Quality Management Performance Measures For Acute-care Contractors and The Division of Developmental Disabilities Measurement Period Ending Sept. 30, 2008 Prepared by the Division of Health Care Management AHCCCS Arizona Health Care Cost Containment System Thomas J. Betlach, Director TABLE OF CONTENTS INTRODUCTION Overview .................................................................................................................... Methodology .............................................................................................................. Data Sources …………............................................................................................... Data Validation ………….......................................................................................... Data Limitations …………......................................................................................... Deviations from Previous Methodology …………..................................................... 1 1 2 2 2 3 HIGHLIGHTS OF THE DATA Results and Analysis .................................................................................................. Contractor Performance Standards and Improvement ................................................ 4 6 THE MEASURES Children’s and Adolescents’ 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 ................................................................................................... Breast Cancer Screening ............................................................................................. Cervical Cancer Screening .......................................................................................... Chlamydia Screening .................................................................................................. Timeliness of Prenatal Care ........................................................................................ 8 20 25 30 35 40 45 49 53 57 ACUTE-CARE MEASURES FOR DES/DDD Overview ..................................................................................................................... Performance Standards ................................................................................................ Children’s and Adolescents’ Access to Primary Care Practitioners ........................... Well-Child Visits in the Third, Fourth, Fifth and Sixth Months of Life ..................... Adolescent Well-Care Visits ……............................................................................... Annual Dental Visits ................................................................................................... 61 61 62 62 63 63 CONCLUSION Overall Results …………………………................................................................... Disparities by Race and Ethnicity ……….................................................................. References .......................................……..………..................................................... 68 68 69 APPENDIX A Race/Ethnicity Hierarchy and Analysis .............................................................................. 73 INTRODUCTION Overview This is the annual report on quality management performance measures by the Arizona Health Care Cost Containment System (AHCCCS). The report includes data on preventive health services provided to members enrolled with nine publicly and privately operated managed care organizations (MCOs) that contract with AHCCCS (referred to as Contractors). These MCOs provide services under the AHCCCS Acute-care program. In addition, data for services provided through the Department of Economic Security’s Division of Developmental Disabilities (DES/DDD) are included in an appendix. This report includes performance measurement data from nine publicly and privately operated managed care organizations These results should be viewed as indicators of utilization of services, rather than absolute rates. These data allow AHCCCS and its Contractors to identify areas for improvement and implement interventions to increase the use of preventive services. Methodology AHCCCS used Healthcare Effectiveness Data and Information Set (HEDIS®) 2009 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 are continuously enrolled for a minimum period of time with one Contractor. Thus, members included in the measures represent only a portion of the AHCCCS acute-care population. This report includes results for the contract year ending Sept. 30, 2008. Results are reported for Contractors overall and by individual health plan. The report also indicates whether changes in rates 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 chi-square test yields a statistically significant value (p<.05); that is, the probability of obtaining a difference by chance is relatively low. National HEDIS averages for Medicaid and commercial managed care plans also are included in this report. However, it should be noted that some HEDIS measures 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 members eligible under Medicaid (Title XIX of the Social Security Act) and those eligible under the Children’s Health Insurance Program (CHIP, or Title XXI), 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 two 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. In addition, members may receive health care services through other programs, such as Indian Health Service, Medicare, other medical coverage, or free/low-cost community providers. Thus, they may have received a service being measured, but it is not counted because it was not paid for under Medicaid or CHIP. To minimize the impact of limited data available for Medicare beneficiaries who also are enrolled in AHCCCS, dual-eligible members who are enrolled in Medicare MCOs or who have fee-forservice Medicare coverage are excluded from the measurement. AHCCCS members who are enrolled in a Medicare plan that is aligned with their Medicaid plan (i.e., operated by or contracted with the same organization) are included. 2 Second, data for both race and ethnicity (i.e., whether or not a person is of Hispanic or Latino origin) are collected according to current U.S. Census Bureau classifications when members apply for AHCCCS; however, the PMMIS system was designed long before current federal standards for collecting race and ethnicity were issued, and does not accommodate both data fields at this time. Data for race and ethnicity are merged into one field when 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. It also should be noted that people of Hispanic origin may be of any race, but they are reported as a separate racial category. And, 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 The HEDIS methodology used for data collection in the current measurement differs from the methodology used for the previous measurement as follows: • Adults’ Access to Preventive/Ambulatory Health Services – NCQA added codes to identify some services for the numerators (nursing facility discharge day management). In addition, AHCCCS added Place of Service (POS) codes to better identify hospital emergency department and inpatient services, which should be excluded from the numerator for this measure. • Breast Cancer Screening – NCQA added codes to include diagnostic, as well as screening, mammograms in the numerator. • Cervical Cancer Screening – NCQA deleted a code that was used to identify a pelvic and clinical breast exam, which was previously counted toward the numerator, and added codes to exclude women who had laproscopic hysterectomies from the denominator. • Children’s and Adolescent’s Access to Primary Care Practitioners; 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 – AHCCCS added Place of Service (POS) codes to better identify hospital emergency department and inpatient services, which should be excluded from the numerators for these measures. AHCCCS also added more codes to identify services provided by physicians’ assistants and nurse practitioners for inclusion in the numerators. • Chlamydia Screening – NCQA decreased the upper age limit from 25 to 24 years and added codes to identify sexually active women for the denominator. 3 • Timeliness of Prenatal Care – NCQA added more codes to identify live births and prenatal services. In addition to these changes, NCQA updates its methodology annually to add or delete codes that have been added or retired from standardized coding sets used by providers, such as Current Procedural Terminology (CPT) and International Classification of Diseases, Ninth Revision (ICD9) coding. AHCCCS makes these coding changes as well. It also should be noted that denominators for these measures increased from the previous year’s measurement, reflecting significant growth in the AHCCCS program. Some of the growth also may be attributed to the inclusion of more members who are covered under health plans’ Acute-care contracts (contract type A); primarily adults who are eligible under expanded eligibility up to 100 percent of the federal poverty level. HIGHLIGHTS OF THE DATA Results and Analysis Measures of access to care and use of preventive services are included in this report. Age groups for Children’s and Adolescents’ Access to PCPs and Adults’ Access to Preventive/Ambulatory Health Services are reported separately. 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, as well as rates in all four age groups, improved over the previous measurement. For KidsCare members, the overall rate and rates for three age groups also improved, while another age group did not show a statistically significant change. KidsCare rates for all age groups exceeded HEDIS national Medicaid means. • Well-Child Visits in the First 15 Months of Life – While the rate for Medicaid-eligible children did not show a statistically significant change, it continues to exceed the national HEDIS Medicaid mean. The rate for KidsCare members also did not change significantly from the previous year, and is well above the national mean for Medicaid health plans. • Well-Child Visits in the Third, Fourth, Fifth and Sixth Years of Life – Overall rates for both Medicaid and KidsCare members increased, with the rate for both Medicaid and KidsCare members exceeding the national Medicaid mean. The KidsCare rate also exceeds the national HEDIS commercial mean. • Adolescent Well-Care Visits – Overall rates for both Medicaid and KidsCare members increased, and the rate for KidsCare members continues to exceed national Medicaid and commercial means. 4 • • • • • • Nearly all AHCCCS rates showed significant increases and most exceeded HEDIS national Medicaid means Annual Dental Visits – Overall rates for both Medicaid and KidsCare populations increased from the previous year and remain well above the national Medicaid mean, with the rate for KidsCare members in the 90th percentile of Medicaid plans nationally. Adults’ Access to Preventive/Ambulatory Health Services – The overall rate, as well as rates for both age groups, increased from the previous measurement, and continue to exceed the national Medicaid means. Breast Cancer Screening – NCQA changed this measure to report a total rate for women ages 42 to 69; previously, separate rates were reported for women ages 42 to 51 and 52 to 69, as well as a total rate. AHCCCS continues to report only the age group of 52 to 69 with this measurement period. The rate for this measure increased from the previous year and exceeds the Medicaid mean reported for this age group in the previous year. Cervical Cancer Screening – This rate also increased from the previous measurement. Chlamydia Screening – The overall rate for this measurement increased over the previous year. Timeliness of Prenatal Care – This measure was the only one to show a decrease from the previous measurement. Data for each measure were analyzed for members identified as Hispanic, Native American, and non-Hispanic Black, 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. In addition, a significant portion of members do not specify their race or ethnicity. As with the previous measurement, there were some disparities in the Medicaid population by race/ethnicity in most measures, with members of Hispanic ethnicity often more likely than non-Hispanic Whites, Blacks, and Native Americans to have a service. Native American members often appeared to be less likely than non-Hispanic Whites to have a service. It should be noted, however, that data for Native American members may be incomplete because these members may receive services through either Indian Health Service (IHS) and tribal health programs or AHCCCS-contracted health plans. Claims for all services provided by IHS or tribal health care providers may not be included in AHCCCS encounter data. African-American members also appear to be less likely than non-Hispanic Whites to have some types of services. There were fewer disparities by race/ethnicity among KidsCare members. For nearly all measures, rates were higher in urban areas of the state compared with rural areas. The exception was the measure of prenatal care, in which the rate in rural areas was significantly higher. Rates by county also were analyzed, although clear trends were not identified. 5 Contractor Performance Standards and Improvement Contractor rates are compared to Minimum Performance Standards, as specified in the AHCCCS CYE 2009 contracts with health plans. The following table shows the AHCCCS Minimum Performance Standard (MPS) for each measure included in this report, as well as the AHCCCS Goal for the measure. Minimum standards are based on the most recent HEDIS national Medicaid mean available from NCQA when the CYE 2009 contract was developed in late 2007 or, if the AHCCCS statewide average already was above the HEDIS mean, a rate slightly above the current rate (note that national HEDIS means have increased since the CYE 2009 contracts were awarded to health plans). The AHCCCS Goal is based on a national “Healthy People 2010” objective set by the U.S. Department of Health and Human Services several years ago. Acute-care Performance Standards Performance Measure Children’s Dental Visits 2 to 21* Well-child Visits 15 Months* Well-child Visits 3 - 6 Years* Adolescent Well-care Visit* Children's Access to PCPs 12-24 Months* Children's Access to PCPs 25 months-6 Years* Children's Access to PCPs 7-11 Years* Children's Access to PCPs 12-19 Years* Cervical Cancer Screening Breast Cancer Screening Adult Preventive/Ambulatory Care 20-44 Years Adult Preventive/Ambulatory Care 45-64 Years Timeliness of Prenatal Care Chlamydia Screening Minimum Performance Standard 55% 65% 64% 41% Goal 57% 90% 80% 50% 93% 97% 83% 83% 81% 65% 50% 97% 97% 97% 90% 70% 78% 96% 85% 80% 51% 96% 90% 62% * Medicaid and KidsCare populations for these measures are evaluated separately against the AHCCCS contractual standards, and are thus counted as two separate measures. The following table shows the number of measures reported for each Contractor and the number for which the Contractor met the AHCCCS MPS in the current measurement. Because of the unique population it serves, the Department of Economic Security’s Comprehensive Medical and Dental Program (CMDP), a health plan for children and adolescents in foster care, has fewer performance standards than most other Acutecare Contractors. In addition, CMDP has too few KidsCare members to measure this population separately. Pima Health System also has fewer performance measures because it serves primarily Medicare-Medicaid dual-eligible adults and any eligible family members who wish to enroll in the plan under its Acute-care contract with AHCCCS. 6 Contractor Performance Number of Measures in Which Contractor was Included Number of Measures for Which MPS was Met Percent of Measures for Which MPS was Met Phoenix Health Plan 22 17 77.3 Mercy Care Plan 22 16 72.3 Care 1st Healthplan of Arizona 22 13 59.1 Arizona Physicians IPA 22 11 50.0 Maricopa Health Plan 22 11 50.0 Health Choice Arizona 22 8 36.7 University Family Care* 20 13 65.0 DES/CMDP 7 5 71.4 Pima Health System 4 2 50.0 Contractor * University Family Care did not have enough KidsCare members who met the eligible population criteria for two measures. Overall rates for nearly all measures increased because of significant increases demonstrated by several Contractors, despite the fact that AHCCCS raised most Minimum Performance Standards in the CYE 2009 contract, which applies to this measurement period. In July 2007, AHCCCS advised Contractors that it would levy financial sanctions if Contractors did not improve their performance, and this action appears to have encouraged health plans to implement interventions and apply the resources necessary to increase rates. AHCCCS will request corrective action plans (CAPs) from Contractors to bring their rates up to compliance with minimum standards when Minimum Performance Standards are not met. 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 and are implementing new or revised actions to improve rates. 7 CHILDREN’S AND ADOLESCENTS’ 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 (Oct. 1, 2007, through Sept. 30, 2008), 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 member-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 member-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 a Minimum Performance Standards by age group, which apply to both Medicaid and KidsCare members, for the current measurement, based on the most recent national Medicaid means reported by NCQA. AHCCCS also has set Goals based on national Healthy People 2010 objectives. These are shown in the following table: 8 AHCCCS Performance Standards for Children’s and Adolescents’ Access to PCPs Minimum Performance Standard (MPS) Goal 12 – 24 Months 93% 97% 25 Months – 6 Years 7 – 11 Years 12 – 19 Years 83% 83% 81% 97% 97% 97% Age Group Results Rates for all age groups in the Medicaid population increased from the previous measurement (Table 1). KidsCare rates for three age groups increased, while the rate for one age group did not significantly change (Table 2). Rates for Medicaid members in all four age groups increased, while rates for KidsCare members in three age groups increased In the current period, the total rate (all age groups combined) for Medicaid members was 80.8 percent, an increase from the previous rate of 76.7 percent in the previous year (p<.001). The total rate for KidsCare members was 87.2 percent, an increase from 83.2percent in the previous year (p<.001). (you don’t have a “total rate” in the table above which makes this somewhat confusing.) When total rates were analyzed by rural and urban counties, both Medicaid-and KidsCare-eligible members in urban counties (i.e., Maricopa and Pima counties) were more likely to have PCP visits than those in rural counties (p<.001 for both groups). However, there was no significant difference among Medicaid members 7 to 11 years old (p=.073). Among KidsCare members, there was no significant difference between urban and rural areas among Medicaid-eligible 7 to 11 years of age and 12 to 19 years of age (p=.933 and p=.892). Overall, Native American and Black Medicaid-eligible members were less likely than non-Hispanic Whites to have PCP visits (refer to Appendix A for detailed analysis by race/ethnicity). These results are consistent with the previous measurement. Comparison with National Benchmarks NCQA has reported national HEDIS means (averages) for Medicaid and commercial health plans, based on the 2008 measurement year. AHCCCS Medicaid and KidsCare rates compare to the national means as follows: 9 AHCCCS Rates Compared with 2008 National HEDIS Means AHCCCS Medicaid Rate AHCCCS KidsCare Rate HEDIS Medicaid Mean HEDIS Commerci al Mean 12 – 24 Months 85.0% 93.7% 93.4% 96.9% 25 Mos – 6 Years 7 – 11 Years 12 – 19 Years 81.6% 78.4% 80.0% 87.5% 86.2% 86.4% 84.3% 85.8% 82.6% 89.4% 89.5% 86.9% Measure/ Age Group 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 Children’s and Adolescents’ Access to PCPs are highest for children 12 to 24 months. Consistent with previous measurements, children enrolled with AHCCCS Contractors through KidsCare have higher 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 need for 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 non-Hispanic White. However, Native American members also may receive primary care through Indian Health Service (IHS) facilities. 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, DES/CMDP met the Minimum Performance Standard (MPS) for three of four age groups for Medicaid-eligible members. No other Contractor met as many minimum standards for that population. Three Contractors ― Maricopa Health Plan, Mercy Care Plan and Phoenix Health Plan ― each met the MPS for all four age groups among KidsCare members. While Contractors are evaluated on their rates by age group, Figures 1 and 2 show Contractor performance when all age groups are combined. 10 Figure 1. Rates by Contractor, Children’s Access to PCPs among Medicaid Members, All Age Groups Combined CYE 2008 compared with CYE 2007 100% 80% 60% 40% 20% 0% APIPA Care1st CMDP HCA MHP CYE2008 MCP PHP UFC CYE2007 As shown above, the Comprehensive Medical and Dental Program (CMDP) had the highest rate of access to PCPs among Medicaideligible members for all age groups combined (87.5 percent). CMDP is a 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 by the state, case managers work to ensure that they have a medical visit as soon as possible. Figure2. Rates by Contractor, Children’s Access to PCPs among KidsCare Members, All Age Groups Combined CYE 2008 compared with CYE 2007 100% 80% 60% 40% 20% 0% APIPA Care1st HCA CYE2008 MHP MCP PHP UFC CYE2007 For KidsCare members, University Family Care recorded the highest total rate (93.6 percent). 11 Table 1 Arizona Health Care Cost Containment System CHILDREN'S ACCESS TO PRIMARY CARE PRACTITIONERS BY CONTRACTOR, MEMBERS ELIGIBLE UNDER MEDICAID Measurement Period Oct. 1, 2007, through Sept. 30, 2008 93 83 83 81 Minimum Performance Standards: 12-24 Months Rates in bold face denote the Contractor met 25 Months - 6 Years the AHCCCS Minimum Performance Standard 7-11 Years 12-19 Years Contractor AZ Physicians IPA Age 12-24 mos. 25 mos. - 6 yrs. 7 - 11 yrs. 12 -19 yrs. Total AZ Physicians IPA 12-24 mos. 25 mos. - 6 yrs. 7 - 11 yrs. 12 -19 yrs. Total Care1st Healthplan 12-24 mos. 25 mos. - 6 yrs 7 - 11 yrs. 12 -19 yrs. Total Care1st Healthplan 12-24 mos. 25 mos. - 6 yrs. 7 - 11 yrs. 12 -19 yrs. Total Percent with 1+ Visits Relative Percent Change From Previous Year Statistical Significance 85.0% 81.0% 78.9% 80.6% 80.7% 4.8% 7.5% 4.3% 4.6% 5.6% p<.001 p<.001 p<.001 p<.001 p<.001 1.7% 7.2% 2.2% 6.8% 5.4% p=.391 p<.001 p=.381 p=.004 p<.001 Number of Members 5,766 27,126 17,221 20,671 Number with 1+ Visits 4,902 21,967 13,593 16,654 70,784 57,116 5,648 26,285 16,524 19,306 67,763 899 3,622 1,211 1,327 4,581 19,801 12,511 14,877 51,770 776 2,956 886 1,018 7,059 5,636 86.3% 81.6% 73.2% 76.7% 79.8% 921 3,204 1,210 1,227 6,562 782 2,440 866 881 4,969 84.9% 76.2% 71.6% 71.8% 75.7% 12 81.1% 75.3% 75.7% 77.1% 76.4% Table 1 Arizona Health Care Cost Containment System CHILDREN'S ACCESS TO PRIMARY CARE PRACTITIONERS BY CONTRACTOR, MEMBERS ELIGIBLE UNDER MEDICAID Measurement Period Oct. 1, 2007, through Sept. 30, 2008 93 83 83 81 Minimum Performance Standards: 12-24 Months Rates in bold face denote the Contractor met 25 Months - 6 Years the AHCCCS Minimum Performance Standard 7-11 Years 12-19 Years Contractor DES/CMDP Age 12-24 mos. 25 mos. - 6 yrs. 7 - 11 yrs. 12 -19 yrs. Total DES/CMDP 12-24 mos. 25 mos. - 6 yrs. 7 - 11 yrs. 12 -19 yrs. Total Health Choice AZ 12-24 mos. 25 mos. - 6 yrs. 7 - 11 yrs. 12 -19 yrs. Total Health Choice AZ 12-24 mos. 25 mos. - 6 yrs. 7 - 11 yrs. 12 -19 yrs. Total Maricopa Health Plan 12-24 mos. 25 mos. - 6 yrs. 7 - 11 yrs. 12 -19 yrs. Total Maricopa Health Plan 12-24 mos. 25 mos. - 6 yrs. 7 - 11 yrs. 12 -19 yrs. Total Number of Members 498 Percent with 1+ Visits Relative Percent Change From Previous Year Statistical Significance 88.8% 84.0% 86.4% 92.7% 87.5% -2.8% 6.4% 1.7% 0.2% 2.4% p=.197 p<.001 p=.546 p=.877 p=.014 0.7% 5.5% 3.3% 2.5% 3.8% p=.516 p<.001 p=.002 p=.014 p<.001 0.6% 10.7% 19.3% 9.2% 11.2% p=.775 p<.001 p<.001 p<.001 p<.001 1,417 382 941 Number with 1+ Visits 442 1,190 330 872 3,238 2,834 426 1,497 532 1,078 3,533 3,457 13,815 6,774 6,692 389 1,182 452 997 3,020 2,860 10,872 5,126 5,163 30,738 24,021 3,087 12,322 6,073 5,953 27,435 1,029 4,098 2,391 2,410 2,535 9,192 4,450 4,482 20,659 845 3,088 1,724 1,628 9,928 7,285 82.1% 75.4% 72.1% 67.6% 73.4% 914 4,101 2,314 2,340 9,669 746 2,791 1,398 1,448 6,383 81.6% 68.1% 60.4% 61.9% 66.0% 13 91.3% 79.0% 85.0% 92.5% 85.5% 82.7% 78.7% 75.7% 77.2% 78.1% 82.1% 74.6% 73.3% 75.3% 75.3% Table 1 Arizona Health Care Cost Containment System CHILDREN'S ACCESS TO PRIMARY CARE PRACTITIONERS BY CONTRACTOR, MEMBERS ELIGIBLE UNDER MEDICAID Measurement Period Oct. 1, 2007, through Sept. 30, 2008 93 83 83 81 Minimum Performance Standards: 12-24 Months Rates in bold face denote the Contractor met 25 Months - 6 Years the AHCCCS Minimum Performance Standard 7-11 Years 12-19 Years Contractor Mercy Care Plan Age 12-24 mos. 25 mos. - 6 yrs. 7 - 11 yrs. 12 -19 yrs. Total Number of Members 7,296 30,053 14,962 15,485 Number with 1+ Visits 6,224 25,068 11,945 12,522 67,796 55,759 6,720 27,249 13,322 13,645 60,936 2,753 11,919 6,330 6,389 5,589 21,451 10,325 10,718 48,083 2,379 9,988 5,003 5,227 Percent with 1+ Visits Relative Percent Change From Previous Year Statistical Significance 85.3% 83.4% 79.8% 80.9% 82.2% 2.6% 6.0% 3.0% 2.9% 4.2% p=.001 p<.001 p<.001 p<.001 p<.001 4.4% 9.9% 4.1% 9.6% 7.9% p<.001 p<.001 p<.001 p<.001 p<.001 Mercy Care Plan 12-24 mos. 25 mos. - 6 yrs. 7 - 11 yrs. 12 -19 yrs. Total Phoenix Health Plan 12-24 mos. 25 mos. - 6 yrs. 7 - 11 yrs. 12 -19 yrs. Total 27,391 22,597 86.4% 83.8% 79.0% 81.8% 82.5% Phoenix Health Plan 12-24 mos. 25 mos. - 6 yrs. 7 - 11 yrs. 12 -19 yrs. 2,452 11,080 5,943 5,828 2,030 8,446 4,514 4,349 82.8% 76.2% 76.0% 74.6% Total 25,303 19,339 76.4% 14 83.2% 78.7% 77.5% 78.5% 78.9% Table 1 Arizona Health Care Cost Containment System CHILDREN'S ACCESS TO PRIMARY CARE PRACTITIONERS BY CONTRACTOR, MEMBERS ELIGIBLE UNDER MEDICAID Measurement Period Oct. 1, 2007, through Sept. 30, 2008 93 83 83 81 Minimum Performance Standards: 12-24 Months Rates in bold face denote the Contractor met 25 Months - 6 Years the AHCCCS Minimum Performance Standard 7-11 Years 12-19 Years Contractor University Family Care Age 12-24 mos. 25 mos. - 6 yrs. 7 - 11 yrs. 12 -19 yrs. Total Percent with 1+ Visits Relative Percent Change From Previous Year Statistical Significance 2,249 91.3% 81.9% 80.9% 84.4% 83.0% 9.2% 8.1% 4.1% 2.4% 4.8% p=.086 p=.003 p=.106 p=.213 p<.001 2.9% 7.2% 4.2% 4.4% 5.4% p<.001 p<.001 p<.001 p<.001 p<.001 Number of Members 104 697 810 1,099 Number with 1+ Visits 95 571 655 928 2,710 University Family Care 12-24 mos. 25 mos. - 6 yrs. 7 - 11 yrs. 12 -19 yrs. Total 116 889 859 1,177 3,041 97 674 667 971 2,409 83.6% 75.8% 77.6% 82.5% 79.2% TOTAL 12-24 mos. 25 mos. - 6 yrs. 7 - 11 yrs. 12 -19 yrs. Total 21,802 92,747 50,081 55,014 219,644 18,523 75,700 39,262 44,012 177,497 85.0% 81.6% 78.4% 80.0% 80.8% TOTAL 12-24 mos. 25 mos. - 6 yrs. 7 - 11 yrs. 12 -19 yrs. Total 20,284 86,627 46,777 50,554 204,242 16,749 65,977 35,183 38,723 156,632 82.6% 76.2% 75.2% 76.6% 76.7% Note: Results of previous measurement period (Oct. 1, 2006, through Sept. 30, 2007) shown in shaded rows. 15 Table 2 Arizona Health Care Cost Containment System CHILDREN'S ACCESS TO PRIMARY CARE PRACTITIONERS BY CONTRACTOR MEMBERS ELIGIBLE UNDER KIDSCARE Measurement Period Oct. 1, 2007, to Sept. 30, 2008 Minimum Performance Standards: Rates in bold face denote the Contractor met the AHCCCS Minimum Performance Standard Contractor Age AZ Physicians IPA 12-24 mos. 25 mos. - 6 yrs. 7 - 11 yrs. 12 -19 yrs. Total AZ Physicians IPA 12-24 mos. 25 mos. - 6 yrs. 7 - 11 yrs. 12 -19 yrs. Total Care1st Healthplan 12-24 mos. 25 mos. - 6 yrs. 7 - 11 yrs. 12 -19 yrs. Total Care1st Healthplan 12-24 mos. 25 mos. - 6 yrs. 7 - 11 yrs. 12 -19 yrs. Total 12-24 Months 25 Months - 6 Years 7-11 Years 12-19 Years 93 83 83 81 Percent with 1+ Visits Relative Percent Change From Previous Year Statistical Significance 91.5% 85.4% 85.2% 86.7% 86.1% -0.7% 8.4% 3.3% 3.0% 4.5% p=.729 p<.001 p=.012 p=.006 p<.001 5.9% 5.0% 3.1% -0.1% 3.5% p=.150 p=.065 p=.565 p=.975 p=.064 Number of Members 422 2,696 2,312 2,930 Number with 1+ Visits 386 2,302 1,970 2,540 8,360 7,198 419 2,726 2,406 3,058 8,609 86 454 178 204 386 2,148 1,985 2,574 7,093 84 403 147 177 922 811 97.7% 88.8% 82.6% 86.8% 88.0% 77 420 156 198 851 71 355 125 172 723 92.2% 84.5% 80.1% 86.9% 85.0% 16 92.1% 78.8% 82.5% 84.2% 82.4% Table 2 Arizona Health Care Cost Containment System CHILDREN'S ACCESS TO PRIMARY CARE PRACTITIONERS BY CONTRACTOR MEMBERS ELIGIBLE UNDER KIDSCARE Measurement Period Oct. 1, 2007, to Sept. 30, 2008 Minimum Performance Standards: Rates in bold face denote the Contractor met the AHCCCS Minimum Performance Standard Contractor Health Choice AZ Health Choice AZ Age 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 Maricopa Health Plan 12-24 mos. 25 mos. - 6 yrs. 7 - 11 yrs. 12 -19 yrs. Total Maricopa Health Plan 12-24 mos. 25 mos. - 6 yrs. 7 - 11 yrs. 12 -19 yrs. Total 12-24 Months 25 Months - 6 Years 7-11 Years 12-19 Years 93 83 83 81 Percent with 1+ Visits Relative Percent Change From Previous Year Statistical Significance 92.9% 85.6% 81.8% 83.8% 84.8% 1.7% 7.7% -0.8% -3.5% 2.0% p=.506 p<.001 p=.729 p=.082 p=.061 7.9% 13.0% n/a n/a 10.7% p=.158 p<.001 p<.001 p=.082 p<.001 Number of Members 280 1,391 894 845 Number with 1+ Visits 260 1,191 731 708 3,410 2,890 253 1,304 875 840 3,272 88 510 387 357 231 1,037 721 729 2,718 82 434 331 290 1,342 1,137 93.2% 85.1% 85.5% 81.2% 84.7% 66 547 383 326 613 57 412 276 247 469 86.4% 75.3% n/a n/a 76.5% 17 91.3% 79.5% 82.4% 86.8% 83.1% Table 2 Arizona Health Care Cost Containment System CHILDREN'S ACCESS TO PRIMARY CARE PRACTITIONERS BY CONTRACTOR MEMBERS ELIGIBLE UNDER KIDSCARE Measurement Period Oct. 1, 2007, to Sept. 30, 2008 Minimum Performance Standards: Rates in bold face denote the Contractor met the AHCCCS Minimum Performance Standard Contractor Mercy Care Plan Age 12-24 mos. 25 mos. - 6 yrs. 7 - 11 yrs. 12 -19 yrs. Total Mercy Care Plan 12-24 mos. 25 mos. - 6 yrs. 7 - 11 yrs. 12 -19 yrs. Total Phoenix Healh Plan 12-24 mos. 25 mos. - 6 yrs. 7 - 11 yrs. 12 -19 yrs. Total Phoenix Health Plan 12-24 mos. 25 mos. - 6 yrs. 7 - 11 yrs. 12 -19 yrs. Total 12-24 Months 25 Months - 6 Years 7-11 Years 12-19 Years Number of Members 639 3,481 2,415 2,369 Number with 1+ Visits 603 3,096 2,122 2,064 8,904 7,885 596 3,437 2,366 2,317 8,716 266 1,838 558 2,836 2,040 1,951 7,385 253 93 83 83 81 Percent with 1+ Visits Relative Percent Change From Previous Year Statistical Significance 94.4% 88.9% 87.9% 87.1% 88.6% 0.8% 7.8% 1.9% 3.5% 4.5% p=.583 p<.001 p=.090 p=.004 p<.001 -0.6% 9.3% 3.7% 4.2% 5.9% p=.782 p<.001 p=.017 p=.017 p<.001 93.6% 82.5% 86.2% 84.2% 84.7% 1,379 1,214 1,646 1,213 1,053 4,697 4,165 95.1% 89.6% 88.0% 86.7% 88.7% 207 1,908 1,380 1,151 4,646 198 1,564 1,171 958 3,891 95.7% 82.0% 84.9% 83.2% 83.7% 18 Table 2 Arizona Health Care Cost Containment System CHILDREN'S ACCESS TO PRIMARY CARE PRACTITIONERS BY CONTRACTOR MEMBERS ELIGIBLE UNDER KIDSCARE Measurement Period Oct. 1, 2007, to Sept. 30, 2008 Minimum Performance Standards: Rates in bold face denote the Contractor met the AHCCCS Minimum Performance Standard Contractor University Family Care University Family Care TOTAL TOTAL Age 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 Number of Members n/a 27 58 86 171 n/a 50 73 145 268 1,781 10,397 7,623 8,005 27,806 1,618 10,392 7,639 8,035 27,684 12-24 Months 25 Months - 6 Years 7-11 Years 12-19 Years Number with 1+ Visits n/a 25 54 81 160 n/a 34 65 128 227 1,668 9,097 6,568 6,913 24,246 1,501 8,386 6,383 6,759 23,029 93 83 83 81 Percent with 1+ Visits n/a 92.6% 93.1% 94.2% 93.6% n/a 68.0% 89.0% 88.3% 84.7% 93.7% 87.5% 86.2% 86.4% 87.2% 92.8% 80.7% 83.6% 84.1% 83.2% Relative Percent Change From Previous Year Statistical Significance n/a 36.2% 4.6% 6.7% 10.5% n/a p=.015 p=.423 p=.139 p=.004 1.0% 8.4% 3.1% 2.7% 4.8% p=.304 p<.001 p<.001 p<.001 p<.001 Notes: Results of previous measurement period (Oct. 1, 2006, through Sept. 30, 2007) shown in shaded rows. University Family Care did not have enough KidsCare members ages 12 to 24 months who met the criteria for the eligible population to be included in the measurement 19 ADULTS’ ACCESS TO PREVENTIVE AND AMBULATORY HEALTH SERVICES Behavioral risk factors such as smoking, poor diet, physical inactivity, and excessive drinking are linked to the leading causes of death in the United States. Controlling these behavioral risk factors and using preventive health services (e.g., influenza vaccinations and cholesterol screenings) can substantially reduce disease and premature death among U.S. adults.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 acute-care 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 The most recent national data, for 2007, show an estimated 19.8 percent of Arizona adults are current cigarette smokers. 8 Rates of smoking increase as income falls below the federal poverty level. 7 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. Yet, a survey by the Centers for Disease Control and Prevention found that only 65.5 percent of Arizona adults had visited a doctor for a routine checkup in the preceding 12 months. 6 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 (Oct. 1, 2007, through Sept. 30, 2008), • 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 member-month), and • had one or more preventive/ambulatory visits, including encounters with primary care physicians, specialists, physician’s assistants, nurse practitioners, ophthalmologists and optometrists. Performance Goals AHCCCS has adopted Minimum Performance Standards by age group for Adults’ Access to Preventive/Ambulatory Health Services for the current measurement, based on the most recent national Medicaid means reported by NCQA. AHCCCS also has set Goals based on national Healthy People 2010 objectives. These are shown in the following table: 20 AHCCCS Performance Standards for Adults’ Access to Preventive/Ambulatory Health Services Minimum Performance Standard (MPS) Goal 20 – 44 Years 78% 96% 45 – 64 Years 85% 96% Age Group Rates for both age groups increased, and exceed the national Medicaid means Results The total rate of both age groups combined increased in the current measurement, to 83.0 percent from 81.7 percent in the previous year (p<.001). Rates for both age groups also showed statistically significant increases (Table 3). When total rates were analyzed by rural and urban counties, members in both age groups and overall who resided in urban counties were more likely to have preventive and ambulatory visits than those in rural counties (p<.001 for both groups and overall). Among members 20 to 44 years of age and overall, non-Hispanic Whites were more likely to have visits than other racial or ethnic groups (refer to Appendix A for detailed analysis by race/ethnicity). There were no significant differences in the age group 45 to 64 years old. In the previous measurement, only Black members were less likely to have visits than non-Hispanic Whites. Comparison with National Benchmarks NCQA has reported national HEDIS means (averages) for Medicaid and commercial health plans, based on the 2008 measurement year. The AHCCCS rates compare to the national means as follows: AHCCCS Rates Compared with 2008 National HEDIS Means AHCCCS Medicaid Rate HEDIS Medicaid Mean HEDIS Commercial Mean 20 – 44 Years 81.0% 76.8% 93.0% 45 – 64 Years 86.7% 82.4% 95.1% Measure/ Age Group 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. 21 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. Five Contractors — Arizona Physicians IPA, Care1st Healthplan, Mercy Care Plan, Phoenix Health Plan and University Family Care ― met the MPS for both age groups. While Contractors are evaluated on their rates by age group, Figure 3 shows Contractor performance when both age groups are combined. Figure 3. Rates by Contractor, Both Age Groups of Adults Combined, Medicaid Members CYE 2008 compared with CYE 2007 100% 80% 60% 40% 20% 0% APIPA Care1st HCA MHP CYE2008 MCP PHP PHS UFC CYE2007 Mercy Care Plan showed the highest rate (84.2 percent) for Adults’ Access to Preventive/Ambulatory Health Services when both age groups were combined. 22 Table 3 Arizona Health Care Cost Containment System ADULTS' ACCESS TO PREVENTIVE/AMBULATORY HEALTH SERVICES BY CONTRACTOR MEMBERS ELIGIBLE UNDER MEDICAID Measurement Period: Oct. 1, 2007, through Sept. 30, 2008 Minimum Performance Standards: 20-44 Years 78 45-64 Years 85 Rates in bold face denote the Contractor met the AHCCCS Minimum Performance Standard Contractor Age AZ Physicians IPA 20-44 45-64 Total AZ Physicians IPA 20-44 45-64 Total Care1st Healthplan 20-44 45-64 Total Care1st Healthplan 20-44 45-64 Total Health Choice AZ 20-44 45-64 Total Health Choice AZ 20-44 45-64 Total Maricopa Health Plan 20-44 45-64 Total Number of Members 37,567 21,306 Number with 1+ Visits 30,632 18,800 58,873 49,432 19,923 9,510 29,433 3,694 1,879 16,214 8,311 24,525 2,898 1,599 5,573 4,497 1,964 784 2,748 15,861 7,889 1,478 644 2,122 12,439 6,520 23,750 18,959 7,987 3,369 11,356 2,817 2,250 6,204 2,744 8,948 2,017 1,853 5,067 3,870 1,566 1,179 2,745 35,267 18,500 1,119 966 2,085 28,989 16,279 Percent with 1+ Visits Relative Percent Change From Previous Year Statistical Significance 81.5% 88.2% 84.0% 0.2% 1.0% 0.8% p=.646 p=.035 p=.015 4.2% 3.6% 4.5% p=.006 p=.056 p<.001 1.0% 1.5% 1.3% p=.186 p=.127 p=.025 0.2% 0.5% 0.6% p=.919 p=.759 p=.677 1.3% 1.1% 1.5% p=.004 p=.031 p<.001 81.4% 87.4% 83.3% 78.5% 85.1% 80.7% 75.3% 82.1% 77.2% 78.4% 82.6% 79.8% 77.7% 81.4% 78.8% 71.6% 82.4% 76.4% Maricopa Health Plan 20-44 45-64 Total Mercy Care Plan 20-44 45-64 Total 53,767 45,268 82.2% 88.0% 84.2% Mercy Care Plan 20-44 45-64 17,767 7,886 14,421 6,864 81.2% 87.0% Total 25,653 21,285 83.0% 23 71.5% 81.9% 76.0% Table 3 Arizona Health Care Cost Containment System ADULTS' ACCESS TO PREVENTIVE/AMBULATORY HEALTH SERVICES BY CONTRACTOR MEMBERS ELIGIBLE UNDER MEDICAID Measurement Period: Oct. 1, 2007, through Sept. 30, 2008 Minimum Performance Standards: 20-44 Years 78 45-64 Years 85 Rates in bold face denote the Contractor met the AHCCCS Minimum Performance Standard Contractor Phoenix Health Plan Phoenix Health Plan Pima Health System Pima Health System University Family Care University Family Care TOTAL TOTAL 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 Number of Members 11,154 5,189 16,343 5,951 2,561 8,512 4,200 2,338 6,538 1,864 936 2,800 1,108 837 1,945 755 553 1,308 111,668 60,188 171,856 57,777 26,778 84,555 Number with 1+ Visits 9,303 4,435 13,738 4,686 2,164 6,850 3,342 1,953 5,295 1,444 759 2,203 882 729 1,611 607 480 1,087 90,502 52,168 142,670 46,173 22,932 69,105 Percent with 1+ Visits Note: Results of previous measurement period (Oct. 1, 2006, through Sept. 30, 2007) shown in shaded rows. 24 83.4% 85.5% 84.1% 78.7% 84.5% 80.5% 79.6% 83.5% 81.0% 77.5% 81.1% 78.7% 79.6% 87.1% 82.8% 80.4% 86.8% 83.1% 81.0% 86.7% 83.0% 79.9% 85.6% 81.7% Relative Percent Change From Previous Year Statistical Significance 5.9% 1.1% 4.5% p<.001 p=.258 p<.001 2.7% 3.0% 2.9% p=.064 p=.094 p=.010 -1.0% 0.3% -0.3% p=.674 p=.872 p=.837 1.4% 1.2% 1.6% p<.001 p<.001 p<.001 WELL CHILD VISITS IN THE FIRST 15 MONTHS OF LIFE The most dramatic growth during childhood – physical, cognitive, social and emotional – occurs during infancy. In the first year of life, an infant’s birth weight triples, his length increases by almost 50 percent, and he achieves most of his brain growth.9 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 (Oct. 1, 2007, through Sept. 30, 2008), • 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 member-month, was allowed), and • had six or more well-child visits during the first 15 months of life. Performance Goals AHCCCS has adopted a Minimum Performance Standard that applies to both Medicaid and KidsCare members for the current measurement, based on the most recent national Medicaid mean reported by NCQA. AHCCCS also has set a Goal based on national Healthy People 2010 objectives. These are shown in the following table: AHCCCS Performance Standards for Well Child Visits in the First 15 Months of Life Age Group Well-Child Visits, 15 Months Minimum Performance Standard (MPS) Goal 65% 90% Results The overall rate for Medicaid members (Table 4) was unchanged, at 59.5 percent, compared with 59.4 percent in the previous measurement (p=.857). The overall rate for KidsCare members (Table 5) did not show a statistically significant increase, with a rate of 71.3 percent, compared with 68.6 percent in the previous measurement (p=.221). 25 When rates were analyzed by rural and urban counties, Medicaideligible children living in urban counties were more likely to have six well-child visits than those living in rural counties (p=.001). Rates between urban and rural counties for KidsCare members did not show a statistically significant difference (p=.057). The AHCCCS rates exceed the national Medicaid mean Overall, Native American and Black Medicaid-eligible members were less likely than non-Hispanic Whites to have visits (refer to Appendix A for detailed analysis by race/ethnicity). These results are consistent with the previous measurement. Comparison with National Benchmarks NCQA has reported national HEDIS means (averages) for Medicaid and commercial health plans, based on the 2008 measurement year. AHCCCS Medicaid and KidsCare rates compare to the national means as follows: AHCCCS Rates Compared with 2008 National HEDIS Means Measure/ Age Group Six Well Child Visits by 15 Months of Age AHCCCS Medicaid Rate AHCCCS KidsCare Rate HEDIS Medicaid Mean HEDIS Commerci al Mean 59.5% 71.3% 53.0% 72.8% Discussion While the AHCCCS overall rate for Well Child Visits in the First 15 Months of Life among Medicaid members is above the national mean, there is still 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 care through Indian Health Services, as well as through AHCCCS health plan providers. This bears further investigation, as part of Contractors’ efforts to ensure that all members receive necessary preventive services in the first 15 months of life. Care1st Healthplan and Phoenix Health Plan met the Minimum Performance Standard for Medicaid-eligible children, while all Contractors met the MPS for the KidsCare population. 26 Figure 4. Rates by Contractor, Well-Child Visits in the First 15 Months of Life, Medicaid Members CYE 2008 compared with CYE 2007 100% 80% 60% 40% 20% 0% APIPA Care1st HCA CYE2008 MHP MCP PHP UFC CYE2007 Care1st Healthplan had the highest rate for this measure in the current period (65.8 percent). Rates by Contractor for KidsCare members are not compared with the previous measurement, as individual Contractor rates for CYE 2007 were not reported for this population. 27 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: Oct. 1, 2007, to Sept. 30, 2008 Minimum Performance Standard: 65 Rates in bold face denote the Contractor met the AHCCCS Minimum Performance Standard Contractor Number of Members 5,150 Number with 6+ Visits 2,937 Percent with 6+ Visits Relative Percent Change From Previous Year AZ Physicians IPA 57.0% 2.8% AZ Physicians IPA 2795 1551 55.5% 758 499 Care1st Healthplan 65.8% 12.1% Care1st Healthplan 431 253 58.7% 2,752 1,596 Health Choice AZ 58.0% -2.2% Health Choice AZ 1,494 886 59.3% 835 526 Maricopa Health Plan 63.0% 9.7% Maricopa Health Plan 444 255 57.4% 6,011 3,545 Mercy Care Plan 59.0% -5.7% Mercy Care Plan 3,230 2,021 62.6% 2,315 1,511 Phoenix Health Plan 65.3% 6.6% Phoenix Health Plan 1,263 773 61.2% 95 49 University Family Care 51.6% -7.5% University Family Care 61 34 55.7% TOTAL 17,916 10,663 59.5% 0.2% TOTAL 9,718 5,773 59.4% Note: Results of previous measurement period (Oct. 1, 2006, through Sept. 30, 2007) shown in shaded rows. 28 Statistical Significance p=.187 p=.014 p=.408 p=.052 p=.001 p=.016 p=.611 p=.857 Table 5 Arizona Health Care Cost Containment System WELL-CHILD VISITS IN THE FIRST 15 MONTHS OF LIFE BY CONTRACTOR MEMBERS ELIGIBLE UNDER KIDSCARE Measurement Period: Oct. 1, 2007, to Sept. 30, 2008 Minimum Performance Standard: 65 Rates in bold face denote the Contractor met the AHCCCS Minimum Performance Standard Relative Percent Contractor AZ Physicians IPA AZ Physicians IPA Care1st Healthplan Care1st Healthplan Health Choice AZ Health Choice AZ Maricopa Health Plan Maricopa Health Plan Mercy Care Plan Mercy Care Plan Phoenix Health Plan Phoenix Health Plan TOTAL TOTAL Number of Number with Percent with Change From Statistical Members 6+ Visits 6+ Visitis Previous Year Significance 467 221 81 46 282 105 85 24 620 307 244 101 1,779 804 322 137 59 31 184 75 63 11 453 226 187 74 1,268 554 69.0% 62.0% 72.8% 67.4% 65.2% 71.4% 74.1% 45.8% 73.1% 73.6% 76.6% 73.3% 71.3% 68.9% 11.2% p=.070 8.1% p=.516 -8.7% p=.251 61.7% p=.009 -0.7% p=.858 4.6% p=.507 3.4% p=.221 Notes: Results of previous measurement period (Oct. 1, 2006, through Sept. 30, 2007) shown in shaded rows. University Family Care did not have enough KidsCare members in this age group who met the criteria for the eligible population to be included in the measurement 29 WELL CHILD VISITS IN THE THIRD, FOURTH, FIFTH AND SIXTH YEARS OF LIFE Children who are healthy are better able to learn and develop.10,11 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 (Oct. 1, 2007, through Sept. 30, 2008), • 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 member-month), and • had at least one well-child visit during the measurement period. Performance Goals AHCCCS has adopted a Minimum Performance Standard that applies to both Medicaid and KidsCare members for the current measurement, based on the most recent national Medicaid mean reported by NCQA. AHCCCS also has set a Goal based on national Healthy People 2010 objectives. These are shown in the following table: AHCCCS Performance Standards for Well Child Visits in the Third, Fourth, Fifth and Sixth Years of Life Age Group Well-Child Visits, 3 through 6 Years Minimum Performance Standard (MPS) Goal 64% 80% Results The overall rate for Medicaid members (Table 6) increased to 66.2 percent from 61.6 percent in the previous measurement (p<.001). The rate for KidsCare members (Table 7) also increased, to 73.4 percent from 68.2 percent in the previous year (p<.001). 30 Rates for both Medicaid and KidsCare members exceed the national means for Medicaid plans, and the KidsCare rate exceeds the commercial health plan mean When analyzed by rural and urban county groups, Medicaid-eligible members in urban counties were more likely to have visits than members in rural areas (p<.001). The same was true for KidsCare members (p<.001). These results are consistent with the previous measurement. For Medicaid members, Native Americans were less likely than nonHispanic Whites to have well child visits, while Hispanic members were more likely to have visits (refer to Appendix A for detailed analysis by race/ethnicity). These results also are consistent with the previous measurement. Comparison with National Benchmarks NCQA has reported national HEDIS means (averages) for Medicaid and commercial health plans, based on the 2008 measurement year. AHCCCS Medicaid and KidsCare rates compare to the national means as follows: AHCCCS Rates Compared with 2008 National HEDIS Means Measure/ Age Group AHCCCS Medicaid Rate AHCCCS KidsCare Rate HEDIS Medicaid Mean HEDIS Commercial Mean Well-Child Visits, 3 through 6 Years 66.2% 73.4% 65.3% 67.8% Discussion 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. Targeted efforts to educate parents about the value of preventive care visits for children in this age range are needed to improve the rate for this measure. 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. Care1st Healthplan, Mercy Care Plan and Phoenix Health Plan met the Minimum Performance Standard for Medicaid-eligible children, while all Contractors met the MPS for the KidsCare population. 31 Figure 5. Rates by Contractor, Well-Child Visits in Third through Sixth Years of Life, Medicaid Members CYE 2008 compared with CYE 2007 100% 80% 60% 40% 20% 0% APIPA Care1st CMDP HCA MHP CYE2008 MCP PHP UFC CYE2007 Phoenix Health Plan had the highest rate of well-child visits for Medicaid members in this age group in the current period (73.0 percent). Six Contractors met the MPS for Medicaid-eligible children. Figure 6. Rates by Contractor, Well-Child Visits in the Third through Sixth Years of Life, KidsCare Members CYE 2008 compared with CYE 2007 100% 80% 60% 40% 20% 0% APIPA Care1st HCA CYE2008 MHP MCP PHP UFC CYE2007 Care1st Healthplan had the highest rate for KidsCare members in the current period (78.4 percent. Six Contractors met the AHCCCS MPS for this population. 32 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 MEDICAID Measurement Period: Oct. 1, 2007, through Sept. 30, 2008 Minimum Performance Standard: 64 Rates in bold face denote the Contractor met the AHCCCS Minimum Performance Standard Contractor AZ Physicians IPA AZ Physicians IPA Care1st Healthplan Care1st Healthplan 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 Phoenix Health Plan University Family Care University Family Care TOTAL TOTAL Number of Members 22,087 Number with 1+ Visits 13,795 21,516 2,837 12,385 1,911 2,400 1,084 1,498 678 1,097 11,045 686 6,777 9,782 3,297 5,776 2,102 3,355 23,938 1,835 16,647 21,693 9,700 14,926 7,085 8,906 600 5,273 351 765 74,588 69,514 416 49,346 42,795 Percent with 1+ Visits 62.5% 57.6% 67.4% 62.4% 62.5% 62.5% 61.4% 59.0% 63.8% 54.7% 69.5% 68.8% 73.0% 59.2% 58.5% 54.4% 66.2% 61.6% Relative Percent Change From Previous Year Statistical Significance 8.5% p<.001 7.9% p<.001 0.0% p=.995 3.9% p=.001 16.6% p<.001 1.1% p=.089 23.4% p<.001 7.6% p=.128 7.5% p<.001 Note: Results of previous measurement period (Oct. 1, 2006 through Sept. 30, 2007) shown in shaded rows. 33 Table 7 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 Oct. 1, 2007, to Sept. 30, 2008 Minimum Performance Standard: 64 Rates in bold face denote the Contractor met the AHCCCS Minimum Performance Standard Relative Percent Contractor AZ Physicians IPA AZ Physicians IPA Care1st Healthplan Care1st Healthplan Health Choice AZ Health Choice AZ Maricopa Health Plan Maricopa Health Plan Mercy Care Plan Mercy Care Plan Phoenix Health Plan Phoenix Health Plan University Family Care University Family Care TOTAL TOTAL Number of Members 2,200 2,286 375 Number with 1+ Visits 1,475 307 1,123 1,385 294 236 764 1,014 423 665 323 463 2,840 291 2,204 2,758 1,537 2,124 1,176 1,578 26 1,040 17 45 8,524 8,451 23 6,253 5,764 Percent with 1+ Visits Change From Previous Year Statistical Significance 67.0% 60.6% 78.4% 76.9% 68.0% 65.6% 76.4% 62.9% 77.6% 77.0% 76.5% 65.9% 65.4% 51.1% 73.4% 68.2% 10.7% p<.001 2.0% p=.634 3.7% p=.229 21.5% p<.001 0.8% p=.596 16.1% p<.001 27.9% p=.243 7.6% p<.001 Note: Results of previous measurement period (Oct. 1, 2006, through Sept. 30, 2007) shown in shaded rows. 34 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 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.6,12 Many of these unhealthy behaviors and other medical problems can lead to chronic health conditions that last throughout life. In recent years, obesity has become a major cause of adolescent morbidity, contributing to a dramatic increase in the number of youth with type 2 diabetes mellitus.13 Several national studies show higher rates of overweight, low fitness, and diabetes among Hispanic and Black adolescents, compared with White adolescents.14 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 (Oct. 1, 2007, through Sept. 30, 2008), • were continuously enrolled with one acute-care Contractor during the measurement period (one break in enrollment, not exceeding one member-month, was allowed), and • had at least one well care visit during the measurement year. Performance Goals AHCCCS has adopted a Minimum Performance Standard that applies to both Medicaid and KidsCare members for the current measurement, based on the most recent national Medicaid mean reported by NCQA. AHCCCS also has set a Goal based on national Healthy People 2010 objectives. These are shown in the following table: AHCCCS Performance Standards for Adolescent Well Care Visits Age Group Minimum Performance Standard (MPS) Goal Adolescent Well-Care Visits 41% 50% 35 Results The overall Medicaid rate for this measure (Table 8) improved to 41.6 percent from 36.3 percent in the previous period (p<.001). The rate for KidsCare members (Table 9) also improved, to 51.6 percent from 43.7 percent in the previous period (p<.001). The rate for KidsCare members exceeds the national means for both Medicaid and commercial health plans When analyzed by rural and urban county groups, Medicaid-eligible adolescents in urban counties were more likely to have a well-care visit (p<.001). This also was true of adolescents covered under KidsCare (p=.001). These results are consistent with the previous measurement period. Among Medicaid members, Native Americans were less likely to have well care visits than non-Hispanic White members, while Hispanic and African-American members were more likely to have visits (refer to Appendix A for detailed analysis by race/ethnicity). Comparison with National Benchmarks NCQA has reported national HEDIS means (averages) for Medicaid and commercial health plans, based on the 2008 measurement year. AHCCCS Medicaid and KidsCare rates compare to the national means as follows: AHCCCS Rates Compared with 2008 National HEDIS Means Measure/ Age Group Adolescent Well Care Visits AHCCCS Medicaid Rate AHCCCS KidsCare Rate HEDIS Medicaid Mean HEDIS Commercial Mean 41.6% 51.6% 42.0% 41.8% 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 rates achieved by some Contractors are encouraging and warrant 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,11 it is important that health plans pay attention to this population to try to reduce their risk of disease and premature death. 36 Figure 7. Rates by Contractor, Adolescent Well-Care Visits, Medicaid Members CYE 2008 compared with CYE 2007 100% 80% 60% 40% 20% 0% APIPA Care1st CMDP HCA MHP CYE2008 MCP PHP UFC CYE2007 CMDP had the highest rate of Adolescent Well Care visits among the Medicaid population (64.3 percent). Figure 8. Rates by Contractor, Adolescent Well-Care Visits, KidsCare Members CYE 2008 compared with CYE 2007 100% 80% 60% 40% 20% 0% APIPA Care1st HCA CYE2008 MHP MCP PHP UFC CYE2007 Phoenix Health Plan had the highest rate for the KidsCare population (65.8 percent), as shown in Figure 18. Five Contractors met the Minimum Performance Standard for Medicaid members in the current measurement, and all Contractors met the MPS for the KidsCare population. 37 Table 8 Arizona Health Care Cost Containment System ADOLESCENT WELL-CARE VISITS BY CONTRACTOR MEMBERS ELIGIBLE UNDER MEDICAID Measurement Period: Oct. 1, 2007 through Sept. 30, 2008 Minimum Performance Standard: 41 Rates in bold face denote the Contractor met the AHCCCS Minimum Performance Standard Contractor AZ Physicians IPA AZ Physicians IPA Care1st Healthplan Care1st Healthplan 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 Phoenix Health Plan University Family Care University Family Care Total Total Number of Members 31,969 Number with 1+ Visits 12,732 27,693 2,419 9,964 1,050 2,058 1,700 724 1,093 1,757 11,762 1,071 4,264 9,442 3,579 3,344 1,242 3,163 26,628 816 11,072 21,075 10,238 7,876 5,275 8,480 1,296 2,907 539 1,319 89,591 74,987 532 37,267 27,234 Percent with 1+ Visits 39.8% 36.0% 43.4% 35.2% 64.3% 61.0% 36.3% 35.4% 34.7% 25.8% 41.6% 37.4% 51.5% 34.3% 41.6% 40.3% 41.6% 36.3% Relative Percent Change From Previous Year Statistical Significance 10.7% p<.001 23.4% p<.001 5.5% p=.043 2.4% p=.207 34.5% p<.001 11.3% p<.001 50.3% p<.001 3.1% p=.514 14.5% p<.001 Note: Results of previous measurement period (Oct. 1, 2006, through Sept. 30, 2007) shown in shaded rows. 38 Table 9 Arizona Health Care Cost Containment System ADOLESCENT WELL-CARE VISITS BY CONTRACTOR MEMBERS ELIGIBLE UNDER KIDSCARE Measurement Period: Oct. 1, 2007 through Sept. 30, 2008 Minimum Performance Standard: 41 Rates in bold face denote the Contractor met the AHCCCS Minimum Performance Standard Contractor AZ Physicians IPA AZ Physicians IPA Care1st Healthplan Care1st Healthplan Health Choice AZ Health Choice AZ Maricopa Health Plan Maricopa Health Plan Mercy Care Plan Mercy Care Plan Phoenix Health Plan Phoenix Health Plan University Family Care University Family Care Total Total Statistical Significance Number of Number with Percent with Relative Percent Change From Members 4,330 1+ Visits 2,066 1+ Visits Previous Year p<.001 1,942 195 28.9% p=.001 341 1,488 150 660 -3.1% p=.454 1,311 548 600 279 45.2% p<.001 502 3,669 176 1,894 15.6% p<.001 3,582 1,868 1,599 1,229 51.8% p<.001 1,804 94 782 47 -4.9% p=.691 154 12,341 12,187 81 6,370 5,330 47.7% 43.2% 56.7% 44.0% 44.4% 45.8% 50.9% 35.1% 51.6% 44.6% 65.8% 43.3% 50.0% 52.6% 51.6% 43.7% 10.4% 4,493 344 18.0% p<.001 Note: Results of previous measurement period (Oct. 1, 2006, through Sept. 30, 2007) shown in shaded rows. 39 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. 15,16 Brushing, flossing and other oral health practices can reduce the risk of developing diseases of the teeth and gums. Regular professional dental care, in combination with these practices, 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.16 Routine dental visits also serve to educate individuals about dental hygiene and preventive measures. The American Association of Pediatric Dentistry recommends that dental visits being by age 1. Description AHCCCS measured the percentage of children and adolescents who: • were ages 2 through 21 years if eligible under Medicaid, or 2 through 19 years if eligible under KidsCare, at the end of the measurement period (Oct. 1, 2007, through Sept. 30, 2008), • were continuously enrolled with one acute-care Contractor during the measurement period (one break in enrollment, not exceeding one member-month, was allowed), and • had at least one dental visit during the measurement year. Performance Goals AHCCCS has adopted a Minimum Performance Standard that applies to both Medicaid and KidsCare members for the current measurement, based on the most recent national Medicaid mean reported by NCQA. AHCCCS also has set a Goal based on national Healthy People 2010 objectives. These are shown in the following table: AHCCCS Performance Standards for Annual Dental Visits Age Group Annual Dental Visits, 2 through 21 Years 40 Minimum Performance Standard (MPS) Goal 51% 57% Results Among Medicaid members (Table 10), the overall rate increased to 60.9 percent from 57.6 percent in the previous year (p<.001). Among KidsCare members (Table 11), the rate also increased, to 71.8 percent from 68.6 percent in the previous year (p<.001). Rates for both Medicaid and KidsCare are well above the national mean for Medicaid health plans When analyzed by rural and urban county groups, both Medicaid and KidsCare members in urban counties were more likely to have a dental visit than those in rural areas (p<.001 for both populations). These results are consistent with the previous measurement. Among Medicaid members, Native American and Black members were less likely to have dental visits, while Hispanic members were more likely to have visits (refer to Appendix A for detailed analysis of results by race/ethnicity). These results also are consistent with the previous measurement. Comparison with National Benchmarks NCQA has reported national HEDIS means (averages) for Medicaid health plans, based on the 2008 measurement year. The HEDIS measure does not apply to commercial health plans because dental services are usually provided through a separate organization. Because AHCCCS Medicaid and KidsCare rates compare favorably to the 90th percentile of Medicaid plans nationally, that rate is also shown. AHCCCS Medicaid and KidsCare rates compare to national means as follows: AHCCCS Rates Compared with 2007 National HEDIS Means Measure/ Age Group Annual Dental Visits, 2 through 21 Years AHCCCS Medicaid Rate AHCCCS KidsCare Rate HEDIS Medicaid Mean Medicaid 90th Percentile 60.9% 71.8% 43.5% 61.3% 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 required all Acute-care Contractors to show statistically significant improvement in rates of annual dental visits. This PIP and other initiatives appear to have had a very positive effect on improving the rate of annual dental visits. While this is a service area in which AHCCCS excels nationally, the rate of annual dental visits is lower than some other preventive services. More work needs to be done to ensure that children and adolescents, particularly those that are Native American or Black, have regular dental checkups. 41 Figure 9. Rates by Contractor, Annual Dental Visits, Medicaid Members CYE 2008 compared with CYE 2007 100% 80% 60% 40% 20% 0% APIPA Care1st CMDP HCA MHP CYE2008 MCP PHP UFC CYE2007 CMDP had the highest rate of Annual Dental Visits for Medicaid members in the current measurement (74.9 percent). All Contractors met the Minimum Performance Standard. Figure 10. Rates by Contractor, Annual Dental Visits, KidsCare Members CYE 2008 compared with CYE 2007 100% 80% 60% 40% 20% 0% APIPA Care1st HCA CYE2008 MHP MCP PHP UFC CYE2007 For the KidsCare population, University Family Care achieved the highest rate (77.0 percent). All Contractors achieved the AHCCCS MPS for this population as well. 42 Table 10 Arizona Health Care Cost Containment System ANNUAL DENTAL VISITS, AGEs 2-21, BY CONTRACTOR MEMBERS ELIGIBLE UNDER MEDICAID Measurement Period: Oct. 1, 2007, through Sept. 30, 2008 Minimum Performance Standard: 55 Rates in bold face denote the Contractor met the AHCCCS Minimum Performance Standard Number of Members Number Receiving Dental Services Percent Receiving Dental Services Relative Percent Change from Previous Year Statistical Significance AZ Physicians IPA AZ Physicians IPA Care1st Healthplan 83,757 77,404 8,040 52,050 44,868 5,004 62.1% 58.0% 62.2% 7.2% p<.001 16.5% p<.001 Care1st Healthplan 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 Phoenix Health Plan University Family Care University Family Care TOTAL TOTAL 7,182 4,118 4,260 36,075 31,038 10,945 10,324 79,538 68,166 31,572 28,161 2,876 3,166 256,921 229,701 3,837 3,083 3,059 21,829 17,983 6,113 5,207 47,851 39,277 18,821 16,174 1,763 1,888 156,514 132,293 53.4% 74.9% 71.8% 60.5% 57.9% 55.9% 50.4% 60.2% 57.6% 59.6% 57.4% 61.3% 59.6% 60.9% 57.6% 4.3% p=.002 4.4% p<.001 10.7% p<.001 4.4% p<.001 3.8% p<.001 2.8% p=.186 5.8% p<.001 Contractor Notes: Results of previous measurement period (Oct. 1, 2006, through Sept. 30, 2007) shown in shaded rows. 43 Table 11 Arizona Health Care Cost Containment System ANNUAL DENTAL VISITS, AGES 2-19, BY CONTRACTOR MEMBERS ELIGIBLE UNDER KIDSCARE Measurement Period: Oct. 1, 2007, through Sept. 30, 2008 Minimum Performance Standard: 55 Rates in bold face denote the Contractor met the AHCCCS Minimum Performance Standard Number of Members Number Receiving Dental Services Percent Receiving Dental Services Relative Percent Change from Previous Year Statistical Significance AZ Physicians IPA 10,760 7,672 71.3% 4.4% p<.001 AZ Physicians IPA 11,019 7,523 68.3% Care1st Healthplan 1,120 828 73.9% 13.4% p<.001 Care1st Healthplan 1,095 714 65.2% Health Choice AZ 4,497 3,188 70.9% 5.3% p<.001 Health Choice AZ 4,038 2,718 67.3% 5.8% p=.026 4.1% p<.001 3.8% p=.001 Contractor Maricopa Health Plan 1,709 1,145 67.0% Maricopa Health Plan 1,628 1,031 63.3% Mercy Care Plan 10,998 7,965 72.4% Mercy Care Plan 10,850 7,550 69.6% Phoenix Health Plan 5,937 4,344 73.2% Phoenix Health Plan 6,001 4,232 70.5% 183 288 141 203 77.0% 70.5% 9.3% p=.118 TOTAL 35,204 25,283 71.8% 4.6% p<.001 TOTAL 34,919 23,971 68.6% University Family Care University Family Care Notes: Results of previous measurement period (Oct. 1, 2006, through Sept. 30, 2007) shown in shaded rows. 44 BREAST CANCER SCREENING Breast cancer is the second leading cause of cancer death among North American women. Approximately 1 in 8 women will receive a diagnosis of breast cancer during her lifetime, and 1 in 30 will die of the disease. Breast cancer incidence increases with age, and although significant progress has been made in identifying risk factors, more than 50 percent of cases occur in women without known major predictors.17 According to the Centers for Disease Control and Prevention, more than 180,000 women are diagnosed with breast cancer each year, and more than 41,000 women die of the disease.18 On average, nearly 700 Arizona women die of breast cancer each year.19 In the last decade, the overall death rate from female breast cancer has declined. However, the rates of decline for Hispanic and black women were lower than for white, non-Hispanic women, and the rates for Asians, Pacific Islanders, American Indians and Alaska Natives were virtually unchanged.20 Screening mammography is an important tool in the early detection of breast cancer. Studies have demonstrated that screening mammography may reduce mortality from the disease by up to 30 percent.17,21,22 However, results from a recent study of managed care plan members showed declining screening rates from 1999 to 2002.18 Description AHCCCS measured the percentage of members who: • were ages 52 through 69 years at the end of the two-year measurement period (Oct. 1, 2006, through Sept. 30, 2008), • were continuously enrolled with one acute-care Contractor during the measurement period (one break in enrollment per year was allowed if each gap did not exceed one member-month), and • had a mammogram in the two-year period. Performance Goals AHCCCS has adopted a Minimum Performance Standard for Breast Cancer Screening for the current measurement, based on the most recent national Medicaid mean reported by NCQA. AHCCCS also has set a Goal based on a comparable national Healthy People 2010 objective. These are shown in the following table: 45 AHCCCS Performance Standards for Breast Cancer Screening Minimum Performance Standard (MPS) Goal 54% 70% Breast Cancer Screening, 52 – 69 Years The AHCCCS rate increased, and exceeds the national mean for Medicaid health plans Results In the current period, the overall rate for breast cancer screening (Table 12) among women 52 to 69 years of age was 62.3 percent, an increase from the previous rate of 51.8 percent (p<.001). When rates were analyzed by rural and urban counties, there was no significant difference in members receiving mammograms between rural and urban counties (p=.683). These results are consistent with the previous measurement. Hispanic members were somewhat more likely than other groups to have mammograms for breast cancer screening, with no other differences based on race/ethnicity (refer to Appendix A for detailed analysis of results by race/ethnicity). These results also are consistent with the previous measurement. Comparison with National Benchmarks NCQA has reported national HEDIS means (averages) for Medicaid and commercial health plans, based on the 2008 measurement year. The AHCCCS rates compare to the national means as follows: AHCCCS Rates Compared with 2008 National HEDIS Means Measure/ Age Group AHCCCS Medicaid Rate HEDIS Medicaid Mean HEDIS Commercial Mean Breast Cancer Screening, 52 – 69 Years 62.3% 54.8% 71.6% Discussion Identification of tumors while they are still localized and potentially curable can significantly reduce breast cancer mortality.23 However many women do not obtain mammograms at the recommended one- to two-year intervals. A significant percentage of women responding to a National Cancer Institute survey said they did not have a mammogram because they did not know they needed one or their doctor had not recommended one.23 Women of some racial or ethnic groups may be especially reluctant to obtain mammograms because of embarrassment or the belief that one can do little to alter the future.24-26 46 Figure 11. Rates by Contractor, Breast Cancer Screening among Medicaid Members CYE 2008 compared with CYE 2007 100% 80% 60% 40% 20% 0% APIPA Care1st HCA MHP CYE2008 MCP PHP PHS UFC CYE2007 University Family Care had the highest rate of breast cancer screening (69.6ercent). Six Contractors met the AHCCCS minimum standard for this measure. 47 Table 12 Arizona Health Care Cost Containment System BREAST CANCER SCREENING, AGES 52-69 YEARS, BY CONTRACTOR Measurement Period: Oct. 1, 2006, through Sept. 30, 2008 Minimum Performance Standard: 54 Rates in bold face denote the Contractor met the AHCCCS Minimum Performance Standard Number Percent Relative Percent Number of Receiving Receiving Change from Statistical Mammograms 4,101 Mammograms Previous Year Significance AZ Physicians IPA Members 6,663 p<.001 Care1st Healthplan 1,876 268 16.3% p=.047 Health Choice AZ 275 2,024 126 1,062 27.5% p<.001 Maricopa Health Plan 1,123 612 462 380 21.2% p=.001 Mercy Care Plan 410 5,862 210 4,033 16.9% p<.001 Phoenix Health Plan 3,060 1,584 1,801 886 23.1% p<.001 Pima Health System 1,034 635 470 378 25.7% p<.001 321 339 152 236 24.2% p=.001 232 18,222 10,092 130 11,344 5,227 61.5% 51.6% 53.3% 45.8% 52.5% 41.1% 62.1% 51.2% 68.8% 58.9% 55.9% 45.5% 59.5% 47.4% 69.6% 56.0% 62.3% 51.8% 19.3% 3,637 503 20.2% p<.001 Contractor University Family Care TOTAL Notes: Results of the previous measurement period (Oct. 1, 2005, through Sept. 30, 2007) shown in shaded rows 48 CERVICAL CANCER SCREENING The American Cancer Society estimates that more than 11,000 new cases of invasive cervical cancer were diagnosed in the United States in 2009, and that more than 4,000 women died from the disease last year. Approximately half of deaths due to cervical cancer occur in women who were not screened at timely intervals.27 Cytologic screening through the use of the Papanicolaou (Pap) test has led to an 80-percent reduction in the incidence of cervical cancer. The Pap test can detect precancerous conditions and infection with the human papilloma virus (HPV). Certain types of HPV are strongly associated with cervical cancer.24 While a vaccine is now available to protect teens and young women against HPV, women should continue to be screened for cervical cancer at regular intervals. The American College of Obstetricians and Gynecologists, the American Cancer Society and the U.S. Preventive Services Task Force recommend that adolescents and other women have a Pap test and pelvic examination when they become sexually active or at age 18, whichever occurs first. Annual Pap tests are recommended until three consecutive Pap tests are interpreted as being normal. Following this, Pap tests can be performed every three years, at the discretion of a woman’s health care provider. Description AHCCCS measured the percentage of members who: • were ages 21 through 64 (or 24 through 64 years at the end of the measurement period, Oc. 1, 2007, through Sept. 30, 2008), • 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 member-month), and • had a Pap test in the measurement period or in either of the two preceding years. Performance Goals AHCCCS has adopted a Minimum Performance Standard for Cervical Cancer Screening for the current measurement, based on the most recent national Medicaid mean reported by NCQA. AHCCCS also has set a Goal based on a comparable national Healthy People 2010 objective. These are shown in the following table: AHCCCS Performance Standards for Cervical Cancer Screening Cervical Cancer Screening 49 Minimum Performance Standard (MPS) Goal 65% 90% Results The overall rate of cervical cancer screening (Table 13) increased in the current measurement, to 63.2 percent from 62.2 percent in the previous year (p<.001). The AHCCCS rate increased, but was lower than the national means for Medicaid and commercial health plans When rates were analyzed by rural and urban counties, urban members were more likely to have a Pap test than those living in rural counties (p<.001). These results are consistent with the previous measurement. Hispanic and Black members were more likely than non-Hispanic Whites to have a Pap test, while Native American members were less likely (refer to Appendix A for detailed analysis of results by race/ethnicity). In the previous measurement, only Hispanic members were more like to have Pap tests, while Native Americans still lagged behind non-Hispanic white members in the rate of Pap tests. Comparison with National Benchmarks NCQA has reported national HEDIS means (averages) for Medicaid and commercial health plans, based on the 2008 measurement year. The AHCCCS rates compare to the national means as follows: AHCCCS Rates Compared with 2008 National HEDIS Means Measure/ Age Group AHCCCS Medicaid Rate HEDIS Medicaid Mean HEDIS Commercial Mean 63.2% 64.8% 81.7% Cervical Cancer Screening Discussion As with breast cancer screening, many women may not have Pap tests at recommended intervals because they are not aware they are due for such screening, embarrassment or cultural factors and beliefs.26,27 Data obtained through this measurement indicate that Native American women enrolled with AHCCCS health plans may Pap tests at a lower rate than women of other races. However, as in the case of mammograms, Native American women enrolled with health plans may receive these services through Indian Health Service facilities on a fee-for-service basis. Thus, data on these services may not be captured in AHCCCS health plan encounter data. Contractors should try to reach these members and identify whether they have been screened for cervical cancer according to recommendations. 50 Figure 12. Rates by Contractor, Cervical Cancer Screening among Medicaid Members CYE 2008 compared with CYE 2007 100% 80% 60% 40% 20% 0% APIPA Care1st HCA MHP CYE2008 MCP PHP PHS UFC CYE2007 Mercy Care Plan (MCP) had the highest rate (65.4 percent) and was the only Contractor that met the AHCCS Minimum Performance Standard for this measure. 51 Table 13 Arizona Health Care Cost Containment System CERVICAL CANCER SCREENING BY CONTRACTOR Measurement Period: Oct. 1, 2007, through Sept. 30, 2008 Minimum Performance Standard: 65 Rates in bold face denote the Contractor met the AHCCCS Minimum Performance Standard Relative Percent Change From Previous Year 0.7% Statistical Significance p=.302 1.5% p=.551 -1.1% p=.331 15.7% p<.001 1.2% p=.083 8.1% p<.001 -1.0% p=.635 1,252 690 556 Percent Receiving Pap Tests 63.8% 63.4% 60.1% 59.2% 59.9% 60.5% 57.0% 49.3% 65.4% 64.6% 61.7% 57.1% 63.6% 64.3% 61.8% 61.2% 0.9% p=.804 91,816 58,070 63.2% 1.7% p<.001 59,178 36,808 62.2% Number of Members 31,631 Number Receiving Pap Tests 20,186 20,742 2,861 13,145 1,720 1,860 12,424 1,102 7,437 7,764 2,521 4,701 1,437 1,756 29,041 865 18,992 18,214 8,793 11,769 5,427 5,986 3,428 3,418 2,181 1,948 1,117 908 TOTAL TOTAL Contractor AZ Physicians IPA AZ Physicians IPA Care1st Care1st Health Choice AZ Health Choice AZ Maricopa Health Plan Maricopa Health Plan Mercy Care Plan Mercy Care Plan Phoenix Health Plan Phoenix Health Plan Pima Health System Pima Health System University Family Care University Family Care Results of previous measurement period (Oct. 1, 2006 through Sept. 30, 2007) shown in shaded rows. 52 CHLAMYDIA SCREENING Chlamydia is one of the most commonly reported sexually transmitted diseases (STDs) in the United States, infecting an estimated 2.8 million people each year. Yet, it often is undetected because up to 80 percent of women and 50 percent of men infected with the Chlamydia trachomatis bacteria have no symptoms. It is estimated that, by age 30, half of sexually active women have had chlamydia.28 If untreated, Chlamydia infection can cause serious reproductive and other health problems. The infection can result in pelvic inflammatory disease, which in turn can lead to infertility, an ectopic or tubal pregnancy, or chronic pelvic pain. In pregnant women, Chlamydia infections may lead to premature delivery and babies born to infected mothers can have eye infections or pneumonia. Because Chlamydia is most prevalent among women in their late teens and early 20s ― and is often without symptoms ― the U.S. Preventive Services Task Force has recommended that all sexually active females 25 and younger be tested for the infection at least once a year. This can be done as part of a routine gynecologic examination. Description AHCCCS measured the percentage of female members who: • were ages 16 through 24 years at the end of the measurement period (Oct. 1, 2007, through Sept. 30, 2008), • were identified as sexually active, based on specific gynecological services received during the measurement period, • 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 member-month), and • were screened for Chlamydia infection during the measurement period. Performance Goals AHCCCS has adopted a Minimum Performance Standard for Chlamydia Screening for the current measurement, based on the most recent national Medicaid mean reported by NCQA. AHCCCS also has set a Goal based on the 90th percentile rate reported for Medicaid health plans nationally. These are shown in the following table: AHCCCS Performance Standards for Chlamydia Screening Age Group Chlamydia Screening, 16 – 24 Years 53 Minimum Performance Standard (MPS) Goal 43% 62% Results The overall rate for Medicaid members (Table 14) improved to 39.9 percent from 38.7 percent in the previous measurement (p=.022). The AHCCCS rate increased and exceeded the national mean for commercial health plans but was lower than the Medicaid health plan mean When rates were analyzed by rural and urban counties, members living in urban counties were much more likely to be screened for Chlamydia than those living in rural counties (p<.001). Members who are Hispanic or Black were more likely to be screened for Chlamydia, while Native American members were less likely to have this service (refer to Appendix A for detailed analysis of results by race/ethnicity). These results are consistent with the previous measurement. Comparison with National Benchmarks NCQA has reported national HEDIS means (averages) for Medicaid and commercial health plans, based on the 2008 measurement year. The AHCCCS rates compare to the national means as follows: AHCCCS Rates Compared with 2008 National HEDIS Means Measure/ Age Group Chlamydia Screening, 16 − 24 Years AHCCCS Medicaid Rate HEDIS Medicaid Mean HEDIS Commercial Mean 39.9% 50.8% 38.1% Discussion The current recommendation for chlamydia screening for all sexually active females ages 16 through 25 was made by the U.S. Preventive Services Task Force in 2001, but it appears that providers have not fully implemented this recommendation. Physicians are sometimes reluctant to discuss such screening with their patients because of the stigma associated with STDs.29 Many women probably do not seek testing because they are not aware of the seriousness of Chlamydia infection or are embarrassed about possibly having a sexually transmitted disease. The often asymptomatic nature of the infection also presents a major barrier to testing. 29 54 Figure 13. Rates by Contractor, Chlamydia Screening, Medicaid Members CYE 2008 compared with CYE 2007 100% 80% 60% 40% 20% 0% APIPA Care1st HCA CYE2008 MHP MCP PHP UFC CYE2007 University Family Care (UFC) had the highest rate for this measure in the current period (57.7 percent), exceeding both the HEDIS Medicaid and commercial means. Two Contractors, UFC and Maricopa Health Plan, met the AHCCCS Minimum Performance Standard for this measure. 55 Table 14 Arizona Health Care Cost Containment System CHLAMYDIA SCREENING, AGES 16-24, BY CONTRACTOR Measurement Period: Oct. 1, 2007, through Sept. 30, 2008 Minimum Performance Standard: 51 Rates in bold face denote the Contractor met the AHCCCS Minimum Performance Standard Contractor AZ Physicians IPA AZ Physicians IPA Care1st HealthPlan Care1st HealthPlan Health Choice AZ Health Choice AZ Maricopa Health Plan Maricopa Health Plan Mercy Care Plan Mercy Care Plan Phoenix Health Plan Phoenix Health Plan University Family Care University Family Care TOTAL TOTAL Number Number of Members Percent of Members Relative Percent of Receiving Receiving Change From Members 7,395 Chlamydia Screening 2,706 Chlamydia Screening Previous Year 12.7% 5,577 833 1,810 359 -5.8% p=.328 544 3,268 249 1,333 3.7% p=.274 2,389 648 940 366 -4.7% p=.360 454 7,470 269 2,961 -0.9% p=.675 5,299 2,563 2,120 1,076 -1.9% p=.584 1,829 234 783 135 -8.3% p=.237 251 22,411 16,343 158 8,936 6,329 36.6% 32.5% 43.1% 45.8% 40.8% 39.3% 56.5% 59.3% 39.6% 40.0% 42.0% 42.8% 57.7% 62.9% 39.9% 38.7% Statistical Significance p<.001 3.0% p=.022 Note: Results of previous measurement period (Oct. 1, 2006, through Sept. 30, 2007) shown in shaded rows. 56 TIMELINESS OF PRENATAL CARE Women who receive early and ongoing prenatal care are more likely to have better pregnancy outcomes than women who receive little or no prenatal care.30-34 Babies of mothers who do not get prenatal care are three times more likely to have a low birth weight and five times more likely to die than those born to mothers who do get care.35 Prenatal care affords physicians and other health care practitioners opportunities to address risk factors such as smoking, alcohol use and improper diet, as well as treat medical complications that can negatively affect the health of mother and baby. In addition, prenatal care provides opportunities to educate pregnant women, especially first-time mothers, on childbirth and infant care. According to the Arizona Department of Health Services, 52.5 percent of deliveries in the state, including those covered by health plans or on a fee-for-service basis, were paid for through AHCCCS in 2008 (it should be noted that more than 17,000 fee-for-service deliveries were to women who were undocumented immigrants and did not qualify for coverage of prenatal care through AHCCCS). In 2008, 71.4 percent of AHCCCS births were to mothers who began care in their first trimester of pregnancy, while 91.5 percent of all mothers covered by private insurance began care in the first trimester.36 Description AHCCCS measured the percentage of female members who: • had a live birth during the measurement period (Oct. 1, 2007, through Sept. 30, 2008). • were continuously enrolled with the same acute-care Contractor for 43 days or more prior to delivery, and • had a prenatal care visit during their first trimester of pregnancy or within 42 days of enrollment, depending on the date of enrollment with the Contractor immediately preceding delivery. Performance Goals AHCCCS has adopted a Minimum Performance Standard for Timeliness of Prenatal Care for the current measurement, based on the most recent national Medicaid mean reported by NCQA. AHCCCS also has set a Goal based on a comparable national Healthy People 2010 objective. These are shown in the following table: 57 AHCCCS Performance Standards for Timeliness of Prenatal Care Age Group Timeliness of Prenatal Care Minimum Performance Standard (MPS) Goal 80% 90% Results The overall rate for Medicaid members (Table 15) declined to 67.1 percent from a rate of 70.7 percent in the previous measurement (p<.001). When analyzed by rural and urban county groups, members in rural counties were more likely to have timely prenatal care than members in urban areas (p<.001). This finding contrasts with other measures, in which members in urban areas are more likely to have services. The AHCCCS rate was lower than the national Medicaid and commercial means Hispanic, Black and Native American members all were less likely than non-Hispanic Whites to have timely prenatal care visits (see Appendix A for detailed analysis of results by race/ethnicity). These results are consistent with the previous measurement. Comparison with National Benchmarks NCQA has reported national HEDIS means (averages) for Medicaid and commercial health plans, based on the 2008 measurement year. The AHCCCS rates compare to the national means as follows: AHCCCS Rates Compared with 2008 National HEDIS Means Measure/ Age Group AHCCCS Medicaid Rate HEDIS Medicaid Mean HEDIS Commercial Mean 67.1% 81.4% 91.9% Timeliness of Prenatal Care Discussion Prenatal, delivery and postpartum services provided through AHCCCS health plans typically are paid for under a “global” fee. Providers may not have reported all dates of prenatal visits when billing for OB services, which likely has resulted in underreporting of rates for this measure. AHCCCS has been working with Contractors to ensure more complete reporting, and expects to convene a work group with health plans to address collection of more complete data for this measure and any additional member outreach efforts needed in this area. 58 Figure 14. Rates by Contractor, Timeliness of Prenatal Care, Medicaid Members CYE 2008 compared with CYE 2007 100% 80% 60% 40% 20% 0% APIPA Care1st HCA CYE2008 MHP MCP PHP UFC CYE2007 Care1st Healthplan had the highest rate for Timeliness of Prenatal Care (76.3 percent). No Contractors met the Minimum Performance Standard for this measure. 59 Table 15 Arizona Health Care Cost Containment System TIMELINESS OF PRENATAL CARE BY CONTRACTOR Measurement Period: Oct. 1, 2007, through Sept. 30, 2008 Minimum Performance Standard: 80 Rates in bold face denote the Contractor met the AHCCCS Minimum Performance Standard Number with Prenatal Visits 5,052 Percent 65.5% Relative Percent Change from Previous Year 5.2% Statistical Significance p<.001 Contractor AZ Physicians IPA Number of Members 7,713 AZ Physicians IPA Care1st Health Plan 6,096 987 3,796 753 62.3% 76.3% -3.8% p=.160 Care1st HealthPlan Health Choice AZ 637 3,956 505 2,968 79.3% 75.0% -2.6% p=.067 Health Choice AZ Maricopa Health Plan 2,516 583 1,938 283 77.0% 48.5% -12.4% p=.038 Maricopa Health Plan Mercy Care Plan 368 9,731 204 6,237 55.4% 64.1% -16.5% p<.001 Mercy Care Plan Phoenix Health Plan 6,244 2,930 4,791 2,092 76.7% 71.4% 3.6% p=.063 Phoenix Health Plan University Family Care University Family Care TOTAL TOTAL 1,986 148 1,369 87 -27.5% p<.001 95 26,048 17,942 77 17,472 12,680 68.9% 58.8% 81.1% 67.1% 70.7% -5.1% p<.001 Note: Results of previous measurement period (Oct. 1, 2006, through Sept. 30, 2007) shown in shaded rows. 60 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, cognitive disability (such as mental retardation) or autism that was made prior to the age of 18 years, and have substantial functional limitations in at least three major areas, such as self-care, learning and mobility. Many of DDD’s clients are dependent on ventilators to breathe. More than 60 percent of Arizonans 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). DDD provides long-term care and supportive services to these members, as well as primary and acute medical services through subcontracts with health plans, most of which also serve AHCCCS Acute-care members. This measurement includes DDD members who are enrolled with ALTCS. Performance Standards Under its contract with DDD, AHCCCS has established Performance Measures and Standards for primary and preventive health care provided to children and adolescents. Performance Standards are designed to drive improvement in DDD’s performance toward Goals that are based on Healthy People 2010 objectives. This section reports DDD’s performance in the following measures: AHCCCS Performance Standards for the Division of Developmental Disabilities (DDD) Minimum Performance Standard (MPS) Goal Children’s Access to PCPs – 12 to 24 Months 78% 97% Children’s Access to PCPs – 25 Months to 6 Years 70% 97% Children’s Access to PCPs – 7 to 11 Years 70% 97% Children’s Access to PCPs – 12 to 19 Years 70% 97% Well-Child Visits 3 – 6 Yrs 44% 80% Adolescent Well-Care Visits 31% 50% Annual Dental Visits, 2 – 21 Yrs 41% 57% 61 Eligibility for ALTCS members, including those with developmental disabilities, differs from eligibility for Acute-care Contractors in that medical and functional criteria are considered, along with financial criteria that are different than for non-DDD Medicaid members. Thus, many DDD members with AHCCCS coverage often have other medical coverage; recent data show that nearly 40 percent of DDD members also are covered by Medicare and/or private insurance. Because services can be provided through other insurers, AHCCCS may not have complete encounters for those services. The above Performance Standards reflect the limitation in collecting complete data for DDD members. Performance Measures are collected according to HEDIS methodology in the same way as Performance Measures for Acute-care Contractors. 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. In the current measurement, rates for three age groups and overall showed significant increases (Table 16). The rate for the 12-to-24month group was statistically unchanged, at 84.3 percent compared with 85.7 percent in the previous measurement (p=.831). The rate for members 25 months to 6 years increased to 76.6 percent from the previous rate of 65.5 percent (p<.001). The rate for members 7 to 11 years increased to 72.2 percent from the previous rate of 67.9 percent (p<.001). The rate for members 12 to 19 years increased to 72.0 percent from 67.2 percent in the previous year (p<.001). The overall rate (all age groups combined) increased to 73.5 percent from 67.0 percent in the current measurement (p<.001). 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, 46.9 percent of children had an annual well-care visit (Table 17), an increase from 36.1percent in the previous year (p<.001). 62 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.37 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, 35.3 percent of adolescents had a wellcare visit (Table 18), an increase from the previous year’s rate of 26.7 percent (p<.001). 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.38 The rate of annual dental visits (Table 19) increased in the current measurement, to 46.9 percent from 36.4 percent in the previous year (p<.001). Discussion In the current measurement, DDD showed statistically significant improvement in all but one performance measure. The Division met the Minimum Performance Standards for all of the measures reported here. Figure 15. DDD Performance Measure Rates CYE 2008 compared with CYE 2007 100% 80% 60% 40% 20% 0% CAP12-24 CAP25-6 CAP7-11 CYE2008 63 CAP12-19 WC 3-6 CYE2007 Adol WC Dental Table 16 Arizona Health Care Cost Containment System CHILDREN'S ACCESS TO PRIMARY CARE PRACTITIONERS MEMBERS ELIGIBLE UNDER DES/DDD Measurement Period Oct. 1, 2007, to Sept. 30, 2008 Minimum Performance Standards: Rates in bold face denote the Contractor met the AHCCCS Minimum Performance Standard 12-24 Months 25 Months - 6 Years 7-11 Years 12-19 Years 78 70 70 70 Age Number of Members Number with 1+ Visits Percent with 1+ Visits Relative Percent Change From Previous Year Statistical Significance DES/DDD 12-24 mos. 25 mos. - 6 yrs 7 - 11 yrs. 12 -19 yrs. Total 51 3,055 3,284 3,785 10,175 43 2,341 2,370 2,727 7,481 84.3% 76.6% 72.2% 72.0% 73.5% -1.6% 17.1% 6.3% 7.3% 9.7% p=.831 p<.001 p<.001 p<.001 p<.001 DES/DDD 12-24 mos. 25 mos. - 6 yrs 7 - 11 yrs. 12 -19 yrs. Total 70 2,930 3,003 3,465 9,468 60 1,918 2,038 2,327 6,343 85.7% 65.5% 67.9% 67.2% 67.0% Contractor Notes: Results of previous measurement period (Oct. 1, 2006, through Sept. 30, 2007) shown in shaded rows. 64 Table 17 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, 2007, through September 30, 2008 Minimum Performance Standard: 44 Rates in bold face denote the Contractor met the AHCCCS Minimum Performance Standard Contractor DES/DDD DES/DDD Number of Members 2,854 Number with 1+ Visits 1,338 2,725 983 Percent with 1+ Visits 46.9% 36.1% Relative Percent Change From Previous Year 30.0% Notes: Results of previous measurement period (Oct. 1, 2006, through Sept. 30, 2007) shown in shaded rows. 65 Statistical Significance p<.001 Table 18 Arizona Health Care Cost Containment System ADOLESCENT WELL-CARE VISITS MEMBERS ELIGIBLE UNDER DES/DDD Measurement Period: October 1, 2007 through September 30, 2008 Minimum Performance Standard: 31 Rates in bold face denote the Contractor met the AHCCCS Minimum Performance Standard Contractor DES/DDD * DES/DDD Total Number of Number with Percent with Members 1+ Visits 1+ Visits 4,708 4,374 1,664 1,166 35.3% 26.7% Relative Percent Change From Previous Year 32.6% Note: Results of previous measurement period (Oct. 1, 2006, through Sept. 30, 2007) shown in shaded rows. 66 Statistical Significance p<.001 Table 19 Arizona Health Care Cost Containment System ANNUAL DENTAL VISITS, AGES 2-21 YEARS MEMBERS ELIGIBLE UNDER DES/DDD Measurement Period: October 1, 2007 to September 30, 2008 Minimum Performance Standard: 41 Rates in bold face denote the Contractor met the AHCCCS Minimum Performance Standard Contractor DES/DDD DES/DDD Total Number of Members 11,343 10,593 Total Dental Services 5,320 3,855 Percent Dental Services 46.9% 36.4% Relative Percent Change from Previous Year 28.9% Note: Results of previous measurement period (Oct. 1, 2006, through Sept. 30, 2007) shown in shaded rows. 67 Statistical Significance p<.001 CONCLUSION Overall Results Despite increase in AHCCCS Minimum Performance Standards for these measures in the current period, Contractors significantly improved rates of primary and preventive care services, as measured under HEDIS. In July 2007, AHCCCS advised Acute-care Contractors that they would face significant financial sanctions in the next couple of years if they do not increase rates to meet Minimum Performance Standards. Facing these financial sanctions, Contractors directed resources to improve Performance Measure rates, and these efforts appear to have had a significant impact. Contractors should continue improvement efforts, focusing on areas where they perform poorly. The data reported here indicate that, overall, children and adults enrolled with AHCCCS have a relatively high degree of access to the health care system, as evidenced by the use of several preventive care services. Compared with Medicaid managed care plans nationally, the AHCCCS rate of Annual Dental Visits compares to or exceeds the 90th percentile of Medicaid health plans nationally, with rates for several other measures also above national Medicaid means. KidsCare members, in particular, have higher rates of utilization than Medicaid and Children’s Health Insurance Program beneficiaries nationally. KidsCare rates for measures such as Well-Child Visits in the First 15 months of Life, Adolescent Well Care Visits and Annual Dental Visits are well above the most recent HEDIS national Medicaid means, which includes members in this beneficiary group, and some exceed comparable national means for commercial health plans. However, Contractors’ rates for Children’s and Adolescents’ Access to PCPs still lad behind national means. AHCCCS-contracted health plans must focus resources on increasing rates for this measure. Use of preventive services such as Pap tests, Chlamydia screening and prenatal care by women also is of concern, and Contractors must ensure that women are receiving these services and complete data are being captured. AHCCCS expects to convene work groups in CYE 2010 to address one or more of these measures. Disparities by Race and Ethnicity Analysis of data continues to indicate lower rates of service among Native Americans for several measures, as well as lower rates for Black and Hispanic members for some measures. 68 Contractors directed resources to improve rates, and these efforts appear to have had a significant impact 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 preventive 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.40 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, 41 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.42 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.43 Any disparities must be reduced in order to improve rates overall. AHCCCS has implemented a Performance Improvement Project (PIP) for all Acute-care Contractors to address racial/ethnic disparities in one of the measures, Adolescent Well Care Visits, and may consider other PIPs for specific measures in the future. AHCCCS also will seek to work with Contractors and others, such as Indian Health Service, to explore mechanisms for collecting more complete data. 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. 69 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 Centers for Disease Control and Prevention. Surveillance of Certain Health Behaviors and Conditions Among States and Selected Local Areas -- Behavioral Risk Factor Surveillance System (BRFSS), United States, 2006. MMWR 2008. 57(SS07);1-188. http://www.cdc.gov/mmwr/preview/mmwrhtml/ss5707a1.htm. Accessed August 14, 2008. 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. State-specific Prevalence and Trends in Adult Cigarette Smoking – United States, 1998 – 2007.. MMWR 2009. 58(09);221-226. http://www.cdc.gov/mmwr/preview/mmwrhtml/mm5809a1.htm. Accessed October 14, 2009. 9 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. 10 Arizona School Readiness Task Force. Growing Arizona. Phoenix, Ariz.: Children’s Action Alliance. 2002. 11 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. 12 Mrela CK, Torres C. Arizona Health Status and Vital Statistics 2006. Arizona Department of Health Services, Bureau of Public Health Services, Health Status and Vital Statistics Section. Available at: http://www.azdhs.gov/plan/report/ahs/ahs2006/toc06.htm. Accessed July 15, 2008, 2008. 13 Elster, A. Guidelines for adolescent preventive services [last updated Jan. 29, 2008]. American Medical Association. Available at: http://www.ama-assn.org/ama/pub/category/1980.html. Accessed May 2, 2007. 14 Fox HB, McManus MA, Zarit M, et al. Racial and ethnic disparities in adolescent health and access to care [fact sheet]. Incenter Strategies, The National Alliance to Advance Adolescent Health. Washington, DC; January 2007. Available at: http://www.incenterstrategies.org/facts.html. Accessed July 16, 2008. 15 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. 16 Arizona Office of Oral Health. Arizona Oral Health Update. Phoenix, AZ: Arizona Department of Health Services. May 2000. 17 . Agency for Healthcare Research and Quality. Breast cancer screening: summary of the evidence. Available at: http://www.ahrq.gov/clinic/3rduspstf/breastcancer/bcscrnsum1.htm. Accessed November 14, 2008. 18 Centers for Disease Control and Prevention. Use of mammograms among women aged >40 years -- United States, 2000--2005. MMWR. 56(03);49-51. Available at: http://www.cdc.gov/mmwr/preview/mmwrhtml/mm5603a1.htm?s_cid=mm5603a1_e Accessed November 14, 2008. 70 19 Arizona Department of Health Services. Office of Chronic Disease Prevention and Nutrition Services. The Arizona Comprehensive Cancer Control Plan. Available at: http://www.azdhs.gov/phs/oncdps/index.htm. Accessed Nov. 3, 2006. 20 Keppel KG, Pearcy JN, Wagener DK. Trends in racial and ethnic-specific rates for health status indicators: United States, 1990-1998. Healthy people statistical notes, no. 23. Hyattsville, Maryland: National Center for Health Statistics. January 2002. 21 National Cancer Institute. Summary of evidence: screening by mammography. Available at: http://www.cancer.gov/cancertopics/pdq/screening/breast/HealthProfessional/page5. Accessed Nov. 3, 2006. 22 Annual Meeting of the 95th American Association for Cancer Research. Conference Report – Early cancer diagnosis: beating the odds. Available at: http://www.medscape.com/viewprogram/3254_pnt. Accessed Aug. 4, 2004. 23 National Cancer Institute. Breast cancer screening physician data query (PDQ®), 2001. Available at: http://www.cancer.gov/cancer_information/pdq. Accessed May 2, 2005. 24 Alarcon M. Breast and cervical cancer among Latino women. National Council of La Raza, Washington, D.C. 1998. 25 Transcultural Nursing. Basic concepts and case studies: Asian community. Available at: http://www.culturediversity.org/asia.htm#Pain. Accessed April 9, 2003. 26 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. 27 American Cancer Society. What are the key statistics about cervical cancer? Available at: http://www.cancer.org/docroot/CRI/content/CRI_2_4_1X_What_are_the_key_statist ics_for_cervical_cancer_8.asp. Accessed Nov. 14, 2008. 28 National Women’s Health Information Center. Chlamydia: Frequently asked questions. U.S. Department of Health and Human Services, Office of Women’s Health. May 2005. Available at: http://www.womenshealth.gov/faq/stdchlam.htm. Accessed Nov. 3, 2006. 29 National Committee for Quality Assurance. Improving chlamydia screening: Strategies from top performing health plans. Emory University. Atlanta, Ga. December 2007. 30 Greenberg RS: The impact of prenatal care in different social groups. Am J Obstet Gyn. April 1, 1983. 31 Leveno KJ, et al: Prenatal care and the low birth weight infant, Obstet Gyn. November 1985. 32 National Center for Health Statistics. 1996 final natality data, prepared by the March of Dimes Perinatal Data Center. 1998 33 Kirkman-Liff B: Analysis of prenatal care in Arizona, Arizona State University School of Health Administration and Policy; December 1993. 34 Centers for Disease Control and Prevention. Surveillance Summaries, July 2, 2004. MMWR 2004:53(SS-4). 35 National Women’s Health Information Center. Prenatal Care: Frequently asked questions. U.S. Department of Health and Human Services, Office of Women’s Health. May 2005. Available at: http://www.womenshealth.gov/faq/prenatal.htm#b. Accessed Nov. 3, 2006. 36 Arizona Department of Health Services. Arizona Health Status and Vital Statistics 2007. Natality: maternal characteristics and newborns’ health. Table 1B-28. Available at: http://www.azdhs.gov/plan/report/ahs/ahs2007/xls/t1b28.xls. Accessed Nov. 21, 2008. 71 37 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. 38 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. 39 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. 40 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. 41 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. 42 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. 43 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 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 72 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 AHCCCS Conversion Native American Hispanic Black Asian/Pacific Islander Asian/Pacific Islander Caucasian/White Unknown/Unspecified Unknown/Unspecified 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 aqua); if the value is < 1.0, members of this group are less likely to have the service (these rows are highlighted in yellow). 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. 73 Prenatal Care Hispanic Black Native American n 7174 7174 7174 Total % 10191 70.40% 10191 70.40% 10191 70.40% n 36275 36275 36275 Total % 62225 58.30% 62225 58.30% 62225 58.30% n 7856 1230 780 Total % RR Std. Err Lower Limit Upper Limit 11914 65.9% 0.9619 0.0180 0.9447 0.9794 2022 60.8% 0.9155 0.0372 0.8821 0.9502 1232 63.3% 0.9384 0.0443 0.8977 0.9809 Dental Care 2-21 Years of Age Hispanic Black Native American n Total % RR Std. Err Lower Limit Upper Limit 97423 152853 63.7% 1.0570 0.0076 1.0489 1.0651 10520 19509 53.9% 0.9513 0.0146 0.9375 0.9652 4647 9216 50.4% 0.9102 0.0213 0.8910 0.9298 Breast Cancer Screening 52-69 Years of Age Hispanic Black Native American n Total % 4879 8389 58.16% 4879 8389 58.16% 4879 8389 58.16% n 4282 552 130 Total % RR Std. Err Lower Limit Upper Limit 6017 71.2% 1.1306 0.0243 1.1036 1.1584 973 56.7% 0.9843 0.0578 0.9291 1.0429 261 49.8% 0.9042 0.1231 0.7994 1.0226 Cervical Cancer Screening Hispanic Black Native American n 24496 24496 24496 Total % 40533 60.43% 40533 60.43% 40533 60.43% n 24395 4486 1498 Total % RR Std. Err Lower Limit Upper Limit 35806 68.1% 1.0757 0.0106 1.0644 1.0872 7011 64.0% 1.0358 0.0192 1.0161 1.0560 2721 55.1% 0.9426 0.0349 0.9103 0.9760 Chlamydia Screening All Age Groups Hispanic Black Native American n Total % 3150 8169 38.56% 3150 8169 38.56% 3150 8169 38.56% n 4496 917 236 Total % RR Std. Err Lower Limit Upper Limit 11085 40.6% 1.0369 0.0355 1.0008 1.0743 1901 48.2% 1.1693 0.0540 1.1078 1.2342 854 27.6% 0.7780 0.1119 0.6956 0.8702 Adult Access 45-64 Years of Age Hispanic Black Native American n 26704 26704 26704 Total % 30791 86.73% 30791 86.73% 30791 86.73% n 16464 3359 898 n 39801 39801 39801 Total % 48088 82.77% 48088 82.77% 48088 82.77% n 36609 7151 3074 n 66505 66505 66505 Total % 78879 84.31% 78879 84.31% 78879 84.31% n 53073 10510 3972 Total % RR Std. Err Lower Limit Upper Limit 18992 86.7% 0.9998 0.0071 0.9927 1.0069 3950 85.0% 0.9895 0.0138 0.9759 1.0032 1089 82.5% 0.9730 0.0277 0.9464 1.0004 Adult Access 20-44 Years of Age Hispanic Black Native American Total % RR Std. Err Lower Limit Upper Limit 45794 79.9% 0.9810 0.0061 0.9750 0.9871 8958 79.8% 0.9803 0.0112 0.9694 0.9913 3919 78.4% 0.9707 0.0169 0.9544 0.9872 Adult Access All Age Groups Hispanic Black Native American Total % RR Std. Err Lower Limit Upper Limit 64786 81.9% 0.9844 0.0047 0.9798 0.9890 12908 81.4% 0.9811 0.0088 0.9725 0.9897 5008 79.3% 0.9669 0.0145 0.9530 0.9810 Children and Adolescents Access to Care 12-24 Months Hispanic Black Native American n Total % 4223 4958 85.18% 4223 4958 85.18% 4223 4958 85.18% n 12088 993 475 Total % RR Std. Err Lower Limit Upper Limit 14140 85.5% 1.0020 0.0135 0.9886 1.0155 1230 80.7% 0.9711 0.0297 0.9427 1.0004 635 74.8% 0.9303 0.0466 0.8880 0.9747 Children and Adolescents Access to Care 2-6 Years of Age Hispanic Black Native American n 15831 15831 15831 Total % 19470 81.31% 19470 81.31% 19470 81.31% n 8647 8647 8647 Total % 10943 79.02% 10943 79.02% 10943 79.02% n 49895 4397 2058 Total % RR Std. Err Lower Limit Upper Limit 60374 82.6% 1.0090 0.0077 1.0013 1.0167 5698 77.2% 0.9712 0.0156 0.9562 0.9866 2985 68.9% 0.9100 0.0250 0.8875 0.9330 Children and Adolescents Access to Care 7-11 Years of Age Hispanic Black Native American n 24480 2754 1099 Total % RR Std. Err Lower Limit Upper Limit 30911 79.2% 1.0012 0.0112 0.9901 1.0125 3698 74.5% 0.9670 0.0212 0.9467 0.9877 1589 69.2% 0.9263 0.0342 0.8951 0.9585 Children and Adolescents Access to Care 12-19 Years of Age Hispanic Black Native American n 11771 11771 11771 Total % 14600 80.62% 14600 80.62% 14600 80.62% n 24343 3911 1401 n 40472 40472 40472 Total % 49971 80.99% 49971 80.99% 49971 80.99% n 9904 9904 9904 Total % 25593 38.70% 25593 38.70% 25593 38.70% n 20873 3443 1057 n Total % 2489 4083 60.96% 2489 4083 60.96% 2489 4083 60.96% n 7148 517 210 Total % RR Std. Err Lower Limit Upper Limit 30044 81.0% 1.0027 0.0097 0.9931 1.0125 5107 76.6% 0.9716 0.0171 0.9551 0.9884 1993 70.3% 0.9248 0.0296 0.8978 0.9526 Children and Adolescents Access to Care All Age Groups Hispanic Black Native American n Total % RR Std. Err Lower Limit Upper Limit 110806 135469 81.8% 1.0055 0.0049 1.0005 1.0104 12055 15733 76.6% 0.9695 0.0096 0.9602 0.9788 5033 7202 69.9% 0.9193 0.0157 0.9049 0.9339 Adolescents Well Care Hispanic Black Native American Total % RR Std. Err Lower Limit Upper Limit 47460 44.0% 1.0948 0.0185 1.0748 1.1152 8206 42.0% 1.0593 0.0298 1.0283 1.0913 3590 29.4% 0.8152 0.0529 0.7732 0.8596 Well Child Visits 15 Months of Life Hispanic Black Native American Total % RR Std. Err Lower Limit Upper Limit 11963 59.8% 0.9876 0.0286 0.9597 1.0163 1028 50.3% 0.8836 0.0655 0.8275 0.9434 488 43.0% 0.7944 0.1050 0.7152 0.8823 Well Child Visits 3rd-6th Years of Life Hispanic Black Native American n 9596 9596 9596 Total % 15633 61.38% 15633 61.38% 15633 61.38% n 33411 2801 1190 Total % RR Std. Err Lower Limit Upper Limit 48453 69.0% 1.0730 0.0138 1.0583 1.0879 4624 60.6% 0.9918 0.0264 0.9660 1.0183 2412 49.3% 0.8686 0.0423 0.8326 0.9061 Dental Care 2-19 Years of Age Hispanic Black Native American n Total % 5622 8331 67.48% 5622 8331 67.48% 5622 8331 67.48% n 16211 595 414 Total % RR Std. Err Lower Limit Upper Limit 21865 74.1% 1.0567 0.0168 1.0390 1.0746 865 68.8% 1.0114 0.0473 0.9647 1.0604 729 56.8% 0.8989 0.0651 0.8423 0.9594 Children and Adolescents Access to Care 12-24 Months Hispanic Black Native American n Total % 462 496 93.15% 462 496 93.15% 462 496 93.15% n 987 38 43 Total % RR Std. Err Lower Limit Upper Limit 1046 94.4% 1.0067 0.0281 0.9788 1.0354 48 79.2% 0.9162 0.1471 0.7909 1.0614 49 87.8% 0.9692 0.1073 0.8706 1.0789 Children and Adolescents Access to Care 2-6 Years of Age Hispanic Black Native American n Total % 1796 2117 84.84% 1796 2117 84.84% 1796 2117 84.84% n 6121 181 144 Total % RR Std. Err Lower Limit Upper Limit 6909 88.6% 1.0235 0.0199 1.0033 1.0441 204 88.7% 1.0243 0.0521 0.9723 1.0791 192 75.0% 0.9337 0.0836 0.8588 1.01519 Children and Adolescents Access to Care 7-11 Years of Age Hispanic Black Native American n Total % 1420 1687 84.17% 1420 1687 84.17% 1420 1687 84.17% n 4304 117 79 Total % RR Std. Err Lower Limit Upper Limit 4946 87.0% 1.0181 0.0233 0.9946 1.0421 135 86.7% 1.0159 0.0693 0.9478 1.0888 109 72.5% 0.9194 0.1175 0.8175 1.0341 Children and Adolescents Access to Care 12-19 Years of Age Hispanic Black Native American n Total % 1952 2250 86.76% 1952 2250 86.76% 1952 2250 86.76% n 3953 205 119 Total % RR Std. Err Lower Limit Upper Limit 4563 86.6% 0.9992 0.0198 0.9797 1.0192 236 86.9% 1.0007 0.0522 0.9498 1.0543 164 72.6% 0.9052 0.0955 0.8227 0.9959 Children and Adolescents Access to Care All Age Groups Hispanic Black Native American n Total % 5630 6550 85.95% 5630 6550 85.95% 5630 6550 85.95% n 15365 541 385 n Total % 1544 3405 45.35% 1544 3405 45.35% 1544 3405 45.35% n 3878 206 109 Total % RR Std. Err Lower Limit Upper Limit 17464 88.0% 1.0125 0.0112 1.0012 1.0240 623 86.8% 1.0055 0.0321 0.9737 1.0383 514 74.9% 0.9265 0.0510 0.8804 0.9750 Adolescents Well Care Hispanic Black Native American Total % RR Std. Err Lower Limit Upper Limit 6999 55.4% 1.1428 0.0424 1.0953 1.1923 405 50.9% 1.0807 0.1026 0.9753 1.1974 313 34.8% 0.8279 0.1560 0.7083 0.9677 Well Child Visits 15 Months of Life Hispanic Black Native American n Total % 360 500 72.00% 360 500 72.00% 360 500 72.00% n 752 19 41 Total % RR Std. Err Lower Limit Upper Limit 1071 70.2% 0.9854 0.0672 0.9214 1.0539 28 67.9% 0.9657 0.2607 0.7441 1.2534 55 74.5% 1.0203 0.1638 0.8661 1.2019 Well Child Visits 3rd-6th Years of Life Hispanic Black Native American n Total % 1127 1695 66.49% 1127 1695 66.49% 1127 1695 66.49% n 4327 117 81 Total % RR Std. Err Lower Limit Upper Limit 5677 76.2% 1.0830 0.0368 1.0439 1.1236 176 66.5% 0.9999 0.1102 0.8955 1.1164 161 50.3% 0.8381 0.1572 0.7162 0.9808