CYE 2003 Performance Improvement Project: Children’s Oral Health Visits First Remeasurement of Performance Prepared by the Division of Health Care Management August 2005 Anthony D. Rodgers Director, AHCCCS For questions or comments about this report, contact: Rochelle Tigner Quality Improvement Manager, Clinical Quality Management Division of Health Care Management, AHCCCS (602) 417-4683 rochelle.tigner@azahcccs.gov CYE 2003 Performance Improvement Project (PIP): Children’s Oral Health (Dental Visits) First Remeasurement of Performance Remeasurement Period: October 1, 2003, through September 30, 2004 I. INTRODUCTION Background Tooth decay is a common chronic disease among children, causing pain, infection and tooth loss if left untreated.1,2 Early tooth loss can result in failure to thrive and impaired speech development. Poor oral health has been related to decreased school performance because children experiencing pain from dental disease miss school or are unable to concentrate.3 According to the National Health and Nutrition Examination Survey (NHANES), approximately 28 percent of U.S. children ages 2 through 5 and 49 percent of youngsters 6 through 11 had dental caries (tooth decay) in primary teeth in the period from 1999 through 2002. The overall rate of caries in the two age groups combined was 41 percent, with tooth decay going untreated in approximately 21 percent of these children.2 According to the Arizona Office of Oral Health, the percent of all Arizona children who have some tooth decay increases from about 5 percent at 2 years of age to 60 percent by age 8.4 A number of studies point to disproportionately low use of dental services among some racial or ethnic groups and low-income people, as well as high rates of dental disease relative to the rest of the population. 1,4-10 Increased access to oral health services, such as the application of topical fluorides and dental sealants, as well as patient/caregiver education, are key to reducing the rate of tooth decay and other oral diseases among children.1,5 AHCCCS and Healthy People Goals AHCCCS has established long-range goals, or benchmarks, for Contractors to achieve in ensuring annual dental visits among children and adolescents, based on an objective set by the U.S. Department of Health and Human Services (DHHS) in Healthy People 2010. The Healthy People objective is to increase the proportion of low-income children and adolescents who receive preventive dental services each year to 57 percent. Likewise, AHCCCS has established a benchmark of 57 percent for annual dental visits by members from 3 through 20 years of age. This benchmark applies to acute-care Contractors and the Department of Economic Security’s two programs that serve AHCCCS-eligible children, the Comprehensive Medical and Dental Program (CMDP) and the Division of Developmental Disabilities (DDD). 1 Purpose The purpose of the Children’s Oral Health Performance Improvement Project (PIP) is to increase the rate of annual dental visits among AHCCCS members 3 through 20 years old, in order to make more progress toward AHCCCS and Healthy People 2010 goals. This project specifically focuses on children who are 3 through 8 years old, as this appears to be a critical time in a child’s life to ensure that he or she receives regular dental care. Contractors participating in this PIP include acute-care health plans, CMDP, DDD and health plans that serve elderly and physically disabled members through the Arizona Long Term Care System (ALTCS). Methodology Using methodology developed by the National Committee for Quality Assurance (NCQA) for the Health Plan Employer Data and Information Set (HEDIS), AHCCCS measured annual dental visits among members ages 3 through 8 who were continuously enrolled during the measurement period with an acute-care Contractor, CMDP, or DDD under Medicaid or KidsCare (the state Children’s Health Insurance Program or SCHIP). Because of the relatively small number of physically disabled children covered under ALTCS, all members 3 through 20 years who were continuously enrolled with these Contractors were included in the measurement. Data for the project were collected from AHCCCS administrative data (i.e., records of claims paid by Contractors, known as encounters). The remeasurement period was the contract year from October 1, 2003, through September 30, 2004. The complete methodology and technical specifications for this project may be found at http://www.azahcccs.gov/Studies. II. RESULTS AND ANALYSIS Medicaid and KidsCare Members A total of 90,491 members ages 3 through 8 years old who were enrolled in AHCCCS under Medicaid or KidsCare were selected for the PIP remeasurement (Table 1). Overall, 52,254 (57.7 percent) of those members had at least one dental visit during the remeasurement period, for a relative increase of 10.5 percent over the baseline measurement. The improvement is significant (p<.001). All Contractors except one, Maricopa Health Plan, showed statistically significant increases from the baseline measurement and/or exceeded the Healthy People 2010 Goal of 57 percent (Tables 1, 3 and 5, Figure 1). Maricopa Health Plan’s rate likely was affected by its delays and omissions in submitting encounters to AHCCCS during the remeasurement period. By area, the greatest increase in the rate of dental visits for both Medicaid and KidsCare members occurred in Pima County (Tables 2 and 4). Overall, the rate of dental visits among members enrolled under KidsCare was significantly higher than for members enrolled under Medicaid. This also was true in each of the three geographic areas analyzed: Maricopa County, Pima County, and the Rural counties (p<.001). 2 Developmentally Disabled (DD) Members A total of 3,511 members ages 3 through 8 years old who were enrolled with DDD were selected for the PIP remeasurement (Table 6). Overall, 1,326 (37.8 percent) of those members had at least one dental visit during the remeasurement period, for a relative increase of 22 percent over the baseline measurement. The improvement is significant (p<.001). DDD also showed significant improvements in its rates among children in Maricopa County and the combined rural counties (p<.001). Approximately two-thirds of members enrolled in DDD have other medical coverage, primarily private insurance. In many cases, routine services such as dental care are paid for by other insurance. Thus, the rate of dental visits among these children probably is higher than the rate reported here because these encounters are not reported to AHCCCS. ALTCS Physically Disabled Members Of the 104 physically disabled members selected for the remeasurement, 28 (26.9 percent) had at least one dental visit (Table 7). Overall, there was no significant change from the previous measurement (p<.696). Data for physically disabled members was not analyzed by individual Contractor because most ALTCS health plans did not have enough members who met the criteria for inclusion in the remeasurement to make statistical comparisons. The lower rates of visits among both developmentally disabled and physically disabled children probably reflects the challenges and barriers to dental care faced by these members. Some patients with special health care needs have difficulty cooperating with dental professionals while receiving care, and must have their care done under sedation. For some special needs children, oral diseases may intensify behavior problems.11 Access to oral health care may be further complicated by limited numbers of dentists with expertise in treating children with disabilities.12 In addition, an overall focus on treating disabled children’s complex medical needs may result in less emphasis on preventive services such as dental care. III. CONCLUSIONS Interventions to Improve Quality To assist Contractors in improving performance, the AHCCCS Clinical Quality Management Unit synthesized research and literature on oral health initiatives from a variety of sources. The Chronic Care Model, developed by Wagner, et al, of the MacColl Institute for Healthcare Innovation at Group Health Cooperative, was adapted for use in organizing various interventions for improving oral health. The model identifies essential elements of a health care system that encourage high-quality care, and are likely to result in healthier patients, more satisfied providers, and cost savings.12 By using this model, AHCCCS and its contracted health plans can identify gaps in quality-improvement strategies and ensure that each of these components is adequately addressed. AHCCCS provided baseline data from this study to all Contractors, who further analyzed their data and identified interventions to improve rates of annual dental visits. Contractors have utilized a variety of interventions to improve the use of dental services and oral health among children enrolled in their plans (Table 8). 3 Performance Improvement Contractors should strive to meet or exceed the Healthy People 2010 Goal of 57 percent for children’s annual dental visits. Under this PIP, a Contractor will have demonstrated improvement when: • it meets or exceeds the AHCCCS overall average for the baseline measurement if its baseline rate was below the average, and the increase is statistically significant, • it shows a statistically significant increase if its baseline rate was at or above the AHCCCS overall average for the baseline measurement, or • it achieves the Healthy People 2010 goal or is the highest performing (benchmark) plan in any remeasurement year, and maintains or improves its rate in successive measurements until the PIP is completed. AHCCCS continues to work with contracted Health Plans to sustain improvements in children’s access to dental services. A second remeasurement, based on the contract year ending September 30, 2005, will be conducted in mid-2006. IV. REFERENCES 1 U.S. Department of Health and Human Services. Oral health in America: A report of the surgeon general. Rockville, MD: Department of Health and Human Services, National Institute of Dental and Craniofacial Research. September 2000. 2 Beltran-Aguilar E, Barker L, Canto M, et al. Surveillance for dental caries, dental sealants, tooth retention, edentulism, and enamel fluorosis – United States, 1988-1994 and 1999-2002. Centers for Disease Control and Prevention. MMWR Surveillance Summaries. Vol 54/SS-3. August 26, 2005. 3 U.S. Department of Health and Human Services. Oral health and learning: When children’s oral health suffers, so does their ability to learn. Arlington VA. National Center for Education in Maternal and Child Health. 2001. 4 Arizona Department of Health Services. Arizona oral health update. Phoenix, AZ: Office of Oral Health. May 2000. 5 U.S. Department of Health and Human Services. Oral health 2000: facts and figures. Rockville, MD: DHHS, Office of the Surgeon General. May 2000. 6 U. S. Department of Health and Human Services. Healthy People 2010: Objectives for improving health, Vol. II. DHHS, Office of Public Health and Science. November 2000. Available at http://www.healthypeople.gov/document/tableofcontents.htm#Volume2. 7 U.S. General Accounting Office. Oral health: Factors contributing to low use of dental services by low-income populations. General Accounting Office, Report to Congressional Requesters. HEHS-00-149. September 2000. Available at http://www.gao.gov/new.items/he00149.pdf. 8 U.S. General Accounting Office. Medicaid: stronger efforts needed to ensure children’s access to health screening services. GAO, Report to Congressional Requesters. GAO-01-749. July 2001. Available at http://frwebgate.access.gpo.gov/cgibin/useftp.cgi?IPaddress=162.140.64.21&filename=d01749.pdf&directory=/ diskb/wais/data/gao 9 U.S. General Accounting Office. Oral health: Dental disease is a chronic problem among low income populations. GAO, Report to Congressional Requesters. HEHS-00-072, April 2000. Available at http://www.gao.gov/new.items/he00072.pdf 10 Mouradian WE, Wehr E, Crall JJ. Disparities in children’s oral health and access to dental care. JAMA. 2000. 284(20):2625-2631. 11 Minnesota Department of Human Services. Dental access for Minnesota health care program beneficiaries: Report to the 2001 Minnesota Legislature. January 2001. 12 Improving Chronic Illness Care website. Overview of the Chronic Care Model. Available at http://improvingchroniccare.org/change/model/components.html. 4 Table 1 Arizona Health Care Cost Containment System (AHCCCS) CYE 2003 PERFORMANCE IMPROVEMENT PROJECT (PIP): CHILDREN'S ANNUAL DENTAL VISITS Members Ages 3 through 8 Years Enrolled under Medicaid and KidsCare, by Contractor Remeasurement Period: October 1, 2003, to September 30, 2004 Number with Percent with Relative Percent Number of One or More One or More Change From Statistical Members Dental Visits Dental Visits Previous Period Significance 32,583 18,190 55.8% 11.6% p<.001 28,021 14,019 50.0% 1,075 656 61.0% -0.5% p=.887 722 443 61.4% 10,763 6,753 62.7% 23.9% p<.001 7,254 3,673 50.6% 5,544 2,335 42.1% -16.7% p<.001 5,048 2,553 50.6% 23,695 14,213 60.0% 9.5% p<.001 20,346 11,144 54.8% 12,846 7,764 60.4% 9.5% p<.001 8,972 4,951 55.2% 2,034 1,216 59.8% 13.9% p<.001 1,151 604 52.5% University Family Care 1,951 2,196 1,127 1,115 57.8% 50.8% 13.8% p<.001 TOTAL 90,491 52,254 57.7% 10.5% p<.001 73,710 38,502 52.2% Contractor AZ Physicians IPA DES/CMDP Health Choice AZ Maricopa Health Plan Mercy Care Phoenix Health Plan/CC Pima Health System Shaded rows are totals and percentages from the baseline measurement period, October 1, 2001, through September 30, 2002. Table 2 Arizona Health Care Cost Containment System (AHCCCS) CYE 2003 PERFORMANCE IMPROVEMENT PROJECT (PIP): CHILDREN'S ANNUAL DENTAL VISITS Members Ages 3 through 8 Years Enrolled under Medicaid, by County Remeasurement Period: October 1, 2003, to September 30, 2004 County Maricopa County Pima County Rural Counties TOTAL Number with Percent with Relative Percent Number of One or More One or More Change From Statistical Members Dental Visits Dental Visits Previous Period Significance 48,076 27,726 57.7% 7.6% p<.001 35,636 19,093 53.6% 13,243 7,685 58.0% 21.1% p<.001 12,098 5,799 47.9% 20,111 10,790 53.7% 8.8% p<.001 18,103 8,925 49.3% 81,430 46,201 56.7% 10.5% p<.001 65,837 33,817 51.4% Shaded rows are totals and percentages from the baseline measurement period, October 1, 2001, through September 30, 2002. Table 3 Arizona Health Care Cost Containment System (AHCCCS) CYE 2003 PERFORMANCE IMPROVEMENT PROJECT (PIP): CHILDREN'S ANNUAL DENTAL VISITS Members Ages 3 through 8 Years Enrolled under Medicaid, by Acute-care Contractor Remeasurement Period: October 1, 2003, to September 30, 2004 Number with Percent with Relative Percent Number of One or More One or More Change From Statistical Members Dental Visits Dental Visits Previous Period Significance 29,561 16,303 55.2% 11.3% p<.001 25,075 12,428 49.6% 1,075 656 61.0% -0.5% p=.887 722 443 61.4% 9,724 6,001 61.7% 23.9% p<.001 6,521 3,248 49.8% 4,959 2,032 41.0% -16.2% p<.001 4,468 2,186 48.9% 21,099 12,389 58.7% 9.5% p<.001 18,170 9,746 53.6% 11,328 6,687 59.0% 9.4% p<.001 7,861 4,242 54.0% 1,892 1,121 59.2% 15.5% p<.001 1,057 542 51.3% University Family Care 1,792 1,963 1,012 982 56.5% 50.0% 12.9% p<.001 TOTAL 81,430 46,201 56.7% 10.5% p<.001 65,837 33,817 51.4% Contractor AZ Physicians IPA DES/CMDP Health Choice AZ Maricopa Health Plan Mercy Care Phoenix Health Plan/CC Pima Health System Shaded rows are totals and percentages from the baseline measurement period, October 1, 2001, through September 30, 2002. Table 4 Arizona Health Care Cost Containment System (AHCCCS) CYE 2003 PERFORMANCE IMPROVEMENT PROJECT (PIP): CHILDREN'S ANNUAL DENTAL VISITS Members Ages 3 through 8 Years Enrolled under KidsCare, by County Remeasurement Period: October 1, 2003, to September 30, 2004 County Maricopa County Pima County Rural Counties TOTAL Number with Percent with Relative Percent Number of One or More One or More Change From Statistical Members Dental Visits Dental Visits Previous Period Significance 5,900 4,045 68.6% 9.8% p<.001 4,722 2,949 62.5% 1,326 885 66.7% 24.9% p<.001 1,389 742 53.4% 1,835 1,123 61.2% 8.5% p<.004 1,762 994 56.4% 9,061 6,053 66.8% 12.3% p<.001 7,873 4,685 59.5% Shaded rows are totals and percentages from the baseline measurement period, October 1, 2001, through September 30, 2002. Table 5 Arizona Health Care Cost Containment System (AHCCCS) CYE 2003 PERFORMANCE IMPROVEMENT PROJECT (PIP): CHILDREN'S ANNUAL DENTAL VISITS Members Ages 3 through 8 Years Enrolled under KidsCare, by Acute-care Contractor Remeasurement Period: October 1, 2003, to September 30, 2004 Contractor AZ Physicians IPA Health Choice AZ Maricopa Health Plan Mercy Care Plan Phoenix Health Plan/CC Pima Health System University Family Care TOTAL Number with Percent with Relative Percent Number of One or More One or More Change From Statistical Members Dental Visits Dental Visits Previous Period Significance 3,022 1,887 62.4% 15.6% p<.001 2,946 1,591 54.0% 1,039 752 72.4% 24.8% p<.001 733 425 58.0% 585 303 51.8% -18.1% p<.001 580 367 63.3% 2,596 1,824 70.3% 9.4% p<.001 2,176 1,398 64.2% 1,518 1,077 70.9% 11.2% p<.001 1,111 709 63.8% 142 95 66.9% 1.4% p=.880 94 62 66.0% 159 233 115 133 72.3% 57.1% 26.7% p=.002 9,061 6,053 66.8% 12.3% p<.001 7,873 4,685 59.5% Shaded rows are totals and percentages from the baseline measurement period, October 1, 2001, through September 30, 2002. Figure 1 Arizona Health Care Cost Containment System (AHCCCS) CYE 2003 PERFORMANCE IMPROVEMENT PROJECT(PIP): CHILDREN’S ANNUAL DENTAL VISITS Members Enrolled under Medicaid and KidsCare, by Contractor First Remeasurement Period Compared with the Baseline Measurement 100% Percent of Children with One or More Dental Visits 90% 80% 70% 60% 50% Baseline Remeas 1 40% 30% 20% 10% 0% APIPA CMDP Health Choice Maricopa Health Plan Mercy Care Plan Phoenix Health Plan/CC Baseline Average Healthy People 2010 Goal Pima Health System University Family Care Table 6 CYE 2003 PERFORMANCE IMPROVEMENT PROJECT (PIP): CHILDREN'S ANNUAL DENTAL VISITS Members Ages 3 through 20 Years Enrolled in DDD, by County Remeasurement Period: October 1, 2003, to September 30, 2004 County Maricopa County Pima County Rural Counties TOTAL Number with Percent with Relative Percent Number of One or More One or More Change From Statistical Members Dental Visits Dental Visits Previous Period Significance 2,434 895 36.8% 18.0% p<.001 1,922 599 31.2% 472 182 38.6% 7.5% p=.405 432 155 35.9% 605 249 41.2% 55.8% p<.001 564 149 26.4% 3,511 1,326 37.8% 22.0% p<.001 2,918 903 30.9% Shaded rows are totals and percentages from the baseline measurement period, October 1, 2001, through September 30, 2002. Table 7 CYE 2003 PERFORMANCE IMPROVEMENT PROJECT (PIP): CHILDREN'S ANNUAL DENTAL VISITS Physically Disabled Members Ages 3 through 20 Years Enrolled in ALTCS, by Contractor Remeasurement Period: October 1, 2003, to September 30, 2004 Number with Percent with Relative Percent Number of One or More One or More Change From Statistical County Members Dental Visits Dental Visits Previous Period Significance Maricopa County 41 6 14.6% -23.2% p=.722 21 4 19.0% 7 1 14.3% -50.0% p=1.00 7 2 28.6% 56 21 37.5% 43.8% p=.220 46 12 26.1% 104 28 26.9% 10.7% p=.696 74 18 24.3% Pima County Rural Counties TOTAL Notes: Cochise Health Systems is not included because no members meeting the enrollment criteria were selected for this Contractor. Shaded rows are totals and percentages from the baseline measurement period, October 1, 2001, through September 30, 2002. Table 8 Contractor Interventions to Improve Rates of Annual Dental Visits by Children The following table includes interventions that one or more AHCCCS Contractors are using to ensure children’s access to oral health services and improve rates of annual dental visits during this PIP. The Chronic Care Model, developed by Wagner, et al, was adapted for use in organizing these interventions. The model identifies essential elements of a health care system that encourage high-quality care, and help ensure increased use of or access to services.1 Community Linkages Tie in outreach efforts with related activities/events; e.g., National Children’s Dental Health Month, community health fairs Collaborate with programs such as Head Start and WIC to assist in reaching members; educate these programs about oral health issues and AHCCCS-covered services Utilize resources of the Arizona Department of Health Office of Oral Health (OOH) for provider and/or member education Health System Utilize ”pay-forperformance” strategies to reward PCPs and/or dentists who met specific benchmarks for dental services Utilize Health Plan staff dedicated to dental outreach and assisting families/members in making and keeping appointments Self-Management Support Mail annual reminders to parents about dental visit; send follow-up reminders to members who do not subsequently receive services Reinforce education through newsletters, telephone hold messages, etc.) to members/parents/ caregivers about: • the importance of good oral health and its relationship to overall health • the positive outcomes of preventive dental care • importance of keeping scheduled appointments Delivery System Design Work with programs that provide services in schools (ADHS, Healthy Kids Dental) and coordinated to follow up on member needs Provide case management services to children in foster care or those with special health care needs/disabilities Recruit additional dental providers to improve access Decision Support Educate Primary Care Providers (physicians, PAs, NPs) and office/ clinic staff about: • early detection of dental disease • EPSDT requirements/ referral for treatment or preventive visits advising parents about the importance of regular dental care Survey parents/caregivers or case managers on reasons dental care was not obtained and develop or enhance activities to address those reasons Clinical Information Systems Routinely monitor dental performance measure/utilization rates: • overall • by county/ geographic area • by provider group Utilize tracking systems to identify members with no dental services or those who missed appointments and attempt to contact and schedule or reschedule an appointment and arrange for transportation if needed Community Linkages Collaborate with the Arizona School of Dentistry and Oral Health to provide services and enhance training of dental professionals, especially in the care of special populations (e.g., individuals with disabilities) Use Health Plan staff and/or dental providers to make presentations in schools; provide educational materials and other items, such as toothbrushes, to take home 1 Health System Self-Management Support Offer incentives to members to encourage them to seek dental care Delivery System Design Follow up with members who miss appointments and arrange for transportation when necessary Make or collaborate with organizations that make home visits to reinforce education about oral health and the importance of regular dental care Improving Chronic Illness Care. Overview of the Chronic Care Model. Available at: http://www.improvingchroniccare.org/change/model/components.html Decision Support Utilize dental consultants to review utilization patterns, practice guidelines and/or treatment plans for specific members Capture dental referral data from EPSDT Tracking Forms for follow up to ensure that appointment was completed Clinical Information Systems Incorporate medical and/or dental chart audits into the performance monitoring processes Develop provider utilization profiles and send feedback to providers on visit rates or lists of specific members in need of services