ARIZONA HEALTH CARE COST CONTAINMENT SYSTEM PERINATAL INDICATORS RESULTS AND ANALYSIS Reporting Period: October 1, 2000, through September 30, 2001 Produced By: The Office of Medical Management Debra M. Brown, M.D., Assistant Medical Director for Quality Phone: (602) 417-4410 EXECUTIVE SUMMARY This report analyzes Contractor Performance Indicators in three perinatal areas: · Low Birth Weight Deliveries · Prenatal Care in the First Trimester · Initiation of Prenatal Care The results of this analysis should be viewed as indicators of access to services, rather than absolute rates for how well AHCCCS and/or its Contractors provide care. Many factors affect whether AHCCCS members use services. By analyzing trends over time, Contractors can identify areas for improvement and implement interventions. AHCCCS used the Health Plan Employer Data and Information Set (HEDIS®), 2002 version, developed by the National Committee for Quality Assurance (NCQA), as a guide in developing the methodology for these indicators. Except for the low-birth-weight indicator, results are based on a selected group of members, who were continuously enrolled for a specific amount of time. This continuous-enrollment criteria reflects the fact that AHCCCS Contractors must have adequate time to contact and educate members, and to facilitate the provision of prenatal care services. Thus, results do not reflect the use of prenatal care services by all AHCCCS members or birth weights of all newborns covered by the program. This report includes results for the measurement period from October 1, 2000, through September 30, 2001. Results of the indicators are reported in aggregate by urban (Maricopa and Pima counties) and rural areas, and by individual Contractors that provide services to Medicaid recipients. Under their contracts with AHCCCS, Contractors are required to improve their rates for Performance Indicators and achieve specific goals for each indicator. AHCCCS will provide individual results to Contractors and require corrective action plans as necessary, based on the findings in this report. Contractors that fail to show improvement may be subject to sanctions. AHCCCS will continue to provide technical assistance, such as identifying new interventions or improvements to existing efforts, to help Contractors better their performance. During the current measurement period, AHCCCS achieved its best overall rates in two of three indicators. Results for the current period include the following: Low Birth Weight Deliveries - This indicator measured the percentage of infants who: ▪ were born to mothers enrolled with an AHCCCS acute-care Contractor at the time of delivery ▪ who subsequently became enrolled in the same health plan as their mothers, and ▪ whose birth weight was less than 2,500 grams. This indicator did not have a continuous enrollment requirement. Findings · The AHCCCS statewide average for the low-birth-weight (LBW) indicator in the current period was 7.91 percent, a relative decrease (improvement) of 3.7 percent over the rate of 8.22 percent in the previous period. The decrease is not statistically significant. i · The lowest (best) rate for this indicator was in the 13 rural counties of Arizona, at 7.75 percent, compared with 7.42 percent in the previous year. The increase in the rate for rural counties is not statistically significant. The rate for Maricopa County was 7.90 percent, compared with a previous rate of 8.21 percent. The change in Maricopa County's total rate is not statistically significant. The rate for Pima County improved to 8.24 percent in the current period, from the previous rate of 9.47 percent. This change is statistically significant. · Among 10 acute-care Contractors, rates ranged from 5.83 percent to 9.93 percent. Seven of 10 Contractors met or did better than the AHCCCS minimum performance standard of 8.0 percent for this indicator. · While the decrease in the rate for the current measurement period is not statistically significant, it represents an important point in the long-term trend for this indicator. The AHCCCS overall average of low-birth-weight deliveries, as measured by this indicator, reached its lowest point in the current measurement period, and is a substantial improvement over the highest rate of 9.18 percent in the period from October 1, 1995, to September 30, 1996. Prenatal Care in the First Trimester - This indicator measures the percentage of pregnant women who: ▪ were continuously enrolled with an AHCCCS acute-care Contractor for 40 weeks (280 days) or more prior to delivery, and ▪ had a prenatal care visit during their first trimester (176 to 280 days prior to delivery). Findings · The AHCCCS overall average was 54.3 percent, compared with 55.2 percent in the previous year, or a relative decrease of 1.6 percent. The decrease is not statistically significant. · The highest rate for this indicator was in the 13 rural counties of Arizona, at 57.0 percent, compared with 51.5 percent in the previous year. This increase is statistically significant. The rate for Maricopa County was 53.0 percent, compared with the previous rate of 55.8 percent. The decrease in Maricopa County's rate is not statistically significant. The rate for Pima County was 54.0 percent in the current period, compared with the previous rate of 58.7 percent. This decrease also is not statistically significant. · Rates for 10 acute-care Contractors ranged from 41.0 percent to 59.5 percent during the measurement period. Two Contractors met the AHCCCS minimum performance standard for this indicator. · Data limitations, which may have resulted in underreporting of rates for this indicator, are discussed in the full report. Initiation of Prenatal Care - This indicator measures the percentage of pregnant women who: ▪ were enrolled with an AHCCCS acute-care Contractor fewer than 40 weeks but more than six weeks prior to delivery, and ▪ received their first prenatal care visit within six weeks of enrollment. ii Findings · The AHCCCS overall average for this indicator was 53.4 percent in the current measurement period, a 7.3-percent relative improvement from the previous rate of 49.8 percent. The increase is statistically significant. · The highest total rate by area was in the rural counties, at 57.3 percent, compared with 49.3 percent in the previous period, reflecting a 16.4 percent relative improvement. This increase is statistically significant The total rate for Maricopa County was 53.4 percent, compared with 50.3 percent in the previous period, for a relative increase of 6.2 percent. The increase in Maricopa County's rate is statistically significant. The total rate for Pima County was 46.9 percent, compared with 48.9 percent in the previous period, or a relative decline of 4.2 percent. The decrease in Pima County's rate is not statistically significant. · Rates for 10 acute-care Contractors ranged from 20.7 percent to 66.9 percent during the measurement period. The AHCCCS minimum performance standard for prenatal care does not apply to this indicator. · Data limitations, which may have resulted in underreporting of rates for this indicator, are discussed in the full report. · The overall percentage of women who initiated prenatal care within six weeks of enrollment in the current measurement period represents the highest rate achieved by AHCCCS. The overall AHCCCS rate for this indicator has increased from its lowest point of 41.9 percent in the period from October 1, 1996, to September 30, 1997, to the current rate. Early initiation of prenatal care allows physicians to identify and address medical or other problems – such as pregnancy-related diabetes, inadequate maternal weight gain, cigarette smoking and substance abuse – and minimize their effects on both mother and baby. Data indicate that women who receive early and adequate prenatal care are less likely to have lowbirth-weight babies and their infants are less likely to die in the first year of life. Numerous financial, cultural, and system barriers to initiating prenatal care have been identified. To counteract these barriers, AHCCCS Contractors should continue to emphasize the importance of early prenatal care to members, and vigorously promote services such as transportation, smoking cessation and nutritional support. They should continue to assess whether transportation and clinical service hours are adequate to meet the needs of members. In addition, Contractors should consider whether their outreach materials and activities adequately and clearly address barriers to early prenatal care. It should be noted that, based on three years of HEDIS® benchmark data, health plans nationwide show weak performance in two areas: maternity services and adolescent care. According to the American Public Human Services Association (APHSA), which studied health plan results, the gap between commercial and Medicaid plans in the maternity care indicators is more than 20 percentage points. The APHSA says that closing this gap will require partnerships between health plans and local or state public health agencies, as well as continuing efforts from primary care providers. iii The AHCCCS rate for prenatal care in the first trimester is slightly below the most recent nationwide Medicaid average for that indicator. The Medicaid average for prenatal care in the first trimester in calendar year 1999 was 59.2 percent, according to the APHSA benchmarking project. There is no national or regional Medicaid data available for comparison with the AHCCCS rates for low-birth-weight deliveries and initiation of prenatal care. AHCCCS will continue to pursue strategies with its Contractors to improve results for these indicators. AHCCCS will work with Contractors whose rates showed a significant decrease in any indicator to try to determine the reasons for the decline and to assist them in improving their results. Contractors that do not meet AHCCCS performance standards and fail to show continued progress toward AHCCCS goals may be required to submit corrective action plans and may face sanctions if their performance does not improve. iv Figure 1 Arizona Health Care Cost Containment System LOW-BIRTH-WEIGHT DELIVERIES - OVERALL TREND AND BY WEIGHT RANGE For the Measurement Periods from October 1, 1995, to September 30, 2001 10 % 9 .18 % 8 .11% 8 .3 7 % 8 .0 8 % 7 .9 5 % 8 .2 2 % 7 .9 1% Percent of Newborns with Low Birth Weight 8% 6.82% 7.09% 6.81% 7.06% 6.80% 6% 4% 2% 1.0 7 % 1.2 3 % 1.2 6 % 1.2 8 % 1.14 % 1.16 % 1.12 % CY 97/98 CY 98/99 CY 99/00 CY 00/01 0% CY 94/95 CY 95/96 CY 96/97 T o t a l LB W ( <2 ,5 0 0 g ) LB W ( 1,5 0 0 - 2 ,4 9 9 g ) VLB W ( 4 4 0 - 1,4 9 9 g ) Note: Data for LBW from 1,500 to 2,499 grams for CY 94/95 and CY 95/96 was not available. Figure 2 ARIZONA Health Care Cost Containment System PRENATAL CARE IN THE FIRST TRIMESTER - OVERALL TREND For the Measurement Periods from October 1, 1996, to September 30, 2001 in the First Trimester Percent of Women with a Prenatal Visit 70% 60% 5 6 .3 % 5 5 .2 % CY 98/99 CY 99/00 5 2 .7 % 5 4 .3 % 50% 4 0 .5 % 40% 30% 20% 10 % CY 96/97 CY 97/98 CY 00/01 Figure 3 Arizona Health Care Cost Containment system INITIATION OF PRENATAL CARE - OVERALL TREND For the Reporting Periods from October 1, 1996, to September 30, 2001 within Six Weeks of Enrollment Percent of Members with a Prenatal Visit 70% 60% 5 1.1% 50% 4 9 .8 % 5 3 .4 % 4 7 .7 % 4 1.9 % 40% 30% 20% 10 % CY 96/97 CY 97/98 CY 98/99 CY 99/00 CY 00/01