The HEDIS measure for rates of children with a well child visit are divided into three age categories: children ages 3-6, 7-11 and 12-19. According to the Iowa Early and Periodic Screening Diagnosis and Treatment (EPSDT) program periodicity schedule, children should receive seven well child visits by the time they reach one year of age, three visits up to age two, annual visits from age three through six and biannual visits up to age 20. Well child visits are defined as those children who had a diagnosis code of well child exam (V20.2, V70.3, V70.5, V70.6, V70.8, V70.9) or a procedure code indicating a preventive exam (99382-99383, 99392-99393, W0052).

Children ages 3-6

Chart 1 shows the percentage of children ages three through six with at least one well child visit across the Iowa managed care plans and the APHSA national average for Medicaid programs. From this chart we see that all Iowa plans meet or exceed the national average for the rate of children with a well child visit with children in MediPASS most likely and those in UHC least likely to have had a well child visit.

Chart 1. Percent children ages three through six with at least one well child visit in 2000 by managed care plan and compared to national benchmark

 

Chart 2 indicates the rates of well child visits broken out by age for this group. The rate of well child visits varies by plan by age with children in the MediPASS program most likely to have a well child or adolescent visit and children in United Health Care least likely to have a well child or adolescent visit for all four age categories. In addition, it appears that once children enter school, age 6, they are much less likely to obtain a well child visit.

Chart 2. Percent of children with at least one
well child visit by managed care plan, 2000.

Children ages 7-11

Table 5 lists the percent of children ages seven through eleven who had a well child visit in calendar year 2000. On average, less than one-third of children within the Medicaid managed care plans ages seven through eleven received a well child visit during 2000. This is much lower than for the younger children and continues the decline found in the six year olds.

Table 5. Percent of children ages seven through eleven
with at least one well child visit, 2000.

Managed care plan	Percent with well child visit
John Deere	29.6%
Iowa Health Solutions	28.5%
United Health Care	24.7%
Coventry	31.9%
MediPASS	42.5%

Children ages 12-19

As children become adolescents there are many issues such as drugs, smoking, and sexuality that need to be addressed. Many of these issues may be addressed and discussed within the preventive visit. Though it may be difficult for an adolescent to talk with parents about their problems or concerns, a medical provider is in a unique position to listen and advise adolescents. Therefore, the adolescent preventive visit is an important component of medical care. Table 6 indicates the rate of adolescent preventive visits across the managed care plan.

Table 6. Rate of adolescents ages 12 through 19
with at least one preventive visit, 2000.

Managed care plan	Percent with well adolescent visit
John Deere	40.3%
Iowa Health Solutions	39.9%
United Health Care	37.2%
Coventry	43.7%
MediPASS	53.2%

The rate of adolescents with at least one preventive visit during 2000 is higher for every managed care plan than it was for children ages seven through eleven. This increased rate of preventive care among adolescents is most likely due to the requirement of the schools that adolescents participating in sports must have a sports physical. Just as in the younger children we see a drop off in the rate of preventive visits after the required pre-school physical, so also we see an increase in the rate as soon as the school requires a preventive visit for participation in sports. School required health care does increase the rate of preventive care in children. It may be useful to consider other time points within the school career at which a preventive visit should be required in order to participate in school activities.

Though it may be difficult to imagine that all children would be able to obtain an annual or biannual preventive visit, it does seem that a higher rate is attainable. It may be prudent for the IDHS and/or the health plans to educate parents on the importance of the preventive visit, especially as children approach adolescence. Preventive visits do not just address the medical needs of the child, but can also provide an opportunity for anticipatory guidance to parents and children.

Ambulatory care visits for children and adolescents

Table 7 indicates the percent of children within each plan and MediPASS who had at least one ambulatory care visit during 1999. Within the HEDIS measures, this rate is designed to determine the percent of children who saw their primary care provider (PCP) at least once, however this had to be modified for these analyses. The administrative data does not allow us to determine whether the child saw their PCP or some other health care provider. Therefore, we have calculated the percent with an ambulatory care visit, regardless of provider. An ambulatory care visit is defined as any visit with the following procedure codes: 99201-99205, 99211-99215, 99241-99245, 99341-99353, 99381-99385, 99391-99395, W0051, 99401-99404, 99411, 99412, 99420, 99429, 99499, 99432 or the following diagnosis codes: V20.2, V70.3, V70.5, V70.6, V70.8, V70.9.

Table 7. Number and percent of children and adolescents with
at least one ambulatory care visit, 1999

 

	MediPASS	John Deere	Iowa Health Solutions	Coventry	United Health Care
Children one year old with an ambulatory visit             Number (%)	1,923  (95.7%)	1,446  (97.8%)	525 (97.2%)	50 (96.2%)	60  (98.4%)
Total children one year old	2,009	1,478	540	52	61
Children ages 2-6 with an ambulatory visit             Number (%)	7,024  (79.7%)	4,738  (86.7%)	1,514 (84.9%)	217 (80.7%)	207  (82.8%)
Total children ages 2-6	8,817	5,463	1,784	269	250
Children ages 7-11 with an ambulatory visit             Number (%)	4,959  (60.8%)	3,156  (70.7%)	1,061 (69.2%)	123 (60.6%)	181  (66.1%)
Total children ages 7-11	8,150	4,463	1,533	203	274
Adolescents ages 12-15 with an ambulatory visit             Number (%)	2,751  (57.8%)	1,734  (71.7%)	562 (70.0%)	83 (62.9%)	115  (71.0%)
Total adolescents ages 12-15	4,763	2,418	803	132	162
Adolescents ages 16-18 with an ambulatory visit             Number (%)	1,413  (62.0%)	904  (73.1%)	323 (73.9%)	45 (60.0%)	69  (73.4%)
Total adolescents ages 16-18	2,278	1,236	437	75	94

 

Children one year of age were most likely to have had an ambulatory care visit, while those between the ages of 12 and 15 were least likely. All plans performed similarly with the younger children however children in MediPASS and Coventry were less likely to have had an ambulatory visit as they reached age seven, and continuing through the adolescents and young adults.

The decline in visits as the children age parallels the results found for well child visits. The decline in age can in part be related to changes in the periodicity schedule for preventive visits, with biannual check-ups scheduled for children over age six. Though the percent of children receiving at least one ambulatory care visit is not below 50% in any age category, the low rates raise concerns about possible access to care problems. The lower rate among adolescents may also be a concern since it is during this period of time that adolescents require evaluation and counseling regarding tobacco abuse, substance abuse and sexual activity. Policies need to be developed that encourage anticipatory guidance activities with adolescents. These may also provide incentives for timely preventive visits.

Comparison to calendar year 1998

Findings for the percentage of children and adolescents with an ambulatory care visit in 1999 are similar to those found for this measure in calendar year 1998 analyses (Table 8). The age decline is more pronounced in the 1999 data. Overall, rates for children and adolescents in 1998 are somewhat higher across all ages and plans. To ensure that this is not an ongoing trend toward reduced utilization of ambulatory care services, ambulatory care visit rates should be reassessed in 2001.

Table 8. Percent of children and adolescents with
at least one ambulatory care visit, 1998

 

	MediPASS	John Deere	Iowa Health Solutions	Coventry	United Health Care
Children one year old	97.6%	95.1%	94.5%	94.0%	92.3%
Children ages 2-6	88.3%	86.9%	89.2%	76.8%	79.9%
Children ages 7-11	76.8%	74.6%	74.4%	57.6%	72.1%
Adolescents ages 12-15	78.0%	74.2%	80.2%	75.0%	60.8%

 

Preventive dental visits for children

In addition to regular preventive medical visits, children are recommended to have regular preventive dental visits. According to the Iowa EPSDT periodicity schedule, children should see a dentist annually at ages one and two and every six months up to age 20. Within the Medicaid managed care program, dental care is considered a ìcarve outî, a service that is not provided within the managed care contract, but rather on a fee-for-service basis through the general Medicaid program. The health plans are thus not held accountable for dental utilization. Providing dental care through the same system, regardless of which managed care plan an enrollee chooses, should reduce the disparity in rates of use between plans.

Children ages 1-11

Table 9 shows the rates of preventive dental visits for children during 2000 by managed care plan. A preventive dental visit is defined as a visit with procedure one of the following procedure codes: 00120, 00140, 00150, 00160, 00210-00340, 00415-00999, and 01110-01550.

Table 9. Number and percent of children with a preventive dental visit
by managed care plan, 2000

	John Deere	Iowa Health Solutions	United Health Care	Coventry	MediPASS
1-3 years	413 (12%)	177 (9%)	18 (9%)	10 (5%)	439 (9%)
4-6 years	1,663 (55%)	705 (47%)	79 (45%)	127 (60%)	2,628 (53%)
7-11 years	2,456 (55%)	1,074 (48%)	146 (50%)	140 (50%)	4,427 (56%)

Though at least yearly preventive dental visits are recommended for children by the Iowa EPSDT periodicity schedule and the American Academy of Pediatric Dentists beginning at age one, only 12% of children one to three had such a visit. There are likely many factors that play into this statistic including parental lack of knowledge regarding this guideline, the reluctance of general dentists to see very young children, and the general perception that young teeth will be replaced with permanent and are, therefore, expendable. The percentage of children with a visit rises dramatically in the four to six year-old category with over half of children ages four through 11 seeing a dentist during 2000.

Adolescents ages 12-19

Annual dental visits are expected for children ages 12-19 according to the Iowa EPSDT periodicity schedule. The percent of adolescents receiving at least one preventive dental visit begins at about 50% and falls over time. It is interesting to note however, that they are more likely to have gotten a preventive dental care visit than a preventive medical care visit. This may be accounted for by the guidelines for these two types of care: preventive medical visits are recommended every other year, while preventive dental visits are recommended every six months.

Table 10. Number and percent of adolescents with
a preventive dental visit managed care plan, 2000

	John Deere	Iowa Health Solutions	United Health Care	Coventry	MediPASS
12-15 years	1,303 (50%)	589 (45%)	90 (51%)	72 (46%)	2,656 (54%)
16-18 years	599 (44%)	257 (37%)	46 (45%)	28 (33%)	1,279 (47%)

Consistent dental care for adolescents is very important. Adolescents are likely to be drinking beverages such as soda high in sugar that will increase the risk of caries. In addition, in adolescence many individuals begin to experiment with smoking or smokeless tobacco. Routine dental screening and the opportunity for a dentist to discuss these activities and their effects on oral health are crucial.

Comparison with calendar year 1998

Chart 3 provides an illustration of how the rates of children and adolescents with a preventive dental visit changed between 1998 and 2000. Though it appears to have decreased some over the two-year time span, there is very little change within any of the managed care plans.

Chart 3. Percentage of children and adolescents with a
preventive dental visit by managed care plan, 1998 and 2000.

Tonsillectomy and Myringotomy Rates

Surgical rates can be indicators of access to specialty services. Table 11 indicates rates per 1000 enrollees for each of the managed care plans and MediPASS within each age group for tonsillectomy procedures. Rates varied widely, ranging from eight to 15 per 1,000 enrollees. Rates of tonsillectomy are based on very small numbers of surgeries making it difficult to determine what a reasonable range of rates might be. In addition, Coventry and United Health Care have small numbers of children (less than 1,000) within each of the categories. With small numbers a difference of one or two surgeries can result in large differences once the calculation is performed on a ìper 1,000î basis. Due to this, results should primarily be drawn from a comparison of MediPASS, John Deere, and Iowa Health Solutions. This comparison reveals that MediPASS had the highest rate of tonsillectomy while Iowa Health Solutions had the lowest rate for children ages 0 to nine. For children and adolescents 10 through 19 years of age the three plans did not vary in the tonsillectomy rate.

Table 11: Tonsillectomy rate by managed care plan
 and age per 1,000 enrollees, 1999

Program	Tonsillectomies per 1,000 enrollees 0-19 years of age	Tonsillectomies per 1,000 enrollees 0-9 years of age	Tonsillectomies per 1,000 enrollees 10-19 years of age
MediPASS	15	19	9
John Deere	12	14	8
Iowa Health Solutions	9	9	7
Coventry	10	9	12
United Health Care	8	12	3
Total	14	17	9

Comparison with calendar year 1998

Table 12 provides the tonsillectomy rate by managed care plan for calendar year 1998. Comparing 1998 to 1999 for MediPASS, John Deere and Iowa Health Solutions reveals that rates increased from one year to the next. Though the rates stayed virtually the same for enrollees 10 to 19 years of age, they increased by at least 20% for enrollees 0 to nine years of age. Increases in surgical rates should be carefully followed to ensure that they do not continue to rise over time without adequate explanation. If the rates continue to rise investigations should be undertaken to determine the explanation for these increases.

Table 12: Tonsillectomy rate by managed care plan
 and age per 1,000 enrollees, 1998

Program	Tonsillectomies per 1,000 enrollees 0-19 years of age	Tonsillectomies per 1,000 enrollees 0-9 years of age	Tonsillectomies per 1,000 enrollees 10-19 years of age
MediPASS	14	16	9
John Deere	9	10	6
Iowa Health Solutions	3	3	3
Coventry	19	24	8
United Health Care	12	17	5
Total	11	13	7

Table 13 shows rates of myringotomy tube placement. There were wide variations in myringotomy rates among the plans, varying from 14 to 29 procedures per 1,000 enrollees. MediPASS and John Deere had the highest rates across both age groups.

Table 13: Myringotomy rate by managed care plan
 and age per 1,000 enrollees, 1999

Program	Myringotomies per 1,000 enrollees 0-19 years of age	Myringotomies per 1,000 enrollees 0-4 years of age	Myringotomies per 1,000 enrollees 5-19 years of age
MediPASS	24	54	13
John Deere	29	62	14
Iowa Health Solutions	20	40	9
Coventry	14	28	8
United Health Care	17	40	3
Total	28	59	13

Although benchmark rates for tonsillectomies and myringotomy tube placement are not established, there is an assumption that the need for surgery is similar across the plans. Variance among the plans may indicate under utilization due to lack of access or over-utilization due to unnecessary surgery. The numbers of surgeries is very low, however, and small variances result in large rate differences that may not be clinically significant.

Summary of child measures

The Medicaid program has children as its primary enrollee group: over 60% of Medicaid eligible persons are under 19 and the majority of these are under 12. The health outcomes for this group are extremely important in assessing the quality of care provided. Most particularly these data allow us to determine whether children have equal access to services across plans.

From an overall perspective, children within the Medicaid program utilize services at rates that appear higher than those seen nationally, however they are not utilizing preventive services at a rate consistent with the established Iowa Medicaid EPSDT guidelines.

From a plan perspective, service utilization varies by plan. United Health Care consistently scores more poorly on most measures. This result would normally point to the need for change within the plan. This is not necessary; however, since United Health Care is no longer participating in the Medicaid managed care program.