Arizona Health Care Cost Containment System Quality Management Performance Measures for Acute-care Contractors Measurement Period Ending September 30, 2004 Prepared by the Division of Health Care Management November 2005 Anthony D. Rodgers Director, AHCCCS TABLE OF CONTENTS INTRODUCTION Overview .................................................................................................................... Methodology .............................................................................................................. Data Sources and Quality ........................................................................................... Rotation of Measures ................................................................................................. Highlights of the Data ................................................................................................ Performance Standards and Improvement ................................................................. Feedback .................................................................................................................... 1 1 1 2 2 2 3 RESULTS Children’s Access to Primary Care Practitioners ........................................................ Adults’ Access to Preventive/Ambulatory Health Services ........................................ Well-child Visits in the First 15 Months of Life ......................................................... Well-child Visits in the Third, Fourth, Fifth and Sixth Years of Life ......................... Adolescent Well-care Visits ........................................................................................ Annual Dental Visits ................................................................................................... 4 13 17 19 23 29 DISCUSSION Overall Results ........................................................................................................... Data Limitations ....................……............................................................................. Quality Improvement Efforts ...................................................................................... Conclusion ................................................................................................................... 33 33 33 34 REFERENCES 34 APPENDIX: METHODOLOGY AND TECHNICAL SPECIFICATIONS i INTRODUCTION included in the results of each measure represent only a portion of AHCCCS members, rather than the entire acute-care population. Overview This document is the annual report on performance measures for preventive health services provided to members enrolled with acute-care health plans that contract with the Arizona Health Care Cost Containment System (AHCCCS). These members were eligible for AHCCCS under Medicaid or the State Children’s Health Insurance Program (SCHIP), known as KidsCare. This report includes results for the contract year ending September 30, 2004. Results are reported in aggregate by Maricopa, Pima and the combined rural counties, and by individual Contractor. Where available, national averages for managed care plans reported by NCQA, as measured under HEDIS, are compared with AHCCCS overall rates. The report includes data from eight publicly and privately operated health plans (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 most measures. The report also indicates whether a change in a rate compared with the rate from the previous measurement period is statistically significant; that is, the probability of obtaining such a difference by chance only is relatively low. Changes from the previous measurement are described as increases or decreases only when analysis using the Pearson chi-square test yields a statistically significant value (p<.05). It is important to note that a finding may be statistically significant but may not be clinically or financially significant. 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 have identified areas for improvement and implemented interventions to increase access to, and use of, services. 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. 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. The rates reported for each Contractor and overall may be negatively affected if Contractors have not submitted complete and accurate encounters to AHCCCS for the period being measured. Methodology AHCCCS uses the Health Plan Employer Data and Information Set (HEDIS®) as a guide for collecting and reporting results of 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 of time with one Contractor. Thus, members 1 AHCCCS conducts data validation studies to evaluate the completeness, accuracy and timeliness of its encounter data. Based on the most recent data validation study by AHCCCS, less than 6 percent of all encounters in PMMIS are inaccurate when compared with corresponding medical records. • • Rotation of Measures In 2000, NCQA began to rotate reporting of measures, and AHCCCS adopted a similar reporting schedule in 2003. This rotation allows Contractors an intervention year between reporting of most rates; thus, providing more time to focus activities on improving specific measures. • When analyzed by area, rates for both Medicaid and KidsCare populations were highest in Pima County for all measures except Well-child Visits in the First 15 Months and Annual Dental Visits. Two measures are reported annually: Children’s Access to Primary Care Practitioners (PCPs) and Adults’ Access to Preventive/Ambulatory Health Services. Results for members eligible under Medicaid and those eligible under KidsCare are reported separately for Children’s Access to PCPs, as well as for other pediatric and adolescent measures. Compared with the most recent national HEDIS means (averages) reported by NCQA for Medicaid health plans, AHCCCS Medicaid rates were higher than the national means for some measures and lower for others. Most notably, the AHCCCS Medicaid rates for Well-child Visits in the First 15 Months of Life and Annual Dental Visits were well above the HEDIS national averages for these measures. The rate for Well-child Visits in the First 15 Months of Life was equivalent to the most recent HEDIS average for commercial health plans. Highlights of the Data All acute-care measures except one improved in the most recent measurement period. Results by measure were as follows: • • • members, as most children in this age range qualify for AHCCCS under this program). Well-child Visits in the Third, Fourth, Fifth and Sixth Years of Life – Overall rates for both Medicaid and KidsCare members showed statistically significant increases and reached their highest levels. Adolescent Well-care Visits – Overall rates for both Medicaid and KidsCare members improved from the previous measurement period. Annual Dental Visits – Rates for this measure also reached their highest levels ever for both Medicaid and KidsCare members. Children’s Access to PCPs – Overall rates for both Medicaid and KidsCare members showed statistically significant increases and reached their highest levels since AHCCCS began measuring these rates. Adults’ Access to Preventive/Ambulatory Health Services – This measure also increased by a statistically significant amount. Well-child Visits in the First 15 Months of Life – The overall rate for this measure showed a relative decline of 2.1 percent (the rate includes only Medicaid Performance Standards and Improvement AHCCCS has established performance standards for contracted health plans for these measures. Contractors should meet the AHCCCS Minimum Performance Standard for a particular measure and should try to achieve higher goals established by the agency. Since the last report of these measures, AHCCCS has raised Minimum Performance Standards in order to encourage Contractors to continue improving their rates. 2 School Readiness Board. It appears that this focused effort has contributed to improvements in the rate of well-child visits among this age group during the most recent measurement period. In order to continue improvements in this area and meet AHCCCS goals, the agency has researched evidencebased strategies for improving well-child visits and is working with Contractors to identify and implement a new standardized intervention. Individual Contractor performance varied widely in the most recent measurement. One Contractor, Pima Health System, met or exceeded AHCCCS Minimum Performance Standards for all measures except one. Three Contractors ─ Health Choice Arizona, Mercy Care Plan and University Family Care ─ met or exceeded minimum standards for eight of 10 measures. CMDP met or exceeded minimum standards for four of five measures (CMDP is included in fewer measures than other Contractors because it does not have adults enrolled in the plan and has few members eligible under KidsCare). The data reported here also may be used in developing future Performance Improvement Projects by AHCCCS or individual Contractors. AHCCCS requires corrective action plans from Contractors that do not meet the Minimum Performance Standard for any measure, or that show a statistically significant decline, even if they met the minimum standard. Contractors that fail to show improvement may be subject to sanctions. 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. This is the first measurement for which the health plan has had enough members who met the continuous enrollment criteria to be included in the report. Some Contractors already have corrective action plans in place for Children’s Access to PCPs and Adults’ Access to Preventive/Ambulatory Health Services, based on rates reported by AHCCCS in late 2004. Contractors are now required to report to AHCCCS on a quarterly basis the results of their internal monitoring of Performance Measure rates according to standardized methodology. AHCCCS will monitor closely Contractor-reported rates for each measure, especially for those plans that have not met Minimum Performance Standards. Feedback For questions or comments about this report, please contact: Rochelle Tigner Quality Improvement Manager Division of Health Care Management Clinical Quality Management, MD 6700 701 E. Jefferson St. Phoenix, AZ 85034 602-417-4683 rochelle.tigner@azahcccs.gov AHCCCS will continue to provide technical assistance, such as identifying new interventions or enhancements to existing efforts, to help Contractors improve their performance. For example, AHCCCS began leading a collaborative effort that includes Contractors and some community agencies in early 2004 to improve well-child visits among children 3 through 6 years of age and to support health-related goals of the Governor’s 3 Children’s Access to Primary Care Practitioners Children’s access to primary care services is critical in helping to prevent the premature onset of disease and disability. Research suggests that lack of access to primary care practitioners (PCPs) may result in unnecessary hospitalizations.1,2 National Comparisons The National Committee for Quality Assurance (NCQA) has reported national averages for Medicaid and commercial health plans by age group for this measure. In calendar year 2003, the most recent year for which national data are available, the averages were (commercial averages are shown for comparison with KidsCare members): 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. Age group 1 year 2 – 6 years 7 – 11 years 12 – 19 years Description AHCCCS 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, 2003, through September 30, 2004), • 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. Medicaid ave. 92.0% 81.5% 81.7% 78.9% Commercial ave. 96.3% 88.4% 88.4% 85.7% Current Results and Trends Children eligible under Medicaid: The AHCCCS total rate was 77.3 percent, an increase from the previous measurement period (p<.001). AHCCCS overall rates for Medicaid-eligible children by age group were: 97.0 percent for members 1 year old, 85.1 percent for members 2 through 6 years, 69.2 percent for members 7 through 11 years, and 69.4 percent for members 12 through 20 years. AHCCCS also reports separate rates for children 2 years old and children 3 through 6 years old. Total rates by Contractor ranged from 66.5 percent to 88.5 percent (Table 1). Four of nine Contractors achieved the AHCCCS Minimum Performance Standard and one, CMDP, exceeded the AHCCCS Goal. Performance Goals AHCCCS has adopted a Minimum Performance Standard that Contractors achieve a rate of 79 percent for this measure. If Contractors have already achieved this rate, they should strive for the AHCCCS Goal of 82 percent. The overall rate for Medicaid-eligible children was highest in Pima County, at 80.8 percent, compared with the combined rural counties, at 78.0 percent, and Maricopa County, at 76.0 percent. 4 highest point in the current measurement period. Compared with HEDIS averages, AHCCCS rates for the youngest age groups ─ one year old and 2 through 6 years old ─ were higher than the national Medicaid means. The AHCCCS Medicaid rate for children one year of age is equivalent to the most recent HEDIS commercial average. Fig. 1: Children’s Access to PCPs, 1998-2003 100% 80% Children eligible under KidsCare: The AHCCCS total rate for KidsCare members was 79.1 percent, an increase over the previous measurement period (p<.001). By age group, rates for KidsCare members were: 97.7 percent for members 1 year old, 90.5 percent for members 2 through 6 years, 75.6 percent for members 7 through 11 years, and 74.7 percent for members 12 through 18 years. 60% 40% 20% 0% CYE 1998 Total rates by Contractor ranged from 68.8 percent to 83.0 percent (Table 2). Four of eight Contractors met or exceeded the AHCCCS Minimum Performance Standard and two Contractors, Mercy Care Plan and University Family Care, exceeded the AHCCCS Goal. CYE 1999 CYE 2000 Medicaid Rates for KidsCare members also were highest in Pima County, at 81.4 percent, compared with the combined rural counties and Maricopa County, at 78.8 percent and 78.7 percent, respectively. Compared with HEDIS averages for commercial health plans, AHCCCS rates for KidsCare members also were higher than the national means in the youngest age groups, one year old and 2 through 6 years old. The AHCCCS overall rate for children’s access to PCPs among Medicaid-eligible members has remained above 70 percent since 1998, and is at its highest point in the current measurement period (Figure 1). The overall rate among KidsCare members was 60 percent in 1999, when the rate for this group was first measured, and reached the 5 CYE 2001 CYE 2002 CYE 2003 CYE 2004 KidsCare 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, 2003, through September 30, 2004 Relative % Contractor DES/CMDP * DES/CMDP Pima Health System * Pima Health System University Family Care * University Family Care Age Number of Members Number with > 1 Visits % with > 1 Visits Group 1 369 361 97.8% 2 320 308 96.3% 3-6 887 814 91.8% 7-11 805 670 83.2% 12-20 1,578 1,352 85.7% Total 3,959 3,505 88.5% 1 245 228 93.1% 2 216 189 87.5% 3-6 629 532 84.6% 7-11 678 517 76.3% 12-20 1,678 1,261 75.1% Total 3,446 2,727 79.1% 1 512 506 98.8% 2 371 352 94.9% 3-6 1,254 1,086 86.6% 7-11 1,454 1,093 75.2% 12-20 1,951 1,454 74.5% Total 5,542 4,491 81.0% 1 424 406 95.8% 2 314 297 94.6% 3-6 842 712 84.6% 7-11 1,049 767 73.1% 12-20 1,348 975 72.3% Total 3,977 3,157 79.4% 1 397 388 97.7% 2 335 316 94.3% 3-6 1,252 1,051 83.9% 7-11 1,328 981 73.9% 12-20 1,940 1,437 74.1% Total 5,252 4,173 79.5% 1 472 460 97.5% 2 383 367 95.8% 3-6 1,494 1,284 85.9% 7-11 1,614 1,213 75.2% 12-20 2,113 1,581 74.8% Total 6,076 4,905 80.7% Shaded rows are totals and percentages for the previous measurement period. * Denotes the Contractor met or exceeded the AHCCCS Minimum Performance Standard. 6 Change from Statistical Previous Period Significance 11.9% p<.001 2.1% p=.045 -1.6% p=.091 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, 2003, through September 30, 2004 Relative % Contractor Mercy Care Plan * Mercy Care Plan Health Choice AZ Health Choice AZ AZ Physicians IPA AZ Physicians IPA Age Number of Members Number with > 1 Visits % with > 1 Visits Group 1 5,666 5,521 97.4% 2 4,465 4,219 94.5% 3-6 14,645 12,381 84.5% 7-11 13,470 9,533 70.8% 12-20 15,760 11,058 70.2% Total 54,006 42,712 79.1% 1 6,426 6,230 96.9% 2 4,948 4,618 93.3% 3-6 15,044 12,553 83.4% 7-11 14,458 10,262 71.0% 12-20 16,733 11,943 71.4% Total 57,609 45,606 79.2% 1 2,593 2,519 97.1% 2 2,002 1,840 91.9% 3-6 6,846 5,686 83.1% 7-11 6,019 4,118 68.4% 12-20 6,897 4,732 68.6% Total 24,357 18,895 77.6% 1 2,228 2,148 96.4% 2 1,726 1,598 92.6% 3-6 5,294 4,393 83.0% 7-11 4,696 3,097 65.9% 12-20 4,838 3,253 67.2% Total 18,782 14,489 77.1% 1 6,360 6,161 96.9% 2 5,218 4,849 92.9% 3-6 19,995 16,562 82.8% 7-11 20,888 14,669 70.2% 12-20 25,775 18,065 70.1% Total 78,236 60,306 77.1% 1 6,529 6,302 96.5% 2 5,152 4,737 91.9% 3-6 18,798 15,457 82.2% 7-11 19,979 13,707 68.6% 12-20 23,088 15,877 68.8% Total 73,546 56,080 76.3% Shaded rows are totals and percentages for the previous measurement period. * Denotes the Contractor met or exceeded the AHCCCS Minimum Performance Standard. 7 Change from Statistical Previous Period Significance -0.1% p=.751 0.6% p=.287 1.1% p<.001 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, 2003, through September 30, 2004 Relative % Contractor Phoenix Health Plan/CC Phoenix Health Plan/CC Care 1st Care 1st Maricopa Health Plan Maricopa Health Plan Age Number of Members Number with > 1 Visits % with > 1 Visits Group 1 2,899 2,805 96.8% 2 2,325 2,165 93.1% 3-6 7,728 6,364 82.3% 7-11 7,224 4,940 68.4% 12-20 8,020 5,476 68.3% Total 28,196 21,750 77.1% 1 2,663 2,587 97.1% 2 1,833 1,688 92.1% 3-6 6,394 5,105 79.8% 7-11 6,006 3,883 64.7% 12-20 6,315 4,116 65.2% Total 23,211 17,379 74.9% 1 201 182 90.5% 2 191 158 82.7% 3-6 676 509 75.3% 7-11 764 479 62.7% 12-20 942 605 64.2% Total 2,774 1,933 69.7% 1 N/A N/A N/A 2 N/A N/A N/A 3-6 N/A N/A N/A 7-11 N/A N/A N/A 12-20 N/A N/A N/A Total N/A N/A N/A 1 1,330 1,279 96.2% 2 997 902 90.5% 3-6 3,469 2,569 74.1% 7-11 3,251 1,725 53.1% 12-20 3,615 1,946 53.8% Total 12,662 8,421 66.5% 1 1,372 1,277 93.1% 2 1,147 939 81.9% 3-6 3,462 1,963 56.7% 7-11 3,507 1,321 37.7% 12-20 3,583 1,388 38.7% Total 13,071 6,888 52.7% Shaded rows are totals and percentages for the previous measurement period. * Denotes the Contractor met or exceeded the AHCCCS Minimum Performance Standard. 8 Change from Statistical Previous Period Significance 3.0% p<.001 N/A N/A 26.2% p<.001 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, 2003, through September 30, 2004 Relative % Contractor TOTAL TOTAL Age Number of Members Number with > 1 Visits % with > 1 Visits Group 1 20,327 19,722 97.0% 2 16,224 15,109 93.1% 3-6 56,752 47,022 82.9% 7-11 55,203 38,208 69.2% 12-20 66,478 46,125 69.4% Total 214,984 166,186 77.3% 1 20,359 19,638 96.5% 2 15,719 14,433 91.8% 3-6 51,957 41,999 80.8% 7-11 51,987 34,767 66.9% 12-20 59,696 40,394 67.7% Total 199,718 151,231 75.7% Shaded rows are totals and percentages for the previous measurement period. * Denotes the Contractor met or exceeded the AHCCCS Minimum Performance Standard. 9 Change from Statistical Previous Period Significance 2.1% 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, 2003, through September 30, 2004 Relative % Contractor Mercy Care Plan * Mercy Care Plan University Family Care * University Family Care Health Choice AZ * Health Choice AZ Age Number of Members Number with > 1 Visits % with > 1 Visits Group 1 62 62 100.0% 2 346 336 97.1% 3-6 1,244 1,130 90.8% 7-11 12-18 2,107 1,672 79.4% 1,991 1,570 78.9% Total 5,750 4,770 83.0% 1 70 66 94.3% 2 336 314 93.5% 3-6 1,215 1,060 87.2% 7-11 12-18 2,060 1,590 77.2% 2,018 1,597 79.1% Total 5,699 4,627 81.2% 1 3 3 100.0% 2 16 16 100.0% 3-6 81 75 92.6% 7-11 12-18 214 171 79.9% 338 275 81.4% Total 652 540 82.8% 1 5 5 100.0% 2 37 36 97.3% 3-6 113 95 84.1% 7-11 12-18 277 222 80.1% 401 322 80.3% Total 833 680 81.6% 1 20 19 95.0% 2 107 105 98.1% 3-6 528 480 90.9% 7-11 12-18 817 636 77.8% 882 659 74.7% Total 2,354 1,899 80.7% 1 12 12 100.0% 2 88 83 94.3% 3-6 390 354 90.8% 7-11 12-18 550 423 76.9% 489 377 77.1% Total 1,529 1,249 81.7% Shaded rows are totals and percentages for the previous measurement period. * Denotes the Contractor met or exceeded the AHCCCS Minimum Performance Standard. 10 Change from Statistical Previous Period Significance 2.2% p=.014 1.5% p=.552 -1.2% p=.430 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, 2003, through September 30, 2004 Relative % Contractor Pima Health System * Pima Health System Phoenix Health Plan/CC Phoenix Health Plan/CC AZ Physicians IPA AZ Physicians IPA Age Number Group of Members Number with > 1 Visits % with > 1 Visits 1 6 6 100.0% 2 13 12 92.3% 3-6 62 58 93.5% 7-11 12-18 162 131 80.9% 215 160 74.4% Total 458 367 80.1% 1 2 2 100.0% 2 20 20 100.0% 3-6 34 33 97.1% 7-11 12-18 109 80 73.4% 126 97 77.0% Total 291 232 79.7% 1 44 41 93.2% 2 204 199 97.5% 3-6 708 637 90.0% 7-11 12-18 1271 949 74.7% 1087 782 71.9% Total 3,314 2,608 78.7% 1 40 37 92.5% 2 146 135 92.5% 3-6 650 559 86.0% 7-11 12-18 942 687 72.9% 771 537 69.6% Total 2,549 1,955 76.7% 1 70 69 98.6% 2 303 286 94.4% 3-6 1,322 1,160 87.7% 7-11 12-18 2,938 2,169 73.8% 3,170 2,366 74.6% Total 7,803 6,050 77.5% 1 79 75 94.9% 2 320 303 94.7% 3-6 1,344 1,171 87.1% 7-11 12-18 2,704 2,002 74.0% 2,928 2,162 73.8% Total 7,375 5,713 77.5% Shaded rows are totals and percentages for the previous measurement period. * Denotes the Contractor met or exceeded the AHCCCS Minimum Performance Standard. 11 Change from Statistical Previous Period Significance 0.5% p=.892 2.6% p=.068 0.1% p=.918 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, 2003, through September 30, 2004 Relative % Contractor Care 1st Care 1st Maricopa Health Plan Maricopa Health Plan TOTAL TOTAL Age Number of Members Number with > 1 Visits % with > 1 Visits Group 1 1 1 100.0% 2 3 2 66.7% 3-6 33 30 90.9% 7-11 12-18 86 60 69.8% 81 53 65.4% Total 204 146 71.6% 1 N/A N/A N/A 2 N/A N/A N/A 3-6 N/A N/A N/A 7-11 12-18 N/A N/A N/A N/A N/A N/A Total N/A N/A N/A 1 10 10 100.0% 2 66 63 95.5% 3-6 310 249 80.3% 7-11 12-18 463 305 65.9% 377 216 57.3% Total 1,226 843 68.8% 1 16 16 100.0% 2 88 73 83.0% 3-6 294 192 65.3% 7-11 12-18 435 214 49.2% 305 125 41.0% Total 1,138 620 54.5% 1 216 211 97.7% 2 1,058 1,019 96.3% 3-6 4,288 3,819 89.1% 7-11 12-18 8,058 6,093 75.6% 8,141 6,081 74.7% Total 21,761 17,223 79.1% 1 224 213 95.1% 2 1,035 964 93.1% 3-6 4,040 3,464 85.7% 7-11 12-18 7,077 5,218 73.7% 7,038 5,217 74.1% Total 19,414 15,076 77.7% Shaded rows are totals and percentages for the previous measurement period. * Denotes the Contractor met or exceeded the AHCCCS Minimum Performance Standard. 12 Change from Statistical Previous Period Significance N/A N/A 26.2% p<.001 1.9% p<.001 Adults’ Access to Preventive/Ambulatory Health Services achieved this rate, they should strive for an AHCCCS-established Goal of 82 percent. Three behaviors – tobacco use, poor nutrition and lack of physical activity – are major contributors to some of this country’s leading killers: cardiovascular disease, cancer and diabetes. These behaviors often worsen the complications of chronic diseases like diabetes, and increase the risk of developing other serious illnesses. 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 2003, the most recent year for which national data are available, the rates were: 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. Age group 20 – 44 years 45 – 64 years Medicaid ave. 74.9% 81.0% Commercial ave. 92.5% 94.5% Current Results and Trend The AHCCCS total rate was 77.8 percent, an increase over the previous measurement period (p<.001). By age group, AHCCCS overall rates were 75.5 percent for members 21 to 44 years and 83.1 percent for members 45 to 64 years, surpassing the most recent HEDIS Medicaid averages for both groups. Description AHCCCS measured the percentage of members who: • were ages 21 through 64 years at the end of the measurement period (October 1, 2003, through September 30, 2004), • 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. Total rates by Contractor ranged from 68.8 percent to 79.8 percent. None of the eight Contractors met the AHCCCS Minimum Performance Standard (Table 3). The overall rate for this measure was highest in Pima County, at 79.7 percent, compared with the combined rural counties and Maricopa County, at 77.5 percent and 77.2 percent, respectively. Results were analyzed overall and for two age groups: 21 through 44 and 45 through 64 years. The AHCCCS overall rate for this measure is at its highest point in the current measurement period (Figure 2). Performance Goals AHCCCS has adopted a Minimum Performance Standard that Contractors achieve a total rate of at least 80 percent for this measure. If Contractors have already 13 Fig. 2: Adults’ Access to Care, 1998-2003 100% 80% 60% 40% 20% 0% CYE 1998 CYE 1999 CYE 2000 CYE 2001 CYE 2002 CYE 2003 CYE 2004 14 Table 3 Arizona Health Care Cost Containment System ADULTS' ACCESS TO PREVENTIVE/AMBULATORY HEALTH SERVICES, BY CONTRACTOR Measurement Period: October 1, 2003, through September 30, 2004 Relative % Contractor Mercy Care Plan Mercy Care Plan University Family Care University Family Care Pima Health System Pima Health System AZ Physicians IPA AZ Physicians IPA Phoenix Health Plan/CC Phoenix Health Plan/CC Health Choice AZ Health Choice AZ Age Number Group of Members Number with > 1 Visits % with > 1 Visits 21-44 20,531 15,925 77.6% 45-64 8,356 7,128 85.3% Total 28,887 23,053 79.8% 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 2,175 1,664 76.5% 45-64 1,079 913 84.6% Total 3,254 2,577 79.2% 21-44 2,486 1,854 74.6% 45-64 1,111 916 82.4% Total 3,597 2,770 77.0% 21-44 2,187 1,644 75.2% 45-64 1,179 985 83.5% Total 3,366 2,629 78.1% 21-44 1,692 1,245 73.6% 45-64 724 589 81.4% Total 2,416 1,834 75.9% 21-44 31,117 23,448 75.4% 45-64 12,554 10,536 83.9% Total 43,671 33,984 77.8% 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 9,024 6,875 76.2% 45-64 3,294 2,711 82.3% Total 12,318 9,586 77.8% 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 8,754 6,593 75.3% 45-64 3,459 2,774 80.2% Total 12,213 9,367 76.7% 21-44 6,443 4,796 74.4% 45-64 2,159 1,740 80.6% Total 8,602 6,536 76.0% Shaded rows are totals and percentages for the previous measurement period. * Denotes the Contractor met or exceeded the AHCCCS Minimum Performance Standard. 15 Change from Statistical Previous Period Significance 1.7% p<.001 2.8% p=.029 2.9% p=.050 2.0% p<.001 2.9% p<.001 0.9% p=.232 Table 3 Arizona Health Care Cost Containment System ADULTS' ACCESS TO PREVENTIVE/AMBULATORY HEALTH SERVICES, BY CONTRACTOR Measurement Period: October 1, 2003, through September 30, 2004 Relative % Contractor Care 1st Care 1st Maricopa Health Plan Maricopa Health Plan TOTAL TOTAL Age Number of Members Number with > 1 Visits % with > 1 Visits Group 21-44 1,024 715 69.8% 45-64 375 272 72.5% Total 1,399 987 70.6% 21-44 N/A N/A N/A 45-64 N/A N/A N/A Total N/A N/A N/A 21-44 3,114 2,008 64.5% 45-64 1,820 1,385 76.1% Total 21-44 4,934 3,220 3,393 1,873 68.8% 58.2% 45-64 Total 1,703 4,923 1,236 3,109 72.6% 63.2% 21-44 77,926 58,872 75.5% 45-64 32,116 26,704 83.1% Total 110,042 85,576 77.8% 21-44 45-64 72,257 26,358 53,545 21,631 74.1% 82.1% Total 98,615 75,176 76.2% Shaded rows are totals and percentages for the previous measurement period. * Denotes the Contractor met or exceeded the AHCCCS Minimum Performance Standard. 16 Change from Statistical Previous Period Significance N/A N/A 8.9% p<.001 2.0% p<.001 Well-child Visits in the First 15 Months of Life The most dramatic growth during childhood – physical, cognitive, social and emotional – occurs during infancy. In the first year of life, an infant’s birth weight triples, his length increases by almost 50 percent, and he achieves most of his brain growth.3 Current Results and Trend The AHCCCS overall Medicaid rate was 66.9 percent, a decline from the previous period (p=.005). However, compared with the most recent HEDIS results for Medicaid health plans, the AHCCCS rate is above the 90th percentile nationally, and is comparable to the most recent commercial average. During this time, health care providers help ensure that children are adequately protected against infectious diseases by vaccinating them at appropriate intervals, and screening for physical illness or developmental delays, which can be minimized with early intervention. This also is an ideal time to counsel parents about infant care, nutrition, sleep position and injury prevention. Individual Contractor rates ranged from 50.0 percent to 72.5 percent (Table 4). Two of eight Contractors achieved the AHCCCS Minimum Performance Standard and one, Pima Health System, met the Goal. Rates were highest in the combined rural counties, at 68.2 percent, compared with Pima and Maricopa counties, at 66.9 percent and 66.6 percent, respectively. Description AHCCCS measured the percentage of children who: • turned 15 months of age during the measurement period (October 1, 2003, through September 30, 2004), • were continuously enrolled with one acute-care Contractor from 31 days of age (one break in enrollment, not exceeding 31 days, was allowed), and • had six or more well-child visits during the first 15 months of life. The AHCCCS overall rate for this measure has risen from 57.6 percent in CYE 1996 and was at its highest point in CYE 2002. There were not enough KidsCare members who met the enrollment criteria to measure a rate for this group. Fig. 3: Well-child Visits: 15 Months, 1996-2004 100% Performance Goals AHCCCS has adopted a Minimum Performance Standard that Contractors achieve a rate of at least 70 percent for this measure. If Contractors have already achieved this rate, they should strive for the AHCCCS Goal of 72 percent. 80% 60% 40% 20% National Comparison NCQA has reported a national average of 44.5 percent for Medicaid health plans for this measure in calendar year 2003. The average for commercial plans that year was 66.6 percent. 0% CYE 1996 CYE 1997 CYE 1998 CYE 1999 CYE 2000 CYE 2001 CYE 2002 CYE 2004 Note: In 1998, AHCCCS increased the minimum number of well-child visits for this age group from five to six 17 Table 4 Arizona Health Care Cost Containment System WELL-CHILD VISITS IN THE FIRST 15 MONTHS OF LIFE, BY CONTRACTOR MEMBERS ELIGIBLE UNDER MEDICAID Measurement Period: October 1, 2003, through September 30, 2004 Relative % Number Contractor Pima Health System * Health Choice AZ * Mercy Care Plan AZ Physicians IPA University Family Care Maricopa Health Plan Phoenix Health Plan/CC DES/CMDP TOTAL of Members Number with > 6 Visits % with > 6 Visits 382 277 72.5% 322 253 78.6% 1,971 1,395 70.8% 1,869 1,241 66.4% 5,004 3,484 69.6% 5,058 3,408 67.4% 5,730 3,780 66.0% 5,142 3,571 69.4% 415 267 64.3% 417 320 76.7% 1,274 799 62.7% 1,200 796 66.3% 2,168 1,353 62.4% 1,691 1,150 68.0% 74 37 50.0% 33 19 57.6% 17,018 11,392 66.9% 15,732 10,758 68.4% Change from Previous Period Significance -7.7% p=.063 6.6% p=.003 3.3% p=.015 -5.0% p<.001 -16.2% p<.001 -5.5% p=.060 -8.2% p<.001 -13.2% p=.469 -2.1% p=.005 Shaded rows are totals and percentages for the previous measurement period. * Denotes the Contractor met or exceeded the AHCCCS Minimum Performance Standard. 18 Statistical Well-child Visits in the Third, Fourth, Fifth and Sixth Years of Life average of 59.9 percent for Medicaid health plans for this measure in calendar year 2003. The average for commercial plans was 62.7 percent. Children who are healthy are better able to learn and develop.1,4,5 Well-child visits during the preschool and early school years are important in helping children reach their full potential and become productive, healthy adults. These visits allow any medical, behavioral or developmental problems to be detected and addressed. Current Results and Trend Children eligible under Medicaid: The AHCCCS overall rate for Medicaid-eligible members in the current measurement period was 56.4 percent, an increase over the previous measurement period (p<.001). The overall rate fell short of the HEDIS national averages. Health care providers also can administer any needed vaccines and educate parents about adequate nutrition, oral health and injury prevention during well-child visits. Some evidence shows that provider counseling can increase the use of seat belts, child safety seats and bicycle helmets, especially when directed at the parents of young children. Individual Contractor rates ranged from 53.7 percent to 67.4 percent (Table 5). Six of nine Contractors achieved the AHCCCS Minimum Performance Standard and one health plan, CMDP, met the Goal. Description AHCCCS measured the percentage of children who: • were 3, 4, 5, or 6 years old at the end of the measurement period (October 1, 2003, through September 30, 2004), • were continuously enrolled with one acute-care Contractor during the measurement period (one break in enrollment, not exceeding 31 days, was allowed), and • had at least one well-child visit during the measurement period. Rates were highest in Pima County, at 57.7 percent, compared with Maricopa and the combined rural counties, at 56.7 percent and 54.7 percent, respectively. Children eligible under KidsCare: The overall rate for this group was 61.0 percent, an increase over the previous rate (p<.001). This rate was slightly under the HEDIS national average for commercial health plans. Performance Goals AHCCCS has adopted a Minimum Performance Standard that Contractors achieve a rate of at least 55 percent for this indicator. If Contractors have already achieved this rate, they should strive for the AHCCCS Goal of 67 percent. Individual Contractor rates ranged from 54.5 percent to 68.0 percent (Table 6). Seven Contractors achieved the Minimum Standard and Health Choice Arizona met the Goal. By county, overall rates for KidsCare members were highest in Pima County, at 63.5 percent, compared with Maricopa and the combined rural counties, at 61.2 percent and 58.0 percent, respectively. National Comparison The National Committee for Quality Assurance (NCQA) has reported a national 19 The AHCCCS overall rate for Medicaideligible members for this measure has increased from 43.3 percent in 1996 to its highest point in the current measurement period (Figure 4). A rate for KidsCare members has only been measured for two periods, CYE 2002 and the current period. Fig. 4: Well-child Visits: 3 – 6 Years, 1996-2004 100% 80% 60% 40% 20% 0% CYE 1996 CYE 1997 CYE 1998 CYE 1999 CYE 2000 CYE 2001 CYE 2002 CYE 2004 20 Table 5 Arizona Health Care Cost Containment System WELL-CHILD VISITS IN THE THIRD, FOURTH, FIFTH & SIXTH YEARS OF LIFE, BY CONTRACTOR MEMBERS ELIGIBLE UNDER MEDICAID Measurement Period: October 1, 2003, through September 30, 2004 Contractor DES/CMDP * Relative % Percent with Change from >1 Visits Previous Period Number of Members Number with >1 Visits 887 598 67.4% 539 331 61.4% 6,846 3,986 58.2% 4,468 2,401 53.7% 14,645 8,306 56.7% 12,350 6,156 49.8% 19,995 11,327 56.6% 16,391 8,559 52.2% Pima Health System * 1,254 696 55.5% 675 366 54.2% University Family Care * 1,252 694 55.4% 1,267 649 51.2% 676 369 54.6% N/A N/A N/A Health Choice AZ * Mercy Care Plan * AZ Physicians IPA * Care 1st Maricopa Health Plan Phoenix Health Plan/CC TOTAL 3,469 1,880 54.2% 3,014 1,499 49.7% 7,728 4,151 53.7% 5,373 2,795 52.0% 56,752 32,007 56.4% 43,538 22,425 51.5% Shaded rows are totals and percentages for the previous measurement period. * Denotes the Contractor met or exceeded the AHCCCS Minimum Performance Standard. 21 Statistical Significance 9.8% p=.021 8.3% p<.001 13.8% p<.001 8.5% p<.001 2.4% p=.590 8.2% p=.034 N/A N/A 9.0% p<.001 3.3% p=.056 9.5% p<.001 Table 6 Arizona Health Care Cost Containment System WELL-CHILD VISITS IN THE THIRD, FOURTH, FIFTH & SIXTH YEARS OF LIFE, BY CONTRACTOR MEMBERS ELIGIBLE UNDER KIDSCARE Measurement Period: October 1, 2003, through September 30, 2004 Relative % Number Contractor Health Choice AZ * Pima Health System * Mercy Care Plan * University Family Care * Phoenix Health Plan/CC Maricopa Health Plan AZ Physicians IPA * Care 1st TOTAL * * of Members Number with >1 Visits % with > 1 Visits Change from Statistical Previous Period Significance 528 359 68.0% 408 266 65.2% 4.3% p=.368 62 39 62.9% 38 24 63.2% -0.4% p=.980 1,244 778 62.5% 19.5% p<.001 1,120 586 52.3% 81 50 61.7% 4.3% p=.716 120 71 59.2% 708 431 60.9% 594 385 64.8% -6.1% p=.143 310 184 59.4% 314 190 60.5% -1.9% p=.769 1,322 755 57.1% 7.3% p=.041 1,439 766 53.2% 33 18 54.5% N/A N/A N/A N/A N/A 7.5% p<.001 4,288 2,614 61.0% 4,033 2,288 56.7% Shaded rows are totals and percentages for the previous measurement period. * Denotes the Contractor met or exceeded the AHCCCS Minimum Performance Standard. 22 Adolescent Well-care Visits achieve a rate of at least 32 percent for this measure. If Contractors have already achieved this rate, they should strive for the AHCCCS Goal of 34 percent. Adolescence generally is characterized by good health. However, data indicate that many teenagers are involved in unhealthy behaviors, including alcohol and other drug use, tobacco use, unprotected sex, driving without seat belts and speeding, poor diet and inadequate physical activity. Nationally and in Arizona, the major causes of death in adolescents are motor vehicle accidents, other unintentional injuries, homicide, and suicide.6,7 National Comparison NCQA has reported an overall average of 37.6 percent for Medicaid health plans for this indicator in calendar year 2003. The overall average for commercial plans was 37.1 percent. Since most of the risk factors that contribute to adolescent morbidity and mortality are preventable, it is crucial to identify early signs of risk-taking or unhealthy behaviors. Regular well-care visits that address the psychological, behavioral and physical aspects of health are very important in helping adolescents become healthy adults. Current Results and Trend Members eligible under Medicaid: The AHCCCS overall rate for Medicaid-eligible members in the current measurement period was 32.6 percent, an increase over the previous measurement period (p<.001). The AHCCCS rate fell short of the HEDIS national average for Medicaid plans. Description This indicator measured the percentage of members who: • were ages 11 through 20 years if eligible under Medicaid, or 11 through 18 years if eligible under KidsCare, at the end of the measurement period (October 1, 2003, through September 30, 2004), • were continuously enrolled with one acute-care Contractor during the measurement period (one break in enrollment, not exceeding 31 days, was allowed), and • had at least one well-care visit during the measurement period. Individual Contractor rates ranged from 24.7 percent to 62.1 percent (Table 7). Six of nine Contractors achieved the AHCCCS Minimum Performance Standard and three health plans ─ CMDP, Pima Health System and University Family Care ─ met or exceeded the Goal. Rates for Medicaid-eligible members were highest in Pima County, at 39.2 percent, compared with the combined rural counties and Maricopa County, at 31.8 percent and 30.8 percent, respectively. Results are reported overall and separately for two age groups, 11 through 15 years and 16 years and older. Members eligible under KidsCare: The overall rate for this group was 37.2 percent, an increase over the previous rate (p=.014). This rate is equivalent to the HEDIS national average for commercial health plans. Performance Goals AHCCCS has adopted a Minimum Performance Standard that Contractors 23 Individual Contractor rates for the KidsCare population ranged from 27.4 percent to 46.6 percent (Table 8). Seven of eight Contractors achieved the Minimum Standard and six of those plans met the Goal. By county, overall rates for KidsCare members were highest in Pima County, at 45.0 percent, compared with the combined rural counties and Maricopa County, at 35.5 percent and 35.2 percent, respectively. AHCCCS has not measured adolescent wellcare visits in a one-year period long enough to establish a trend. Previously, Contractors were measured against a standard for visits over a two-year period. 24 Table 7 Arizona Health Care Cost Containment System ANNUAL ADOLESCENT WELL-CARE VISITS, BY CONTRACTOR MEMBERS ELIGIBLE UNDER MEDICAID Measurement Period October 1, 2003, through September 30, 2004 Relative % Age Contractor DES/CMDP * DES/CMDP University Family Care * University Family Care Pima Health System * Pima Health System AZ Physicians IPA * AZ Physicians IPA Health Choice AZ * Health Choice AZ Mercy Care Plan * Mercy Care Plan Number Number with % with Group of Members >1 Visits > 1 Visits 11-15 1,316 831 63.1% 16-20 431 254 58.9% Total 1,747 1,085 62.1% 11-15 1,307 805 61.6% 16-20 334 176 52.7% Total 1,641 981 59.8% 11-15 1,679 704 41.9% 16-20 575 152 26.4% Total 2,254 856 38.0% 11-15 1,525 608 39.9% 16-20 487 111 22.8% Total 2,012 719 35.7% 11-15 1,590 632 39.7% 16-20 662 152 23.0% Total 2,252 784 34.8% 11-15 959 380 39.6% 16-20 318 67 21.1% Total 1,277 447 35.0% 11-15 22,020 7,826 35.5% 16-20 7,747 1,964 25.4% Total 29,767 9,790 32.9% 11-15 16,836 5,567 33.1% 16-20 5,240 1,216 23.2% Total 22,076 6,783 30.7% 11-15 5,948 2,076 34.9% 16-20 2,092 543 26.0% Total 8,040 2,619 32.6% 11-15 3,548 1,139 32.1% 16-20 1,089 289 26.5% Total 4,637 1,428 30.8% 11-15 13,326 4,597 34.5% 16-20 4,997 1,352 27.1% Total 18,323 5,949 32.5% 11-15 11,284 3,651 32.4% 16-20 3,965 953 24.0% Total 15,249 4,604 30.2% Shaded rows are totals and percentages for the previous measurement period. * Denotes the Contractor met or exceeded the AHCCCS Minimum Performance Standard. 25 Change from Statistical Previous Period Significance 3.9% p=.165 6.3% p=.130 -0.5% p=.909 7.0% p<.001 5.8% p=.039 7.5% p<.001 Table 7 Arizona Health Care Cost Containment System ANNUAL ADOLESCENT WELL-CARE VISITS, BY CONTRACTOR MEMBERS ELIGIBLE UNDER MEDICAID Measurement Period October 1, 2003, through September 30, 2004 Relative % Age Contractor Care 1st Care 1st Phoenix Health Plan/CC Phoenix Health Plan/CC Maricopa Health Plan Maricopa Health Plan TOTAL TOTAL Number Number with % with Group of Members >1 Visits > 1 Visits 11-15 793 256 32.3% 16-20 299 80 26.8% Total 1,092 336 30.8% 11-15 N/A N/A N/A 16-20 N/A N/A N/A Total N/A N/A N/A 11-15 6,909 2,054 29.7% 16-20 2,443 583 23.9% Total 9,352 2,637 28.2% 11-15 4,702 1,389 29.5% 16-20 1,398 254 18.2% Total 6,100 1,643 26.9% 11-15 3,220 877 27.2% 16-20 1,055 181 17.2% Total 4,275 1,058 24.7% 11-15 2,677 682 25.5% 16-20 784 146 18.6% Total 3,461 828 23.9% 11-15 56,801 19,853 35.0% 16-20 20,301 5,261 25.9% Total 77,102 25,114 32.6% 11-15 42,838 14,221 33.2% 16-20 13,615 3,212 23.6% Total 56,453 17,433 30.9% Shaded rows are totals and percentages for the previous measurement period. * Denotes the Contractor met or exceeded the AHCCCS Minimum Performance Standard. 26 Change from Statistical Previous Period Significance N/A N/A 4.7% p=.086 3.4% p=.401 5.5% p<.001 Table 8 Arizona Health Care Cost Containment System ANNUAL ADOLESCENT WELL-CARE VISITS, BY CONTRACTOR MEMBERS ELIGIBLE UNDER KIDSCARE Measurement Period October 1, 2003, through September 30, 2004 Relative % Contractor University Family Care * Pima Health System * Mercy Care Plan * Health Choice AZ * AZ Physicians IPA * Care 1st * Age Number Number with % with Group of Members >1 Visits > 1 Visits 11-15 321 156 48.6% 16-18 72 27 37.5% Total 393 183 46.6% 11-15 360 170 47.2% 16-18 97 28 28.9% Total 457 198 43.3% 11-15 209 88 42.1% 16-18 42 14 33.3% Total 251 102 40.6% 11-15 96 54 56.3% 16-18 20 8 40.0% Total 116 62 53.4% 11-15 1,997 841 42.1% 16-18 378 109 28.8% Total 2,375 950 40.0% 11-15 1,846 692 37.5% 16-18 406 110 27.1% Total 2,252 802 35.6% 11-15 871 359 41.2% 16-18 176 50 28.4% Total 1,047 409 39.1% 11-15 469 177 37.7% 16-18 77 21 27.3% Total 546 198 36.3% 11-15 3,060 1159 37.9% 16-18 683 211 30.9% Total 3,743 1,370 36.6% 11-15 2,782 951 34.2% 16-18 614 147 23.9% Total 3,396 1,098 32.3% 11-15 76 29 38.2% 16-18 20 4 20.0% Total 96 33 34.4% 11-15 N/A N/A N/A 16-18 N/A N/A N/A Total N/A N/A N/A Shaded rows are totals and percentages for the previous measurement period. * Denotes the Contractor met or exceeded the AHCCCS Minimum Performance Standard. 27 Change from Statistical Previous Period Significance 7.5% p=.344 -24.0% p=.022 12.3% p=.002 7.7% p=.275 13.2% p<.001 N/A N/A Table 8 Arizona Health Care Cost Containment System ANNUAL ADOLESCENT WELL-CARE VISITS, BY CONTRACTOR MEMBERS ELIGIBLE UNDER KIDSCARE Measurement Period October 1, 2003, through September 30, 2004 Relative % Contractor Phoenix Health Plan/CC Maricopa Managed Care TOTAL TOTAL * Age Number Number with % with Group of Members >1 Visits > 1 Visits 11-15 1,113 376 33.8% 16-18 179 42 23.5% Total 1,292 418 32.4% 11-15 712 263 36.9% 16-18 144 39 27.1% Total 856 302 35.3% 11-15 384 108 28.1% 16-18 65 15 23.1% Total 449 123 27.4% 11-15 304 90 29.6% 16-18 47 10 21.3% Total 351 100 28.5% 11-15 8,031 3,116 38.8% 16-18 1,615 472 29.2% Total 9,646 3,588 37.2% 11-15 6,569 2,397 36.5% 16-18 1,405 363 25.8% Total 7,974 2,760 34.6% Shaded rows are totals and percentages for the previous measurement period. * Denotes the Contractor met or exceeded the AHCCCS Minimum Performance Standard. 28 Change from Statistical Previous Period Significance -8.3% p=.159 -3.8% p=.732 7.5% p=.014 Annual Dental Visits achieve a rate of at least 49 percent for this indicator. If Contractors have already achieved this rate, they should strive for the AHCCCS Goal of 56 percent. Oral health is inseparable from overall health status. A child's ability to learn and function well can be affected by problems of the teeth and gums. But, while most oral diseases are preventable, tooth decay is one of the most common health problems among children today. National Comparison The National Committee for Quality Assurance (NCQA) has reported a national average of 39.4 percent for Medicaid health plans for this measure in calendar year 2003. The measure applies to Medicaid plans only. Brushing, flossing and other oral health practices can reduce the risk of developing diseases of the teeth and gums. Regular professional dental care also is important. Preventive services, such as the application of topical fluorides and dental sealants, are known to reduce the rate of tooth decay and other oral diseases in children. Routine dental visits serve to educate individuals about dental hygiene and preventive measures. Current Results and Trend Children eligible under Medicaid: The AHCCCS overall rate for Medicaideligible members was 53.9 percent, an increase over the previous measurement period (p<.001). The AHCCCS rate is just below the HEDIS 90th-percentile rate of 55.3 percent for Medicaid plans. Description AHCCCS measured the percentage of children who: • were ages 3 through 20 years if eligible under Medicaid, or 3 through 18 years if eligible under KidsCare, at the end of the measurement period (October 1, 2003, through September 30, 2004), • were continuously enrolled with one acute-care Contractor during the measurement period (one break in enrollment, not exceeding 31 days, was allowed), and • had at least one dental visit during the measurement period. By Contractor, rates ranged from 37.9 percent to 70.2 percent (Table 9). Eight of nine Contractors achieved the AHCCCS Minimum Performance Standard and four health plans met or exceeded the Goal. Rates were highest in Maricopa County, at 55.2 percent, compared with Pima and the combined rural counties, at 54.4 percent and 50.8 percent, respectively. Children eligible under KidsCare: The overall rate for this group was 63.5 percent, a 9.9-percent relative increase over the previous rate (p<.001). Results were analyzed by the proportion of members who received either preventive dental services only, treatment only, or both preventive services and treatment. Individual Contractor rates ranged from 50.9 percent to 69.2 percent (Table10). All eight Contractors achieved the AHCCCS Minimum Standard and seven exceeded the Goal. Performance Goals AHCCCS has adopted a Minimum Performance Standard that Contractors 29 By county, overall rates for KidsCare members were highest in Maricopa County, at 66.2 percent, compared with Pima and the combined rural counties, at 61.9 percent and 58.0 percent, respectively. The AHCCCS overall rate for Medicaideligible members for this measure has increased from 31.8 percent in 1996 to its highest point in the current measurement period (Figure 6). A rate for KidsCare members has only been measured for two periods, CYE 2002 and the current period. Fig. 6: Annual Dental Visits, 1996-2004 100% 80% 60% 40% 20% 0% CYE 1996 CYE 1997 CYE 1998 CYE 1999 CYE 2000 CYE 2001 CYE 2002 CYE 2004 30 Table 9 Arizona Health Care Cost Containment System ANNUAL DENTAL VISITS, BY CONTRACTOR MEMBERS ELIGIBLE UNDER MEDICAID Measurement Period: October 1, 2003, through September 30, 2004 Number with % with Number of Any Dental Any Dental Change from Statistical Members Visit Visit Previous Period Significance DES/CMDP * 3,270 2,295 70.2% 1.8% p=.290 2,670 1,840 68.9% Health Choice AZ * 19,762 11,582 58.6% 24.1% p<.001 12,422 5,865 47.2% 22,972 12,926 56.3% 12.5% p<.001 15,554 7,782 50.0% 43,875 24,669 56.2% 10.9% p<.001 37,299 18,907 50.7% Pima Health System * 4,659 2,472 53.1% 15.0% p<.001 2,664 1,229 46.1% AZ Physicians IPA * 66,658 34,731 52.1% 10.8% p<.001 52,702 24,793 47.0% 4,520 2,346 51.9% 14.4% p<.001 4,507 2,045 45.4% 2,382 1,203 50.5% N/A N/A N/A N/A N/A 10,335 3,921 37.9% -13.7% p<.001 8,986 3,950 44.0% 11.0% p<.001 Contractor Phoenix Health Plan/CC * Mercy Care Plan * University Family Care * Care 1st * Maricopa Health Plan TOTAL 178,433 96,145 53.9% 136,804 66,411 48.5% Shaded rows are totals and percentages for the previous measurement period. * Denotes the Contractor met or exceeded the AHCCCS Minimum Performance Standard. 31 Relative % Table 10 Arizona Health Care Cost Containment System ANNUAL DENTAL VISITS, BY CONTRACTOR MEMBERS ELIGIBLE UNDER KIDSCARE Measurement Period: October 1, 2003, through September 30, 2004 Contractor Phoenix Health Plan/CC Health Choice AZ * Mercy Care Plan * Pima Health System* University Family Care * Care 1st * AZ Physicians IPA * Maricopa Health Plan TOTAL * * Number with % with Number of Any Dental Any Dental Change from Statistical Members Visit Visit Previous Period Significance 3,066 2,123 69.2% 8.4% p<.001 2,198 1,404 63.9% 2,227 1,538 69.1% 21.4% p<.001 1,431 814 56.9% 5,342 3,644 68.2% 9.8% p<.001 4,958 3,081 62.1% 439 264 60.1% -4.6% p=.462 238 150 63.0% 633 377 59.6% 13.1% p=.009 790 416 52.7% 200 119 59.5% N/A N/A 11.3% p<.001 -18.5% p<.001 9.9% p<.001 N/A N/A N/A 7,430 4,364 58.7% 7,107 3,750 52.8% 1,150 585 50.9% 1,053 657 62.4% 20,487 13,014 63.5% 17,775 10,272 57.8% Shaded rows are totals and percentages for the previous measurement period. * Denotes the Contractor met or exceeded the AHCCCS Minimum Performance Standard. 32 Relative % DISCUSSION focused efforts more intensely on ensuring children 3 to 6 years of age receive their annual well-child visits. Overall Results The data reported here indicate that children and adults enrolled with AHCCCS have a high degree of access to the health care system. Consistent with previous measurements, children enrolled with AHCCCS Contractors through KidsCare have higher overall rates of preventive services than those enrolled under Medicaid. Depending on their incomes, parents of KidsCare members may pay a premium for coverage and thus may be more likely to ensure that their children receive covered benefits, including well-care visits. These parents also may have a higher level of education and a better understanding of the value of preventive health care services. Data Limitations As previously described, rates for each measure are based on AHCCCS encounter data. Data submitted by Contractors is processed monthly, with approximately 600 edits that examine the accuracy of encounter data. If errors are found, the encounter is “pended” and must be corrected by the Contractor before it is finalized. Numerator data for these measures include only finalized encounters. Therefore, services may have been provided, but if the associated encounters have not been submitted or finalized, the data reported here will not reflect those services. These data also show that, even though AHCCCS raised performance standards since the last measurement, many Contractors are meeting these new expectations. However, ensuring that adult members use preventive services continues to be a challenge for contracted health plans. This may be due to lack of knowledge among members about when and what types of routine preventive health services are recommended, reluctance to see doctors when they are not ill, skepticism about the effectiveness of prevention or even avoidance of health professionals’ advice ─ especially if a person is engaging in unhealthy behaviors like smoking. Quality Improvement Efforts Routine reminders to members that they are due for particular screenings or exams do not appear to be enough to continue improving rates of preventive health services. Personal outreach coupled with culturally relevant education materials may be more effective in improving rates for these measures. Contractors’ printed member materials reflect the language and cultural beliefs of enrollees, and AHCCCS continues to work with them to provide resources to reach an increasingly diverse membership. Some health plans have implemented or are considering a more personal approach to providing information to encourage members to use preventive services that may help them maintain or improve their health status. Research shows that, compared with mailed or telephone reminders, personal contacts and motivational telephone calls from health plans that address specific barriers to receiving services have been successful in increasing the use of wellwoman services.11-16 While the overall rate of well-child visits by 15 months of age exceeds that of most Medicaid health plans nationally, the decline in this measure in the current period is of concern. The drop may be the result of refocusing of Contractor efforts to ensure immunizations are completed by 2 years of age in light of vaccine shortages and significant declines in completion rates. During this time, Contractors also have 33 and Human Services, National Institute of Dental and Craniofacial Research, September 2000. 9 Arizona Office of Oral Health. Arizona Oral Health Update. Phoenix, AZ: Arizona Department of Health Services. May 2000. 10 National Institute of Dental and Craniofacial Research. National Call to Action to Promote Oral Health. Rockville, MD: U.S. Department of Health and Human Services, National Institute of Dental and Craniofacial Research, NIH Publication No. 03-5303, Spring 2003. Available at: http://www.surgeongeneral.gov/topics/oralhealth/nati onalcalltoaction.htm. Accessed May 4, 2004. 11 Research Tested Intervention Programs. Maximizing Mammography Participation. National Cancer Institute. Available at http://cancercontrol.cancer.gov/rtips_details. Accessed July 15, 2005. 12 Research Tested Intervention Programs. Empowering Physicians to Improve Breast Cancer Screening. National Cancer Institute. Available at http://cancercontrol.cancer.gov/rtips_details.asp?prog ramID=1. Accessed July 15, 2005. 13 Davis NA, Nash E, et al. Evaluation of three methods for improving mammography rates in a managed care plan. Am J Prev Med 1997; 13(4):298302. Cited from The Manual of Intervention Strategies to Increase Mammography Rates. The Prudential Center for Health Care Research and The Centers for Disease Control and Prevention. 14 Lantz PM, Stencil D, et al. Breast and cervical cancer screening in a low-income managed care sample: the efficacy of physician letters and phone calls. Am J Public Health 1995; 85(6):834-836. Cited from The Manual of Intervention Strategies to Increase Mammography Rates. The Prudential Center for Health Care Research and The Centers for Disease Control and Prevention. 15 Research Tested Intervention Programs. Friend to Friend. National Cancer Institute. Available at http://cancercontrol.cancer.gov/rtips/rtips_details. Accessed July 15, 2005. 16 Research Tested Intervention Programs. Cambodian Women’s Health Project. National Cancer Institute. Available at http://cancercontrol.cancer.gov/rtips_details. Accessed July 15, 2005. 17 California Healthcare Foundation. IHA reports success with pay-for-performance program. iHealth Beat. July 11, 2005. Available at: http://www.ihealthbeat.org/index.cfm?Action=dspIte m&itemID=112598. Accessed July 15, 2005. 18 Improving Preventive Care Services for Children. Best Clinical and Administrative Practices for Medicaid Health Plans Toolkit. Center for Health Care Strategies Inc. Lawrenceville, NJ. March 2002. Some Contractors also are using incentives, such as gift certificates for members who complete medical visits or “pay-forperformance” arrangements that reward providers with the highest rates, to improve overall performance. These approaches also have shown some success in other programs.17,18 Conclusion As noted, several Contractors already have corrective action plans in place to improve performance in specific measures. All contracted health plans continue to explore mechanisms to increase member use of preventive health services, and AHCCCS will continue to assist them with these efforts. References 1 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, Ariz.: Arizona Department of Health Services, April 2001. 3 American Academy of Pediatrics. Bright Futures: Guidelines for Health Supervision of Infants, Children and Adolescents. Available at: http://brightfutures.aap.org/web/publicHealthProfessi onalstoolsAndResources.asp. Accessed Nov. 2, 2005. 4 Arizona School Readiness Task Force. Growing Arizona. Phoenix, Ariz.: Children’s Action Alliance. 2002. 5 Arizona School Readiness Board. Early Childhood Health Screening Fact Sheet. Available at: http://www.azgovernor.gov/cyf/school_readiness/ind ex_school_readiness.html. Accessed Nov. 2, 2005. 6 National Center for Health Statistics. Health, United States, 2004. Available at: http://www.cdc.gov/nchs/hus.htm. Accessed Nov. 2, 2005. 7 Arizona Department of Health Services. Arizona Health Status and Vital Statistics, Mortality Rates for the Five Leading Causes of Death Among Adolescents. Available at: http://www.azdhs.gov/plan/report/ahs/ahs2004/t2cam .htm. Accessed Nov. 2, 2005. 8 Office of the Surgeon General. Oral Health in America. Rockville, MD: U.S. Department of Health 34 APPENDIX B Technical Specifications for Acute-care Performance Measures for the Measurement Period from October 1, 2003, through September 30, 2004 I. CHILDREN'S ACCESS TO PRIMARY CARE PRACTITIONERS 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 Contractor for the entire measurement period (enrollment was selected only for contract types ‘A,’ ‘B,’ or ‘N’; and rate codes 6011 through 6015 for KidsCare members). • 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 exceeding 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. • Because only acute-care Contractors were evaluated, any enrollment that changed from an acutecare 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 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. i Encounter Subsystem Requirements Utilizing data from the Recipient Subsystem: • All encounters selected (Form 1500 and UB 82/92) for the eligible population 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) 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. Service Selection Criteria CPT-4 Codes for Preventive Medicine Services (UB82/92 or HCFA 1500) 99381 - 99385 Initial comprehensive preventive medicine 99391 - 99395 Periodic comprehensive preventive medicine 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 99341 - 99350 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. Exclusions Form Type = “I” Form type = “O” with revenue code = 450 (Emergency Room) ii Form Type = “A” with place of service = 23 (Emergency Room) or 21 (Inpatient Hospital). If principal/first-listed diagnosis codes ICD-9-CM = 290-316 If principal/first-listed diagnosis codes ICD-9-CM = 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: 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. Deviations from HEDIS 2004 Codes to Identify Ambulatory or Preventive Care Services AHCCCS uses the ICD-9 revenue code V70.7 (examination for normal comparison or control in clinical research) to identify preventive visits when used in conjunction with CPT-4 codes for evaluation and management; HEDIS does not use this code. • AHCCCS requires that certain CPT-4 codes be used in conjunction with ICD-9 revenue codes in order to ensure that visits are for primary care purposes. • iii II. ADULTS’ ACCESS TO PREVENTIVE/AMBULATORY HEALTH SERVICES 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 (enrollment was selected only for contract type ‘A’ or ‘B’). • 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 exceeding 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. • Because only acute-care Contractors were evaluated, any enrollment that changed from an acutecare 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 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. Encounter Subsystem Requirements Utilizing data from the Recipient Subsystem: • All encounters selected (Form 1500 and UB 82/92) for the eligible population 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) were excluded. Children receiving services through CRS or BHS who also were enrolled with another Contractor were included in the other Contractor’s data. iv • • 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. 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 – 99353 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 v 520 521 522 523 526 529 530 531 539 982 983 Freestanding clinic Rural clinic Rural/home Family practice clinic Freestanding urgent care clinic Other freestanding clinic Osteopath services Osteopath Rx Other Osteopath services Professional fees, outpatient services Professional fees, clinic Service Exclusionary Criteria ICD-9 Diagnostic Codes (UB 82/92): Principal/first listed diagnosis codes ICD-9 CM = 290.XX – 316, mental disorders V40.X Mental and behavioral problems Deviations from HEDIS 2004 Codes to Identify Preventive/Ambulatory Health Services AHCCCS uses UB-92 revenue codes 530, 531 and 539 to identify services provided by osteopathic physicians; HEDIS does not use these codes. • HEDIS uses UB-92 revenue codes 770, 771 and 779 to identify services; AHCCCS does not use these codes. • AHCCCS uses CPT codes 99341 ─ 99353; HEDIS uses codes 99341 ─ 99350. • vi III. WELL-CHILD VISITS IN THE FIRST 15 MONTHS OF LIFE Recipient Subsystem Requirements • Each member’s 15-month birthday must have occurred within the measurement period. • Members must have been continuously enrolled from 31 days of age through the 15-month birthday. • The enrollment-begin date for the member was the 31st day after the day of birth, and the enrollment-end date was the 15-month birthday. The 31st day of life is calculated as the child’s day of birth plus 30 days; the 15-month birthday as the child’s first birthday plus 90 days. • Members must have been enrolled with the same acute-care Contractor for the entire 14-month measurement period (enrollment was selected only for contract types ‘A,’ ‘B,’ or ‘N’; and rate codes 6011 through 6015 for KidsCare members). • 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 exceeding 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. • Because only acute-care Contractors were evaluated, any enrollment that changed from an acutecare 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 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. vii Encounter Subsystem Requirements Utilizing data from the Recipient Subsystem: • All encounters selected (Form 1500 and UB 82/92) for the eligible population 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) 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. Service Selection Criteria CPT-4 Codes Preventive Medicine Services (UB82/92 or HCFA 1500) 99381 New patient under 1 year 99382 New patient (ages 1 - 4 years) 99391 Established patient under 1 year 99392 Established patient (ages 1 - 4 years) 99431 Newborn care (history and examination) 99432 Normal newborn care OR CPT-4 Codes Evaluation and Management (UB82/92 or HCFA 1500) 99201 - 99205 New Patient 99211 - 99215 Established patient In conjunction with ICD-9 Diagnosis codes V20.2 Routine infant or child health check V70.0 General medical examination (routine) V70.3 - V70.9 General medical examination AND Not in conjunction with Category of Service 03 Respiratory Therapy 06 Physical Therapy 07 Speech/Hearing Therapy 11 Dental 12 Pathology & Laboratory 13 Radiology 15 Durable Medical Equipment & Supplies 30 Home Health Nurse Service 31 Non-emergency Transportation viii 40 Medical Supplies Deviations from HEDIS 2004 Codes to Identify Well-child Visits • AHCCCS uses the CPT-4 preventive medicine code 99431 (newborn care, history and examination) to identify well-child visits; HEDIS does not use this code. • AHCCCS requires that certain CPT-4 codes be used in conjunction with ICD-9 revenue codes and/or not in conjunction with certain category of service codes in order to ensure that well-child services were provided. ix IV. WELL-CHILD VISITS IN THE THIRD, FOURTH, FIFTH AND SIXTH YEARS OF LIFE Recipient Subsystem Requirements • Members must have been 3 through 6 years old 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 Contractor for the entire measurement period (enrollment was selected only for contract types ‘A,’ ‘B,’ or ‘N’; and rate codes 6011 through 6015 for KidsCare members). • 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 exceeding 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. • Because only acute-care Contractors were evaluated, any enrollment that changed from an acutecare 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 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. Encounter Subsystem Requirements Utilizing data from the Recipient Subsystem: • All encounters selected (Form 1500 and UB 82/92) for the eligible population 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) were excluded. Children receiving services through CRS or BHS who also were enrolled with another Contractor were included in the other Contractor’s data. x • • 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. Service Selection Criteria CPT-4 Codes Preventive Medicine Services (UB82/92 or HCFA 1500) 99382 New patient (ages 1 - 4 years) 99383 New patient (ages 5 – 11 years) 99392 Established patient (ages 1 - 4 years) 99393 Established patient (ages 5 – 11 years) OR CPT-4 Codes Evaluation and Management (UB82/92 or HCFA 1500) 99201 - 99205 New Patient 99211 - 99215 Established patient In conjunction with ICD-9 Diagnosis codes V20.2 Routine infant or child health check V70.0 General medical examination (routine) V70.3 - V70.9 General medical examination AND Not in conjunction with Category of Service 03 Respiratory Therapy 06 Physical Therapy 07 Speech/Hearing Therapy 11 Dental 12 Pathology & Laboratory 13 Radiology 15 Durable Medical Equipment & Supplies 30 Home Health Nurse Service 31 Non-emergency Transportation 40 Medical Supplies Deviations from HEDIS 2004 Codes to Identify Well-child Visits • AHCCCS requires that certain CPT-4 codes be used in conjunction with ICD-9 revenue codes and/or not in conjunction with certain category of service codes in order to ensure that well-child services were provided. xi V. ADOLESCENT WELL-CARE VISITS Recipient Subsystem Requirements • Members selected must have been 11 through 20 years old, or 11 through 18 years old if eligible under KidsCare, 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 must have been enrolled with the same acute-care Contractor for the entire measurement period (enrollment was selected only for contract types ‘A,’ ‘B,’ or ‘N’; and rate codes 6011 through 6015 for KidsCare members). • 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 exceeding 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. • Because only acute-care Contractors were evaluated, any enrollment that changed from an acutecare 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 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. Encounter Subsystem Requirements Utilizing data from the Recipient Subsystem: • All encounters selected (Form 1500 and UB 82/92) for the eligible population 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) were excluded. Children receiving services through CRS or BHS who also were enrolled with another Contractor were included in the other Contractor’s data. xii • • 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. Service Selection Criteria CPT-4 Codes Preventive Medicine Services (UB82/92 or HCFA 1500) 99383 New patient (ages 5 – 11 years) 99384 New patient (ages 12 - 17 years) 99385 New patient (ages 18 - 39 years) 99393 Established patient (ages 5 – 11 years) 99394 Established patient (ages 12 - 17 years) 99395 Established patient (ages 18 - 39 years) OR CPT-4 Codes Evaluation and Management (UB82/92 or HCFA 1500) 99201 - 99205 New Patient 99211 - 99215 Established patient In conjunction with ICD-9 Diagnosis codes: V20.2 Routine infant or child health check V70.0 General medical examination (routine) V70.3 - V70.9 General medical examination AND Not in conjunction with Category of Service: 03 Respiratory Therapy 06 Physical Therapy 07 Speech/Hearing Therapy 11 Dental 12 Pathology & Laboratory 13 Radiology 15 Durable Medical Equipment & Supplies 30 Home Health Nurse Service 31 Non-emergency Transportation 40 Medical Supplies Deviations from HEDIS 2004 Codes to Identify Well-child Visits • AHCCCS requires that certain CPT-4 codes be used in conjunction with ICD-9 revenue codes and/or not in conjunction with certain category of service codes in order to ensure that wellcare services were provided. xiii VI. ANNUAL DENTAL VISITS Recipient Subsystem Requirements • Members must have been 3 through 20 years old, or 3 through 18 years old 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 Contractor for the entire measurement period (enrollment was selected only for contract types ‘A,’ ‘B,’ or ‘N’; and rate codes 6011 through 6015 for KidsCare members). • 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 exceeding 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. • Because only acute-care Contractors were evaluated, any enrollment that changed from an acutecare 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 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. Encounter Subsystem Requirements Utilizing data from the Recipient Subsystem: • All encounters selected (Form 1500 and UB 82/92) for the eligible population 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) were excluded. Children receiving xiv • • 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. Service Selection Criteria Preventive Services For services reported on Form “D” (Dental) use the following logic Procedure class code = 70 or 71 or Procedure code range = D0100 – D0999 or D1000 – D1999 For services reported on any other form CPT-4 codes (UB82/92 or HCFA 1500) 70300 - 70320 Radiological exams (partial, complete, single, unilateral, bilateral) 70350 Cephalogram, Orthodontic 70355 Orthopantogram OR Procedure Class Codes 70 Diagnostic D0100-D0999 71 Preventive D1000-D1999 OR ICD-9-CM Procedure Code (UB 82/92) 87.11 Full mouth X-Ray of Teeth 87.12 Other dental X-Ray 89.31 Dental examination OR ICD-9 Diagnostic Code (UB 82/92) V72.2 Dental examination In conjunction with Revenue Code 510 Clinic 512 Dental Clinic 515 Pediatric Clinic 519 Other Clinic xv OR HCPCS Codes (UB82/92 or HCFA 1500) D1310 Nutritional counseling for the control of dental disease OR ICD-9 Diagnostic Code (HCFA 1500) V72.2 Dental examination In conjunction with Provider Types 07 Dentist 54 Dental Hygienist OR In conjunction with Category of Service 11 Dental OR In conjunction with Provider Specialty Type 800 Dentist – General 801 Dentist – Orthodonture 802 Dentist – Endodontist 803 Dentist - Oral Pathologist 804 Dentist – Pedodontist 805 Dentist – Prosthodontist 806 Dentist – Periodontist 807 Dentist - Public Health 808 Dentist - Oral Surgeon 809 Dentist – Anesthesiologist Treatment Services For services reported on Form “D” (Dental) use the following logic Procedure class codes = 72 through 79 or Procedure range = D2000 – D9999 For services reported on any other form Procedure Class Codes 72 Restorative 73 Endodontics 74 Periodontics D2000-D2999 D3000-D3999 D4000-D4999 xvi 75 76 76 77 78 79 Prosthodontics Implant Services Fixed Prosthodontics Oral Surgery Orthodontics Adjunctive General Services D5000-D5999 D6000-D6199 D6200-D6999 D7000-D7999 D8000-D8999 D9000-D9999 OR ICD-9 Procedure Code (UB 82/92) 23.xx Removal and restoration of teeth 24.xx Other operations on teeth, gums, and alveoli 93.55 Dental wiring 96.54 Dental scaling, polishing and debridement 97.22 Replacement of dental packing 97.33 Removal of dental wiring 97.34 Removal of dental packing 97.35 Removal of dental prosthesis 99.97 Fitting of denture Deviations from HEDIS 2004 Codes to Identify Annual Dental Visits • Procedure classification codes for dental services were used to select services in lieu of individual CPT codes when possible. • AHCCCS uses HCPCS/CDT-3 code ranges D0100 – D0999 and D1000 – D1999; HEDIS uses code ranges D0120 – D0999 and D1110 – D1550 • HEDIS uses ICD-9-CM procedure codes 23, 24, 93.55, 96.54, 97.22, 97.33-97.35, and 99.97; AHCCCS does not select services based on these specific codes. AHCCCS uses ICD-9 diagnostic code V72.2 (dental examination) to select services; HEDIS does not use this code. xvii