Arizona Health Care Cost Containment System Quality Management Performance Measures for Acute-care Contractors Measurement Period Ending September 30, 2006 Prepared by the Division of Health Care Management December 2007 Anthony D. Rodgers Director, AHCCCS TABLE OF CONTENTS INTRODUCTION Overview .................................................................................................................... Methodology .............................................................................................................. Data Sources …………............................................................................................... Data Validation ………….......................................................................................... Data Limitations …………......................................................................................... Rotation of Measures ………….................................................................................. Highlights of the Data ................................................................................................. Performance Standards and Improvement .................................................................. 1 1 2 2 2 3 3 4 THE MEASURES 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 Months of Life ..................... Adolescent Well-Care Visits ……............................................................................... Annual Dental Visits ................................................................................................... Acute-care Measures for DES/DDD ........................................................................... 6 18 23 26 31 36 41 CONCLUSION Overall Results …………………………................................................................... Disparities by Race and Ethnicity ……….................................................................. Strategies for Improvement ……..……….................................................................. References …………….........……............................................................................. 49 49 50 50 APPENDICES INTRODUCTION Overview This 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). The report includes data from nine publicly and privately operated health plans (Contractors). These results should be viewed as indicators of utilization of services, rather than absolute rates. By analyzing trends over time, AHCCCS and its Contractors have identified areas for improvement and implemented interventions to increase the use of preventive services. This report includes performance measurement data from nine publicly and privately operated health plans (Contractors) Methodology AHCCCS used Health Plan Employer Data and Information Set (HEDIS®) 2006 specifications to collect and report 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 HEDIS requirements for selecting members to be included in the measures is that they be continuously enrolled for a minimum period of time with one Contractor. Thus, members included in the results of each measure represent only a portion of AHCCCS members, rather than the entire acute-care population. This report includes results for the contract year ending September 30, 2006. Results are reported in aggregate and by individual Contractor. Data also are analyzed by race or ethnicity and county. The report indicates whether changes in rates overall or by Contractor are statistically significant, when compared with rates in the previous measurement. Changes from the previous measurement are described as increases or decreases only when analysis using the Pearson chisquare test yields a statistically significant value (p<.05); that is, the probability of obtaining a difference by chance is relatively low. National averages for managed care plans reported by NCQA, as measured under HEDIS, are included in this report. However, it should be noted that the HEDIS measures for Well-Child Visits in the First 15 Months of Life; Well-Child Visits in the Third, Fourth, Fifth and Sixth Years of Life; and Adolescent Well-Care Visits may be calculated using data extracted from medical records, as well as claims for services (this is known as a hybrid data collection methodology). The use of medical records may reflect more complete data (and thus higher rates) than claims alone. Because national averages include data reported by health plans using the hybrid data collection methodology, they may not be directly comparable to rates reported by AHCCCS, which does not currently use a hybrid methodology to collect data for these measures. 1 In addition, some health plans in other states report HEDIS rates based on combined data for Medicaid members and those eligible under the State Children’s Health Insurance Program (SCHIP), known in Arizona as KidsCare. In Arizona, rates for these measures are typically higher among members covered under KidsCare. However, because the populations differ in terms of socioeconomic status, Arizona reports rates for these eligibility groups separately. The difference in reporting Medicaid rates separately from KidsCare rates may also limit comparisons between Arizona and national HEDIS rates. The numerator data are based on encounters for professional services, primarily physician office and clinic visits Data Sources AHCCCS uses an 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 encounter data (records of services provided and related claims paid by Contractors) in PMMIS. The numerator data reported here are based on encounters for professional services, primarily physician office and clinic visits. Data Validation AHCCCS conducts annual data validation studies of encounters. Based on the most recent data validation study by AHCCCS, approximately 90 percent of all encounters for acute-care professional services are complete when compared with corresponding medical records. Approximately 85 percent are fully accurate, compared with services documented in members’ medical records. Data Limitations The data reported here are subject to at least three limitations. First, because rates are based on encounter data, they may be negatively affected if Contractors have not submitted complete and accurate encounters to AHCCCS. Second, data for both race and ethnicity (i.e., whether or not a person is of Hispanic or Latino origin) is limited by the way these data are stored by AHCCCS. Race and ethnicity data are collected according to current U.S. Census Bureau classifications when members apply for AHCCCS. However, the PMMIS system was designed long before the current federal standards for collecting race and ethnicity were issued in 1997, and does not accommodate both data fields at this time. After applicants become eligible, data for race and ethnicity are merged into one field and loaded into PMMIS. AHCCCS has developed a hierarchy for merging race and ethnicity data (Appendix A), so they are still useful in evaluating member demographics and possible trends. But, while people of Hispanic origin may be of any race, the hierarchy does not allow AHCCCS to identify the race of members who are classified as Hispanic. Thus, people of Hispanic origin are reported separately, and are not included in any race category. 2 Third, despite the limitations of storing race and ethnicity data, people whose racial makeup includes more than one race may identify themselves as “other”. In addition, members who do not identify their race and/or ethnicity on the AHCCCS application are placed in the “unknown/unspecified category.” Thus, race or ethnicity of some members included in this measurement can only be described as unknown, unspecified or other. Deviations from Previous Methodology Except for the measures of Adults’ Access to Preventive/Ambulatory Health Services and Annual Dental Visits, the methodology used for data collection in the current measurement differs slightly from previous methodology. Some coding changes were made to ensure data collection conforms to HEDIS, which has resulted in slightly lower rates for some measures. Several of the AHCCCS rates exceeded the comparable HEDIS national means Highlights of the Data A total of 18 measures in six areas of access to care and use of preventive services are reported. Age groups for Children’s and Adolescents’ Access to PCPs and Adults’ Access to Preventive/Ambulatory Health Services are considered separate measures. In addition, Medicaid and KidsCare rates for each of the child and adolescent measures are reported as separate measures. Results include the following: • Children’s Access to PCPs – The overall rate for Medicaid-eligible members decreased slightly as a result of programming revisions to conform to HEDIS methodology. For KidsCare members, the overall rate and rates for all age groups also declined somewhat. • Adults’ Access to Preventive/Ambulatory Health Services – The rate for the age group of 45 to 64 years showed a statistically significant increase from the previous measurement, while the overall rate and the rate for the age group of 20 to 44 years was unchanged. Both age groups had rates that exceeded the national Medicaid means reported by NCQA. • Well-Child Visits in the First 15 Months of Life – Rates for both Medicaid and KidsCare members increased from the previous year. Both rates also are above the comparable national Medicaid and commercial managed care means reported by NCQA. • Well-Child Visits in the Third, Fourth, Fifth and Sixth Years of Life – The overall rate for Medicaid members was unchanged from the previous year, and the rate for KidsCare members declined. • Adolescent Well-Care Visits – The overall rates for both Medicaid and KidsCare members did not show statistically significant increases. However, the rate for KidsCare members exceeded the HEDIS commercial mean. • Annual Dental Visits – Overall rates for both Medicaid and KidsCare populations increased over the previous year, and are well above the national Medicaid mean (NCQA does not report commercial health plan rates for this measure). 3 Using multivariate analysis, data for each measure were analyzed for members identified as Hispanic, Native American, non-Hispanic Black or other/unknown race, compared with non-Hispanic White members (data also are collected for members identified as Asian/Pacific Islander or Cuban/Haitian; however, these groups generally were not large enough to be analyzed separately). There were disparities by race/ethnicity in nearly all measures; in most cases, non-Hispanic Whites had higher rates of service. For example, Hispanic, Black, and Native American children and adolescents were less likely than nonHispanic Whites to have a PCP visit. However, Hispanic members 4 to 21 years of age were more likely than non-Hispanic Whites to have a visit to a dentist. Black adolescents were more likely than White members to have a comprehensive well-care visit. Rates by county and rural vs. urban areas also are compared for each measure. In general, there were significant differences in utilization of services between members in urban counties and those in rural counties. These findings are described in the sections on the specific measures. In addition, rates for several of the measures are reported for the Division of Developmental Disabilities (DDD), which is part of the Arizona Department of Economic Security (DES). These data are reported separately because of the uniqueness of the population and how medical services are delivered. Performance Standards and Improvement Contractor rates are compared to Minimum Performance Standards for up to 18 measures, as specified in the AHCCCS CYE 2007 contracts with health plans. This is the first measurement period for which AHCCCS has established minimum standards for each of the age groups. The Agency also has established Goals that Contractors should meet if they are already meeting the MPS. The following table shows the number of measures for which each Contractor met the AHCCCS Minimum Performance Standard (MPS): Number of Measures in Which Contractor was Included Number of Measures for Which MPS was Met Mercy Care Plan 18 12 University Family Care 18 11 Arizona Physicians IPA 18 10 Phoenix Health Plan 18 9 Care 1st Healthplan of Arizona 18 7 Health Choice Arizona 18 7 Pima Health System 18 6 Maricopa Health Plan 12 3 DES/CMDP 7 7 DES/DDD 7 3 Contractor 4 In addition, the Comprehensive Medical and Dental Program operated by DES met the MPS for all seven of the measures in which it was included (this Contractor is excluded from measures for which it has few or no members meeting the HEDIS enrollment criteria, such as the KidsCare and adult measures). The DES Division of Developmental Disabilities (DDD) was included in seven measures and met the MPS for three of them. Maricopa Health Plan also was not included in all 18 measures. This Contractor came under new management on October 1, 2005. Because of the change in management, Maricopa Health Plan members did not meet the selection criteria for some measures, which required continuous enrollment prior to October 1, 2005. Of the 12 measures in which Maricopa Health Plan members were included, the Contractor met the MPS for three of those measures. Contractors that did not meet the MPS for any measure will be required to implement corrective action plans (CAPs) to bring their rates up to compliance with AHCCCS contractual standards or will face sanctions. If Contractors already have CAPs in place as a result of the previous measurement, they will have to demonstrate that they have evaluated the effectiveness of interventions to improve rates and are implementing new or revised actions for improvement. The data reported here also may be used in developing future Performance Improvement Projects by AHCCCS or individual Contractors. Finally, the data reported here indicate disparities between certain racial and ethnic subgroups, compared with their non-Hispanic White peers. Data published by AHCCCS in December 2006 ― showed similar disparities in rates for Children’s and Adolescents’ Access to PCPs and Adults’ Access to Preventive/Ambulatory Health Services as in the current report. In the previous report, there also were significant differences in rates of breast cancer screening among women who were identified as Hispanic and Native American, as well as lower rates of cervical cancer screening among Native American women. These disparities must be addressed in order to improve rates overall. 5 Children’s and Adolescent’s Access to Primary Care Practitioners Access to primary care services by children and adolescents is critical to preventing 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 In addition, routine primary and preventive care helps support healthy development and the ability to learn. 3-5 PCPs can address physical, nutritional, developmental and behavioral health needs, and make referrals to specialists or to services such as nutritional support and developmental services. If members are receiving general health care services through a PCP, they likely have access to other levels of the health care system. Description AHCCCS measured the percentage of children and adolescents who: • were at least 12 months but not older than 19 years during the measurement period (October 1, 2005, through September 30, 2006), and • had one or more visits with PCPs (pediatricians, general or family practitioners, internists, physician’s assistants, nurse practitioners or obstetrician/gynecologists) during the measurement period. To be included in the denominator, members in the age groups of 12 to 24 months and 25 months to 6 years had to be continuously enrolled with the same Contractor during the measurement year (one break in enrollment was allowed if the gap did not exceed one month). To be counted in the numerator, these members would have had one or more PCP visits during the measurement year. Members 7 to 11 years and 12 to 19 years were included in the denominator if they were continuously enrolled with the same Contractor during the measurement year and the previous year (one break in enrollment was allowed per year if the gap did not exceed one month). These members were counted in the numerator if they had at least one PCP visit during the two-year period. Results for members who were eligible under Medicaid and the State Children’s Health Insurance Program (SCHIP), known as KidsCare, were calculated separately, by age group. Performance Goals AHCCCS has adopted Minimum Performance Standards and Goals for both Medicaid and KidsCare members for the current measurement. The following table also includes the most recent HEDIS means for Medicaid and commercial health plans, which are reported by NCQA: 6 Age Group AHCCCS CYE 2007 MPS AHCCCS CYE 2007 Goal NCQA 2006 Medicaid Mean NCQA 2006 Commercial Mean 12 – 24 Months 85% 86% 92.4% 97.0% 25 Mos – 6 Years 7 – 11 Years 12 – 19 Years 78% 77% 79% 80% 79% 81% 82.8% 82.9% 80.5% 89.3% 88.6% 86.1% Results Overall and by Age Group In the current period, the total rate (all age groups combined) for Medicaid members was 75.8 percent, a decrease from the previous rate of 78.3 percent in the previous year (p<.001). The total rate for KidsCare members was 82.2 percent, a decline from the previous rate of 84.7 percent (p<.001). As previously noted, changes in rates overall and by age group were likely due to changes in coding to mirror HEDIS specifications. Children 12 to 24 Months: The overall rate for Medicaid-eligible children in this age group (Table 1) decreased to 81.0 percent from 84.9 percent in the previous year (p<.001). The rate for children eligible under KidsCare (Table 2) decreased to 90.8 percent from a rate of 95.3 percent in the previous year (p<.001). Figure 1. Children’s and Adolescents’ Access to PCPs by County, 12 – 24 Months, Medicaid Members GREENLEE 2 80.0 – 84.9% 75.0 – 79.9% 70.0 – 74.9% 65.0 – 69.9% Children 25 months to 6 Years: The overall rate for Medicaid-eligible children in this age group was 75.4 percent, a decrease from the previous rate of 77.1 percent (p<.001). The rate for children eligible under KidsCare declined to 79.0 percent from 83.2 percent in the previous year (p<.001). Children 7 to 11 Years: The overall rate for Medicaid-eligible children in this age group decreased to 74.1 percent from 76.8 percent in the previous year (p<.001). The overall rate for children eligible under KidsCare also decreased, to 83.0 percent from 84.6 percent in the previous year (p=.029). Children 12 to 19 Years: The overall rate for Medicaid-eligible members decreased to 75.9 percent from 78.9 percent in the previous year (p<.001). The rate for children eligible under KidsCare declined to 83.7 percent from 85.0 percent in the previous year (p=.044). Results by County 12 to 24 Months: Current rates by county for Medicaid-eligible members ranged from 65.0 percent in Greenlee County to 81.9 percent in Yuma County. Figure 1 shows relative rates by county for Medicaid members. Rates for KidsCare members by county cannot be compared because most counties had population sizes for this eligibility group that were too small to make valid comparisons. 7 25 Months to 6 Years: Current rates by county for Medicaid-eligible members ranged from 61.8 percent in Apache County to 79.8 percent in Santa Cruz County. Figure 2 shows relative rates by county for Medicaid members. Rates for KidsCare members by county ranged from 62.5 percent in Apache County to 87.5 percent in Gila County, although some counties had relatively small population sizes for this eligibility group. Figure 2. Children’s and Adolescents’ Access to PCPs by County, 25 Months – 6 Years, Medicaid Members G R EEN LEE 2 7 to 11 Years: Current rates by county for Medicaid-eligible members ranged from 67.3 percent in La Paz County to 81.8 percent in Santa Cruz County. Figure 3 shows relative rates by county for Medicaid members. Current rates for KidsCare members by county ranged from 63.6 percent in Apache County to 90.6 percent in Gila County, although some counties also had relatively small population sizes for this eligibility group. 75.0 – 79.9% 12 to 19 Years: Current rates for individual counties for Medicaideligible members ranged from 65.0 percent in Greenlee County to 81.9 percent in Yuma County. Figure 4 shows relative rates by county for Medicaid members. Current rates for KidsCare members by county ranged from 66.7 percent in La Paz County to 96.1 percent in Graham County, although some counties also had relatively small population sizes for this eligibility group. 70.0 – 74.9% 65.0 – 69.9% 60.0 – 64.9% When rates were analyzed by rural and urban counties, there were significant differences for members 12 to 19 years and overall. Members 12 to 19 years in rural counties were more likely to have a PCP visits (77.1 percent compared with 75.4 percent) and rural members in all age groups combined also were more likely to have a PCP visit (76.0 percent compared with 75.3 percent). Figure 3. Children’s and Adolescents’ Access to PCPs by County, 7– 11 Years, Medicaid Members Comparison with National Benchmarks AHCCCS Medicaid rates for all age groups were lower than the most recent national HEDIS means for Medicaid health plans. Rates for KidsCare members were lower than the commercial means. GREENLEE 2 80.0 – 84.9% 75.0 – 79.9% 70.0 – 74.9% 65.0 – 69.9% Results by Race or Ethnicity For all groups combined (and for three of the four age groups when analyzed separately), Hispanic, Black and Native American Medicaideligible members were less likely than non-Hispanic Whites to have a PCP visit. This was especially true for Native American children and adolescents. There were no significant differences among children and adolescents covered under KidsCare by age group; however, overall, Native American members were somewhat less likely to have a PCP visit. Specific rates by age group and race/ethnicity for Medicaid members are shown in Appendix A, along with results of multivariate analysis comparing the likelihood of service utilization relative to nonHispanic White members. 8 Figure 4. Children’s and Adolescents’ Access to PCPs by County, 12 – 19 Years, Medicaid Members GREENLEE 2 80.0 – 84.9% 75.0 – 79.9% 70.0% – 74.9% 65.0 – 69.9% Discussion Children 24 months and younger typically have a higher rate of primary care visits because they are receiving immunizations that must be given at specific intervals, and are screened for developmental milestones during this period of rapid growth. After these “baby shots” are completed and children’s growth and development begins to slow, they are less likely to have PCP visits, unless they are ill or have other specific needs. Thus, rates for this measure are highest for children 12 to 24 months. Consistent with previous measurements, children enrolled with AHCCCS Contractors through KidsCare have higher overall rates of preventive services than those enrolled under Medicaid. Parents of KidsCare members pay premiums for coverage and thus may be more likely to ensure that their children receive services such as 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 obtained through this measurement indicate that Native American children and adolescents enrolled with AHCCCS health plans may have the lowest rate of access to PCPs relative to members identified as White. However, Native American members also may receive primary care through Indian Health Service (IHS) facilities on a feefor-service basis. Data for services provided by IHS facilities is not included in these data, unless a health plan paid for the service. In the current measurement, only DES/CMDP met the MPS for all age groups for Medicaid-eligible members; University Family Care met the Minimum standard for two age groups and Mercy Care Plan met the minimum standard for one age group. While Contractors are evaluated on their rates by age group, the following graph shows Contractor performance when all age groups are combined. Figure 5. Rates by Contractor, Children’s Access to PCPs among Medicaid Members, All Age Groups Combined CYE 2005 and CYE 2006 100% Benchmark Plan: CMDP 80% 60% 40% 20% 0% APIPA Care 1st CMDP 9 HCA MHP MCP PHP/CC PHS UFC As shown in Figure 5, the Comprehensive Medical and Dental Program (CMDP) had the highest rate of access to PCPs among Medicaid-eligible members for all age groups combined (85.1 percent). CMDP is a special needs health plan operated by the state Department of Economic Security (DES) for children and adolescents in foster care. When these children and adolescents are taken into custody, case managers try to ensure that they are quickly seen by PCPs and other providers to identify any physical, developmental or behavioral health needs. 10 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, 2005, through September 30, 2006 * Denotes that the Contractor achieved the AHCCCS Minimum Performance Standard for the age group in the current measurement. Age Total Number of Members Number with 1+ Visits Percent with 1+ Visits Relative Percent Change From Previous Year Statistical Significance AZ Physicians IPA 12-24 mos. 25 mos. - 6 yrs 7 - 11 yrs. 12 -19 yrs. Total 5,388 26,420 16,766 19,395 67,969 4,354 19,678 12,465 14,765 51,262 80.8% 74.5% 74.3% 76.1% 75.4% -4.0% -2.3% -3.7% -4.0% -3.3% p<.001 p<.001 p<.001 p<.001 p<.001 AZ Physicians IPA 12-24 mos. 25 mos. - 6 yrs 7 - 11 yrs. 12 -19 yrs. Total 6,463 28,636 15,977 18,429 69,505 5,441 21,834 12,339 14,611 54,225 84.2% 76.2% 77.2% 79.3% 78.0% Care 1st 12-24 mos. 25 mos. - 6 yrs 7 - 11 yrs. 12 -19 yrs. Total 968 2,851 1,084 1,141 6,044 778 1,917 720 785 4,200 80.4% 67.2% 66.4% 68.8% 69.5% -9.5% -8.7% -6.2% 0.8% -10.6% p<.001 p<.001 p=.079 p=.186 p<.001 Care 1st 12-24 mos. 25 mos. - 6 yrs 7 - 11 yrs. 12 -19 yrs. Total 1,443 2,180 514 604 4,741 1,282 1,605 364 434 3,685 88.8% 73.6% 70.8% 71.9% 77.7% DES/CMDP 12-24 mos. * 25 mos. - 6 yrs * 7 - 11 yrs. * 12 -19 yrs. * Total 528 1,802 511 1,046 3,887 471 1,457 424 957 3,309 89.2% 80.9% 83.0% 91.5% 85.1% -3.5% -4.0% -4.3% -1.7% -3.3% p=.076 p=.009 p=.121 p=.188 p<.001 DES/CMDP 12-24 mos. 25 mos. - 6 yrs 7 - 11 yrs. 12 -19 yrs. Total 489 1,654 399 898 3,440 452 1,393 346 836 3,027 92.4% 84.2% 86.7% 93.1% 88.0% Contractor 11 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, 2005, through September 30, 2006 * Denotes that the Contractor achieved the AHCCCS Minimum Performance Standard for the age group in the current measurement. Age Total Number of Members Number with 1+ Visits Percent with 1+ Visits Relative Percent Change From Previous Year Statistical Significance Health Choice AZ 12-24 mos. 25 mos. - 6 yrs 7 - 11 yrs. 12 -19 yrs. Total 2,843 11,713 5,487 5,500 25,543 2,289 8,516 3,944 4,048 18,797 80.5% 72.7% 71.9% 73.6% 73.6% -4.0% -4.6% -3.0% -4.6% -4.3% p=.001 p<.001 p=.012 p<.001 p<.001 Health Choice AZ 12-24 mos. 25 mos. - 6 yrs 7 - 11 yrs. 12 -19 yrs. Total 2,879 11,956 4,614 4,775 24,224 2,415 9,114 3,420 3,684 18,633 83.9% 76.2% 74.1% 77.2% 76.9% Maricopa Health Plan 12-24 mos. 25 mos. - 6 yrs 7 - 11 yrs. 12 -19 yrs. Total 837 4,317 n/a n/a 5,154 592 2,721 n/a n/a 3,313 70.7% 63.0% n/a n/a 64.3% n/a n/a n/a n/a n/a n/a n/a n/a n/a n/a Maricopa Health Plan 12-24 mos. 25 mos. - 6 yrs 7 - 11 yrs. 12 -19 yrs. Total 1,064 4,979 2,361 2,677 11,081 886 3,458 1,566 1,770 7,680 83.3% 69.5% 66.3% 66.1% 69.3% Mercy Care Plan 12-24 mos. 25 mos. - 6 yrs * 7 - 11 yrs. 12 -19 yrs. Total 6,117 25,041 12,463 12,873 56,494 5,059 19,752 9,429 9,884 44,124 82.7% 78.9% 75.7% 76.8% 78.1% -3.2% 1.2% -2.3% -1.7% -0.8% p<.001 p=.009 p=.002 p=.013 p=.009 Mercy Care Plan 12-24 mos. 25 mos. - 6 yrs 7 - 11 yrs. 12 -19 yrs. Total 6,367 25,147 10,521 11,298 53,333 5,438 19,595 8,143 8,826 42,002 85.4% 77.9% 77.4% 78.1% 78.8% Contractor 12 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, 2005, through September 30, 2006 * Denotes that the Contractor achieved the AHCCCS Minimum Performance Standard for the age group in the current measurement. Age Total Number of Members Number with 1+ Visits Percent with 1+ Visits Relative Percent Change From Previous Year Statistical Significance Phoenix Health Plan/CC 12-24 mos. 25 mos. - 6 yrs 7 - 11 yrs. 12 -19 yrs. Total 2,489 10,898 6,031 5,959 25,377 2,001 8,194 4,381 4,354 18,930 80.4% 75.2% 72.6% 73.1% 74.6% -3.5% -2.8% -3.0% -4.3% -3.4% p=.005 p<.001 p=.007 p<.001 p<.001 Phoenix Health Plan/CC 12-24 mos. 25 mos. - 6 yrs 7 - 11 yrs. 12 -19 yrs. Total 2,883 11,962 5,605 5,650 26,100 2,402 9,249 4,196 4,313 20,160 83.3% 77.3% 74.9% 76.3% 77.2% Pima Health System 12-24 mos. 25 mos. - 6 yrs 7 - 11 yrs. 12 -19 yrs. Total 689 2,728 1,355 1,703 6,475 443 1,909 1,003 1,269 4,624 64.3% 70.0% 74.0% 74.5% 71.4% -22.4% -12.7% -9.6% -11.0% -12.6% p<.001 p<.001 p<.001 p<.001 p<.001 Pima Health System 12-24 mos. 25 mos. - 6 yrs 7 - 11 yrs. 12 -19 yrs. Total 821 2,469 1,065 1,436 5,791 680 1,978 872 1,202 4,732 82.8% 80.1% 81.9% 83.7% 81.7% University Family Care 12-24 mos. * 25 mos. - 6 yrs 7 - 11 yrs. 12 -19 yrs. * Total 151 1,148 957 1,393 3,649 130 864 723 1,150 2,867 86.1% 75.3% 75.5% 82.6% 78.6% -1.0% -3.5% -6.2% -1.4% -3.2% p=.797 p=.097 p=.008 p=.406 p=.004 University Family Care 12-24 mos. 25 mos. - 6 yrs 7 - 11 yrs. 12 -19 yrs. Total 284 1,483 1,002 1,474 4,243 247 1,157 807 1,234 3,445 87.0% 78.0% 80.5% 83.7% 81.2% Contractor 13 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, 2005, through September 30, 2006 * Denotes that the Contractor achieved the AHCCCS Minimum Performance Standard for the age group in the current measurement. Age Total Number of Members Number with 1+ Visits Percent with 1+ Visits Relative Percent Change From Previous Year Statistical Significance TOTAL 12-24 mos. 25 mos. - 6 yrs 7 - 11 yrs. 12 -19 yrs. Total 19,173 82,601 44,654 49,010 195,438 15,525 62,287 33,089 37,212 148,113 81.0% 75.4% 74.1% 75.9% 75.8% -4.6% -2.2% -3.5% -3.7% -3.3% p<.001 p<.001 p<.001 p<.001 p<.001 TOTAL 12-24 mos. 25 mos. - 6 yrs 7 - 11 yrs. 12 -19 yrs. Total 21,629 85,487 39,697 44,564 191,377 18,357 65,925 30,487 35,140 149,909 84.9% 77.1% 76.8% 78.9% 78.3% Contractor Notes: Results of previous measurement period (Oct. 1, 2004, through Sept. 30, 2005) shown in shaded rows. Because of a change in management, Maricopa Health Plan members are not included in two age groups in thecurrent measurement, which measure services in a two-year period. 14 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, 2005, to September 30, 2006 * Denotes that the Contractor achieved the AHCCCS Minimum Performance Standard for the age group in the current measurement. Age Total Number of Members Number with 1+ Visits Percent with 1+ Visits Relative Percent Change From Previous Year Statistical Significance AZ Physicians IPA 12-24 mos. * 25 mos. - 6 yrs 7 - 11 yrs. * 12 -19 yrs. * Total 395 2,607 2,203 2,615 7,820 362 2,025 1,792 2,188 6,367 91.6% 77.7% 81.3% 83.7% 81.4% -1.8% -4.3% -3.3% -1.3% -2.9% p=.386 p=.003 p=.019 p=.295 p<.001 AZ Physicians IPA 12-24 mos. 25 mos. - 6 yrs 7 - 11 yrs. 12 -19 yrs. Total 331 2,221 1,939 2,310 6,801 309 1,803 1,631 1,958 5,701 93.4% 81.2% 84.1% 84.8% 83.8% Care 1st 12-24 mos. * 25 mos. - 6 yrs 7 - 11 yrs. * 12 -19 yrs. * Total 95 316 104 98 613 87 243 89 82 501 91.6% 76.9% 85.6% 83.7% 81.7% -8.4% -10.3% -2.5% 0.1% -9.5% p=.001 p=.039 p=.715 p=.988 p<.001 Care 1st 12-24 mos. 25 mos. - 6 yrs 7 - 11 yrs. 12 -19 yrs. Total 119 126 49 67 361 119 108 43 56 326 100.0% 85.7% 87.8% 83.6% 90.3% Health Choice AZ 12-24 mos. * 25 mos. - 6 yrs 7 - 11 yrs. * 12 -19 yrs. * Total 223 1124 669 696 2,712 191 839 550 574 2,154 85.7% 74.6% 82.2% 82.5% 79.4% -10.5% -11.5% -0.7% -4.0% -6.8% p=.001 p<.001 p=.797 p=.089 p<.001 Health Choice AZ 12-24 mos. 25 mos. - 6 yrs 7 - 11 yrs. 12 -19 yrs. Total 162 1,001 540 604 2,307 155 844 447 519 1,965 95.7% 84.3% 82.8% 85.9% 85.2% Contractor 15 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, 2005, to September 30, 2006 * Denotes that the Contractor achieved the AHCCCS Minimum Performance Standard for the age group in the current measurement. Age Total Number of Members Number with 1+ Visits Percent with 1+ Visits Relative Percent Change From Previous Year Statistical Significance Maricopa Health Plan 12-24 mos. * 25 mos. - 6 yrs 7 - 11 yrs. 12 -19 yrs. Total 52 501 n/a n/a n/a 45 332 n/a n/a n/a 86.5% 66.3% n/a n/a n/a -6.7% -17.7% n/a n/a n/a n/a n/a n/a n/a n/a Maricopa Health Plan 12-24 mos. 25 mos. - 6 yrs 7 - 11 yrs. 12 -19 yrs. Total 55 446 321 249 1,071 51 359 269 196 875 92.7% 80.5% 83.8% 78.7% 81.7% Mercy Care Plan 12-24 mos. * 25 mos. - 6 yrs * 7 - 11 yrs. * 12 -19 yrs. * Total 485 2811 1921 1926 7,143 445 2334 1636 1636 6,051 91.8% 83.0% 85.2% 84.9% 84.7% -4.4% -1.6% 0.3% 0.2% -0.9% p=.010 p=.194 p=.862 p=.895 p=.225 Mercy Care Plan 12-24 mos. 25 mos. - 6 yrs 7 - 11 yrs. 12 -19 yrs. Total 418 2,305 1,495 1,498 5,716 401 1,945 1,270 1,270 4,886 95.9% 84.4% 84.9% 84.8% 85.5% Phoenix Healh Plan/CC 12-24 mos. * 25 mos. - 6 yrs * 7 - 11 yrs. * 12 -19 yrs. * Total 224 1,519 1,123 980 3,846 209 1,193 927 808 3,137 93.3% 78.5% 82.5% 82.4% 81.6% -0.2% -5.7% -1.8% -2.8% -3.5% p=.924 p=.002 p=.366 p=.188 p=.001 Phoenix Health Plan/CC 12-24 mos. 25 mos. - 6 yrs 7 - 11 yrs. 12 -19 yrs. Total 201 1,285 891 751 3,128 188 1,070 749 637 2,644 93.5% 83.3% 84.1% 84.8% 84.5% Contractor 16 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, 2005, to September 30, 2006 * Denotes that the Contractor achieved the AHCCCS Minimum Performance Standard for the age group in the current measurement. Contractor Pima Health System Pima Health System University Family Care University Family Care TOTAL TOTAL Age Total Number of Members Number with 1+ Visits Percent with 1+ Visits 12-24 mos. 25 mos. - 6 yrs 7 - 11 yrs. * 12 -19 yrs. * Total 12-24 mos. 25 mos. - 6 yrs 7 - 11 yrs. 12 -19 yrs. Total 12-24 mos. * 25 mos. - 6 yrs 7 - 11 yrs. * 12 -19 yrs. * Total 12-24 mos. 25 mos. - 6 yrs 7 - 11 yrs. 12 -19 yrs. Total 12-24 mos. 25 mos. - 6 yrs 7 - 11 yrs. 12 -19 yrs. Total 12-24 mos. 25 mos. - 6 yrs 7 - 11 yrs. 12 -19 yrs. Total 42 179 121 208 550 47 148 115 173 483 3 58 85 182 328 8 68 114 224 414 1,467 8,614 6,226 6,705 23,012 1,286 7,154 5,143 5,627 20,281 35 129 104 170 438 46 127 104 139 416 3 45 72 155 275 7 54 105 206 372 1,332 6,808 5,170 5,613 18,923 1,225 5,951 4,349 4,785 17,185 83.3% 72.1% 86.0% 81.7% 79.6% 97.9% 85.8% 90.4% 80.3% 86.1% 100.0% 77.6% 84.7% 85.2% 83.8% 87.5% 79.4% 92.1% 92.0% 89.9% 90.8% 79.0% 83.0% 83.7% 82.2% 95.3% 83.2% 84.6% 85.0% 84.7% Relative Percent Change From Previous Year Statistical Significance -14.9% -16.0% -5.0% 1.7% -7.5% p=.024 p=.003 p=.287 p=.731 p=.006 14.3% -2.3% -8.0% -7.4% -6.7% p=1.000 p=.803 p=.100 p=.030 p=.015 -4.7% -5.0% -1.8% -1.6% -3.0% p<.001 p<.001 p=.029 p=.044 p<.001 Notes: Results of previous measurement period (Oct. 1, 2004, through Sept. 30, 2005) shown in shaded rows. Because of a change in management, Maricopa Health Plan members are not included in two age groups in thecurrent measurement, which measure services in a two-year period. 17 Adults’ Access to Preventive and Ambulatory Health Services 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, chronic lower respiratory diseases and diabetes.6 Smoking and other unhealthy behaviors often worsen the complications of chronic diseases, and increase the risk of developing other serious illnesses. A recent survey of AHCCCS acutecare health plan members found that 44 percent of adults have smoked 100 or more cigarettes in their lifetimes and, of those, 62 percent still smoke either sometimes or every day (current smokers). 7 National data for 2006 show an estimated 20.8 percent of U.S. adults are current cigarette smokers, and the rate increases to 30.6 percent among adults living below the federal poverty level. 8 Access to routine ambulatory medical services for adults is essential to the early diagnosis and treatment of disease. Regular health care visits also provide opportunities for clinicians to educate and counsel patients on smoking cessation, diet, exercise and other healthy behaviors. Description AHCCCS measured the percentage of Medicaid members who: • were ages 20 through 44 and 45 through 64 years at the end of the measurement period (October 1, 2005, through September 30, 2006), • were continuously enrolled with one acute-care Contractor during the measurement period (one break in enrollment was allowed if the gap did not exceed one month), and • had one or more preventive/ambulatory visits during the measurement period, including encounters with primary care physicians, specialists, physician’s assistants, nurse practitioners, ophthalmologists and optometrists. Performance Goals AHCCCS has established Minimum Performance Standards and Goals for this measure. The following table also includes the most recent HEDIS means for Medicaid and commercial health plans, which are reported by age group by NCQA: AHCCCS CYE 2007 MPS AHCCCS CYE 2007 Goal NCQA 2006 Medicaid Mean NCQA 2006 Commercial Mean 20 – 44 Years 78% 84% 76.4% 92.7% 45 – 64 Years 83% 72% 81.4% 94.8% Age Group 18 Figure 6. Adults’ Access to Preventive/Ambulatory Health Services by County, 20 – 44 Years, Medicaid Members Results Overall and by Age Group Compared with the previous measurement period, the total rate (i.e., both ages combined) was unchanged (Table 3). The total rate in the current measurement was 79.5 percent, compared with 79.2 percent in the previous year (p=.081). 20 to 44 Years: This rate was unchanged, at 77.3 percent in both the current and previous years. GREENLEE 2 45 to 64 Years: This rate showed a statistically significant increase from the previous year. The rate in the current measurement was 84.1 percent, compared with 83.4 percent in the previous year (p=.020). Results by County 20 to 44 Years: Rates by county ranged from 71.1 percent in La Paz County to 85.5 percent in Greenlee County. Figure 6 shows relative rates by county. 85.0 – 89.9% 80.0 – 84.9% 75.0% – 79.9% 70.0 – 74.9% Figure 8. Adults’ Access to Preventive/Ambulatory Health Services by County, 45 – 44 Years, Medicaid Members 45 to 64 Years: Rates by county ranged from 79.7 percent in La Paz County to 92.7 percent in Greenlee County. Figure 8 shows relative rates by county When rates were analyzed by rural and urban counties, rural members in both age groups and overall were more likely to have a preventive or ambulatory care visit than those living in urban counties (80.6 percent compared with 79.1 percent overall). Comparison with National Benchmarks AHCCCS rates for both age groups are higher than the most recent national HEDIS means for Medicaid health plans. G R E E NL E E 2 90.0 – 94.9% 85.0 – 89.9% 80.0% – 84.9% 75.0 – 79.9% Results by Race or Ethnicity For both age groups combined, Blacks were less likely than nonHispanic Whites to have a visit. Specific rates by age group and race/ethnicity for Medicaid members are shown in Appendix A, along with results of multivariate analysis comparing the likelihood of service utilization relative to non-Hispanic White members. Discussion Ensuring that adult members use preventive services is challenging. This may be due to lack of awareness among members about when and what types of routine preventive health services are recommended, skepticism about the effectiveness of prevention or avoidance ─ especially if a person is engaging in unhealthy behaviors like smoking. In addition, medical professionals no longer recommend that adults have an annual checkup. 19 However, given the risks associated with smoking alone and the substantial portion of members who use tobacco, yearly preventive health care visits may be an important service for AHCCCS members. In general, African Americans and Hispanic patients have fewer primary care visits than Whites, and fewer primary care visits are associated with lower rates of preventive care. Patient characteristics associated with poverty, namely income and low educational attainment, explain these disparities.9 Other data show that Blacks have higher rates of hypertension, smoking and leisure-time physical inactivity.6 Thus, the significantly lower rates of annual preventive/ambulatory health visits among members who are Black should be addressed by Contractors. One Contractor, Arizona Physicians IPA, met the MPS for both age groups; Mercy Care Plan and University Family Care each met the minimum standard for the age group of 45 to 64 years. While Contractors are evaluated on their rates by age group, the following graph shows Contractor performance when all age groups are combined. Figure 7. Rates by Contractor, Both Age Groups of Adults Combined, Medicaid Members CYE 2005 and CYE 2006 100% Benchmark Plan: APIPA 80% 60% 40% 20% 0% APIPA Care 1st HCA MHP MCP PHP/CC PHS UFC As shown in Figure 7 above, APIPA had the highest rate (81.1 percent) for Adults’ Access to Preventive/Ambulatory Health Services when both age groups were combined. This contractor met the MPS for both age groups. Mercy Care Plan and University Family Care each met the MPS for one age group. 20 Table 3 Arizona Health Care Cost Containment System ADULTS' ACCESS TO PREVENTIVE/AMBULATORY HEALTH SERVICES BY CONTRACTOR MEMBERS ELIGIBLE UNDER MEDICAID Measurement Period October 1, 2005, through September 30, 2006 * Denotes that the Contractor achieved the AHCCCS Minimum Performance Standard for the age group in the current measurement. Contractor AZ Physicians IPA AZ Physicians IPA Care 1st Care 1st Health Choice AZ Health Choice AZ Maricopa Health Plan Maricopa Health Plan Mercy Care Plan Mercy Care Plan Age 20-44 * 45-64 * Total 20-44 45-64 Total 20-44 45-64 Total 20-44 45-64 Total 20-44 45-64 Total 20-44 45-64 Total 20-44 45-64 Total 20-44 45-64 Total 20-44 45-64 * Total 20-44 45-64 Total Total Number of Members 22,218 10,806 33,024 24,241 10,748 34,989 2,144 882 3,026 2,252 890 3,142 8,301 3,787 12,088 8,717 3,628 12,345 2,075 1,837 3,912 2,537 1,970 4,507 18,501 8,711 27,212 19,028 8,182 27,210 Number with 1+ Visits 17,499 9,296 26,795 18,980 9,142 28,122 1,587 701 2,288 1,624 684 2,308 6,304 3,054 9,358 6,708 2,912 9,620 1,481 1,451 2,932 1,780 1,563 3,343 14,418 7,473 21,891 14,859 6,971 21,830 21 Percent with 1+ Visits 78.8% 86.0% 81.1% 78.3% 85.1% 80.4% 74.0% 79.5% 75.6% 72.1% 76.9% 73.5% 75.9% 80.6% 77.4% 77.0% 80.3% 77.9% 71.4% 79.0% 74.9% 70.2% 79.3% 74.2% 77.9% 85.8% 80.4% 78.1% 85.2% 80.2% Relative Percent Change From Previous Year Statistical Significance 0.6% 1.1% 1.0% p=.224 p=.043 p=.012 2.6% 3.4% 2.9% p=.154 p=.181 p=.052 -1.3% 0.5% -0.7% p=.120 p=.680 p=.338 1.7% -0.4% 1.0% p=.368 p=.789 p=.415 -0.2% 0.7% 0.3% p=.710 p=.277 p=.522 Table 3 Arizona Health Care Cost Containment System ADULTS' ACCESS TO PREVENTIVE/AMBULATORY HEALTH SERVICES BY CONTRACTOR MEMBERS ELIGIBLE UNDER MEDICAID Measurement Period October 1, 2005, through September 30, 2006 * Denotes that the Contractor achieved the AHCCCS Minimum Performance Standard for the age group in the current measurement. Contractor Phoenix Health Plan/ CC Phoenix Health Plan CC Pima Health System Pima Health System University Family Care University Family Care TOTAL TOTAL Age Total Number of Members Number with 1+ Visits Percent with 1+ Visits 20-44 45-64 Total 20-44 45-64 Total 20-44 45-64 Total 20-44 45-64 Total 20-44 45-64 * Total 20-44 45-64 Total 20-44 45-64 Total 20-44 45-64 Total 6,557 2,829 9,386 7,433 2,902 10,335 2,138 1,198 3,336 2,210 1,173 3,383 1,218 868 2,086 1,580 952 2,532 63,152 30,918 94,070 67,998 30,445 98,443 5,047 2,345 7,392 5,669 2,377 8,046 1,519 949 2,468 1,700 947 2,647 938 722 1,660 1,240 787 2,027 48,793 25,991 74,784 52,560 25,383 77,943 77.0% 82.9% 78.8% 76.3% 81.9% 77.9% 71.0% 79.2% 74.0% 76.9% 80.7% 78.2% 77.0% 83.2% 79.6% 78.5% 82.7% 80.1% 77.3% 84.1% 79.5% 77.3% 83.4% 79.2% Note: Results of previous measurement period (Oct. 1, 2004, through Sept. 30, 2005) shown in shaded rows. 22 Relative Percent Change From Previous Year Statistical Significance 0.9% 1.2% 1.2% p=.327 p=.329 p=.124 -7.6% -1.9% -5.4% p<.001 p=.356 p<.001 -1.9% 0.6% -0.6% p=.353 p=.772 p=.688 0.0% 0.8% 0.4% p=.885 p=.020 p=.081 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.10 During this time, health care providers help ensure that children are adequately protected against infectious diseases by vaccinating them 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. Description AHCCCS measured the percentage of children who: • turned 15 months old during the measurement period (October 1, 2005, through September 30, 2006), • were continuously enrolled with one acute-care Contractor from 31 days of age through their 15-month birthdays (one break in enrollment, not exceeding one month, was allowed), and • had six or more well-child visits during the first 15 months of life. Performance Goals AHCCCS has adopted Minimum Performance Standards and Goals for both Medicaid and KidsCare members for the current measurement. The following table also includes the most recent HEDIS means for Medicaid and commercial health plans reported by NCQA: Well-Child Visits, 15 Months AHCCCS CYE 2007 MPS AHCCCS CYE 2007 Goal NCQA 2006 Medicaid Mean NCQA 2006 Commercial Mean 70% 72% 48.6% 71.0% Overall Results The overall rate for Medicaid members (Table 4) increased to 58.0 percent from 54.0 percent in the previous measurement (p<.001). The overall rate for KidsCare members also increased, to 72.5 percent from 59.0 percent in the previous measurement (p<.001). This report does not include a table of results by individual health plan for KidsCare members for this measure because several Contractors had population sizes that were too small to make valid comparisons. Results by County Rates by county for Medicaid members ranged from 37.6 percent in Santa Cruz County to 63.2 percent in Yavapai County. Figure 9 shows relative rates by county for these members. Rates for KidsCare members by county cannot be compared because most counties had small population sizes for this eligibility group. 23 Figure 9. Well-Child Visits in the First 15 months of Life, by County, Medicaid Members When analyzed by rural and urban county groups, Medicaid-eligible children living in urban counties were more likely to have six wellchild visits than those living in rural counties (58.5 percent compared with 52.5 percent). Comparison with National Benchmarks The AHCCCS overall rate for Medicaid members is substantially above the most recent national HEDIS mean reported by NCQA for Medicaid health plans. The rate for KidsCare members is above the most recent national mean for commercial managed care plans. GREENLEE 2 60.0 – 64.9% 55.0 – 59.9% 50.0 – 54.9% 45.0 – 49.9% 40.0 – 44.9% 35.0 – 39.9% Results by Race or Ethnicity For Medicaid members, Black and Native American children, as well as those of other or unknown race/ethnicity, were less likely than nonHispanic White members to have six well-child visits. Native Americans had the greatest disparity with Whites for this measure. Specific rates by age group and race/ethnicity for Medicaid members are shown in Appendix A, along with results of multivariate analysis comparing the likelihood of service utilization relative to non-Hispanic White members. Discussion While the AHCCCS overall rate for Well-Child Visits in the First 15 Months of Life among Medicaid members is well above the national mean, there is still much room for improvement in this rate, given the goal that AHCCCS has established. The rate for Native American children may lag behind other groups as many of these members are able to receive preventive care visits through Indian Health Services, as well as through AHCCCS health plan providers. This bears further investigation, as does the low rate for well visits in Santa Cruz County. Figure 10. Rates by Contractor, Well-Child Visits in the First 15 Months of Life, Medicaid Members CYE 2005 and CYE 2006 100% Benchmark Plan: Care 1st 80% 60% 40% 20% 0% APIPA Care 1st HCA MCP PHP/CC PHS UFC As shown in Figure 10, Care 1st Healthplan had the highest rate for this measure in the current period (64.4 percent). 24 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, 2005, to September 30, 2006 Total Number of Children Number with 6+ Visits AZ Physicians IPA 3,006 AZ Physicians IPA Percent with 6+ Visits Relative Percent Change From Previous Year Statistical Significance 1,590 52.9% 2.2% p=.342 4,204 2,176 51.8% Care 1st 452 291 64.4% 9.0% p=.074 Care 1st 672 397 59.1% Health Choice AZ 1,542 914 59.3% 20.1% p<.001 Health Choice AZ 1,637 808 49.4% Mercy Care Plan 3,163 1,913 60.5% 6.3% p=.003 Mercy Care Plan 3,739 2,128 56.9% Phoenix Health Plan/CC 1,333 797 59.8% 10.7% p=.001 Phoenix Health Plan/CC 1,736 938 54.0% Pima HealthSystem 391 222 56.8% -0.2% p=.968 Pima HealthSystem 441 251 56.9% University Family Care 111 68 61.3% 1.8% p=.852 University Family Care 211 127 60.2% TOTAL 9,998 5,795 58.0% 7.3% p<.001 TOTAL 12,640 6,825 54.0% Contractor Notes: Results of previous measurement period (Oct. 1, 2004, through Sept. 30, 2005) shown in shaded rows. Because of a change in management, Maricopa Health Plan members are not included in the current measurement. 25 Well-Child Visits in the Third, Fourth, Fifth and Sixth Years of Life Children who are healthy are better able to learn and develop.11,12 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. Health care providers also can administer any needed vaccines and educate parents about adequate nutrition, oral health and injury prevention during well-child visits. Evidence shows that provider counseling can increase the use of seat belts, child safety seats and bicycle helmets, especially when directed at the parents. Description AHCCCS measured the percentage of members who: • were ages 3 through 6 years at the end of the measurement period (October 1, 2005, through September 30, 2006), • were continuously enrolled with one acute-care Contractor during the measurement period (one break in enrollment was allowed if the gap did not exceed one month), and • had at least one well-child visit during the measurement period. Performance Goals AHCCCS has adopted the following Minimum Performance Standard and Goal for both Medicaid and KidsCare members for the current measurement. The following table also includes the most recent HEDIS means for Medicaid and commercial health plans reported by NCQA: Well-Child Visits, 3 through 6 Years AHCCCS CYE 2007 MPS AHCCCS CYE 2007 Goal NCQA 2006 Medicaid Mean NCQA 2006 Commercial Mean 56% 58% 63.3% 65.5% Overall Results The overall rate for Medicaid members (Table 5) was 58.5 percent, unchanged from the previous rate of 58.3 percent (p=.514). The rate for KidsCare members (Table 6) decreased slightly to 64.0 percent from 65.7 percent in the previous year (p=.032). Results by County Rates by county for Medicaid members ranged from 36.1 percent in Greenlee County to 63.3 percent in Yuma County. Figure 11 shows relative rates by county for these members. Rates for KidsCare members ranged from 44.7 percent in Santa Cruz County to 68.3 percent in Coconino County. 26 Figure 11. Well-Child Visits in the Third through Sixth Years of Life, By County, Medicaid Members When analyzed by rural and urban county groups, Medicaid-eligible members in urban counties were more likely to have an annual wellchild visit than members in rural areas (59.0 percent compared with 56.6 percent). The same was true for KidsCare members (65.2 percent compared with 58.3 percent). Comparison with National Benchmarks The AHCCCS overall rate for Medicaid members is lower than the most recent national HEDIS mean for Medicaid health plans. The KidsCare rate is slightly lower than the national commercial mean. GREENLEE 2 60.0 – 64.9% 55.0 – 59.9% 50.0 – 54.9% 45.0 – 49.9% 40.0 – 44.9% 35.0 – 39.9% Results by Race or Ethnicity For Medicaid members, Blacks and Native Americans were less likely than non-Hispanic Whites to have a visit. Rates by race/ethnicity for Medicaid members are shown in Appendix A, along with results of multivariate analysis comparing the likelihood of service utilization relative to non-Hispanic White members. Discussion Children in this age group typically have a lower rate of well-child visits than younger children. In the first two years of life, children are receiving immunizations that must be given at specific intervals, and are screened for developmental milestones during this period of rapid growth. After these “baby shots” are completed and children’s growth and development begins to slow, they are less likely to have primary care visits, unless they are ill or have other specific needs. As seen in the measure of Well-Child Visits in the First 15 Months of Life, Native American children may have lower rates because they are receiving services through IHS, but this bears further investigation to ensure that they are receiving the necessary services for optimum health and development. Figure 12. Rates by Contractor, Well-Child Visits in Third through Sixth Years of Life, Medicaid Members CYE 2005 and CYE 2006 100% Benchmark Plan: Mercy Care Plan 80% 60% 40% 20% 0% APIPA Care 1st CMDP 27 HCA MHP MCP PHP/CC PHS UFC As seen in the preceding figure, Mercy Care Plan had the highest rate of well-child visits for Medicaid members in this age group in the current period, at 68.2 percent. Three Contractors met the MPS for Medicaideligible children and five met the minimum standard for KidsCare. 28 Table 5 Arizona Health Care Cost Containment System WELL-CHILD VISITS IN THE THIRD, FOURTH, FIFTH AND SIXTH YEARS OF LIFE BY CONTRACTOR MEMBERS ELIGIBLE UNDER MEDICAID Measurement Period October 1, 2005, through September 30, 2006 * Denotes that the Contractor achieved the AHCCCS Minimum Performance Standard in the current measurement. Total Number of Members Percent with 1+ Visits Relative Percent Change From Previous Year Number with 1+ Visits Statistical Significance AZ Physicians IPA * 22,015 12,319 56.0% -3.4% p<.001 AZ Physicians IPA 23,134 13,397 57.9% Care 1st 1,801 930 51.6% -0.5% p=.875 Care 1st 1,808 938 51.9% DES/CMDP * 1,385 913 65.9% -4.0% p=.159 DES/CMDP 1,272 873 68.6% Health Choice AZ 9,674 5,379 55.6% -6.5% p<.001 Health Choice AZ 9,449 5,619 59.5% Maricopa Health Plan 3,609 1,761 48.8% -13.1% p<.001 Maricopa Health Plan 3,905 2,193 56.2% Mercy Care Plan * 20,596 14,006 68.0% 16.3% p<.001 Mercy Care Plan 19,810 11,584 58.5% Phoenix Health Plan/CC 9,045 4,929 54.5% -7.7% p<.001 Phoenix Health Plan/CC 9,472 5,590 59.0% Pima Health System 2,118 940 44.4% -22.9% p<.001 Pima Health System 1,947 1,121 57.6% 972 519 53.4% -4.4% p=.310 University Family Care 1,189 664 55.8% TOTAL 71,215 41,696 58.5% 0.4% p=.514 TOTAL 71,986 41,979 58.3% Contractor University Family Care Note: Results of previous measurement period (Oct. 1, 2004, through Sept. 30, 2005) shown in shaded rows. 29 Table 6 Arizona Health Care Cost Containment System WELL-CHILD VISITS IN THE THIRD, FOURTH, FIFTH AND SIXTH YEARS OF LIFE BY CONTRACTOR MEMBERS ELIGIBLE UNDER KIDSCARE Measurement Period October 1, 2005, to September 30, 2006 * Denotes that the Contractor achieved the AHCCCS Minimum Performance Standard in the current measurement. Total Contractor Number of Members Relative Percent Number with 1+ Visits Percent with 1+ Visits Change From Previous Year Statistical Significance -7.9% p=.002 6.4% p=.527 -12.9% p<.001 -25.0% p<.001 16.8% p<.001 -10.5% p<.001 -39.1% p<.001 AZ Physicians IPA * 2,099 1,190 56.7% AZ Physicians IPA 1,818 1,119 61.6% Care 1st * 166 105 63.3% Care 1st 106 63 59.4% Health Choice AZ * 889 540 60.7% Health Choice AZ 826 576 69.7% Maricopa Health Plan 416 222 53.4% Maricopa Health Plan 360 256 71.1% Mercy Care Plan * 2,295 1,768 77.0% Mercy Care Plan 1,873 1,235 65.9% Phoenix Health Plan/CC * 1,266 772 61.0% Phoenix Health Plan/CC 1,047 713 68.1% Pima Health System 135 56 41.5% Pima Health System 116 79 68.1% University Family Care University Family Care 51 60 28 39 54.9% 65.0% -15.5% p=.278 TOTAL 7,317 4,681 64.0% -2.7% p=.032 TOTAL 6,206 4,080 65.7% Notes: Results of previous measurement period (Oct. 1, 2004, through Sept. 30, 2005) shown in shaded rows. 30 Adolescent Well-Care Visits 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, homicide, suicide, malignant neoplasms (cancer) and disease of the heart.6,13 Since most of the factors that contribute to adolescent morbidity and mortality are preventable or may be minimized with medical treatment, it is crucial to identify early signs of unhealthy behaviors or physical problems. Regular well-care visits that address the psychological, behavioral and physical aspects of health are very important in helping adolescents become healthy adults. • • • Description This indicator measured the percentage of members who: were ages 12 to 21 years if eligible under Medicaid or 12 to 19 years if eligible under KidsCare at the end of the measurement period (October 1, 2005, through September 30, 2006), were continuously enrolled with one acute-care Contractor during the measurement period (one break in enrollment, not exceeding one month, was allowed), and had at least one well-care visit during the measurement year. Performance Goals AHCCCS has adopted the following Minimum Performance Standard and Goal for both Medicaid and KidsCare members for the current measurement. The following table also includes the most recent HEDIS means for Medicaid and commercial health plans reported by NCQA: Adolescent Care Visits AHCCCS CYE 2007 MPS AHCCCS CYE 2007 Goal NCQA 2006 Medicaid Mean NCQA 2006 Commercial Mean 37% 38% 40.6% 38.7% Well- Overall Results The overall rate for this measure was unchanged from the previous period (Table 7). The rate for Medicaid-eligible adolescents was 32.8 percent, compared with from 33.1 percent in the previous period (p=.201). The rate for KidsCare members (Table 8) also did not show a statistically significant change, at 39.5 percent, compared with 40.3 percent in the previous period (p=.221). 31 Results by County Rates for Medicaid members by county ranged from 22.7 percent in La Paz County to 37.0 percent in Pima County. Figure 13 shows relative rates by county for these members. Rates for KidsCare members ranged from 17.4 percent in La Paz County (which had only 23 members in this eligibility group) to 43.7 percent in Pima County. Figure 13. Adolescent Well-Care Visits, by County, Medicaid Members GREENLEE 2 35.0 – 39.9% 30.0 – 34.9% 25.0 – 29.9% 20.0 – 24.9% When analyzed by rural and urban county groups, Medicaid-eligible adolescents in urban counties were more likely to have a well-care visit (33.2 percent compared with 31.9 percent). This also was true of adolescents covered under KidsCare (40.4 percent compared with 36.9 percent). Comparison with National Benchmarks The AHCCCS overall rate for Medicaid members is lower than the most recent national mean for Medicaid health plans reported by NCQA. However, the rate for KidsCare members exceeds the HEDIS national mean for commercial health plans. Results by Race or Ethnicity Among Medicaid members, Native Americans were less likely to have a well-care visit than non-Hispanic White members and Blacks were more likely to have a visit. Among KidsCare members, Native Americans also were less likely to have a well-care visit than nonHispanic White members and Hispanic adolescents were more likely to have a visit. Rates by race/ethnicity for Medicaid members are shown in Appendix A, along with results of multivariate analysis comparing the likelihood of service utilization relative to non-Hispanic White members. Discussion The relatively low rates for adolescent preventive care visits, both nationally and among AHCCCS health plans, demonstrates the difficulty in getting adolescents to do something they may not think is worthwhile, and parents not taking them to the doctor unless they are sick. However, the rate in Pima County is encouraging and warrants exploration of strategies used to get these members in for well visits. The low rate among Native American youth may be affected by data collection issues, as previously noted (i.e., if services are obtained through IHS, they will not be encountered in this measurement). It also may be that this population is even less likely to obtain health care services when they perceive no need. Given that the death rate in Arizona for Native American adolescents is twice that of non-Hispanic White teens,12 it is important that health plans pay attention to this population to try to reduce their risk of disease and premature death. Contractors should explore strategies to better reach Native American adolescents and encourage them to receive annual well-care visits. 32 Figure 14. Members Rates by Contractor, Adolescent Well-Care Visits, Medicaid CYE 2005 and CYE 2006 100% Benchmark Plan: CMDP 80% 60% 40% 20% 0% APIPA Care 1st CMDP HCA MHP MCP PHP/CC PHS UFC As shown in figure 14 above, CMDP had the highest rate of Adolescent Well-Care Visits among the Medicaid population, at 65.1 percent. CMDP and University Family Care were the only Contractors to meet the MPS for Medicaid members in the current measurement; however, six Contractors met the minimum standard for the KidsCare population. 33 Table 7 Arizona Health Care Cost Containment System ADOLESCENT WELL-CARE VISITS BY CONTRACTOR MEMBERS ELIGIBLE UNDER MEDICAID Measurement Period October 1, 2005 through September 30, 2006 * Denotes that the Contractor achieved the AHCCCS Minimum Performance Standard in the current measurement. Contractor AZ Physicians IPA AZ Physicians IPA Care 1st Care 1st DES/CMDP * DES/CMDP Health Choice AZ Health Choice AZ Maricopa Health Plan Maricopa Health Plan Mercy Care Plan Mercy Care Plan Phoenix Health Plan/CC Phoenix Health Plan/CC Pima Health System Pima Health System University Family Care * University Family Care Total Total Total Number of Members 27,520 28,783 2,118 2,202 1,910 1,758 8,878 8,987 3,317 3,840 20,022 19,959 8,430 9,087 2,545 2,595 1,550 1,846 76,290 79,057 Number with 1+ Visits 9,034 9,622 628 615 1,244 1,135 2,757 2,932 725 980 6,936 6,440 2,494 2,852 592 909 639 714 25,049 26,199 Percent with 1+ Visits 32.8% 33.4% 29.7% 27.9% 65.1% 64.6% 31.1% 32.6% 21.9% 25.5% 34.6% 32.3% 29.6% 31.4% 23.3% 35.0% 41.2% 38.7% 32.8% 33.1% Relative Percent Change From Previous Year Statistical Significance -1.8% p=.129 6.2% p=.212 0.9% p=.718 -4.8% p=.024 -14.4% p<.001 7.4% p<.001 -5.7% p=.010 -33.6% p<.001 6.6% p=.131 -0.9% p=.201 Note: Results of previous measurement period (Oct. 1, 2004, through Sept. 30, 2005) shown in shaded rows. 34 Table 8 Arizona Health Care Cost Containment System ADOLESCENT WELL-CARE VISITS BY CONTRACTOR MEMBERS ELIGIBLE UNDER KIDSCARE Measurement Period October 1, 2005 through September 30, 2006 * Denotes that the Contractor achieved the AHCCCS Minimum Performance Standard in the current measurement. Contractor AZ Physicians IPA * AZ Physicians IPA Care 1st * Care 1st Health Choice AZ * Health Choice AZ Maricopa Health Plan Maricopa Health Plan Mercy Care Plan * Mercy Care Plan Phoenix Health Plan/CC * Phoenix Health Plan/CC Pima Health System Pima Health System University Family Care * University Family Care Total Total Total Number of Members 4,065 3,617 240 169 1,228 1,052 442 452 3,105 2,575 1,619 1,279 361 279 194 234 11,254 9,657 Number with 1+ Visits 1,599 1,412 103 68 482 432 133 180 1,321 1,061 604 486 104 130 95 122 4,441 3,891 Percent with 1+ Visits 39.3% 39.0% 42.9% 40.2% 39.3% 41.1% 30.1% 39.8% 42.5% 41.2% 37.3% 38.0% 28.8% 46.6% 49.0% 52.1% 39.5% 40.3% Relative Percent Change From Previous Year Statistical Significance 0.8% p=.789 6.7% p=.588 -4.4% p=.378 -24.4% p=.002 3.3% p=.308 -1.8% p=.703 -38.2% p<.001 -6.1% p=.514 -2.1% p=.221 Note: Results of previous measurement period (Oct. 1, 2004, through Sept. 30, 2005) shown in shaded rows. 35 Annual Dental Visits 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. Dental disease results in children’s failure to thrive, impaired speech development, absence from and inability to concentrate in school and reduced self-esteem. Even though most oral diseases are preventable, tooth decay is one of the most common health problems among children today. 14,15 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, are known to reduce the rate of tooth decay and other oral diseases in children.15 Routine dental visits serve to educate individuals about dental hygiene and preventive measures. • • • Description AHCCCS measured the percentage of children and adolescents who: were ages 4 to 21 years if eligible under Medicaid, or 4 to 19 years if eligible under KidsCare, at the end of the measurement period (October 1, 2005, through September 30, 2006), were continuously enrolled with one acute-care Contractor during the measurement period (one break in enrollment, not exceeding one month, was allowed), and had at least one dental visit during the measurement year. Performance Goals AHCCCS has adopted the following Minimum Performance Standards and Goals for the current measurement. The following table also includes the most recent HEDIS means for Medicaid and commercial health plans reported by NCQA: NCQA does not report rates for annual dental visits for commercial health plans, since employersponsored dental coverage is typically provided through a separate managed care plan or other arrangement. Annual Dental Visits, 4 – 21 Yrs AHCCCS CYE 2007 MPS AHCCCS CYE 2007 Goal NCQA 2006 Medicaid Mean NCQA 2006 Commercial Mean 51% 57% 41.0% N/A 36 Figure 15. Annual Dental Visits, by County, Medicaid Members GREENLEE 2 60.0 – 64.9% 55.0 – 59.9% 50.0 – 54.9% 45.0 – 49.9% 40.0 – 44.9% 35.0 – 39.9% Overall Results Among Medicaid members (Table 9), the overall rate improved to 59.6 percent from 58.2 percent in the previous year (p<.001). Among KidsCare members (Table 10), the rate also improved, to 71.0 percent from 69.7 percent in the previous year (p=.002). Results by County For Medicaid members, the lowest rate was in Graham County, at 38.7 percent, and the highest rate was in Coconino County, at 63.4 percent. Figure 15 shows relative rates by county for these members. KidsCare rates ranged from 50.0 percent in both Apache and Graham counties to 69.2 percent in Pinal County. When analyzed by rural and urban county groups, members in urban counties were more likely to have a dental visit than those in rural areas. This was true for Medicaid (60.6 percent compared with 56.8 percent) and KidsCare (72.5 percent compared with 65.8 percent). Comparison with National Benchmarks The rate of dental visits among children covered under Medicaid is well above the most recent national HEDIS mean for Medicaid health plans, and also exceeds the threshold for the 90th percentile of Medicaid plans, which was 52.8 percent in 2006. As noted, there is no national commercial rate with which to compare AHCCCS rates. Results by Race or Ethnicity Among Medicaid members, Native American and Black members, as well as those of other or unknown race, were somewhat less likely to have a dental visit than non-Hispanic White members. Hispanics were more likely to have a visit. Among KidsCare members, Native Americans were less likely to have a dental visit than non-Hispanic White members, and Hispanics were more likely to have a visit. Rates by race/ethnicity for Medicaid members are shown in Appendix A, along with results of multivariate analysis comparing the likelihood of service utilization relative to non-Hispanic White members. Discussion Over the last several years, AHCCCS has focused much attention on improving rates of dental services among enrolled children and adolescents. In 2003, the Agency implemented a Performance Improvement Project (PIP), which is requiring all Acute-care Contractors to show statistically significant improvement in rates of annual dental visits. This PIP and other previous initiatives appear to have had a very positive effect on improving this measure. The high rates among Medicaid and KidsCare members in two rural counties, Coconino and Pinal respectively, may be the result of focused efforts in those areas, particularly among Head Start programs, to ensure that younger children receive dental services. 37 While this is a service area in which AHCCCS excels nationally, more work needs to be done to ensure that children and adolescents who are Native American or Black have regular dental check ups. Figure 16. Rates by Contractor, Annual Dental Visits, Medicaid Members CYE 2005 and CYE 2006 100% Benchmark Plan: CMDP 80% 60% 40% 20% 0% APIPA Care 1st CMDP HCA MHP MCP PHP/CC PHS UFC As shown in Figure 16, CMDP had the highest rate of Annual Dental Visits for Medicaid members in the current measurement (79.2 percent). All Contractors met the MPS for both the Medicaid and KidsCare populations. 38 Table 9 Arizona Health Care Cost Containment System ANNUAL DENTAL VISITS AGE 4-21 BY CONTRACTOR MEMBERS ELIGIBLE UNDER MEDICAID Measurement Period October 1, 2005, through September 30, 2006 * Denotes that the Contractor achieved the AHCCCS Minimum Performance Standard in the current measurement. Total Number of Members Total Dental Services Percent Dental Services Relative Percent Change from Previous Year Statistical Significance AZ Physicians IPA * 66,561 39,664 59.6% 2.9% p<.001 AZ Physicians IPA 70,179 40,652 57.9% Care 1st * 5,210 2,819 54.1% 5.4% p=.004 Care 1st 5,300 2,721 51.3% DES/CMDP * 4,037 3,198 79.2% 1.1% p=.369 DES/CMDP 3,682 2,886 78.4% Health Choice AZ * 23,945 13,399 56.0% 1.3% p=.107 Health Choice AZ 24,068 13,292 55.2% Maricopa Health Plan * 8,846 5,068 57.3% 2.4% p=.065 Maricopa Health Plan 10,100 5,652 56.0% Mercy Care Plan * 52,636 31,931 60.7% 1.5% p=.002 Mercy Care Plan 52,026 31,083 59.7% 3.2% p<.001 1.8% p=.256 Contractor Phoenix Health Plan/CC * 23,032 13,909 60.4% Phoenix Health Plan/CC 24,615 14,403 58.5% Pima Health System * 5,924 3,410 57.6% Pima Health System 5,875 3,321 56.5% University Family Care * University Family Care 3,313 3,989 1,924 2,269 58.1% 56.9% 2.1% p=.305 TOTAL 193,504 115,322 59.6% 2.4% p<.001 TOTAL 199,834 116,279 58.2% Note: Results of previous measurement period (Oct. 1, 2004, through Sept. 30, 2005) shown in shaded rows. 39 Table 10 Arizona Health Care Cost Containment System ANNUAL DENTAL VISITS AGE 4-19 BY CONTRACTOR MEMBERS ELIGIBLE UNDER KIDSCARE Measurement Period October 1, 2005, through September 30, 2006 * Denotes that the Contractor achieved the AHCCCS Minimum Performance Standard in the current measurement. Total Number of Members Total Dental Services Percent Dental Services Relative Percent Change from Previous Year Statistical Significance AZ Physicians IPA * 9,224 6,247 67.7% 1.3% p=.209 AZ Physicians IPA 8,237 5,505 66.8% Care 1st * 632 444 70.3% 7.2% p=.109 Care 1st 412 270 65.5% 4.2% p=.023 0.3% p=.920 1.4% p=.180 0.0% p=.981 7.8% p=.062 Contractor Health Choice AZ * 3,086 2,124 68.8% Health Choice AZ 2,729 1,802 66.0% Maricopa Health Plan * 1,256 869 69.2% Maricopa Health Plan 1,242 857 69.0% Mercy Care Plan * 8,043 5,934 73.8% Mercy Care Plan 6,609 4,811 72.8% Phoenix Health Plan/CC * 4,460 3,372 75.6% Phoenix Health Plan/CC 3,604 2,724 75.6% Pima Health System * 677 471 69.6% Pima Health System 550 355 64.5% University Family Care * University Family Care 335 409 207 262 61.8% 64.1% -3.5% p=.524 TOTAL 27,713 19,668 71.0% 1.8% p=.002 TOTAL 23,792 16,586 69.7% Note: Results of previous measurement period (Oct. 1, 2004, through Sept. 30, 2005) shown in shaded rows. 40 Acute-care Measures for DES/DDD Overview The Arizona Department of Economic Security’s Division of Developmental Disabilities (DDD) provides needed supports to Arizona residents who are at risk of having a developmental disability if younger than 6 years or, if older, have a diagnosis of epilepsy, cerebral palsy, mental retardation or autism, which was made prior to the age of 18 years. The Division also provides services to Arizonans who have substantial functional limitations in at least three major areas, such as self-care, learning and mobility. More than 60 percent of clients served by DDD also are covered under Medicaid through the Arizona Long Term Care System (ALTCS), a program of the Arizona Health Cost Containment System (AHCCCS). In addition to long-term care and supportive services provided through DDD, these members also receive primary and acute medical services through subcontracts with health plans. Performance Standards Under its contract with DDD, AHCCCS has established Performance Standards for primary and preventive care provided to children and adolescents. These standards measure the extent to which DDD ensures that these members receive necessary health services and screenings, including well-child visits and regular dental care. These measures are collected according to HEDIS methodology in the same way as Performance Measures for Acute-care Contractors. This section reports DDD’s performance in four of the following measures: AHCCCS CYE 2007 MPS AHCCCS CYE 2007 Goal NCQA 2006 Medicaid Mean Children’s Access to PCPs (All Ages Combined) 73% 75% N/A Well-Child Visits 3 – 6 Yrs 42% 46% 63.3% Adolescent Well-Care Visits 31% 33% 40.6% Annual Dental Visits, 4 – 21 Yrs 39% 41% 41.0% Eligibility for ALTCS members, including those with developmental disabilities, differs from eligibility for Acute-care health plans in that medical and functional criteria are considered, along with a different set of financial criteria. Thus, as many as two-thirds of DDD members with AHCCCS coverage also have other insurance coverage. Because DDD does not pay for services provided through other insurers, AHCCCS not does not have encounters for those services. The above Performance Standards reflect the limitation in collecting complete data for DDD members. 41 In addition to the four measures above, AHCCCS also attempted to collect data for Well-Child Visits in the First 15 Months of Life for DDD members. However, there were no DDD members in that age group who met the HEDIS enrollment criteria. Children’s and Adolescents’ Access to PCPs As with the Acute-care population, this measure looks at visits to pediatricians, family physicians and other primary care practitioners as a way to gauge general access to care for children and adolescents with developmental disabilities. By age group, there were significant changes in rates for children 12 to 24 months and overall (Table 11). The rate for the 12-to-24-month group was 77.6 percent in the current year, a decrease from the previous year’s rate of 90.1 percent (p=.050). The rate for members 25 months to 6 years was 67.7 percent in the current year, compared with the previous rate of 69.2 percent (p=.244). The rate for members 7 to 11 years was 67.6 percent in the current year, unchanged from the previous rate of 67.9 percent (p=.827). The rate for members 12 to 19 years was 68.8 percent, compared with 70.9 percent in the previous year (p=.062). The overall rate (all age groups combined) was 68.1 percent in the current measurement, a decline from the previous year’s rate of 69.6 percent (p=.037). With the exception of children 12 to 24 months, there were significant disparities in rates for racial/ethnic subgroups compared with nonHispanic white members. Among children 25 months to 6 years and 7 to 11 years, Native Americans were less likely then Whites to have a PCP visit, while Hispanic children were more likely to have a visit. Among members 12 to 19 years and overall, Native Americans again were less likely to have a PCP visit, while both Hispanic and Black members were more likely to have a visit (see Appendix A). Well-Child Visits in the Third through Sixth Years of Life Like all children, those with special health care needs require preventive health care services. In addition to early intervention services and therapies to help support optimal development, children with disabilities should have well-child checkups at regular intervals to monitor and improve their health. In the current measurement, 43.8 percent of children in this age group had an annual well-care visit (Table 12), an increase over the previous year’s rate of 38.4 percent (p<.001). 42 Native American children were about half as likely to have a well-care visit as non-Hispanic whites, while Hispanics, Blacks and those identified as other or unknown were more likely to have a well-child visit than White members (see Appendix A). Adolescent Well-Care Visits Many children and adolescents with developmental disabilities have comorbid physical conditions, such as asthma, cerebral palsy and diabetes. They also suffer from emotional and behavioral problems, and adolescents in particular are more likely to need mental health services than younger children with special health care needs.16 Adolescent well-care visits enable providers to focus on the special needs of these members, so that they may experience the best possible health. In the current measurement, 28.8 percent of adolescents had a wellcare visit (Table 13), which was unchanged from the previous year’s rate of 28.3 percent (p=.637). Here too, Native Americans were about half as likely to have a wellcare visit as non-Hispanic whites, while Hispanics and Blacks were more likely to have a well-child visit than White members (see Appendix A). Annual Dental Visits In general, people with developmental disabilities have poorer oral health and oral hygiene than those without such disabilities. Data indicate that people who have mental retardation have more untreated caries and a higher prevalence of gingivitis and other periodontal diseases than the general population. Medications, malocclusion, multiple disabilities, and poor oral hygiene combine to increase the risk of dental disease in people with developmental disabilities.17 In the current measurement, 40.7 percent of children and adolescents had an annual dental visit (Table 14), which was unchanged from the previous rate of 41.1 percent (p=.549). Native American children were less likely to have a dental visit than non-Hispanic whites, while Hispanic members were more likely to have a dental visit than White members (see Appendix A). Discussion Overall performance for DDD was mostly unchanged from the previous year, as rates for five measures showed no statistically significant changes, while one rate increased. The Division met its Minimum Performance Standard for three of seven measures. 43 Native American children and adolescents enrolled in DDD displayed significantly lower rates of service in nearly all measures. As with the Acute-care population, these members may show lower rates of visits because they are receiving services through Indian Health Service, which are not encountered by AHCCCS. However, this requires further investigation to determine if these members are receiving important health care services, especially given their special needs status and increased risk of physical complications. 44 Table 11 Arizona Health Care Cost Containment System CHILDREN'S ACCESS TO PRIMARY CARE PRACTITIONERS MEMBERS ELIGIBLE UNDER DES/DDD Measurement Period October 1, 2005, to September 30, 2006 * Denotes that the Contractor achieved the AHCCCS Minimum Performance Standard in the current measurement. Age Total Number of Members Number with 1+ Visits DES/DDD 12-24 mos. * 25 mos. - 6 yrs 7 - 11 yrs. 12 -19 yrs. Total 58 2,874 2,748 3,269 8,949 DES/DDD 12-24 mos. 25 mos. - 6 yrs 7 - 11 yrs. 12 -19 yrs. Total 71 2,778 2,517 3,047 8,413 Contractor Percent with 1+ Visits Relative Percent Change From Previous Year Statistical Significance 45 1,946 1,857 2,248 6,096 77.6% 67.7% 67.6% 68.8% 68.1% -13.9% -2.1% -0.4% -3.0% -2.1% p=.050 p=.244 p=.827 p=.062 p=.037 64 1,921 1,708 2,161 5,854 90.1% 69.2% 67.9% 70.9% 69.6% Note: Results of previous measurement period (Oct. 1, 2004, through Sept. 30, 2005) shown in shaded rows. 45 Table 12 Arizona Health Care Cost Containment System WELL-CHILD VISITS IN THE THIRD, FOURTH, FIFTH AND SIXTH YEARS OF LIFE MEMBERS ELIGIBLE UNDER DES/DDD Measurement Period October 1, 2005, through September 30, 2006 * Denotes that the Contractor achieved the AHCCCS Minimum Performance Standard in the current measurement. Total Number of Members Number with 1+ Visits DES/DDD * 2,690 DES/DDD 2,592 Contractor Percent with 1+ Visits Relative Percent Change From Previous Year Statistically Significance 1,178 43.8% 14.0% p<.001 996 38.4% Note: Results of previous measurement period (Oct. 1, 2004, through Sept. 30, 2005) shown in shaded rows. 46 Table 13 Arizona Health Care Cost Containment System ADOLESCENT WELL-CARE VISITS MEMBERS ELIGIBLE UNDER DES/DDD Measurement Period October 1, 2005 through September 30, 2006 Total Number of Members Number with 1+ Visits DES/DDD 4,169 1,200 Percent with 1+ Visits 28.8% DES/DDD 3,935 1,114 28.3% Contractor Relative Percent Change From Previous Year Statistical Significance 1.7% p=.637 Note: Results of previous measurement period (Oct. 1, 2004, through Sept. 30, 2005) shown in shaded rows. 47 Table 14 Arizona Health Care Cost Containment System ANNUAL DENTAL VISITS - Ages 4-21 MEMBERS ELIGIBLE UNDER DES/DDD Measurement Period October 1, 2005 to September 30, 2006 * Denotes that the Contractor achieved the AHCCCS Minimum Performance Standard in the current measurement. Total Number of Members Total Dental Services Percent Dental Services Relative Percent Change from Previous Year Statistical Significance DES/DDD * 9,545 3,882 40.7% -1.1% p=.549 DES/DDD 8,909 3,662 41.1% Contractor Note: Results of previous measurement period (Oct. 1, 2004, through Sept. 30, 2005) shown in shaded rows. 48 CONCLUSION Overall Results The data reported here indicate that children and adults enrolled with AHCCCS have a relatively high degree of access to the health care system, as evidenced by rates of primary care visits. AHCCCS excels in rates of Well-Child Visits in the First 15 months of Life and Annual Dental Visits, compared with Medicaid managed care plans nationally. Rates for Adults’ Access to Preventive/Ambulatory Health Services also are above national Medicaid means. However, health plans must focus resources on increasing rates of children’s access to primary care and well-care visits among 3- through 6-year-olds and adolescents. Disparities by Race and Ethnicity Analysis of data indicates lower rates of service among Native Americans for several measures, as well as lower rates for Black and Hispanic members for some measures . American Indians and Alaska Natives are more likely to live in poverty and have less than a high school education than non-Hispanic Whites, both of which indicate less access to primary care and prevention services. A recent report from several leading cancer organizations found that more Native Americans than non-Hispanic Whites reported being obese; and that screening rates for breast, colorectal, prostate and cervical cancers were lower among Native Americans than Whites. The report also notes high rates of smoking among Native Americans.18 Other national data show that racial and ethnic minorities are more likely to rate their health as fair or poor, compared with non-Hispanic White persons: Native Americans are about twice as likely to rate their health as fair or poor, and Blacks and Hispanics also are more likely to rate their health as such. In addition Black and Mexican-American children generally have higher rates of obesity and untreated dental decay, 6 problems that could be addressed with regular medical and dental care. Research suggests that Native American populations experience more perceived barriers to care than their White counterparts. Many Native Americans indicate that work or family responsibilities, lack of transportation, and inconvenient clinic/office hours of operation are common barriers to care. Native Americans also perceive more issues of racial and economic discrimination by providers. Others have indicated a lack of trust and confidence in their child’s provider.19 Other studies have shown that Hispanic parents identify language differences, transportation difficulties, and long waiting times as major barriers to health care for their children.20 49 Strategies for Improvement These trends underscore the disparities in use of services among racial/ethnic subgroups, as indicated by this analysis of AHCCCS Performance Measure data. Strategies to reduce disparities and improve Performance Measure rates may include: 21-25 • Utilizing community lay health workers, who encourage members or parents of children to receive preventive services. • Conducting one-on-one outreach to educate and motivate patients. • Seeking member feedback to strengthen commitment and adherence to medical regimens. • Ensuring the diversity and cultural competency of providers through provider and staff education so that members feel comfortable seeing them. • Encouraging expanded clinic hours among providers to make it easier for families to take their children to well-care visits. • Implementing incentives, either with providers or members, to increase rates of preventive care visits. • Partner with other community programs to reach populations also enrolled in AHCCCS, including Head Start, which serves low-income children 3 to 6 years old and Early Head Start, which focuses on younger children. While AHCCCS health plans may be using some of these approaches, and the program overall has a strong cultural competency focus, Contractors should consider whether these and other approaches could be better used to improve rates among specific groups of members. Contracted health plans also should try to determine if Native Americans enrolled I their plans are receiving services through IHS or not at all. In July 2007, AHCCCS advised Acute-care Contractors that they would face financial sanctions in the next couple of years if they do not increase rates to meet Minimum Performance Standards. Detailed data from this measurement will be provided to Contractors, and may further guide interventions to improve performance, particularly in specific geographic areas or among certain populations. 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/publicHealthProfessionalstoolsAndResources.asp. Accessed Nov. 2, 2006. 50 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/index_school_readiness.html. Accessed Nov. 2, 2005. 6 National Center for Health Statistics. Health, United States, 2006. Hyattsville, MD: 2006. Available at: http://www.cdc.gov/nchs/hus.htm. Accessed November 28, 2007. 7. wba Market Research. 2006 Acute Care Health Plan Customer Satisfaction Survey. Presentation to AHCCCS health plan medical directors and chief executive officers. Oct. 20, 2006. 8 Centers for Disease Control and Prevention. Cigarette smoking among adults--United States, 2006. MMWR 2007 56(44);1157-1161. Available at http://www.cdc.gov/mmwr/preview/mmwrhtml/mm5644a2.htm?s_cid=mm5644a2_e Accessed Nov. 14, 2007. 9 Fischella K, Holt K. Impact of primary care patient visits on racial and ethnic disparities in preventive care in the United States. Medscape Today. Nov. 30, 2007. Available at: http://www.medscape.com/viewarticle/565792?src=mp. Accessed December 12, 2007. 10 American Academy of Pediatrics. Bright Futures: Guidelines for Health Supervision of Infants, Children and Adolescents. Available at: http://brightfutures.aap.org/web/publicHealthProfessionalstoolsAndResources.asp. Accessed Nov. 2, 2007. 11 Arizona School Readiness Task Force. Growing Arizona. Phoenix, Ariz.: Children’s Action Alliance. 2002. 12 Arizona School Readiness Board. Early Childhood Health Screening Fact Sheet. Available at: http://www.azgovernor.gov/cyf/school_readiness/index_school_readiness.html. Accessed Nov. 2, 2005. 13 Arizona Department of Health Services. Arizona Health Status and Vital Statistics: Age-specific mortality, adolescents. Available at: http://www.azdhs.gov/plan/report/ahs/ahs2006/toc06.htm. Accessed Nov. 28, 2007. 14 Office of the Surgeon General. Oral Health in America. Rockville, MD: U.S. Department of Health and Human Services, National Institute of Dental and Craniofacial Research, September 2000. 15 Arizona Office of Oral Health. Arizona Oral Health Update. Phoenix, AZ: Arizona Department of Health Services. May 2000. 16 U.S. Department of Health and Human Services, Health Resources and Services Administration, Maternal and Child Health Bureau. The National Survey of Children with Special Health Care Needs Chartbook 2001. Rockville, Maryland: U.S. Department of Health and Human Services, 2004. Available at: http://mchb.hrsa.gov/chscn/index.htm. Accessed Mar. 1, 2006. 17 Health Resources and Services Administration. Oral Health for Children and Adolescents with Special Health Care Needs: Challenges and Opportunities. 2005. Available at: http://www.ask.hrsa.gov/detail.cfm?PubID=MCH00156. Accessed March 1, 2006. 18 National Cancer Institute. Annual report to the nation finds cancer death rate decline doubling: Special feature examines cancer in American Indians and Alaska Natives. U.S. National Institutes of Health. October 2007. Available at: http://www.cancer.gov/newscentr/pressreleases/ReportNation2007Release. Accessed Nov. 28, 2007. 19 Call KT, McAlpine DD, Johnson PJ, Beebe TJ, McRae JA, Song, Yunjie. Barriers to care among American Indians in public health care Programs. Med Care. 2006 Jun;44(6):595-600. 51 20 Flores G, Abreu M, Olivar MA, Kastner B. Access barriers to health care for Latino children. Arch Pediatr Adolesc Med. 1998 Nov;152(11):1119-25. 21 Martin C. Reducing racial and ethnic disparities: Quality improvement in Medicaid managed care toolkit. Center for Health Care Strategies. January 2007. Available at: http://www.chcs.org/publications3960/publications_show.htm?doc_id=440684. Accessed Nov. 27, 2007 22 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. 23 Adams ML. The African American cancer outreach project: Partnering with communities. Family & Community Health. Supplement 1:S85-S94, January/March 2007. 24 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=dspItem&itemID=112598. Accessed July 15, 2005. 25 Hudson Health Plan: Improving preventive and dental care for adults in need. Center for Health Care Strategies Inc. November 2005. Available at: http://www.chcs.org/info-url3969/info-url_show.ht,?doc_id=317315. Accessed Nov. 27, 2007. For questions or comments about this report, please contact: Rochelle Tigner, Quality Improvement Manager Clinical Quality Management Unit Division of Health Care Management, MD 6700 701 E. Jefferson St. Phoenix, AZ 85034 rochelle.tigner@azahcccs.gov 52 Appendix A PMMIS Race/Ethnicity Hierarchy AI HI BL AS NH WH UD RA DES Field Coded with “Y” American Indian (Native American) Hispanic or Latino Black Asian Native Hawaiian/Pacific Islander White (Caucasian) Unable to Determine (Other) Refused to Answer NA HS BL AS AS CW UN UN i AHCCCS Conversion Native American Hispanic Black Asian/Pacific Islander Asian/Pacific Islander Caucasian/White Unknown/Unspecified Unknown/Unspecified Performance Measure Rates (%) by Race/Ethnicity, Medicaid Members Children’s and Adolescents’ Access to PCPs Asian/ Pacific Islander 78.1 75.9 73.4 71.3 Age Group 12 – 24 Months 25 Mos – 6 Years 7 – 11 Years 12 – 19 Years Black 76.0 71.6 69.7 72.8 White 82.9 77.2 76.7 77.9 Hispanic 80.4 74.9 74.1 76.5 Native American 69.5 61.1 63.6 67.8 Other/ Unknown* 87.0 76.7 75.7 70.3 Adults’ Access to Preventive/Ambulatory Health Services Asian/ Pacific Islander 71.5 85.0 Age Group 20 – 44 Years 45 – 64 Years Black 75.1 80.5 White 78.0 83.5 Hispanic 77.4 85.2 Native American 80.4 82.7 Other/ Unknown* 71.9 86.6 Well-Child Visits in the First 15 Months of Life Well-Child Visits, 15 Months Asian/ Pacific Islander Black White Hispanic Native American Other/ Unknown* 66.1 50.6 59.6 58.0 36.9 41.9 Well-Child Visits in the Third through Sixth Years of Life Well-Child Visits, 3 through 6 Years Asian/ Pacific Islander Black White Hispanic Native American Other/ Unknown* 58.3 53.8 58.4 59.8 43.1 55.3 Adolescent Well-Care Visits Adolescent Well-Care Visits Asian/ Pacific Islander Black White Hispanic Native American Other/ Unknown* 31.1 34.2 32.6 33.5 24.9 31.2 Annual Dental Visits Annual Dental Visits, 4 to 21 Years Asian/ Pacific Islander Black White Hispanic Native American Other/ Unknown* 62.4 50.6 57.3 62.8 51.3 52.1 * Includes Cuban/Haitian and members who did not specify a race or ethnicity ii Multivariate Analysis of Performance Measures by Race/Ethnicity The following tables include results of multivariate analysis of data by race/ethnicity for each performance measure. This analysis was conducted to identify disparities in utilization of health care services among racial/ethnic minorities relative to utilization of services by non-Hispanic White members. Highlighted rows indicate disparities between the racial/ethnic subgroup and non-Hispanic whites included in the measurements (these disparities may be either positive or negative). RR equals relative risk: if the value in this column is > 1.0, members in this group are more likely than non-Hispanic white members to have the particular service being measured (these rows are highlighted in blue); if the value is < 1.0, members of this group are less likely to have the service (these rows are highlighted in tan). Note: For purposes of this analysis, the “Other” category includes Asian/Pacific Islanders and Cuban/Haitians, as these groups generally did not have large enough population sizes to be analyzed separately, as well as members for whom race was unknown or unspecified. Medicaid Members Hispanic Black Native American Other Hispanic Black Native American Other Hispanic Black Native American Other Hispanic Black Native American Other n 3638 3638 3638 3638 n 14622 14622 14622 14622 n 8335 8335 8335 8335 n 10833 10833 10833 10833 Total 4391 4391 4391 4391 Children’s and Adolescents’ Access to PCPs, 12-24 Months Std. Lower Err Limit % n Total % RR 82.85% 10769 13391 80.4% 0.9837 0.0158 0.9683 82.85% 784 1032 76.0% 0.9528 0.0369 0.9183 82.85% 372 535 69.5% 0.9052 0.0577 0.8544 82.85% 554 661 83.8% 1.0063 0.0361 0.9706 Upper Limit 0.9994 0.9886 0.9589 1.0433 Total 18951 18951 18951 18951 Children’s and Adolescents’ Access to PCPs, 25 Months-6 Years Std. Lower Err Limit % n Total % RR 77.16% 42628 56943 74.9% 0.9830 0.0091 0.9741 77.16% 3750 5240 71.6% 0.9578 0.0187 0.9400 77.16% 1641 2687 61.1% 0.8706 0.0312 0.8439 77.16% 2367 3097 76.4% 0.9947 0.0210 0.9739 Upper Limit 0.9920 0.9759 0.8981 1.0158 Total 10871 10871 10871 10871 Children’s and Adolescents’ Access to PCPs, 7-11 Years Std. Lower % n Total % RR Err Limit 76.67% 19741 26637 74.1% 0.9808 0.0126 0.9686 76.67% 2353 3374 69.7% 0.9467 0.0245 0.9238 76.67% 968 1522 63.6% 0.8958 0.0394 0.8612 76.67% 1692 2250 75.2% 0.9890 0.0259 0.9638 Upper Limit 0.9932 0.9702 0.9318 1.0150 Total 13899 13899 13899 13899 Children’s and Adolescents’ Access to PCPs, 12-19 Years Std. Lower % n Total % RR Err Limit 77.94% 20213 26441 76.4% 0.9891 0.0111 0.9782 77.94% 3373 4636 72.8% 0.9615 0.0197 0.9427 77.94% 1294 1910 67.7% 0.9220 0.0322 0.8928 77.94% 1499 2124 70.6% 0.9446 0.0289 0.9177 Upper Limit 1.0002 0.9806 0.9522 0.9722 iii Hispanic Black Native American Other Hispanic Black Native American Other Hispanic Black Native American Other Hispanic Black Native American Other n 37428 37428 37428 37428 Children’s and Adolescents’ Access to PCPs, All Age Groups Combined Std. Lower Err Limit Total % n Total % RR 48112 77.79% 93351 123412 75.6% 0.9843 0.0057 0.9786 48112 77.79% 10260 14282 71.8% 0.9555 0.0113 0.9447 48112 77.79% 4275 6654 64.2% 0.8940 0.0185 0.8776 48112 77.79% 6112 8132 75.2% 0.9807 0.0134 0.9676 Upper Limit 0.9899 0.9663 0.9107 0.9939 n 22304 22304 22304 22304 Adults’ Access to Preventive/Ambulatory Health Services, 20-44 Years Std. Lower Err Limit Total % n Total % RR 28596 78.00% 18258 23602 77.4% 0.9954 0.0092 0.9862 28596 78.00% 4319 5755 75.0% 0.9784 0.0161 0.9628 28596 78.00% 1675 2083 80.4% 1.0172 0.0221 0.9950 28596 78.00% 2237 3116 71.8% 0.9537 0.0229 0.9321 Upper Limit 1.0046 0.9943 1.0399 0.9757 n 12962 12962 12962 12962 Adults’ Access to Preventive/Ambulatory Health Services, 45-64 Years Std. Lower Total % n Total % RR Err Limit 15532 83.45% 6797 7979 85.2% 1.0112 0.0115 0.9996 15532 83.45% 2003 2489 80.5% 0.9802 0.0206 0.9603 15532 83.45% 484 585 82.7% 0.9953 0.0377 0.9585 15532 83.45% 3745 4333 86.4% 1.0191 0.0137 1.0052 Upper Limit 1.0229 1.0006 1.0335 1.0332 n 35266 35266 35266 35266 Adults’ Access to Preventive/Ambulatory Health Services, Both Age Groups Combined Std. Lower Upper Total % n Total % RR Err Limit Limit 44128 79.92% 25055 31581 79.3% 0.9959 0.0073 0.9887 1.0033 44128 79.92% 6322 8244 76.7% 0.9771 0.0128 0.9647 0.9897 44128 79.92% 2159 2668 80.9% 1.0069 0.0190 0.9880 1.0263 44128 79.92% 5982 7449 80.3% 1.0027 0.0122 0.9906 1.0150 Well Child Visits, First 15 Months of Life (6 or More Visits) Hispanic Black Native American Other n 1371 1371 1371 1371 Total 2302 2302 2302 2302 % 59.56% 59.56% 59.56% 59.56% n 3956 251 104 196 Total 6820 496 282 403 % 58.0% 50.6% 36.9% 48.6% RR 0.9835 0.9002 0.7218 0.8766 Std. Err 0.0393 0.0932 0.1564 0.1058 Lower Limit 0.9457 0.8201 0.6173 0.7886 Upper Limit 1.0229 0.9882 0.8440 0.9745 Lower Limit 0.9992 0.9193 0.7770 0.9400 Upper Limit 1.0303 0.9775 0.8591 1.0127 Well Child Visits, Third through Sixth Years of Life Hispanic Black Native American Other n 8968 8968 8968 8968 Total 15347 15347 15347 15347 % 58.43% 58.43% 58.43% 58.43% n 27273 2326 932 1393 iv Total 45604 4327 2161 2478 % 59.8% 53.8% 43.1% 56.2% RR 1.0147 0.9479 0.8170 0.9757 Std. Err 0.0153 0.0307 0.0502 0.0372 Adolescent Well Care Visits Hispanic Black Native American Other n 7282 7282 7282 7282 Total 22366 22366 22366 22366 Std. Err 0.0233 0.0369 0.0635 0.0555 Lower Limit 0.9976 1.0001 0.7626 0.9160 Upper Limit 1.0453 1.0768 0.8659 1.0235 Std. Err 0.0088 0.0172 0.0238 0.0212 Lower Limit 1.0498 0.9072 0.9088 0.9511 Upper Limit 1.0684 0.9389 0.9532 0.9923 Lower Limit 0.7789 0.2141 0.7756 Upper Limit 1.3518 1.4311 1.4184 Children’s and Adolescents’ Access to PCPs, 25 Months-6 Years Lower Limit % n Total % RR Std. Err 63.53% 641 816 78.6% 1.1324 0.0534 1.0735 63.53% 57 81 70.4% 1.0632 0.1468 0.9180 63.53% 37 108 34.3% 0.6568 0.2642 0.5043 63.53% 319 465 68.6% 1.0473 0.0732 0.9734 Upper Limit 1.1946 1.2312 0.8555 1.1268 % 32.56% 32.56% 32.56% 32.56% n 13506 2506 784 971 Total 40342 7326 3144 3112 % 33.5% 34.2% 24.9% 31.2% RR 1.0212 1.0377 0.8126 0.9682 Annual Dental Visits, 4-21 Years Hispanic Black Native American Other n 28734 28734 28734 28734 Total 50175 50175 50175 50175 % 57.27% 57.27% 57.27% 57.27% n 70537 7946 3666 4439 Total 112371 15698 7151 8109 % 62.8% 50.6% 51.3% 54.7% RR 1.0590 0.9229 0.9307 0.9715 DDD Children’s and Adolescents’ Access to PCPs, 12-24 Months Hispanic Native American Other Hispanic Black Native American Other Hispanic Black Native American Other Hispanic Black Native American Other n 14 14 14 N 892 892 892 892 n 1017 1017 1017 1017 n 1290 1290 1290 1290 Total 17 17 17 Total 1404 1404 1404 1404 Total 1529 1529 1529 1529 Total 1917 1917 1917 1917 % 82.35% 82.35% 82.35% n 19 3 9 Total 22 9 10 % 86.4% 33.3% 90.0% RR 1.0261 0.5536 1.0489 Std. Err 0.2757 0.9498 0.3018 Children’s and Adolescents’ Access to PCPs, 7-11 Years Std. Err % n Total % RR 66.51% 611 803 76.1% 1.0818 0.0526 66.51% 68 99 68.7% 1.0194 0.1377 66.51% 61 154 39.6% 0.7103 0.1982 66.51% 100 163 61.3% 0.9519 0.1269 Lower Limit 1.0263 0.8883 0.5826 0.8384 Upper Limit 1.1402 1.1698 0.8660 1.0807 Children’s and Adolescents’ Access to PCPs, 12-19 Years of Age Std. Lower Err Limit % n Total % RR 67.29% 641 807 79.4% 1.1005 0.0470 1.0500 67.29% 153 189 81.0% 1.1122 0.0759 1.0309 67.29% 78 217 35.9% 0.6573 0.1803 0.5489 67.29% 87 140 62.1% 0.9528 0.1330 0.8341 Upper Limit 1.1535 1.1998 0.7872 1.0883 v Hispanic Black Native American Other Hispanic Black Native American Other n 3213 2321 3213 3213 Children’s and Adolescents’ Access to PCPs, All Age Groups Combined Std. Lower Err Limit Total % n Total % RR 4867 66.02% 1912 2448 78.1% 1.1028 0.0291 1.0712 3463 67.02% 278 369 75.3% 1.0708 0.0629 1.0055 4867 66.02% 179 488 36.7% 0.6749 0.1183 0.5996 4867 66.02% 515 778 66.2% 1.0016 0.0541 0.9489 Upper Limit 1.1354 1.1403 0.7596 1.0573 n 497 497 497 497 Well Child Visits, Third through Sixth Years of Life Std. Err % n Total % RR 37.37% 421 757 55.6% 1.3138 0.0943 37.37% 44 81 54.3% 1.2940 0.2115 37.37% 16 100 16.0% 0.5070 0.4545 37.37% 200 422 47.4% 1.1820 0.1223 Lower Limit 1.1955 1.0473 0.3219 1.0460 Upper Limit 1.4437 1.5987 0.7987 1.3357 Std. Err 0.1070 0.1711 0.3379 0.1985 Lower Limit 1.1004 1.1322 0.3446 0.9713 Upper Limit 1.3632 1.5941 0.6774 1.4446 Std. Err 0.0515 0.1148 0.1577 0.0939 Lower Limit 1.1901 0.9984 0.6017 0.9214 Upper Limit 1.3193 1.2561 0.8248 1.1119 Children’s and Adolescents’ Access to PCPs, 12-24 Months Std. Err % n Total % RR 94.06% 829 919 90.2% 0.9785 0.0329 94.06% 27 32 84.4% 0.9442 0.1512 94.06% 36 45 80.0% 0.9170 0.1482 94.06% 76 84 90.5% 0.9800 0.0738 Lower Limit 0.9468 0.8117 0.7907 0.9103 Upper Limit 1.0112 1.0983 1.0635 1.0550 Total 1330 1330 1330 1330 Adolescent Well Care Visits Hispanic Black Native American Other n 653 653 653 653 Total 2441 2441 2441 2441 % 26.75% 26.75% 26.75% 26.75% n 350 93 31 73 Total 1004 235 273 219 % 34.9% 39.6% 11.4% 33.3% RR 1.2248 1.3434 0.4832 1.1845 Annual Dental Visits, 4-21 Years Hispanic Black Native American Other n 1958 1958 1958 1958 Total 5250 5250 5250 5250 % 37.30% 37.30% 37.30% 37.30% n 1305 181 124 314 Total 2529 414 524 828 % 51.6% 43.7% 23.7% 37.9% RR 1.2530 1.1199 0.7044 1.0122 KidsCare Hispanic Black Native American Other n 364 364 364 364 Total 387 387 387 387 vi Hispanic Black Native American Other Hispanic Black Native American Other n 1551 1551 1551 1551 n 1345 1345 1345 1345 n Hispanic Black Native American Other Hispanic Black Native American Other 1819 1819 1819 1819 n 5079 5079 5079 5079 Total 1948 1948 1948 1948 Children’s and Adolescents’ Access to PCPs, 25 Months-6 Years Std. Lower Err Limit % n Total % RR 79.62% 4530 5761 78.6% 0.9931 0.0262 0.9674 79.62% 103 136 75.7% 0.9722 0.0977 0.8817 79.62% 135 189 71.4% 0.9400 0.0929 0.8566 79.62% 489 580 84.3% 1.0320 0.0417 0.9898 Children’s and Adolescents’ Access to PCPs, 7-11 Years Std. Err % n Total % RR 82.52% 3282 3924 83.6% 1.0074 0.0263 82.52% 106 128 82.8% 1.0020 0.0820 82.52% 106 136 77.9% 0.9688 0.0922 82.52% 331 408 81.1% 0.9907 0.0519 Upper Limit 1.0194 1.0721 1.0315 1.0759 Lower Limit 0.9813 0.9231 0.8835 0.9406 Upper Limit 1.0342 1.0876 1.0624 1.0435 Lower Limit Upper Limit 0.9719 0.9362 0.8576 0.9717 1.0181 1.0696 1.0195 1.0504 Children’s and Adolescents’ Access to PCPs, All Age Groups Combined Std. Lower Err Limit Total % n Total % RR 6123 82.95% 11696 14264 82.0% 0.9937 0.0137 0.9802 6123 82.95% 382 469 81.4% 0.9900 0.0447 0.9468 6123 82.95% 413 552 74.8% 0.9439 0.0497 0.8982 6123 82.95% 1353 1604 84.4% 1.0092 0.0239 0.9853 Upper Limit 1.0074 1.0353 0.9920 1.0336 Total 1630 1630 1630 1630 Total 2158 2158 2158 2158 Children’s and Adolescents’ Access to PCPs, 12-19 Years Std. % n Total % RR Err 305 5 84.29% 3660 83.5% 0.9947 0.0232 84.29% 146 173 84.4% 1.0007 0.0666 84.29% 136 182 74.7% 0.9350 0.0864 84.29% 457 532 85.9% 1.0103 0.0389 Well Child Visits, First 15 Months of Life n Hispanic Black Native American Other Hispanic Black Native American Other 125 125 125 125 n 938 938 938 938 Total 168 168 168 168 Total 1571 1571 1571 1571 % RR Std. Err Lower Limit Upper Limit 73.5% 56.3% 51.9% 77.8% 0.9932 0.8438 0.8004 1.0255 0.1075 0.4411 0.3741 0.2203 0.8920 0.5428 0.5506 0.8228 1.1060 1.3117 1.1636 1.2782 Well Child Visits, Third through Sixth Years of Life Std. % n Total % RR Err 59.71% 3282 4991 65.8% 1.0611 0.0453 59.71% 62 114 54.4% 0.9423 0.1730 59.71% 65 137 47.4% 0.8607 0.1809 59.71% 334 504 66.3% 1.0661 0.0744 Lower Limit 1.0142 0.7926 0.7183 0.9897 Upper Limit 1.1103 1.1202 1.0314 1.1484 % 74.40% 74.40% 74.40% 74.40% n 275 9 14 21 vii Total 374 16 27 27 Adolescent Well Care Visits Hispanic Black Native American Other n 1245 1245 1245 1245 Total 3436 3436 3436 3436 % 36.23% 36.23% 36.23% 36.23% n 2587 144 78 387 Total 6226 344 328 920 % 41.6% 41.9% 23.8% 42.1% RR 1.1037 1.1095 0.7223 1.1133 Std. Err 0.0532 0.1322 0.1988 0.0879 Lower Limit 1.0464 0.9721 0.5921 1.0196 Upper Limit 1.1640 1.2663 0.8812 1.2155 Std. Err 0.0184 0.0595 0.0686 0.0333 Lower Limit 1.0408 0.9129 0.8282 0.9814 Upper Limit 1.0797 1.0282 0.9499 1.0491 Annual Dental Visits, 4-21 Years Hispanic Black Native American Other n 4921 4921 4921 4921 Total 7350 7350 7350 7350 % 66.95% 66.95% 66.95% 66.95% n 12521 427 387 1412 viii Total 16932 672 701 2058 % 73.9% 63.5% 55.2% 68.6% RR 1.0601 0.9689 0.8870 1.0147