Adult measures

Maternal length of stay

The length of time a mother spends in the hospital following the delivery of a newborn varies. Within the context of measuring quality we would not want to see an average length of stay that is either too long or too short. Long lengths of stay may indicate that deliveries were more complex or had more complications. This in turn could indicate a lack of prenatal care or poor management of the pregnancy through the provider network within the managed care plan. Short lengths of stay may indicate that the managed care plans are discharging the mother too soon following the delivery. Early discharge could lead to complications later increasing the cost of care. It has become widely accepted that maternal length of stay should average at least 2 days. This allows for the mother to recover from the delivery, the mother and father to obtain patient education regarding care of an infant at home, and the family to prepare for their return home. To date, the encounter data for maternal length of stay has not been easily available. Within the medical claims and encounter data there are 6,659 women within the managed care programs who have delivered a child during 2000. However, the inpatient data yields claims and encounters for only 4,835 of these. Table 14 provides a comparison of the number of women with a medical claim/encounter indicating a delivery and the number of women with an inpatient claim/encounter indicating a delivery by managed care program.

The percent of women with a medical claim/encounter who also have an inpatient claim/encounter varies greatly by managed care program. United Health Care has the highest rate of missing inpatient data at 78%, while MediPASS has the lowest percentage of women with missing inpatient data at 9%. Varying rates of missing inpatient data and the level of missing inpatient data make it inappropriate to calculate the maternal length of stay at this time. Work is continuing to identify why inpatient data cannot be readily identified in the encounter files used for outcome research at the University of Iowa Public Policy Center. At the time of this report, the HMOs are working to determine whether the missing inpatient data is resident on their systems. Should the data be present, efforts will be made to determine whether the data is lost during transfer of information to ACS or the University of Iowa.

Table 14. Number of women with a medical and/or inpatient claim
 or encounter indicating a delivery, 2000

Cesarean section rate

The rate of Cesarean sections (C-sections) is used to determine the complexity of deliveries within the plans. If this rate is high within a plan and remains high over time it may indicate that action should be taken to determine why C-sections are being performed and lower the rate. Table 15 indicates the rate of C-sections across plans in calendar year 2000 (Coventry and United Health Care are removed from these analyses due to high rates of missing data). MediPASS has the highest rate at 22% of women delivering a child by C-section, while John Deere has the lowest rate with only 17% of women delivering a child by C-section. This 5% spread between the managed care plan with the highest and lowest rates of C-section does seem to be large. Though variance is expected, the rate in MediPASS is 30% greater than that in John Deere. C-section rates should continue to be monitored.

Table 15: C-section rate by managed care plan, 2000

Comparison to calendar year 1998

Table 16 provides the C-section rate by managed care plan for calendar year 1998. The C-section rates for MediPASS and Iowa Health Solutions increased by 16% and 58% respectively during the period 1998 to 2000. In comparing this to a 6% increase for John Deere, it is important to consider why these two plans had a more pronounced increase. MediPASS and Iowa Health Solutions may have enrollees that are more at risk for C-section than those in John Deere. Another explanation may be that the provider panel for John Deere is significantly different than that for MediPASS or Iowa Health Solutions, resulting in a different practice style. Finally, it may be that John Deere has systems in place to monitor and reduce the use of C-sections for enrollees within the plan. Further research to determine why these differences exist may be worthwhile, particularly if the results provide for reductions in other plans.

Table 16: C-section rate by managed care plan, 1998

Well adult visits

Table 17 presents the rate for preventive visits among adults within the Medicaid program, without regard for managed care plan. There are no established periodicity schedules for the receipt of well adult examinations after the age of 20 by the Iowa Medicaid program. Similar codes were used to determine the rates of well adult exams as were used for well child exams for children.

Enrollees between the ages of 19 and 24 have the highest proportion of well visits. In fact, this age group has a higher proportion of well visits than children ages seven through 11 years, the group with the lowest rate for well child visits.

Table 17. Proportion of Medicaid eligible
adults with a well visit in 2000.

Chart 4 compares the well visit rate by age and gender. Chart 4 clearly indicates that men are far less likely to have a well visit than women, particularly between the ages of 25 and 54 years. During this time period women may be more likely to be required to see a physician due to the use of contraceptives or determination and supervision of pregnancy. In particular, the use of contraceptives requires a well visit yearly, thereby forcing women to make time to visit the doctor. No such incentive exists for men.

Chart 4. Proportion of Medicaid eligible
adults with a well visit in 2000 by gender

Table 18 provides the breakdown of well adult visits by managed care plan. The rate of well visits varies by age and managed care plan. The rate generally decreases as age increases with the exception of increases in the rate from 35-44 years to 45-54 years in John Deere, Iowa Health Solutions, and Coventry. When looking at the table by plan, MediPASS has the best rates for adult well visits for all age groups, except those age 45-54 years. For this group Coventry had the best rate at 39%. Also, MediPASS did not have the best rate for those age 55-64 years (there were no enrollees in this group within United Health Care and Coventry).

Table 18. Number and percent of adults with a
well visit by managed care plan, 2000

*No adults within this plan met the criteria for inclusion in the proportion.

Adult cancer screening

Two cancer screening procedures are being evaluated: cervical cancer screening and breast cancer screening. The predominance of women in the adult Medicaid population makes these measures particularly appropriate for evaluation.

Breast cancer screening

Breast cancer screening guidelines suggest that women between ages 52 and 65 should have a screening mammography with manual exam every three years. The breast cancer screening measure for HEDIS determines the proportion of women who are eligible for at least 22 months within a two year span that have had a screening mammography within the two year period. For these analyses, we have evaluated mammography rates for the   population, as well as the proportion for women with a screening mammography for two additional age groups: 32-41 years and 42-51 years.

Table 19 indicates the number of women who were eligible for at least 11 months in both 1999 and 2000 who had a screening mammography during 1999 or 2000. The rates vary widely by plan with John Deere having the highest proportion of women with a mammogram.

Table 19. Number and percent of women with a
screening mammogram by managed care plan, 1999 and 2000

*No women within this plan that meet the criteria for inclusion in the table.

In past reports, we have only been able to compute the proportion on an annual basis. Thus to allow for comparison to past reports, the annual rate for 2000 is included in Table 20. Comparing the two tables allows us to conclude that some women may be obtaining a mammogram every other year, however, the rates are still low.

Table 20. Number and percent of women with a
screening mammogram by managed care plan, 2000

*No women within this plan that meet the criteria for inclusion in the proportion.

Cervical cancer screening

The rates for cervical cancer screening (Table 21) are somewhat low. Guidelines indicate that this screening should occur at least once every three years. Plans with a rate of 30% or greater may be considered to be in compliance with this guideline. During the period 1998 through 2000 approximately one-third of women received the screening exams. Iowa Health Solutions, United Health Care and Coventry appear to have extremely low rates during 1999, while United Health Care and Coventry have very low rates during 1998. This may be due to missing claims or low utilization of this screening procedure. During 2000 more women within these plans are reflected as having had a screening exam, however the rates are still lower than those in John Deere and MediPASS. Future outcome analyses should include women who have been eligible for at least three years in this measure.

Table 21. Number and percent of women 21-64 years of age with a
cervical cancer screening by managed care plan, 1998, 1999, 2000 and National

Obtaining cervical cancer screening and/or mammography screening requires a well visit with the doctor. Cervical cancer screening is normally performed during the well visit and mammogram referrals are normally made in tandem with the well visits and a manual breast exam. Therefore, the rate of cervical cancer screening and mammography will not exceed the rate for well visits. Additional research linking preventive visits with screening activities, in particular focusing upon the timing of screening, would be useful.

Adult dental visits

In addition to well person visits, preventive dental visits play an important role in the over all health of individuals within the Medicaid program. The Iowa Medicaid program provided for comprehensive adult dental services during calendar year 2000. Table 22 indicates that the rate for adult preventive dental visits is fairly consistent across age groups and plans. Though there are wide variations within United Health Care and Coventry, these variations are most likely attributable to the small numbers of adults in each category. Small numbers allow the percentages to vary greatly with the addition or subtraction of only one person to the rate. For example, since there are only 36 adults ages 35-44 years in Coventry, if one extra person has a visit it increases the rate by almost 3%. For the larger managed care plans the rates are very stable, remaining about 40%. This does drop in all three plans for the 55 through 64 age group, but this drop may also be due to small numbers.

Table 22. Number and percent of adults with a
preventive dental visit by managed care plan, 2000

*No adults within this plan met the criteria for inclusion in the table.

Comparison to calendar year 1998

The percent of adults who were able to obtain a preventive dental visit changed little between 1998 and 2000 (Tables 22 and 23). Within both years the percent of adults with a preventive visit remained at about 40% for all age groups except those 45-54 years old and those 55-64 years old. Little can be said about the 55-64 years old age group because there are very few people within this group for either year. For those age 45-54 years in the two largest plans, MediPASS and John Deere, the rate increased for MediPASS, from 35% in 1998 to 40% in 2000, while it remained about the same in John Deere, 44% in 1998 and 43% in 2000.

Table 23. Number and percent of adults with a
preventive dental visit by managed care plan, 1998