginal (any reporting system), collected in preservative fluid, manual screening and rescreening G0144 Screening cytopathology smears, cervical or vaginal (any reporting system), collected in preservative fluid, manual screening and computer-assisted rescreening G0145 Screening cytopathology smears, cervical or vaginal (any reporting system), collected in preservative fluid, manual screening and computer-assisted rescreening using cell selection G0147 Screening cytopathology smears, cervical or vaginal, performed by automated system under physician supervision G0148 Screening cytopathology smears, cervical or vaginal, performed by automated system under physician supervision, manual rescreening OR ICD-9 Procedure Code (UB 82/92): 91.46 Cell block and Papanicolaou smear OR ICD-9 Diagnostic Code (UB 82/92 or HCFA 1500): V76.2 Screening for malignant neoplasms of cervix NOT in conjunction with HCPCS codes: AXXXX Medical and surgical supplies DXXXX Dental procedures G0001 to G0132 Procedures and professional services AND NOT in conjunction with CPT-4 codes: 80029 to 88140 Laboratory and pathology (not cytopathology, cervical or vaginal) 88230 to 89399 Laboratory and pathology (not cytopathology, cervical or vaginal) OR 45 Revenue Codes (UB82/92): 923 Cervical cancer screening OR Revenue Codes (UB82/92): 300 Laboratory 310 Pathology Lab 311 Pathology /cytology In conjunction with ICD-9 Diagnosis codes: 180.X Malignant neoplasm of cervix 233.1 Carcinoma in situ of cervix 236.0 Neoplasm of uncertain behavior, uterus 622.X Non-inflammatory disorders of cervix 795.0 Nonspecific abnormal Papanicolaou smear of cervix 795.1 Nonspecific abnormal Papanicolaou smear of other site Service Exclusionary Criteria ICD-9 Procedure Codes (UB 82/92): 68.4 Total abdominal hysterectomy 68.5 Vaginal hysterectomy 68.6 Radical abdominal hysterectomy 68.7 Radical vaginal hysterectomy 68.8 Pelvic evisceration OR CPT-4 Procedure Codes (HCFA 1500 or UB 82/92) 56308 Laparoscopy, surgical, with vaginal hysterectomy 58150 Total abdominal hysterectomy (corpus and cervix) 58152 Total abdominal hysterectomy (corpus and cervix), with colpo-urethrocystopexy 58200 Total abdominal hysterectomy, including partial vaginectomy 58210 Radical abdominal hysterectomy, with bilateral total pelvic lymphadenectomy 58240 Pelvic exenteration for gynecologic malignancy, with total abdominal hysterectomy or cervicectomy 58260 Vaginal hysterectomy 58262 Vaginal hysterectomy, with removal of tube(s) and/or ovary(ies) 58263 Vaginal hysterectomy, with removal of tube(s) and/or ovary(ies), with repair of enterocele 58267 Vaginal hysterectomy, with colpo-urethrocystopexy 58270 Vaginal hysterectomy, with repair of enterocele 58275 Vaginal hysterectomy, with total or partial colpectomy 46 58280 Vaginal hysterectomy, with total or partial colpectomy, with repair of enterocele 58285 Vaginal hysterectomy, radical 59135 Surgical treatment of interstitial, uterine pregnancy requiring total hysterectomy 47 V. TIMELINESS OF PRENATAL CARE Population Members were selected from the acute-care population only. Sample Frame AHCCCS used the Health Plan Employer Data and Information Set (HEDIS®), 2003 version, as a guide in developing the methodology for this measure. Enrollment criteria Members who: • had a live birth during the measurement period • were continuously enrolled with the same acute-care Contractor for 43 days or more prior to delivery For this measure, Prior Period Coverage (PPC) was excluded when determining the start of enrollment or was considered a break in enrollment. Service selection criteria Members who: • met the enrollment criteria and • had a prenatal care visit in the first trimester (176 to 280 days prior to delivery) if enrolled 280 or more days prior to enrollment. • had a prenatal care visit in the first trimester if continuously enrolled 176 or more days but less than 280 prior to enrollment. • did not have a prenatal care visit during the first trimester but, had a prenatal care visit within 42 days of being enrolled in a health plan and were continuously enrolled for 43 or more prior to delivery. Sample Selection All members who met the sample frame criteria were included in this measure. Population Stratification The sample frame was stratified by: • Maricopa, Pima and the combined rural counties, and • acute-care Contractor. Population Exclusions This measure did not include: • Members who were enrolled in the Arizona Long Term Care System (ALTCS), the Department of Economic Security (DES) Division of Developmental Disabilities (DDD), Indian Health Services (IHS), Emergency Services Program (ESP) and Fee For Service (FFS) program. Any members who also were Medicare recipients were excluded. • Women who had live births but were not continuously enrolled for at least 43 days prior to delivery. 48 • • Women whose pregnancies did not result in a live birth (i.e., miscarriage or stillbirth) were excluded. Women whose single pregnancy resulted in multiple live births wree counted only once for this measure. Women who had two separate deliveries (different dates of service) within the measurement period were counted twice. Data Sources • Recipient data were used to identify members who meet the enrollment selection criteria. • Encounter data were used to identify enrolled women who had live births during the measurement period and dates of prenatal visits. Data Collection The Information Service Division (ISD) of AHCCCS collected administrative data from the Prepaid Medical Management Information System (PMMIS). No outside data were collected. Data Validation Data Validation was performed to ensure that all data received from the Information Services Division (ISD) were from the appropriate service records and met this measure’s service selection criteria, and that all recipients selected met the proper enrollment criteria. The Data Analysis and Research Unit (DAR) in the Division of Health Care Management (DHCM) has developed a Quality Control (QC) process based on the measure methodology. DAR verified that members selected met the sample frame criteria. A QC report provided by ISD was used to complete data validation. Denominator The number of members who met the sample frame criteria for enrollment Numerator The number of members who met the sample frame criteria for service selection Comparative Analysis • The total for all Contractors was compared to results for the previous measurement period. • Results for Maricopa, Pima and the combined rural counties were compared to each other and to results for the previous measurement period. • Individual Contractor rates were compared to their rates for the previous year. • Individual Contractor rates were compared to the AHCCCS Minimum Performance Standard and Goal. • If available, the total rate for all Contractors was compared to the national average for this measure as reported by the National Committee for Quality Assurance (NCQA). 49 Deviations from HEDIS This measure differed from HEDIS 2003 in the following area: • AHCCCS does not measure the number or percentage of women who had a postpartum visit, as HEDIS does. Because postpartum visits are not measured, AHCCCS requires only a minimum of 43 days of continuous enrollment prior to delivery. The HEDIS measure requires that women included in the denominator be enrolled continuously from 43 days prior to delivery to 56 days after delivery. Recipient Subsystem Requirements • Only female members were selected. • Members must have been continuously enrolled for more than 43 days prior to the delivery date. • Member must have been enrolled with one acute capitated Contractor for the entire enrollment period through the delivery date. • Members must have delivered during the measurement period. • The PPC period was considered a break in determining start of enrollment. • A member with one single enrollment gap, not exceeding 31 days, was considered to have continuous enrollment. • A change of county-service-area with the same Contractor without any gap of enrollment is not considered a break in enrollment. • For those members who stayed with the same Contractor but moved to a different county during the measurement period, the member was assigned to the last county of residence. • The enrollment begin-date for the member was the first date of enrollment prior to the start of the prenatal period (280 days prior to delivery), and the enrollment end-date was the delivery date. • Any member enrolled with the following acute-care Contractors was included: 010083 Maricopa Health Plan 010124 Pima Health System 010158 Arizona Physicians IPA 010166 DES CMDP 010306 Mercy Care Plan 010299 Phoenix Health Plan 010497 Health Choice Arizona 010314 University Health Plan 010545 Community Connection • Any member with Medicare Part A and/or Part B during the measurement period is to be excluded. Note: A data file containing the information for each member was created and used to identify the services received. Encounter Subsystem Requirements Utilizing data from Recipient Subsystem: • All encounters (Form 1500 and UB 82/92) were selected for members in the denominator based on the service selection criteria listed below. 50 • • Encounters from the Arizona Department of Health Services/Children’s Rehabilitative Services (CRS) and ADHS/Behavioral Health Services (BHS) were excluded. Children receiving services through CRS or BHS who also were enrolled with another Contractor were included in the other Contractor’s data.The selected encounters are sorted by member primary ID. All services for the member were reported under the member’s last county of residence in the measurement period. Identifying live births The following codes were used to identify deliveries and verify live births: ICD-9 Codes: 74.0-74.2*, 74.4*, 74.99*, 640.x1, 641.x1, 642.x2, 643.x1, 644.21, 645.11, 645.21, 646.x1, 646.12, 646.22, 646.42, 646.52, 646.62, 646.82, 647.x1, 647.x2, 648.x1, 648.x2, 651.x1, 652.x1, 653.x1, 654.x1, 654.02, 654.12, 654.32, 654.42, 654.52, 654.62, 654.72, 654.82, 654.92, 655.x1, 656.01, 656.11, 656.21, 656.31, 656.51, 656.61, 656.71, 656.81, 656.91, 657.01, 658.x1, 659.x1, 660.x1, 661.x1, 662.x1, 663.x1, 664.x1, 665.01, 665.11, 665.22, 665.31, 665.41, 665.51, 665.61, 665.71, 665.72, 665.81, 665.82, 665.91, 665.92, 666.x2, 667.x2, 668.x1, 668.x2, 669.01, 669.02, 669.11, 669.12, 669.21, 669.22, 669.32, 669.41, 669.42, 669.51, 669.61, 669.71, 669.81, 669.82, 669.91, 669.92, 670.02, 671.01, 671.02, 671.11, 671.12, 671.21, 671.22, 671.31, 671.42, 671.51, 671.52, 671.81, 671.82, 671.91, 671.92, 672.02, 673.x1, 673.x2, 674.01, 674.x2, 675.x1, 675.x2, 676.x1, 676.x2 CPT codes: 59400, 59409, 59410, 59510, 59514, 59515, 59610, 59612, 59614, 59618, 59620 and 59622. Codes used to identify deliveries not resulting in a live birth: 656.4**, v27.1**, v27.4**, v27.7** Service Selection Criteria to Identify Prenatal Visits Decision Rule 1: Prenatal care visit to an OB practitioner, midwife or family practitioner with documentation of when prenatal care was initiated Service provider HCFA1500 AND 59400 Routine obstetric care including antepartum Provider –type: 09 – Certified Nurse-midwife care and postpartum care 05 – Clinic 59510 Routine obstetric care including antepartum care, cesarean delivery and postpartum care 59610 Routine obstetric care including antepartum care, Or vaginal delivery and postpartum care, after previous cesarean delivery Provider type 08 (Physician) w/ 59618 Routine obstetric care including antepartum care, following specialty cesarean delivery and postpartum care following attempted 089 – OB/GYN vaginal delivery after previous cesarean delivery 091 – OB 59425 Antepartum care only; 4-6 visits 092 – Maternal & Fetal Medicine 59426 Antepartum care only; 7 or more visits 095– Women’s HC OB/GYN NP 51 Decision Rule 2: Any visit to an OB practitioner or midwife Service provider HCFA1500/UB 92 AND Provider type: Administrative Codes: 09 – Certified Nurse-midwife 99201 – 99205 New Patient 05 – Clinic 99211 – 99215 Established Patient or Revenue code 514 OR Provider type 08 (Physician) with the following specialty: 089 – OB/GYN 091 – OB 092 – Maternal & Fetal Medicine 095 – Women’s HC OB/GYN NP WITH EITHER One of the following laboratory or radiology services: CPT Codes – Procedure based: 76805 Echography, pregnant uterus complete 76810 Echography, pregnant uterus complete, first trimester 76815 Echography, pregnant uterus limited 76816 Echography, pregnant uterus follow-up or repeat 76818 Fetal Biophysical profile with non-stress test 80055 Obstetric panel 80090 TORCH antibody panel 86762 Antibody; rubella with 86900 Blood typing; ABO or 86901 Blood typing; Rh (D) OR One of the following ICD-9 diagnosis codes: 640.0X – 648.9X, 651.0X – 659.9X, where fifth digit is 3 V22.X Normal pregnancy V23.X Supervision of high-risk pregnancy V28.X Antenatal screening 52 Decision Rule 3: Any visit to family practitioner or other primary care practitioner HCFA1500/UB 92 Provider type: AND Administrative Codes: 08 – Physician 99201 – 99205 New Patient 05 – Clinic 99211 – 99215 Established Patient or Revenue code 514 WITH BOTH One of the following laboratory or radiology services: CPT Codes – Procedure based: 76805 Echography, pregnant uterus complete 76810 Echography, pregnant uterus complete, first trimester 76815 Echography, pregnant uterus limited 76816 Echography, pregnant uterus follow-up or repeat 76818 Fetal Biophysical profile with non-stress test 80055 Obstetric panel 80090 TORCH antibody panel 86762 Antibody; rubella with 86900 Blood typing; ABO or 86901 Blood typing; Rh (D) AND One of the following ICD-9 diagnosis codes: 640.0X – 648.9X, 651.0X – 659.9X, where fifth digit is 3 V22.X Normal pregnancy V23.X Supervision of high-risk pregnancy V28.X Antenatal screening 53 Decision Rule 4: Any visit to an OB/GYN, family practitioner or other primary care practitioner with either an ultrasound or principal diagnosis of pregnancy Service provider HCFA1500/UB 92 AND 59400 Routine obstetric care including antepartum care Provider type: 09 – Certified Nurse-midwife and postpartum care 05 – Clinic 59510 Routine obstetric care including antepartum care, cesarean delivery and postpartum care 59610 Routine obstetric care including antepartum care, OR vaginal delivery and postpartum care, after previous cesarean delivery Provider type 08 (Physician) 59618 Routine obstetric care including antepartum care, with the following specialty: cesarean delivery and postpartum care following attempted 089 – OB/GYN vaginal delivery after previous cesarean delivery 091 – OB 59425 Antepartum care only; 4-6 visits 092 – Maternal & Fetal 59426 Antepartum care only; 7 or more visits Medicine or 095 – Women’s Revenue code 514 HC OB/GYN NP WITH EITHER One of the following laboratory or radiology services: CPT Codes – Procedure based: 76805 Echography, pregnant uterus complete 76810 Echography, pregnant uterus complete, first trimester 76815 Echography, pregnant uterus limited 76816 Echography, pregnant uterus follow-up or repeat 76818 Fetal Biophysical profile with non-stress test OR One of the following ICD-9 diagnosis codes: 640.0X – 648.9X, 651.0X – 659.9X, where fifth digit is 3 V22.X Normal pregnancy V23.X Supervision of high-risk pregnancy V28.X Antenatal screening 54