Childhood Immunization
Completion Rates
A biennial report to the Arizona Governor, President
of the Senate and Speaker of the House evaluating
the compliance rates of childhood immunizations of
children by two years of age enrolled in AHCCCS,
Arizona’s Medicaid program.
Acute Care Contractors and the
Division of Development
Disabilities
Thomas J. Betlach, Director
Prepared by the Division of
Health Care Management
“Our first care is your health care.”

April 2016
1

For questions or comments about this report, please contact:
Regina Cameron, MSW
Quality Improvement Coordinator
Division of Health Care Management, AHCCCS
602.417.4352
Regina.Cameron@azahcccs.gov
2

CHILDHOOD IMMUNIZATION STATUS AT 24 MONTHS OF AGE
A Biennial Report to the Governor, President of the Senate, and Speaker of the House for the Measurement Period Ending
September 30, 2015
TABLE OF CONTENTS

EXECUTIVE SUMMARY.....................................................................................................................................1
OVERVIEW............................................................................................................................................................4
 Background
 Healthy People and AHCCCS Goals
PURPOSE OF THE MEASUREMENT..................................................................................................................6
QUALITY INDICATORS......................................................................................................................................6
METHODOLOGY..................................................................................................................................................7
 Eligible Population
 Study Sample
 Data Collection
 Data Analysis
RESULTS................................................................................................................................................................9
 Results by Contractor
 Results by County
 Results by Race/Ethnicity
DISCUSSION AND CONCLUSIONS.................................................................................................................17
REFERENCES......................................................................................................................................................20
APPENDIX A: Statistical Significance Calculation Table ..................................................................................21
APPENDIX B: Recommended Immunization Schedule for Persons Aged 0-6,...................................................23
United States, 2011; Catch-Up Immunization Schedule included
APPENDIX C: Methodology................................................................................................................................25

3

CHILDHOOD IMMUNIZATION STATUS AT 24 MONTHS OF AGE
A Biennial Report to the Governor, President of the Senate, and Speaker of the House for the Measurement Period Ending
September 30, 2015

EXECUTIVE SUMMARY
“Diseases that used to be common in this country and around the world, including polio, measles, diphtheria, pertussis
(whooping cough), rubella (German measles), mumps, tetanus, rotavirus and Haemophilus influenzae type b (Hib) can
now be prevented by vaccination”1. Children are born with an immune system made up of cells, tissues and organs
designed to defend the body against infectious organisms. When organisms are introduced into the body, several cells
work together to detect, and respond to them with antibodies 2. Once produced, antibodies remain in the body so that in
the event the body encounters these organisms again they can respond quickly. Immunizations prevent specific diseases
by introducing the body to antigens which will in turn protect a person from future attacks by organisms or germs by
acting quickly to attack and remove them.
The Department of Health and Human Services established a goal that 90 percent of children 19-35 months of age will be
fully vaccinated for nationally recommended vaccines by the year 2020. The most recent rates reported by the National
Committee for Quality Assurance (NCQA) indicate that Medicaid overall has not met the 90 percent goal for most
vaccines. Nationally, Medicaid has met this goal for the measles, mumps and rubella (MMR) vaccine only.3 While
commercial plans were relatively higher than Medicaid for all vaccinations, they only met the Healthy People goal for
approximately half of the vaccinations. It is important to note that this study does not focus on 19-35 months of age but
rather birth-24 months of age.
Since 1993, the Arizona Health Care Cost Containment System (AHCCCS) has regularly measured the immunization
status of children 24 months of age. This report is presented in accordance to state law (ARS 36-2904), which requires a
biennial status of 24-month immunization completion rates for children served by the Arizona Health Care Cost
Containment System (AHCCCS). This report evaluates the performance of AHCCCS contracted health plans
(Contractors) individually and overall.
One barrier that continues since the previous measurement period is the concern and miseducation by parents regarding
complications and risks associated with vaccinating children. Many of these parents are choosing to refuse or delay
vaccinating their child. These decisions put not only their child at risk but also those within their communities, especially
those who cannot be vaccinated due to illness or other medical reasons; for example those who experience vaccine failure
and children too young to be vaccinated. Two national surveys conducted on parents of children under the age of six
indicate over 20 percent of parents had reservations regarding the risks of vaccinations4,5.
Arizona law requires children to receive specific vaccines to attend school with exceptions only for medical, religious or
personal belief reasons. The Arizona Department of Health Services evaluates exemption rates and reported an increase in
2014. Childcare and Kindergarten exception rates increased from 3.8 to 4.1 and 3.9 to 4.7 respectively6.
AHCCCS has established minimum performance standards (MPS) for childhood immunization rates which are used to
evaluate Contractor performance. Contractors must meet the MPS for each vaccine and vaccine series; if they perform
lower than the MPS they must implement a Corrective Action Plan (CAP) and may be subject to sanctions if they fail to
improve their rates. AHCCCS also encourages Contractors to strive to meet the Healthy People 2020 goals once the MPS
has been achieved.
Methodology
1

AHCCCS used the Centers for Medicare and Medicaid Services (CMS) technical specifications developed for the Core
Set of Children’s Health Care Quality Measures for Medicaid and CHIP (Child Core Set). A random sample of children
who turned 24 months of age on or between October 1, 2014 and September 30, 2015 and who were continuously
enrolled twelve months prior to the child’s second birthday were included in this study.
All data was collected according to applicable privacy and confidentiality laws and safeguards. AHCCCS fist sent the
sample to the Arizona State Immunization Information System (ASIIS), an electronic registry maintained by the Arizona
Department of Health Services (ADHS). AHCCCS sent a sample of 493 members per contracted health plan to ASIIS,
where ASIIS staff searched the registry using the members first and last name and date of birth to identify vaccinations
received by AHCCCS members. ADHS then provided all immunizations date in the registry for those members it was
able to match to AHCCCS. Members with no records or incomplete records found in the ASIIS registry were sent to their
respective contracted health plans. The Contractors conducted a hybrid audit for those members, meaning they gathered
medical records and/or claims to confirm a member’s receipt of any missing vaccinations.
Overall Results and Analysis
Aggregate performance rates for individual and combination immunizations are shown in the table below. The final
sample consisted of 4,663 children enrolled with 11 health plans whose second birthdays occurred during Contract Year
Ending (CYE) 2015.
Since the last report additional measures have been included, they cannot be compared to the previous measurement
period. The new measures include:




Hep A: Hepatitis A
RV:
Rotavirus
Flu:
Influenza
Aggregate Individual Immunization Completion Rates by 24 months of age
Measurement period ending September 30, 2015

AHCCCS MPS
(%)
Health People
2020 Goal
Current AHCCCS
Rate (%)
Previous
AHCCCS Rate
(%)

RV*

DTaP

IPV

MMR

HiB

Hep B

VZV

PCV

Hep A*

(4 doses)

(3 doses)

(1 dose)

(3 doses)

( 3 doses)

(1 dose)

( 4 doses)

(1 dose)

(2-3
doses)

(2 doses)

85%

91%

91%

90%

90%

88%

82%

40%

60%

45%

90%

90%

90%

90%

85%

90%

90%

85%

80%

80%**

81.7

89.6

92.4

88.5

88.6

92.0

78.8

92.0

76.4

45.0

79.5

91.4

91.3

91.5

87.9

90.5

79.9

*

*

*

*This immunization was not included in the previous measurement period
Rates in bold met or exceeded the AHCCCS MPS
** This goal was set in 2011 and has since been archived by Healthy People

2

Flu*

Aggregate Immunization Combination Completion Rates by 24 months of age
Measurement period ending September 30, 2015
Combo 2

Combo 3

(DTap, IPV, MMR, HIB, Hep B, VZV)

(DTap, IPV, MMR, HIB, Hep B, VZV, PCV)

AHCCCS MPS (%)

74%

68%

Health People 2020 Goal

80%

80%

Current AHCCCS Rate (%)

76.0

71.7

Previous AHCCCS Rate (%)

72.9

69.1

AHCCCS rates for all immunizations, except influenza, met or exceeded the most recent national means for Medicaid
health plans reported by the National Committee for Quality Assurance (NCQA) within the State of Health Care Quality
2015 report. NCQA produces this report annually and it focuses on quality issues this country faces and assists in driving
improvement in the delivery of evidence-based medicine and care. The report trends performance overtime, tracks
variations in care and recommends quality improvement. When compared on a national Medicaid level, Arizona has high
compliance rates regarding childhood immunization.
Conclusion
AHCCCS will provide the data and rates for this measurement period to Contractors for additional analysis so they may
identify barriers and develop interventions to improve their performance. Contractors continue comprehensive outreach
efforts to encourage parents to complete scheduled immunizations for their children and to providers to schedule
appointments necessary to administer vaccinations. AHCCCS and its Contractors continue to promote completion and
timely immunizations for all populations served with a specific focus on childhood and adolescent immunizations.
AHCCCS, AHCCCS Contractors and relevant stakeholders work collaboratively to develop interventions and education
initiatives between measurement periods, which include monitoring local, state and national trends that could potentially
impact immunization rates.
AHCCCS will continue to work with and monitor Contractors, especially those with lower compliance, to assist them in
making progress toward reaching state and national goals.

3

CHILDHOOD IMMUNIZATION STATUS AT 24 MONTHS OF AGE
A Biennial Report to the Governor, President of the Senate, and Speaker of the House for the Measurement Period Ending
September 30, 2015

OVERVIEW
Background
Since 1993, AHCCCS has measured the immunization rates of children by two years of age. Arizona Revised Statute 362904 requires that AHCCCS submit a report to the Governor and Legislature that represents a statistically valid sample
evaluating the number of AHCCCS enrolled children who received immunizations recommended by the Centers for
Disease Control and Prevention (CDC) by age two. This biannual report evaluates childhood immunization compliance
for each AHCCCS Acute-care and DDD contracted health plans (Contractor).
This report includes 2015 measurement results of nine individual vaccines, two combination vaccines and the influenza
vaccine, which protect against fourteen different diseases and viruses: diphtheria, tetanus and acellular (DTaP);
inactivated poliovirus (IPV); measles, mumps and rubella (MMR); haemophilus influenza type b (Hib); hepatitis B (Hep
B); varicella zoster (VZV); pneumoccal conjugate (PCV); hepatitis A (Hep A); rotavirus (RV) and influenza. The
recommended vaccination schedule can be found in Appendix B.
Vaccination is important not only to the individual but also to those living in their communities. “When sufficiently high
proportion of a population is vaccinated against communicable diseases, the entire population can obtain protection”7.
Within the United States childhood diseases have decreased by 95 percent due to immunizations since the end of the 20 th
century8. Monitoring of immunization completion rates is critical to identifying under-vaccinated populations and
increasing coverage levels in order to prevent outbreaks of disease.
AHCCCS established Minimum Performance Standards (MPS) for childhood immunization rates, both individual and
combinations, which are used in evaluating Contractor performance. If a Contractor does not meet the MPS set for a
specific immunization or combination, they must develop and implement a Corrective Action Plan (CAP) and may be
subject to financial sanctions. It is important to note that a Contractor may not meet the MPS for and individual
immunization but may meet it for a particular combination as the MPS set for combinations are lower than those for
individual immunizations.
Changes


Two Contractors are no longer contracted with AHCCCS as an acute-care health plan. Also for this reporting
period one Contractor entered into contract with AHCCCS as an acute-care health plan. Additionally, members
with a qualifying diagnosis for the Children’s Rehabilitative Services program (CRS) were fully integrated as of
10/01/2014, meaning that CRS is now responsible for the comprehensive health care needs of their members
where they would not have been included in previous reports.



Since the last report additional measures have been included, therefore they cannot be compared to the previous
measurement period.
o Hep A: Hepatitis A
o RV:
Rotavirus
o Flu:
Influenza

4

Healthy People
Based on the CDC’s recommendations, the U.S. Department of Health and Human Services (DHHS) established a goal
that, by 2020, 90 percent of children 19 to 35 months of age will be fully vaccinated for universally recommended
vaccines. This goal applies to completion of the appropriate doses of individual vaccines. A second goal is that 80 percent
of children receive the full series of seven vaccines (DTap, IPV, MMR, Hib, HBV, VZV and PCV) by age 3. Once
Contractors reach the AHCCCS MPS they are encouraged to strive to reach the Healthy People goals, however they may
set their own goals which must be higher than the AHCCCS MPS.

AHCCCS Performance Measure Standards for Childhood Immunizations
Measurement period ending September 30, 2015

AHCCCS Minimum Performance
Standard (MPS)

Healthy People 2020 Objectives

DTaP – 4 doses

85%

90%

IPV – 3 doses

91%

90%

MMR – 1 dose

91%

90%

HiB – 3 doses

90%

90%

Hep B – 3 doses

90%

90%

VZV – 1 dose

88%

90%

PCV – 4 doses

82%

90%

Hep A – 1 dose

40%

90%

RV – 2-3 doses

60%

90%

Influenza – 2 doses

45%

90%

4:3:1:2:3:1 Series

74%

80%

4:3:1:2:3:1:4 Series

68%

80%

Immunization

5

PURPOSE OF THE MEASUREMENT
This study was conducted to determine the immunization rates of AHCCCS members who turned age two by September
30, 2015, as required by state law (ARS 36-2904) and to evaluate Contractor performance. Aggregate rates are reported to
determine the compliance rates of children enrolled in AHCCCS statewide. Individual Contractor rates are reported
separately to evaluate the performance of each Contractor. Results of the current measurement year stratified by
race/ethnicity and county are also included to determine if any disparities exist and assist in identifying opportunities for
improvement.
QUALITY INDICATORS
This immunization study utilized the Centers for Medicare and Medicaid Services (CMS) technical specifications and
resource manual for federal fiscal year 2015 reporting specific to the Core Set of Children’s Health Care Quality
Measures for Medicaid and CHIP (Child Core Set). The Children's Health Insurance Program Reauthorization Act of
2009 (CHIPRA) included provisions to strengthen the quality of care provided to and health outcomes of children in
Medicaid and CHIP. CHIPRA required HHS to identify and publish a core measure set of children’s health care quality
measures for voluntary use by State Medicaid and CHIP programs 9. All quality indicators are based on identical
denominator criteria. These indicators are listed below with the numerator criteria.


DTaP – the total number of children in the denominator who received at least four DTaP (diphtheria, tetanus and
acellular pertussis) vaccinations with different dates of service on or before the child’s second birthday.



IPV – the total number of children in the denominator who received at least three IPV (inactivated poliovirus)
vaccinations with different dates of service on or before the child’s second birthday.



MMR – the total number of children in the denominator who received any of the following with a date of service
on or before the child’s second birthday
o
o
o

at least one MMR (measles, mumps and rubella) vaccination
at least one measles and rubella vaccination and at least one mumps vaccination
at least one measles vaccination or history of the illness and at least one mumps vaccination or history of
the illness and at least one rubella vaccination or history of the illness on the same date of service or on
different dates of service



HiB – the total number of children in the denominator who received at least three HiB (haemophilus influenza
type b) vaccinations with different dates of service on or before the child’s second birthday



Hep B – the total number of children in the denominator who received either of the following with a date of
service on or before the child’s second birthday
o
o



At least three hepatitis B vaccinations with different dates of service
History of hepatitis illness

VZV – the total number of children in the denominator who received either of the following
o At least one VZV (varicella) vaccination with a date of service on or before the child’s second birthday
o History of varicella zoster illness

6



PCV – the total number of children in the denominator who received at least four PCV (pneumococcal conjugate)
vaccinations with dates of service on or before the child’s second birthday



Hep A – the total number of children in the denominator who received either of the following
o At least one hepatitis A vaccination with a date of service on or before the child’s second birthday
o History of hepatitis A illness



RV – the total number of children in the denominator who received any of the following on or before the child’s
second birthday
o At least two doses of the two-dose rotavirus vaccine on different dates of service
o At least three doses of the three-dose rotavirus vaccine on different dates of service
o At least one dose of the two-dose rotavirus vaccine and at least two doses of the three-dose rotavirus
vaccine, all on different dates of service



Influenza – the total number of children in the denominator who received at least two influenza vaccinations, with
different dates of service, on or before the child’s second birthday



Combination #2 – the total number of children in the denominator who received four DTaP/DT vaccinations,
three IPV vaccinations, one MMR vaccination, three Hib vaccinations, three HBV vaccinations and one VZV
vaccination on or before their second birthdays



Combination #3 – the total number of children in the denominator who received four DTaP/DT vaccinations,
three IPV vaccinations, one MMR vaccination, three Hib vaccinations, three HBV vaccinations, one VZV
vaccination and four PCV vaccinations on or before their second birthdays
METHODOLOGY

The measurement included children who turned two years of age during the contract year ending (CYE) September 30,
2015, who were continuously enrolled with AHCCCS Contractors and were eligible under Medicaid (Title XIX of the
Social Security Act).
Eligible population





Children who turn 2 years old during the measurement year
Children who were continuously enrolled 12 months prior to the child’s second birthday
Children with no more than one gap in enrollment of up to 45 days during the 12 months prior to the child’s
second birthday.
Children who were enrolled on their second birthday

Study Sample
AHCCCS pulled a random sample of 411 eligible members plus a 20 percent oversample for a total of 493 members per
Contractor. Two Contractors did not have a large enough population to pull a sample from; therefore their entire eligible
population was used for this measure. The total sample for all contractors was 4796 members.

7

Data Collection
AHCCCS identified all eligible children enrolled with AHCCCS. AHCCCS then collaborated with the Arizona
Department of Health Services (ADHS) to obtain data from the Arizona State Immunization Information System (ASIIS)
which is an electronic registry maintained by ADHS. AHCCCS provided ASIIS with an electronic file containing all
members eligible for this study. The ASIIS registry was searched by first and last name and date of birth within the
AHCCS file, the registry was further searched to match against other factors such as child or mothers social security
number this was done only in the event that more than one member was found with the same name and date of birth.
ADHS provided AHCCCS with all immunizations in the registry for those members included in the file if an
immunization exists within the registry.
The data was then merged with any vaccination data for administration of vaccines collected from the AHCCCS
encounter system through the AHCCCS Data Warehouse. AHCCCS then pulled a random sample of 493 members for
each Contractor and provided the respective samples to Contractors with the vaccination data that had been collected.
Contractor personnel were instructed on the purpose of the study, the methodology, data collection methods and internal
quality control/validation procedures to ensure that data was collected and reported to AHCCCs in a consistent and
reliable manner.
Contractor staff collected additional data from medical records and/or any claims (encounter) not yet received or
processed by AHCCCS. Dates collected were entered into an excel file and all relevant documentation which provides
proof that a vaccine was administered was submitted by the Contractors to AHCCCS. AHCCCS reviewed documentations
submitted by contractors to validate administration of vaccinations.
Data Analysis
Once data collection was finalized, AHCCCS merged the data from Contractors and performed analysis using COGNOS
software in the Data Warehouse. The primary analysis provided results on the percentage of members who were ageappropriately immunized by two years of age for each quality indicator overall, by individual Contractor, by county and
by race/ethnicity. Following CMS technical specifications, if the data showed that an individual member received two
doses of the same vaccine with dates of service that were within 14 days of each other, the doses were considered a single
immunization. This allowed for data from different sources to be combined, while reduce the possibility of counting the
same immunization twice due to data entry errors.
See Appendix C of this report for the complete technical specifications

8

RESULTS
The sample consisted of 4796 children enrolled in AHCCCS across ten Contractors. The sample included 493 members
for all but two health plans, both of which had an eligible population too small to sample from; therefore their entire
population was used for the study. Compliance rates for the combined health plans along with comparative data are as
follows:

Aggregate Individual Immunization Completion Rates by 24 months of age
Measurement period ending September 30, 2015
RV*

DTaP

IPV

MMR

HiB

Hep B

VZV

PCV

Hep A*

(4 doses)

(3 doses)

(1 dose)

(3 doses)

( 3 doses)

(1 dose)

( 4 doses)

(1 dose)

(2-3
doses)

(2 doses)

Flu*

AHCCCS MPS
(%)

85

91

91

90

90

88

82

40

60

45

Health People
2020 Goal (%)

90

90

90

90

85

90

90

85

80

80**

Current AHCCCS
Rate (%)

81.7

89.6

92.4

88.5

88.6

92.0

78.8

92.0

76.4

45.0

Previous
AHCCCS Rate
(%)

79.5

91.4

91.3

91.5

87.9

90.5

79.9

*

*

*

Rates in bold met or exceeded the AHCCCS MPS
*This immunization was not included in the previous measurement period
** This goal was set in 2011 and has since been archived by Healthy People

Aggregate Immunization Combination Completion Rates by 24 months of age
Measurement period ending September 30, 2015
Combo 2

Combo 3

(DTap, IPV, MMR, HIB, Hep B, VZV)

(DTap, IPV, MMR, HIB, Hep B, VZV,
PCV)

AHCCCS MPS (%)

74%

68%

Health People 2020 Goal

80%

80%

Current AHCCCS Rate (%)

76.0

71.7

Previous AHCCCS Rate (%)

72.9

69.1

Rates in bold met or exceeded the AHCCCS MPS

Statewide 50 percent of the individual immunization rates met the MPS set and both combination immunization series met
their MPS. The total number of children receiving DTaP showed a statistically significant increase from the previous
measurement period. Both IPV and HiB had significant decreases from the previous measurement period and the
remaining immunizations maintained compliance. As previously mentioned, Hepatitis A, Rotavirus and Influenza are new
immunizations evaluated this measurement period; therefor comparison could not be completed. The MMR vaccine
exceeded the Healthy People goal established and all vaccines, except Influenza, met or exceeded the national Medicaid
average for each.
9

Graph 1:
Percentage of Contractors meeting MPS, by Immunization

Percentage of Contractors meeting MPS
100%
90%
80%
70%
60%
50%
40%
30%
20%
10%
0%
Combo 3

Combo 2

Flu

RV

Hep A

PCV

VZV

Hep B

Hib

MMR

IPV

DTaP

% meeting MPS

Result by Contractor
For the Medicaid population, there are 63 reported rates that allow for calculation of statistical significance when looking
at individual immunizations by Contractor. While decreases were experienced in the aggregate for 50 percent of the
immunizations it is important to note that only seven individual immunizations rates (11%) showed a statistically
significant decrease when analyzed by Contractor. A combination of a statistically significant decrease by one Contractor
and several non-significant decreases by other Contractors contributed to a statistically significant decrease for two
individual immunizations statewide.
Eight of the eleven Contractors had combination compliance rates that met or exceeded the MPS for these combinations.
Compliance rates for five Contractors exceeded the Healthy People goal of 80 percent for combination number two. One
Contractor exceeded the goal for combination number 3.
Two Contractors met the goal for a measures evaluated within this study. Refer graph 1 to review the percentage of
immunization each Contractor met or exceeded the AHCCCS established MPS.

10

Table 1:
Medicaid Rates for Individual Immunizations, by Health Plan
AHCCCS
Contractor

Percent of Immunizations Completed by 24 Months of Age
DTaP

IPV

MMR

Hib

Hep B

VZV

PCV

Hep A

RV

Flu

(4 doses)

(3 doses)

(1 dose)

(3 doses)

(3 doses)

(1 dose)

(4 doses)

(1 dose)

(2-3 doses)

(2 doses)

85.8

92.9

93.3

92.5

94.5

93.3

82.6

93.1

83.2

49.1

88.5

96.8

94.2

96.2

94.2

92.9

87.2

n/a

n/a

n/a

82.9

92.7

94.9

94.1

92.2

94.3

82.4

93.7

65.3

53.3

n/a

n/a

n/a

n/a

n/a

n/a

n/a

n/a

n/a

n/a

82.4

95.1

98.0

94.5

93.1

97.4

77.7

96.1

70.8

55.8

85.1

95.5

95.2

94.4

95.2

95.2

85.1

n/a

n/a

n/a

63.9

72.2

84.2

81.2

66.2

81.2

58.6

86.5

57.1

40.6

74.2

79.6

80.7

87.1

78.5

82.8

76.3

n/a

n/a

n/a

90.9

93.7

93.5

94.7

91.1

93.9

88.8

94.7

89.5

52.7

77.5

88.8

89.7

89.4

84.5

88.7

75.3

n/a

n/a

n/a

52.0

63.8

80.3

27.1

62.4

79.0

49.3

82.5

59.8

10.5

n/a

n/a

n/a

n/a

n/a

n/a

n/a

n/a

n/a

n/a

85.2

91.5

93.7

90.1

89.2

93.7

81.3

93.5

81.9

43.2

86.6

94.7

96.8

94.3

82.9

95.5

86.9

n/a

n/a

n/a

76.9

83.2

88.2

85.2

81.3

87.8

72.6

90.9

76.9

35.3

83.5

93.6

92.6

93.5

93.6

92.0

85.4

n/a

n/a

n/a

87.8

92.7

93.7

93.7

91.1

93.5

84.8

93.7

87.6

44.6

77.2

91.0

90.2

90.8

87.0

89.1

77.6

n/a

n/a

n/a

76.7

89.2

91.3

91.3

90.1

89.9

77.5

87.8

66.3

42.6

78.9

91.3

91.9

92.1

88.6

91.1

79.6

n/a

n/a

n/a

85.6

92.5

93.3

90.7

93.1

93.1

80.5

90.7

79.3

45.8

75.3

91.9

90.4

91.2

92.2

90.3

79.2

n/a

n/a

n/a

TOTAL

81.7

89.6

92.5

88.5

88.6

92.0

78.8

92.0

76.4

45.0

PREVIOUS TOTAL

79.5

91.4

91.3

91.5

87.9

90.5

79.9

n/a

n/a

n/a

Care 1st Arizona

CRS

DES/CMDP

DES/DDD

Health Choice Arizona

Health Net Access

Maricopa Health Plan

Mercy Care Plan

Phoenix Health Plan

United Health Care

University Family Care

11

Table 2:
Medicaid Rates for 4:3:1:3:3:1 Combo #2 and 4:3:1:3:3:1:4 Combo #3, by Health Plan
Percent of Immunizations Completed by 24
Months of Age
AHCCCS Contractor

Care 1st Arizona

CRS

DES/CMDP

DES/DDD

Health Choice Arizona

Health Net Access

Maricopa Health Plan

Mercy Care Plan

Phoenix Health Plan

United Health Care

University Family Care

Total

DTaP, IPV, MMR, Hib, HBV,
and VZV Rate
(4:3:1:3:3:1 Combo)
83.4

DTaP, IPV, MMR, Hib,
HBV, VZV, and PCV Rate
(4:3:1:3:3:1:4 Combo)
78.5

87.2

80.8

79.8

76.1

n/a

n/a

78.1

68.8

85.1

77.3

45.9

42.1

76.3

60.2

86.0

84.6

75.3

65.2

21.8

20.9

n/a

n/a

80.7

76.3

87.0

69.1

69.6

64.9

85.4

77.9

83.8

79.9

77.6

65.6

74.0

70.6

79.6

69.4

82.2

77.1

79.2

79.2

76.0

71.7

72.9

69.1

12

Graph 2:
Percentage of Immunizations meeting MPS, by Health Plan

Percentage of Immunizations meeting MPS
100%
90%
80%
70%
60%
50%
40%

% meeting MPS

30%
20%
10%
0%

13

Results by County
The data was analyzed by county in order to determine if any disparities exists. For comparative purposes Greenlee was
not included in the analysis due to the small, incomparable population size. Counties who had 100 percent compliance for
any immunization were not included in the disparity analysis. While these counties are included in the tables below, they
were not used in calculating disparities. For individual immunizations, Gila County had comparatively lower rates for
three immunizations; DTaP, MMR and Hep A. Vaccine combinations showed no disparities within the counties.
Contractors which serve counties showing disparities for any vaccine will be encouraged to study potential barriers
leading to lower compliance.

Table 3:
Percentage of Immunizations Completed by 24 Months of Age, by County
Percent of Immunizations Completed by 24 Months of Age
County

DtaP

IPV

MMR

Hib

Hep B

VZV

PCV

Hep A

RV

Flu

doses)

(3 doses)

(1 dose)

(3 doses)

(3 doses)

(1 dose)

(4 doses)

(1 dose)

(2-3 doses)

(2 doses)

Apache

80.0

100.0

80.0

100.0

80.0

80.0

40.0

60.0

40.0

60.0

Cochise

82.7

93.9

98.0

93.9

94.9

98.0

76.5

91.8

61.2

49.0

Coconino

87.2

100.0

97.4

97.4

97.4

97.4

89.7

97.4

71.8

56.4

Gila

58.6

75.9

65.5

72.4

79.3

65.5

58.6

75.9

55.2

17.2

Graham

91.3

91.3

91.3

91.3

95.7

87.0

87.0

91.3

65.2

26.1

Greenlee

100

100.0

100.0

50.0

100.0

100.0

0

100.0

0

100.0

La Paz

87.5

100.0

100.0

100.0

100.0

100.0

87.5

87.5

75.0

37.5

Maricopa

80.2

88.1

91.9

86.6

86.7

91.4

77.1

92.1

77.0

41.2

Mohave

80

91.2

94.4

89.6

88.0

92.0

76.0

90.4

73.6

44.0

Navajo

86.1

86.1

91.7

88.9

83.3

91.7

80.6

86.1

77.8

50.0

Pima

86.0

92.8

93.4

92.3

93.4

93.6

86.1

92.3

74.4

62.8

Pinal

87.3

93.6

95.9

93.2

91.4

95.9

81.8

95.9

81.4

50.5

Santa Cruz

87.5

95.8

97.9

95.8

97.9

97.9

83.3

93.8

72.9

37.5

Yavapai

71.3

86.1

86.1

87.1

86.1

83.2

69.3

81.2

71.3

40.6

Yuma

91.1

96.4

95.9

95.9

95.9

95.9

86.4

96.4

91.1

42.6

TOTAL

81.7

89.6

92.5

88.5

88.6

92.0

78.8

92.0

76.4

45.0

(4

Bold indicates a disparity exists

14

Table 4:
Percentage of Immunizations Completed by 24 Months of Age, by County
Percent of Immunizations Completed by 24
Months of Age
County

Apache

DtaP, IPV, MMR, Hib, HBV,
and VZV Rate
(4:3:1:3:3:1 Combo)
40.0

DtaP, IPV, MMR, Hib, HBV,
VZV, and PCV Rate
(4:3:1:3:3:1:4 Combo)
20

Cochise

77.6

69.4

Coconino

87.2

84.6

Gila

55.2

51.7

Graham

87.0

82.6

Greenlee

50.0

0.0

La Paz

87.5

75.0

Maricopa

73.3

68.9

Mohave

76.8

72.0

Navajo

83.3

77.8

Pima

82.8

80.7

Pinal

83.6

77.7

Santa Cruz

87.5

81.3

Yavapai

68.3

63.4

Yuma

88.8

83.4

TOTAL

76.0

71.7

15

Results by Race/Ethnicity
The data was analyzed by race/ethnicity in order to determine if any disparities exists. For individual immunizations, both
African Americans and Caucasians showed disparities for all immunizations. American Indians showed disparities for
DtaP, IPV, Hib, PCV and RV, all of which require more than one dose of the vaccine and may be attributing to the lower
rates. Contractors must further analyze their data to identify any trends leading to these disparities and develop
interventions to improve compliance rates.

Table 5:
Percentage of Immunizations Completed by 24 Months of Age, by Race/Ethnicity
Percent of Immunizations Completed by 24 Months of Age
Race/Ethnicity

DtaP

IPV

MMR

Hib

Hep B

VZV

PCV

Hep A

RV

Flu

doses)

(3 doses)

(1 dose)

(3 doses)

(3 doses)

(1 dose)

(4 doses)

(1 dose)

(2-3 doses)

(2 doses)

American Indian

75.8

87.0

91.9

82.6

89.4

90.7

71.4

93.2

68.9

39.8

African American

75.9

84.9

89.4

83.9

84.4

90.1

72.1

88.9

65.2

36.6

Asian/Pacific Islander

82.4

86.1

90.7

83.3

83.3

88.9

76.9

90.7

76.9

46.3

Caucasian

76.8

85.6

89.1

84.3

84.5

87.8

73.9

87.7

74.1

41.7

Hispanic

86.6

93.3

94.8

92.0

92.2

94.7

83.9

94.9

81.4

47.7

Other

75.0

75.0

87.5

87.5

62.5

87.5

62.5

100.0

62.5

75.0

Unknown

75.5

86.9

92.9

88.8

85.3

92.4

73.6

91.0

67.8

49.3

TOTAL

81.7

89.6

92.5

88.5

88.6

92.0

78.8

92.0

76.4

45.0

(4

Bold indicates a disparity exists

Table 6:
Percentage of Immunizations Completed by 24 Months of Age, by Race/Ethnicity
Percent of Immunizations Completed by 24
Months of Age
County

DtaP, IPV, MMR, Hib, HBV,
and VZV Rate
(4:3:1:3:3:1 Combo)

DtaP, IPV, MMR, Hib, HBV,
VZV, and PCV Rate
(4:3:1:3:3:1:4 Combo)

American Indian

67.1

62.7

African American

69.5

63.8

Asian/Pacific Islander

72.2

66.7

Caucasian

69.8

65.8

Hispanic

81.8

77.6

Other

50.0

50.0

Unknown

71.7

67.3

TOTAL

76.0

71.7

Bold indicates a disparity exists

16

DISCUSSION AND CONCLUSION
The methodology used to administer these performance measures have been used by Medicaid health plans since 1995
and provide a reliable method to measure compliance with immunization for children two years of age who have been
enrolled in these health plans for a year or more. AHCCCS Contractors are contractually mandated to track and trend
performance for childhood immunization and provide an action plan for how each will work to reach the established MPS
and potential goals. Contractors who do not meet the MPS must submit a Corrective Action Plans (CAPs) and may be
subject to sanctions if improvement does not occur.
AHCCCS provides data to Contractors for further analysis and to identify barriers and areas in need for improvement so
that interventions can be developed and implemented. AHCCCS will continue to work with Contractors, especially those
with the lowest rates of childhood immunizations, to assist them in making progress toward state and national goals.
Sustained success and continual improvement will be the major focus over the next two years.
National Comparisons
AHCCCS rates for all immunizations, except influenza, met or exceeded the most recent national means for Medicaid
health plans reported by the National Committee for Quality Assurance (NCQA) within the State of Health Care Quality
2015 report. NCQA produces this report annually and it focuses on quality issues this country faces and assists in driving
improvement in the delivery of evidence-based medicine and care. The report trends performance overtime, tracks
variations in care and recommends quality improvement. When compared on a national Medicaid level, Arizona has high
compliance rates regarding childhood immunization.

Graph 3:
Percentage of Immunizations meeting or exceeding
national average MPS, by Immunization
Combo 3
Combo 2
Flu
RV
Hep A
PCV

AHCCCS Aggregate

VZV

NCQA Medicaid Mean

Hep B
HiB
MMR
IPV
DTaP
0

20

40

60

80

17

100

The following recommendations to improve or maintain immunization completion rates among two year old members
enrolled in AHCCCS were compiled from evidence-based research and identified best practices Many AHCCCS
Contractors have implemented several of these strategies, and their continued use should help sustain or further improve
performance.
Contractors should continue using a variety of means to reach parents/guardians and encourage them to complete
their children’s immunizations. Mail and telephone reminders to parents and providers have been found to be effective
in improving immunization-completion rates. In addition, Contractors may consider offering incentives to parents of
children who complete all immunizations by 24 months.
In addition to ongoing monitoring of completion of all childhood vaccinations, Contractors should focus on rates of
DTaP and PCV completion, particularly those children who have received only three doses. Given the effect that
missing the fourth dose has on completion rates for the full series of immunizations, health plans and providers should
focus on ensuring that children receive all the necessary doses of these vaccines.
Since all childhood vaccines can be completed at about 15 months of age, Contractors should begin checking the
immunization status of members at 12 months of age. If members are lacking doses, this could give parents time to get
immunizations completed by the time their children turn 2 years. Contractors should utilize the CDC’s “catch up”
immunization schedule, which is included in Appendix B, to help plan for completion of vaccinations. When children are
overdue, Contractors should consider the additional step of assisting parents/guardians with making appointments with
their Primary Care Physicians (PCPs) and make arrangements for transportation assistance if needed.
Contractors should target outreach for specific racial/ethnic groups, as needed. Results showed that African
Americans and Caucasian children had consistent disparities when compared to their Hispanic counterparts. American
Indian members also showed disparities for several vaccines. Contractors should work to bring rates up within these
populations by conducting a needs analysis and developing culturally competent interventions.
Contractors should continue or enhance member education to overcome parental fears regarding vaccination. This
includes direct communication with members and working with providers to ensure that parents and guardians understand
the potential consequences of not having children fully immunized ― including seizures, meningitis, hearing impairment
and even death due to infectious diseases.
Contractors should use and encourage its network providers to utilize resources from the CDC’s National Immunization
Program (NIP), such as Vaccine Information Statements, which provide easy-to-understand information on the benefits
and risks of specific vaccines. A Vaccine Information Statement (VIS) must be provided to the recipient of any vaccine
covered by the National Childhood Vaccine Injury Act (NVCIA), which includes most immunizations given in childhood,
and are available for all vaccines licensed in the U.S. Copies of VISs are available from state health authorities
responsible for immunization, or they can be obtained from the CDC’s website (www.cdc.gov) or from the Immunization
Action Coalition (www.immunize.org). Translations of VISs into languages other than English also are available from the
Immunization Action Coalition website and may be available from state immunization programs.
One approach to overcoming unwarranted parental refusal that is seeing some success nationally is to educate providers
that a parent’s refusal at one visit does not necessarily mean that unnecessary fears and objections cannot be overcome in
the future. Providers should continue to try educating parents that have previously refused vaccines, focusing on those that
are the subject of the least amount of misinformation. Parents may agree to a few vaccines at first and their fears may be
eased over time.
Contractors should target outreach activities in specific geographic areas, as needed. Results showed that Gila
County had a few disparities for DTaP, MMR and HEP A. Contractors who serve these counties should work to bring
18

rates in these areas up, including working with providers and possibly county health departments to identify barriers to
immunizations and resources to address those barriers. Education in vaccine management and delivery for providers
serving some areas of the state may be helpful.
Contractors should continue to ensure that health care professionals providing immunizations report all
vaccinations to ASIIS. With complete reporting, an automated registry is a valuable tool in helping providers determine
the immunization status of children they are seeing at each visit, so that opportunities to vaccinate are not missed. This is
especially important when children receive immunizations at multiple sites and parents do not have current immunization
records. Use of ASIIS to check patients’ immunization status should prevent the need for them to return for vaccinations.
Contractors should encourage providers to implement an Electronic Health Record (EHR) system. Not only is there
value in automating health records for the providers, but would also aid the Contractors in gathering complete data
without relying on paper records or disrupting physician office routines. In addition, eligible providers may be eligible to
receive incentive payments from CMS if they meet the necessary requirements, one of which being to electronically share
immunization information utilizing a certified EHR to the state immunization system, ASIIS.
AHCCCS and its Contractors will continue to monitor immunization coverage levels among children. AHCCCS also will
continue to work with low-performing Contractors to ensure they meet contractual standards and goals.

19

Works Cited
1. Centers for Disease Control and Prevention. Vacines and Immunizations. CDC. [Online] May 19, 2014.
http://www.cdc.gov/vaccines/vac-gen/howvpd.htm.
2. Nemours. Immune System. KidsHealth. [Online] http://kidshealth.org/en/parents/immune.html.
3. National Committee for Quality Assurance. The State of Health Care Quality. Washington, DC : NCQA, 2015.
4. Confidence About Vaccines in the United States: Understanding Parents' Perceptions. Kennedy, Allison, et al., et al.
2011, Health Affairs, pp. 1151-1159.
5. Vaccine Attitudes, Concerns, and Information Sources Reported by Parents of Young Children: Results From the 2009
HealthStyles Survey. Kennedy, Allison, Basket, Michelle and Sheedy, Kristine. 2011, Pediatrics, Vol. 127.
6. Arizona Department of Health Services. AZ Losing Traction on Vaccine Front. Arizona Department of Health Services.
[Online] July 21, 2014. http://directorsblog.health.azdhs.gov/az-losing-traction-on-vaccine-front/.
7. Lee, Emily Oshima, Rosenthal, Lindsay and Scheffler, Gabriel. The Effect of Childhood Vaccine. Washington, DC :
Center for American Progress, 2013.
8. Reviews of Evidence Regarding Interventions to Improve Vaccination Coverage in Children, Adolescents, and Adults.
Briss, Peter A, et al., et al. 2000, American Journal of Preventive Medicine, pp. 97-140.
9. Centers for Medicare and Medicaid Services. CHIPRA Initial Core Set of Children's Health Care Quality Measures.
Medicaid. [Online] [Cited: March 10, 2016.] https://www.medicaid.gov/Medicaid-CHIP-Program-Information/ByTopics/Quality-of-Care/CHIPRA-Initial-Core-Set-of-Childrens-Health-Care-Quality-Measures.html.

20

Appendix A – Statistical Significance Calculation Tables

21

AHCCCS
Contractor

Percent of Immunizations Completed by 24 Months of Age
DTaP
(4 doses)

IPV
(3 doses)

MMR
(1 dose)

Hib
(3 doses)

Hep B
(3 doses)

VZV
(1 dose)

PCV
(4 doses)

Hep A
(1 dose)

RV
(2-3 doses)

Flu
(2 doses)

85.8

92.9

93.3

92.5

94.5

93.3

82.6

93.1

83.2

49.1

88.6

96.8

94.2

96.2

94.2

92.9

87.2

n/a

n/a

n/a

P=.197

P=.078

P=.682

P=.109

P=.889

P=.877

P=.173

82.9

92.7

94.9

94.1

92.2

94.3

82.4

93.7

65.3

53.3

n/a

n/a

n/a

n/a

n/a

n/a

n/a

n/a

n/a

n/a

Statistical Significance (p value)

n/a

n/a

n/a

n/a

n/a

n/a

n/a

n/a

n/a

n/a

DES/CMDP

82.4

95.1

98.0

94.5

93.1

97.4

77.7

96.1

70.8

55.8

85.1

95.5

95.2

94.4

95.2

95.2

85.1

n/a

n/a

n/a

P=.326

P=.800

P=.031

P=.109

P=.258

P=.111

P=.014

63.9

72.2

84.2

81.2

66.2

81.2

58.6

86.5

57.1

40.6

74.2

79.6

80.7

87.1

78.5

82.8

76.3

n/a

n/a

n/a

P=.102

P=.205

P=.485

P=.239

P=.044

P=.760

P=.006

90.9

93.7

93.5

94.7

91.1

93.9

88.8

94.7

89.5

52.7

77.5

88.8

89.7

89.4

84.5

88.7

75.3

n/a

n/a

n/a

P<.001

P=.002

P=.014

P=.001

P<.001

P=.001

P<.001

52.0

63.8

80.4

27.1

62.4

79.0

49.3

82.5

59.8

10.5

n/a

n/a

n/a

n/a

n/a

n/a

n/a

n/a

n/a

n/a

Statistical Significance (p value)

n/a

n/a

n/a

n/a

n/a

n/a

n/a

n/a

n/a

n/a

Maricopa Health Plan

85.2

91.5

93.7

90.1

89.2

93.7

81.3

93.5

81.9

43.2

86.6

94.7

96.7

94.3

82.9

95.5

86.9

n/a

n/a

n/a

P=.611

P=.114

P=.082

P=.051

P=.016

P=.315

P=.053

76.9

83.2

88.2

85.2

81.3

87.8

72.6

90.9

76.9

35.3

83.5

93.6

92.6

93.5

93.6

92.0

85.4

n/a

n/a

n/a

P=.005

P<.001

P=.012

P<.001

P<.001

P=.020

P<.001

87.8

92.7

93.7

93.7

91.1

93.5

84.8

93.7

87.6

44.6

77.2

91.0

90.2

90.8

87.0

89.1

77.6

n/a

n/a

n/a

P<.001

P=.251

P=.020

P=.050

P=.020

P=.005

P=.001

76.7

89.3

91.3

91.3

90.1

89.9

77.5

87.8

66.3

42.6

78.9

91.3

91.9

92.1

88.6

91.1

79.6

n/a

n/a

n/a

P=.351

P=.226

P=.713

P=.587

P=.410

P=.486

P=.372

85.6

92.5

93.3

90.7

93.1

93.1

80.5

90.7

79.3

45.8

75.3

91.9

90.4

91.2

92.2

90.3

79.2

n/a

n/a

n/a

P<.001

P=.710

P=.091

P=.785

P=.592

P=.097

P=.605

TOTAL

81.7

89.6

92.5

88.5

88.6

92.0

78.8

92.0

76.4

45.0

PREVIOUS TOTAL

79.5

91.4

91.3

91.5

87.9

90.5

79.9

n/a

n/a

n/a

P=.005

P=.003

P=.035

P<.001

P=.262

P=.008

P=.171

Care 1st Arizona

Statistical Significance (p value)
CRS

Statistical Significance (p value)
DES/DDD

Statistical Significance (p value)
Health Choice Arizona

Statistical Significance (p value)
Health Net Access

Statistical Significance (p value)
Mercy Care Plan

Statistical Significance (p value)
Phoenix Health Plan

Statistical Significance (p value)
United Health Care

Statistical Significance (p value)
University Family Care

Statistical Significance (p value)

Statistical Significance (p value)

22

Appendix B – Immunization Schedule

23

24

Appendix C – Technical Specifications

25

26

27

28

29