December 2004 MassHealth HEDIS 2004 Prepared by: Center for Health Policy and Research (CHPR) in collaboration with the Office of Acute and Ambulatory Care (OAAC) Project Team Center for Health Policy and Research Rebecca Ouellette Greg Leung Ann Lawthers Office of Acute and Ambulatory Care: Kate Willrich-Nordahl David Tringali Michael Schieffelin Liza Rudell Mary Ann Mark Susan Maguire Amina Khan Marlene Kane John DeLuca Louise Bannister Table of Contents Purpose This report presents the MassHealth HEDIS 2004 results. This report is designed to be used by MassHealth program managers and by managed care plan managers to identify their plan's performance, compare performance against other plans and national rates, identify opportunities for improvement and set quality improvement goals. This report also provides detailed information that can facilitate more in-depth analyses. Organization of This Report This report has three major sections: - Staying Healthy: The measures reported in this section focus on how well the Plan provides services that maintain good health and prevent illness, with a particular emphasis on immunizations and routine check-ups. -Living with Illness: The measures reported in this section emphasize how well the Plan cares for people when they are sick, with a particular focus on diabetes and asthma. -Behavioral Health Care: The measures reported in this section provide information on the rate of use for mental health and substance abuse services. The sections include Statistical Summaries for each measure that show each Plan's performance compared to national and Massachusetts benchmarks. Each Plan's performance is also compared to its own rates from prior HEDIS data collection efforts, when available. The Individual Measure Pages show Plan results charted side-by-side with selected benchmarks. Plans that performed significantly better than the MassHealth average have white bars. Benchmarks are in black. All other results are depicted as gray bars. Each section concludes with the Measure and Benchmark Details for the measures reported in that section. The Details page reports the rates for each individual plan as well as the numerator, denominator and confidence intervals. The report also includes three Appendices that include antigen-specific immunization rates and breakouts of data for the Basic and non-Basic populations for selected Mental Health and Chemical Dependency measures. Table of Contents Executive Summary es i Introduction HEDIS 2004 Participant Profiles 1 Data Collection and Analysis Methods 2 Caveats for the Interpretation of Results 4 Staying Healthy Statistical Summary - Childhood and Adolescent 5 Immunization Childhood Immunization Status 6 Adolescent Immunization Status 7 Statistical Summary- Well-Child Visits and Adolescent Well 10 Care Visits Well-Child Visits 11 Adolescent Well-Care Visits 12 Statistical Summary - Children and Adolescents' Access to PCPs 14 Children and Adolescent's Access to PCPs 15 Living with Illness Statistical Summary - Comprehensive Diabetes Care 19 Comprehensive Diabetes Care 21 Statistical Summary - Use of Appropriate Meds for People with Asthma 27 Use of Appropriate Medications for People with Asthma 28 Behavioral Health Care Mental Health Services 32 Chemical Dependency Services 33 Appendix A Antigen-Specific Immunization Rates 34 Appendix B Mental Health Services, Basic and Non-Basic Populations 39 Appendix C Chemical Dependency Services, Basic and Non-Basic 45 Populations Appendix D Summary of MassHealth Performance 51 Appendix E Data Collection Methodology Table 53 References 54 Executive Summary The National Committee for Quality Assurance (NCQA) developed the Health Plan Employer Data and Information Set (HEDIS(r)) to standardize the measurement and reporting of health plan performance. NCQA's goal has been to develop a set of measures that are consistent over time and that are specified in sufficient detail so that the results will be comparable among health plans. HEDIS is part of NCQA's integrated system to establish accountability in health care organizations. HEDIS Measurement Domains HEDIS measures have been developed across a number of domains that include: Effectiveness of Care, Access and Availability of Care, and Use of Services. These categories are described below. -Effectiveness of care measures are intended to demonstrate the impact of health care delivered during the designated measurement period. These measures allow both purchasers and consumers to draw inferences about the clinical effectiveness of health care interventions delivered by the Plan. -Access and availability of care measures estimate the extent to which covered services are obtainable. Measures in this domain provide evidence of the extent to which members do in fact access specified health services. Highly motivated members may overcome substantial barriers to obtain desired care, while even minor barriers to receiving care may deter others. These measures offer some insight into how members access important and basic services. -Use of services measures are intended to provide insight into plan performance by describing the utilization of services in a manner that focuses on what services are obtained by populations that can expect to need them, such as routine well-child visits for young children. These measures also include the rate of use, generally expressed in terms of either percentage of services having a particular characteristic, or as the number of services delivered for every 1000 months of membership (e.g. the rate of mental health services). Utilization measures can suggest how efficiently a plan delivers services to the population. Utilization rates that are very low may suggest barriers to care. MassHealth HEDIS 2004 Data Collection The MassHealth Office of Acute and Ambulatory Care (OAAC) used a subset of HEDIS measures to assess the performance of the five health plans that provided health care services to MassHealth Managed Care members during the 2003 calendar year. This report presents HEDIS 2004 performance data based on care provided by Boston Medical Center HealthNet Plan (BMCHP), Fallon Community Health Plan (FCHP), Neighborhood Health Plan (NHP) and Network Health (NH) as well as the Primary Care Clinician Plan (PCCP), the primary care case management program administered by the Executive Office of Health and Human Services (EOHHS). The HEDIS data offer useful information on the performance of the health plans. The results provide MassHealth with a means for assessing whether the health plans are performing satisfactorily and contribute information about potential areas for improvement. These data are integral to MassHealth's efforts to improve the quality of health care delivered to members. Measures Collected for HEDIS 2004 Staying Healthy Access and Availability of Care • Children and Adolescent's Access to Primary Care Practitioners Effectiveness of Care Childhood Immunization Status Adolescent Immunization Status Measures Collected for HEDIS 2004 Use of Services Well-Child Visits in the First 15 Months of Life Well-Child Visits in the Third, Fourth, Fifth and Sixth Years of Life Adolescent Well-Care Visits Living with Illness Effectiveness of Care Comprehensive Diabetes Care Use of Appropriate Medications for People with Asthma Behavioral Health Care Use of Services Mental Health Utilization- Inpatient Discharges and ALOS Mental Health Utilization- Percentage Using Services Chemical Dependency Utilization- Inpatient Discharges and ALOS Chemical Dependency Utilization- Percentage Using Services Summary of Performance Overall, performance across MassHealth Plans has improved. Although MassHealth Plans generally outperformed national Medicaid benchmarks and, in some cases, national Commercial benchmarks, there is potential for improvement in a number of areas. In the results section of this report, comparisons to benchmarks and potential opportunities for improvement are noted for each individual measure or group of measures. The Summary Tables on the following pages present the overall results for MassHealth Plans for HEDIS 2004, as well as Massachusetts Commercial, national Commercial and national Medicaid benchmarks. Appendix D presents the MassHealth average and individual plan results for all HEDIS 2004 measures. Executive Summary Table A: Summary of Staying Healthy Measures (The original document contain the table) Table B: Summary of Living with Illness Measures(The original document contain the table) Table C: Summary of Behavioral Health Care Measures (The original document contain the table) Introduction HEDIS 2004 Participant Profiles The following five health Plans submitted data for this report. Boston Medical Center HealthNet Plan (BMCHP) The Boston Medical Center HealthNet Plan (BMCHP) began operations in July 1997 as a provider-sponsored health plan, owned and operated by Boston Medical Center, the largest public safety net hospital in Boston. As of December 2003, BMCHP served approximately 121,000 MassHealth members. BMCHP's membership is spread throughout much of the state. Beyond Boston, BMCHP serves members living in Brockton, Quincy, Springfield, Holyoke, Northampton, Greenfield, and Westfield as well as in Adams, Pittsfield, Fall River, New Bedford and Wareham, as of 2002, and Taunton, as of 2003. BMCHP's provider network includes community health centers and hospital outpatient departments, as well as many group and individual practices. Fallon Community Health Plan (FCHP) Fallon Community Health Plan (FCHP) is a non-profit managed care organization that serves commercial, Medicare and Medicaid members. As of December 2003, FCHP served approximately 9,000 MassHealth members. FCHP's provider network is based primarily at 24 Fallon Clinic sites, which are group practices in Central Massachusetts. Network Health (NH) Network Health (NH) is a growing MassHealth managed care organization that was started by the Cambridge Health Alliance in July 1997. As of December 2003, NH served approximately 55,000 MassHealth members. Since 2001, NH's membership has grown in areas outside its traditional service area of Cambridge, Somerville, Arlington, Malden and Revere, to include Worcester, Gardner-Fitchburg, Southbridge, Lowell, Lawrence, Springfield, Southbridge, Holyoke and Haverhill, beginning in 2003. NH's provider network includes community health centers, group practices and hospital outpatient departments. Neighborhood Health Plan (NHP) Neighborhood Health Plan (NHP) is a non-profit managed care organization that serves primarily Medicaid members. As of December 2003, NHP served approximately 91,000 MassHealth members. The Plan's membership is spread throughout the state, with a large portion of its membership residing in the Greater Boston area. NHP's provider network includes mostly community health centers, in addition to Harvard Vanguard Medical Associates, group practices and hospital-based clinics. Primary Care Clinician Plan (PCCP) The Primary Care Clinician Plan (PCCP) is a primary care case management program administered by the Executive Office of Health and Human Services. The PCC Plan is a statewide managed care option for MassHealth members. As of December 2003 there were approximately 302,000 members in the PCC Plan. Each member who chooses or is assigned to the PCC Plan is enrolled with a primary care clinician who delivers primary and preventive care services, and coordinates most other health care services. The PCC Plan provider network includes individual physicians, group practices, community health centers, outpatient departments and independent nurse practitioners. Behavioral health services for PCC Plan members are managed through a carve-out contract with the Massachusetts Behavioral Health Partnership (MBHP). Data Collection and Analysis Methods In December 2003, the MassHealth Office of Acute and Ambulatory Care (OAAC) provided plans with the list of measures to be collected for HEDIS 2004. Each Plan was responsible for collecting and reporting the data according to the HEDIS specifications. The Plans submitted data to NCQA using NCQA’s Data Submission Tool (DST) and forwarded a copy of the DST to the Center for Health Policy and Research (CHPR). MassHealth Mean The MassHealth Mean is a weighted average of the five managed care Plans participating in HEDIS 2004. The weighted average is calculated by multiplying the performance rate for each Plan by the number of individuals who were enrolled in the MassHealth portion of that Plan during the year and who met the eligibility criteria for the measure. The values are then summed across Plans and divided by the total eligible population for all the Plans. MassHealth Median The median value for the Plans was identified and reported as the MassHealth Median. The median is defined as the middle value of a set of values. If there are an even number of values, then the median is the arithmetic mean of the values on either side of the midpoint. Confidence Intervals A 95% confidence interval was calculated for each measure. The 95% confidence interval defines a range that would be expected to contain the actual population mean 95% of the time, if the measurement were repeated using the same sample size. Confidence intervals reported here are used to test whether the observed performance rate for a Plan is the same as the benchmark rate. If a Plan's confidence interval includes the benchmark rate, we can conclude with 95% certainty that there is no difference between the benchmark rate and the Plan rate. That is, they are statistically the same. The width of the confidence interval varies by the observed rate and by the sample size. Large samples generate narrower confidence intervals; small samples generate broader ones. Benchmarks Benchmarks in this report include Massachusetts Commercial, national Commercial and national Medicaid means. These benchmarks were obtained from the 2004 NCQA Quality Compass(r). NCQA releases Quality Compass in July of each year with the rates for Commercial and Medicare plans. NCQA provides national Medicaid benchmarks in a supplement to Quality Compass that is released in late Fall. Although NCQA included some Medicaid data in its 2004 State of Health Care Quality Report that was released in June, these data were based on the Medicaid submissions that were available to NCQA at the time the report was released and therefore were not suitable as benchmarks for this report. Data from the State of Health Care Quality Report is discussed here only for first-year measures for which no national Medicaid benchmark data were available through Quality Compass. This report includes a comparison of each Plan's performance to its prior HEDIS rate, where applicable. Two rates were collected for the first time this year (the 12-19 year old rate for Children and Adolescents' Access to Primary Care Practitioners and the LDL <100 mg/dL rate for Comprehensive Diabetes Care). Because these were first-year rates, no historical MassHealth or benchmark data from Quality Compass were available. Quality Compass Quality Compass(r) is a registered trademark of NCQA. The source for national and Massachusetts HEDIS 2004 data contained in this publication is Quality Compass and is used with the permission of the National Committee for Quality Assurance ("NCQA" ). Any analysis, interpretation or conclusion based on these data are solely that of the authors, and NCQA specifically disclaims responsibility for any such analysis, interpretation or conclusion. Statistical Summaries The Statistical Summary pages compare individual Plan performance to national and Massachusetts Commercial benchmarks for HEDIS 2004, national Medicaid Benchmarks for HEDIS 2004 and the Plan's own prior performance on the measure (as feasible). Each Plan's rate was compared to the benchmark and assigned a statistical rating as follows: (The original document contain the statisticl rating for the table) Note: Two health plans may have identical scores, but due to different sample sizes, produce different results on the statistical significance tests. This is because smaller sample sizes at the Plan level yield less precise measures of performance and may be insufficient to achieve statistical significance. Therefore, readers should take sample size into account when interpreting the results of the statistical table. Administrative vs. Hybrid Data Collection The data used in this report were acquired using two data collection methodologies, administrative and hybrid. The administrative methodology requires Plans to identify the denominator and numerator using claims or encounter data or other administrative databases. For measures collected using the administrative methodology, the denominator includes all eligible members. Eligible members are those who satisfy all criteria specified in the measure including any age and continuous enrollment requirements and who do not meet any of the exclusion criteria. The Plan's rate is based on all members who meet the denominator criteria and who are found through administrative data to have received the service reported in the numerator. The hybrid methodology requires Plans to identify the numerator through both administrative and medical record data. The medical record is the collective accumulation of notes kept by all practitioners who treat a member - it constitutes the official record of patient visits and treatment. For measures collected using the hybrid methodology, the denominator consists of a systematic sample of members drawn from the measure's eligible population. Eligible members are those who satisfy all criteria specified in the measure. The measure's rate is based on members in the sample who are found through either administrative or medical record data to have received the service reported in the numerator. With the exception of the Comprehensive Diabetes Care measure, Plans may not report a measure using the hybrid methodology when the numerator is derived solely from administrative data. In general, each Plan was responsible for collecting data for both the administrative and hybrid measures and reporting that data to CHPR. The only exception is that CHPR contracted with MassPRO, an independent review organization, to collect the hybrid measures for the PCC Plan. Appendix E lists the methodology (administrative or hybrid) used by the Plans for all HEDIS 2004 measures. Continuous Enrollment Some measures specify continuous enrollment, the minimum amount of time a member must be enrolled in the Plan before becoming eligible for the measure. The intent of continuous enrollment is to ensure that the Plan has a sufficient amount of time to render service(s) to its members and be held accountable for providing those services. The continuous enrollment period is specified for each measure along with an allowable gap for that continuous enrollment period. For the majority of measures, a member is considered continuously enrolled if the member was enrolled in the Plan during the measurement year and had no more than one gap in enrollment of up to 45 days during any time from January 1 through December 31, 2003. Caveats for the Interpretation of Results Before reviewing the results, the reader must be cautioned against over-interpretation of the findings. All data analyses have limitations and those presented here are no exception. Comparability of Results Across Plans Measures may not be fully comparable across Plans. HEDIS does not provide for risk adjustment across populations in terms of social risk, existing comorbidities or severity of condition. Thus, statistically significant differences in these measures may reflect differences in the populations served and not in the quality or use of services offered or delivered. Sample Sizes Plan sample sizes vary, thereby affecting the comparability of data between Plans. Large sample sizes lead to more precise estimates and generate narrower confidence intervals. If a sample size is large enough, even a small difference in performance may be statistically significant. However, statistical significance should not be confused with clinical significance. Small sample sizes (less than 30 members) yield less precise performance estimates with wide confidence intervals. Confidence intervals for smaller Plans may be so wide as to prevent comparison between health Plans. Overlapping Provider Networks Many of the providers caring for MassHealth members have contracts with more than one Plan. Other providers will deliver care to MassHealth members in only a single Plan. The presence of overlapping contractual arrangements dilute the ability of any one Plan to substantially influence a provider's behavior. HEDIS rates for any one Plan may not entirely be due to that Plan's activities. Utilization is Not the Same as Quality Some HEDIS measures, especially the Well-Child Visits, Adolescent Well-Care, Children and Adolescents' Access to Primary Care Practitioners, Mental Health and Chemical Dependency Utilization measures, reflect the use of and access to services rather than the technical quality of service delivery. Access to services is necessary but not a sufficient condition for good quality care. Availability of Benchmarks The limited availability of benchmarks for the Medicaid population makes interpretation of these results challenging. A benchmark can be defined as a goal to be achieved. Sometimes a benchmark is set at the highest achievable performance for a Plan; in other situations a benchmark may be defined as the usual or average performance, which is the manner benchmarks will be used in the report. One important source of these benchmarks, as discussed under the Methods section of this report, is the 2004 NCQA Quality Compass. These data allow for the use of national and regional averages for commercial and Medicaid populations as benchmarks. Variation in Data Quality HEDIS data are collected and supplied by the Plans. Although there are standard specifications and definitions for the measures, MassHealth does not monitor the uniformity of the actual systems and methods used to collect the data. Factors that may affect the comparability of individual Plan results from year to year include staffing changes, internal systems changes and use of the HEDIS administrative or hybrid methodology. Although Plans may audit data for their commercial populations to submit to Quality Compass(r) and/or for NCQA accreditation, MassHealth does not require data submitted by Plans to be audited. "What Gets Measured, Gets Improved" Because there are a limited number of standardized measures for evaluating health plan performance, it has been suggested that health plans may concentrate performance improvement efforts in only those areas measured by HEDIS. Therefore, it is important not to extrapolate from the measures contained in this report to more general aspects of overall health plan performance. Unmeasured Aspects of Care Some aspects of the health plan's performance will not be captured directly by these measures. MassHealth conducts members surveys and other activities to complement the data discussed in this report. PCC Plan Enrollment Relative to Other Plan Enrollment Interpretation of the MassHealth Weighted Mean requires careful consideration. Because the PCC Plan has an enrollment of similar size to all MassHealth MCOs combined, it contributes more to the weighted mean (when the administrative data collection methodology is used) than does the performance of other Plans. The MassHealth weighted mean describes care for the average enrollee who is eligible for the measure, but does not necessarily describe the performance of the typical MassHealth Plan. The median value describes 'middle of the road' performance within the MassHealth managed care plans. It is less sensitive to extreme variations within a sample, and is a better measure of 'skewed' populations. Staying Healthy Staying Healthy Statistical Summary This page summarizes the performance of MassHealth Plans on the HEDIS 2004 effectiveness of care measures related to immunization practices. These data include the Childhood Immunization Status and the Adolescent Immunization Status measures. (The original document contain the table) Staying Healthy Childhood Immunization Status Prior to routine immunization, vaccine-preventable disease was a major cause of morbidity and mortality for children in the United States. Routine immunization is a cost-effective means of avoiding many vaccine-preventable diseases such as polio, diphtheria, hepatitis B, influenza, mumps, measles, rubella and chicken pox (1, 2). With every dollar spent on immunization now, $10-$14 are saved by preventing disease in the future (3). Despite advances in immunization coverage and the cost effectiveness of vaccination, immunization levels for children are still below nationally-recognized goals such as the 90% target set forth in Healthy People 2010. Combination 1 This chart shows the percentage of children who received the following immunizations by their second birthday: four DTaP (diphtheria-tetanus-pertussis) or four DT vaccinations; three OPV/IPV (oral or injectable polio) vaccinations; one MMR (measles-mumps-rubella); three HiB (H influenza type B) vaccinations; and three Hepatitis B vaccinations. MassHealth mean 76% Nat'l Mcaid 2004 62% MA Comm 82% Nat'l Comm 74% PCCP 76% NHP 77% NH 71% FCHP 90% BMCHP 75% Combination 2 This chart shows the percentage of children who received all of the immunizations for Combination 1, plus one VZV (chicken pox) vaccination, by their second birthday. MassHealth mean 73% Nat'l Mcaid 2004 58% MA Comm 79% Nat'l Comm 70% PCCP 71% NHP 74% NH 66% FCHP 87% BMCHP 73% Understanding the Results Childhood immunization rates for the MassHealth population continue to improve. In 2003, 76% of enrolled children received the HEDIS Combination 1 immunizations, compared to 73% in 2001. Seventy-three percent (73%) of children received the HEDIS Combination 2 immunizations in 2003, compared to 67% in 2001. MassHealth's 2003 average rates for Combination 1 andCombination 2 are higher than the national Medicaid (62% and 58%) and national Commercial averages (74% and 70%). Despite outperforming the national Medicaid and Commercial benchmarks, MassHealth's 2003 rates are lower than the Massachusetts Commercial averages (82% and 79% for Combination 1 and Combination 2, respectively). Massachusetts Commercial plans typically have some of the highest immunization rates in the country, so these findings are not surprising, but do indicate a potential for improvement. The most pervasive barriers to immunization are those related to poverty (4). Other barriers can be categorized as client-related (e.g., misconceptions about severity of vaccine-preventable disease), provider-related (e.g., missed opportunities during visits) and system-related (e.g., inadequate access) (5). Interventions for increasing immunization rates have been well-studied and include client-based interventions such as reminder/recall systems, patient/family incentives, and patient-held medical records; provider-based interventions such as reminder/recall systems, assessment and feedback, and standing orders; and system interventions such as community education, vaccination programs in WIC settings, and home visits. (Standing orders authorize nurses to administer vaccinations according to an institution-or physician-approved protocol without the need for a physician's direct order.) Staying Healthy Adolescent Immunization Status Although many vaccination programs emphasize childhood immunizations, the booster shots that are administered during adolescence are critical to providing complete coverage against certain vaccine-preventable diseases. Prior to routine vaccination, nearly 4 million people were infected with measles annually and nearly 500 deaths occurred each year (6). Routine immunization and the introduction of the 2-dose MMR (mumps-measles-rubella) vaccination schedule has led to the elimination of measles from the United States and record low incidences of mumps and rubella. Despite the importance of adequate immunization coverage, adolescent immunization rates for the measles-mumps-rubella, Hepatitis B and chicken pox vaccinations fall short of national targets, such as those set by the Centers for Disease Control and Prevention. Combination 1 This chart shows the percentage of enrolled adolescents who received a second dose of MMR (measles-mumps-rubella) and three Hepatitis B vaccinations by their thirteenth birthday MassHealth mean 79% Nat'l Mcaid 2004 52% MA Comm 84% Nat'l Comm 59% PCCP 79% NHP 79% NH 80% FCHP 82% BMCHP 78% Combination 2 This chart shows the percentage of enrolled adolescents who received the Combination 1 immunizations as well as one VZV (chicken pox) vaccination by their thirteenth birthday. MassHealth mean 67% Nat'l Mcaid 2004 34% MA Comm 78% Nat'l Comm 42% PCCP 60% NHP 69% NH 70% FCHP 75% BMCHP 65% Understanding Results Adolescent immunization rates for the MassHealth population have improved dramatically since these data were last collected. In 2003, 79% of adolescents enrolled in MassHealth received the HEDIS Combination 1 immunizations, compared to 64% in 2001. Sixty-seven (67%) of enrolled adolescents received the HEDIS Combination 2 immunizations in 2003, compared to 49% in 2001. Individual plan 2003 rates range from 78% to 82% for Combination 1, with all 5 plans performing better than the national Medicaid and Commercial means. For Combination 2, individual plan 2003 rates range from 60% to 75%, with all 5 plans performing better than the national Medicaid and Commercial means. Although MassHealth outperformed the national Medicaid and Commercial means (52% and 59% for Combination 1 and 34% and 42% for Combination 2), its 2003 average rates are much lower than those for Massachusetts Commercial plans (84% for Combination 1 and 78% for Combination 2). This is not surprising considering that the New England region continues to report the highest Commercial HEDIS rates for adolescent immunization in the country. In general, adolescents utilize the health care system to a far lesser extent than children or adults. Because adolescents have fewer contacts with the health care system, providing routine primary care, including immunizations, to adolescents is a challenge. Successful interventions to improve adolescent coverage take into account the unique needs of adolescent patients. Staying Healthy Measure and Benchmark Details Childhood Immunization Status (The original document contain the table) Staying Healthy Measure and Benchmark Details Adolescent Immunization Status (The original document contain the table) Staying Healthy Statistical Summary This page summarizes the performance of MassHealth Plans on the HEDIS 2004 use of service and access measures related to well-child visits and adolescent well-care.(The original document contain the table) Staying Healthy Well-Child Visits Well-child visits-routine visits with a primary care practitioner according to the recommended schedule-are a critical component to reducing mortality and morbidity in the early years of a child's life. Well-child visits create the opportunity to detect health care problems early, when intervention can have its greatest impact. These visits also provide the opportunity to monitor developmental stages, provide health education and injury prevention guidance, and administer vaccines. Despite the importance of routine well-child care and the removal of financial barriers, studies have shown Medicaid-enrolled children use fewer preventive services and more emergency services, and have higher hospitalization rates as compared to Commercially-enrolled children (7, 8, 9). Well-Child Visits in First 15 Months of Life (6 or more visits) This chart shows the percentage of members who turned 15 months old during the measurement year and who received six or more well-child visits with a primary care practitioner during the first 15 months of life. MassHealth mean 68% Nat'l Mcaid 2003 45% MA Comm 84% Nat'l Comm 67% PCCP 62% NHP 77% NH 85% FCHP 41% BMCHP 69% Well-Child Visits in Third, Fourth, Fifth, and Sixth Years of Liffe This chart shows the percentage of members who were three, four, five or six years of age during the measurement year and who received one or more well-child visits with a primary care practitioner. MassHealth mean 81% Nat'l Mcaid 2003 61% MA Comm 86% Nat'l Comm 63% PCCP 77% NHP 81% NH 90% FCHP 94% BMCHP 83% Understanding the Results Approximately 68% of children enrolled in MassHealth had six or more visits with a primary care practitioner by the age of 15 months, compared to 62% the last time these data were collected. Individual plan rates ranged from 41% to 85%. Four of the five plans performed statistically better than the national Medicaid average (45%) and two of the five plans statistically outperformed the national Commercial rate (67%). Approximately 81% of children ages three, four, five or six had at least one well-child visit with a primary care practitioner in 2003, compared to 75% in 2001. All MassHealth plans performed better than the national Medicaid and national Commercial averages (61% and 63%), but only two performed better than the Massachusetts' commercial rate (86%). Factors associated with inadequate well-child care include lower maternal education level, poverty, unmarried marital status, maternal age younger than 20 years and higher birth order for the infant (10). In addition, African American race, Hispanic ethnicity and inadequate prenatal care are also factors associated with incomplete well-child care (11). An ongoing relationship with a family physician prior to and during pregnancy or establishing a relationship with a pediatrician during the prenatal period may promote adequate well-child care (12). It should be noted that the well-child measures assess only whether a member had a visit during the measurement year and, like the adolescent well-care measures, do not provide any information on the quality or the content of the visits. Staying Healthy Adolescent Well-Care Visits The importance of routine, comprehensive well-care visits for the adolescent population cannot be overstated. Well-care visits during adolescence provide critical opportunities for physicians to screen and counsel patients on a number of causes of adolescent morbidity and mortality such as alcohol use, sexual activity, depression, suicide, smoking and violence (13). This screening and counseling is important since many of the health-related behaviors developed during adolescence influence a patient's health for many years(14). Despite the importance of these visits, many adolescents do not have regular visits to a primary care practitioner and make relatively little use of health services in general. Adolescent Well-Care Visits This chart shows the percentage of members 12-21 years of age who had at least one comprehensive well-care visit with a primary care practitioner or an OB/GYN practitioner during 2003. MassHealth mean 59% Nat'l Mcaid 2004 37% MA Comm 61% Nat'l Comm 37% PCCP 55% NHP 57% NH 71% FCHP 53% BMCHP 70% Understanding the Results Approximately 59% of adolescent MassHealth members 12-21 years of age had a well-care visit with a primary care practitioner or OB/GYN in 2003, compared to 51% in 2001. This rate is well above the national Medicaid and Commercial averages, both 37%, and slightly below the Massachusetts Commercial average of 61%. Individual plan rates ranged from 53% to 71%. Interventions that may increase adolescent well-care visits include assuring private and confidential visits and reducing the number of inconvenient service sites. Because adolescents use the health care system infrequently, designing effective interventions to increase the number of adolescents who receive a well-care visit is a challenge. It should be noted that the adolescent well-care measure assesses only whether a member had a visit during the measurement year and, like the well-child visit measures, does not provide any information on the quality or the content of the visits. The quality of well-care provided to adolescents and children is an area that may warrant future consideration. For example, one study found that adolescents who had a HEDIS defined well-care visit were not more likely to have received counseling and screening for risky behaviors, sexual activity and sexually transmitted diseases, or emotional health and relationship issues and were less likely than adolescents with any other type of visit to have been counseled or screened for diet, weight and exercise, or have access to a private and confidential visit (15). Staying Healthy Measure and Benchmark Details Well-Care Visits Well-Child Visits in the First 15 Months of Life ( 6+ Visits) Benchmark 2004(The original document contain the table) Well-Child Visits in the Third, Fourth, Fifth and Sixth Years of Life Benchmark 2004(The original document contain the table) Adolescent Well-Care Visits Benchmark 2004(The original document contain the table) Staying Healthy Statistical Summary This page summarizes the performance of MassHealth Plans on the HEDIS 2004 access measures related to children and adolescent's access to primary care practitioners. (The original document contain the table) Staying Healthy Children and Adolescents' Access to Primary Care Practitioners Nationally, publicly-insured children and adolescents living in urban areas face limited access to primary care (16). Problems with access to primary care can lead to higher utilization of acute settings for primary care services, a costly and ineffective alternative to routine access to primary care providers. Age 12-24 months This chart shows the percentage of enrolled members 12-24 months of age who had at least one ambulatory care or preventive care visit with a primary care practitioner in 2003. MassHealth mean 95% Nat'l Mcaid 2004 92% MA Comm 98% Nat'l Comm 96% PCCP 97% NHP 97% NH 90% FCHP 98% BMCHP 93% Ages 25 months - 6 years This chart shows the percentage of enrolled members 25 months-6 years of age who had at least one ambulatory care or preventive care visit with a primary care practitioner in 2003. MassHealth mean 92% Nat'l Mcaid 2004 82% MA Comm 95% Nat'l Comm 88% PCCP 93% NHP 92% NH 89% FCHP 95% BMCHP 90% Ages 7-11 years This chart shows the percentage of enrolled members 7-11 years of age who had at least one ambulatory care or preventive care visit with a primary care practitioner in 2003 or 2002. MassHealth mean 96% Nat'l Mcaid 2004 82% MA Comm 96% Nat'l Comm 89% PCCP 97% NHP 95% NH 95% FCHP 98% BMCHP 95% Staying Healthy Children and Adolescents' Access to Primary Care Practitioners Ages 12-19 years This chart shows the percentage of enrolled members 12-19 years of age who had at least one ambulatory care or preventive care visit with a primary care practitioner in 2003 or 2002. This age band is a first-year measure. Because of the measure's first-year status, there are no national or Massachusetts benchmarks MassHealth mean 94% Nat'l Mcaid 2004 MA Comm Nat'l Comm PCCP 95% NHP 92% NH 92% FCHP 94% BMCHP 93% Understanding Results MassHealth rates for access to primary care practitioners for children aged 12 months to 11 years have improved since last measured. In many cases, individual plan 2003 rates exceeded national Medicaid, national Commercial and Massachusetts Commercial averages. (Note that there are no 2004 Quality Compass benchmarks for children ages 12-19 because this rate was a first-year measure. This measure was also not included in the 2004 State of Health Care Quality Report.) Children 7-11 years of age had the highest rate of visits to a primary care practitioner, with 96% of these children receiving a visit in 2002 or 2003. The rate of visits in 2003 for children 12-24 months of age was also high (95%), followed by adolescents ages 12-19 (94%), and children ages 25 months to 6 years (92%). Barriers to routine primary care include lack of a regular source of care and lack of transportation. To maintain and increase children and adolescents' access to primary care providers, health plans should assess whether these or other issues are barriers to care for their population and develop and implement interventions to address these obstacles. Staying Healthy Measure and Benchmark Details Children's Access to Primary Care Providers (The original document contain the table) Living with Illness Statistical Summary This page summarizes the performance of MassHealth Plans on the HEDIS 2004 effectiveness of care measures related to diabetes care. (The original document contain the table) Living with Illness Statistical Summary This page summarizes the performance of MassHealth Plans on the HEDIS 2004 effectiveness of care measures related to diabetes care. (The original document contain the table) Living with Illness Comprehensive Diabetes Care According to the American Diabetes Association, diabetes affects 18.2 million people in the United States, or 6.3% of the population. Diabetes and its complications exact an enormous economic toll; according to a 2002 analysis, $132 billion in direct and indirect medical expenditures can be attributed to diabetes (17). Uncontrolled diabetes can lead to significant morbidity, including visual impairment, blindness, kidney disease and failure, cardiovascular disease and lower-extremity amputations. Routine monitoring of hemoglobin A1c, LDL cholesterol and microalbumin levels as well as annual eye exams, can prevent complications from diabetes and are critical components to any diabetes management plan. HbA1c Testing This chart shows the percentage of members 18-64 years of age with diabetes who had a hemoglobin A1c (HbA1c) test during the measurement year. MassHealth mean 87% Nat'l Mcaid 2004 75% MA Comm 89% Nat'l Comm 85% PCCP 87% NHP 87% NH 89% FCHP 88% BMCHP 87% Poor HbA1c Control This chart shows the percentage of members 18-64 years of age with diabetes who had a hemoglobin A1c (HbA1c) test during the measurement year and whose HbA1c was poorly controlled (>9.0%). MassHealth mean 46% Nat'l Mcaid 2004 49% MA Comm 29% Nat'l Comm 32% PCCP 47% NHP 42% NH 51% FCHP 34% BMCHP 37% Understanding the Results Approximately 87% of MassHealth members with diabetes received at least one HbA1c screening in 2003, compared to 82% in 2001. All five MassHealth plans performing significantly better than the national Medicaid average and one plan performing significantly better than the national Commercial average. MassHealth plans were not different statistically from the Commercial average for all Massachusetts plans (89%). All five of the plans performed very well and individual plan rates ranged from 87% to 89%; there was little variation among the plans. Approximately 46% of MassHealth members with diabetes had poor HbA1c control. (Keep in mind that for this rate, higher values indicate poorer performance). Individual plan rates ranged from 34% to 51%. Three of the five plans performed statistically better than the national Medicaid average of 49%. None of the plans performed statistically better than the national and Massachusetts Commercial averages (32% and 29%, respectively). Comparisons can not be made to the 2002 MassHealth average of 53% because the measure's criteria has changed (poor control was defined as HbA1c greater than 9.5% in 2002). Living with Illness Comprehensive Diabetes Care Eye Exams This chart shows the percentage of members 18-64 years of age with diabetes who had a retinal eye exam. MassHealth mean 51% Nat'l Mcaid 2004 45% MA Comm 61% Nat'l Comm 49% PCCP 51% NHP 52% NH 51% FCHP 58% BMCHP 51% Monitoring Nephropathy This chart shows the percentage of members 18-64 years of age with diabetes who were monitored for diabetic nephropathy (kidney disease). MassHealth mean 53% Nat'l Mcaid 2004 44% MA Comm 58% Nat'l Comm 48% PCCP 52% NHP 57% NH 49% FCHP 61% BMCHP 59% Understanding the results Fewer MassHealth members with diabetes received a dilated retinal eye exam in 2003 (51%) than in 2001 (60%), although this decline was statistically significant for only one plan. Despite the decline, all five plans performed better than the national Medicaid average (45%) and one performed better than the national Commercial average (49%). One possible explanation for the decline in eye exam rates from the last measurement is the specification change for HEDIS 2004 that required a more stringent criterion for counting eye exams in the year prior to the measurement year. Approximately 53% of MassHealth members with diabetes were monitored for diabetic nephropathy in 2003, compared to 43% in 2001. Individual plan rates ranged from 49% to 61%. All five plans performed statistically better than the national Medicaid average (44%) and one plan performed statistically better than the national Commercial average (48%). Living with Illness Comprehensive Diabetes Care LDL-C Screening This chart shows the percentage of members 18-64 years of age with diabetes who had an LDL screening in the measurement year or the year prior. MassHealth mean 87% Nat'l Mcaid 2004 76% MA Comm 91% Nat'l Comm 88% PCCP 89% NHP 82% NH 85% FCHP 88% BMCHP 82% LDL-C Level (<130 mg/dL) This chart shows the percentage of members 18-64 years of age with diabetes who had an LDL screening performed in the measurement year or the year prior and who had an LDL level <130 mg/dL. MassHealth mean 45% Nat'l Mcaid 2004 48% MA Comm 60% Nat'l Comm 60% PCCP 44% NHP 50% NH 41% FCHP 57% BMCHP 50% LCL-C Level (<100 mg/dL) This chart shows the percentage of members 18-64 years of age with diabetes who had an LDL screening performed and who had an LDL level <100 mg/dL. This measure is new for HEDIS 2004 and there are no national Medicaid, national Commercial or Massachusetts Commercial benchmarks available. MassHealth mean 28% Nat'l Mcaid 2004 MA Comm Nat'l Comm PCCP 28% NHP 28% NH 23% FCHP 24% BMCHP 30% Understanding the Results Approximately 87% of MassHealth members with diabetes received a LDL screening in 2003 or 2002, compared to 74% in 2001. Individual plan rates ranged from 82% to 89%. Forty-five percent (45%) of MassHealth members with diabetes had their LDL cholesterol controlled to <130 mg/dL and only 28% had their LDL cholesterol controlled according to the new guidelines (<100 mg/dL). One plan performed better than the national Medicaid average (48%) for the LDL<130 mg/dL measure. None of the plans performed betterthan the national or Massachusetts Commercial averages for the LDL <130 mg/dL measure (60% each). Although the 2003 MassHealth rate did not meet or exceed most national rates or any Massachusetts Commercial rates, it does represent an improvement from the 2001 rate of 33%. (Because the LDL<100 mg/dL rate is a first-year measure, NCQA did not include any benchmarks in Quality Compass. However, NCQA did provide a national Medicaid rate for this measure in its 2004 State of Health Care Quality Report (28%). This rate was based on 2004 Medicaid HEDIS submissions available to NCQA at the time of the report's release.) Patient-related barriers to good diabetes care include non-compliance with treatment, denial and the willingness to live with mild symptoms without treatment. Interventions to address these barriers can include efforts to increase patients' knowledge of diabetes, change lifestyle behaviors and teach coping skills. Provider-related barriers to good diabetes care include lack of awareness of current clinical guidelines; lack of computerized tracking and reminder systems; and inadequate means of identifying high-risk patients. Interventions to address these barriers include increased access to clinical information and decision support systems. Living with Illness Measure and Benchmark Details Comprehensive Diabetes Care HbA1C Testing Benchmarks 2004(The original document contain the table) Poor HbA1c Control Benchmarks 2004(The original document contain the table) Eye Exams Benchmarks 2004(The original document contain the table) Living with Illness Measure and Benchmark Details Comprehensive Diabetes Care Monitoring Nephropathy Benchmarks 2004(The original document contain the table) LDL-C Screening Benchmarks 2004(The original document contain the table) LDL-C Level(<130 mg/dL)Screening Benchmarks 2004(The original document contain the table) Living with Illness Measure and Benchmark Details Comprehensive Diabetes Care LDL-C Level(<100 mg/dL) Benchmarks 2004(The original document contain the table) Living with Illness Statistical Summary This page summarizes the performance of MassHealth Plans on the HEDIS 2004 effectiveness of care measures related to the management of asthma with appropriate medications. (The original document contain the table) Living with Illness Use of Appropriate Medications for People with Asthma As one of the most common chronic conditions in the United States, asthma affects nearly 15 million people, including 5 million children (18). Because asthma disproportionatelyaffects the poor, measuring the use of appropriate asthma medications is an important indicator of the quality of care provided to Medicaid members. Inhaled corticosteroids, leukotriene modifiers and nedocromil (inhaled non-steroidal anti-inflammatory medication) are the acceptable therapies for asthma, although inhaled corticosteroids are the preferred therapy for long-term asthma control. Appropriate use of these therapies can prevent exacerbations that can lead to hospitalizations (19) and emergency department visits (20). In fact, high performance on the asthma HEDIS measure has been found to be associated with the reduced risk of subsequent ER visits (21). Despite this, many children and adults with asthma do not receive adequate therapy. Medicaid-insured children and poor children living in urban areas are at particularly high risk for inadequate asthma care (22, 23). Ages 5-9 This chart shows the percentage of members ages 5-9 with persistent asthma who were appropriately prescribed medication during the measurement year. MassHealth mean 69% Nat'l Mcaid 2004 62% MA Comm 78% Nat'l Comm 72% PCCP 69% NHP 68% NH 70% FCHP BMCHP 66% Ages 10-17 This chart shows the percentage of members ages 10-17 with persistent asthma who were appropriately prescribed medication during the measurement year. MassHealth mean 66% Nat'l Mcaid 2004 62% MA Comm 72% Nat'l Comm 68% PCCP 65% NHP 69% NH 62% FCHP 65% BMCHP 66% Ages 18-56 This chart shows the percentage of members ages 18-56 with persistent asthma who were appropriately prescribed medication during the measurement year. MassHealth mean 62% Nat'l Mcaid 2004 62% MA Comm 73% Nat'l Comm 72% PCCP 61% NHP 66% NH 63% FCHP 45% BMCHP 68% Living with Illness Use of Appropriate Medications for People with Asthma Combined Ages This chart shows the percentage of members ages 5-56 with persistent asthma who were appropriately prescribed medication during the measurement year. MassHealth mean 64% Nat'l Mcaid 2004 64% MA Comm 73% Nat'l Comm 71% PCCP 63% NHP 68% NH 65% FCHP 49% BMCHP 67% Understanding the Results Approximately 64% of MassHealth members ages 5-56 with persistent asthma were appropriately prescribed medication in 2003, compared to 59% in 2000. In fact, the 2003 MassHealth average was better than the average from 2000 for every age stratification. In 2003, 69% of members aged 5-9 were appropriately prescribed medications, compared to 56% in 2000. Also in 2003, 66% of members aged 10-17 and 62% aged 18-56 were appropriately prescribed medications, compared to 56% and 61% in 2000. Two plans performed statistically better than the 2003 national Medicaid average for 5-56 year olds (64%) and two performed statistically worse. None of the plans performed statistically better than the 2003 national or Massachusetts Commercial averages (71% and 73%, respectively). Although MassHealth plans did not perform better than the national and Massachusetts Commercial averages, rates for children and adolescents (ages 5-9 and 10-17) are statistically no different from Commercial benchmarks for several plans. There are several known barriers to appropriate medication use for patients with asthma. Employment status, income and education level are all factors that been shown to impact anti-inflammatory use. Other factors that are more actionable for health plans include lack of regular scheduled visits and ongoing communication with a provider; lack of patient awareness of symptoms and ability to accurately describe the frequency, severity and duration of symptoms; and parental expectations and perceptions that asthma is uncontrollable. In addition, access to specialists may also serve as a barrier. Some research has suggested that primary care physicians provide less adequate asthma care than asthma specialists (24, 25). Living With Illness Measure and Benchmark Details Use of Appropriate Medications for People with Asthma (The original document contain the tables) Behavioral Health Care Mental Health Services These data measure both access to care (members with at least one service) and utilization of mental health services (discharges per 1000 members). Substance abuse services are not included in this measure; substance abuse services are reported in the Chemical Dependency Services measure. The National Medicaid average rate for each measure appears below; average utilization rates for National and Massachusetts Commercial Plans appear on page esiii. Numerous epidemiological studies have documented that vulnerable populations are at particular risk for mental health or chemical dependency issues. When utilization of inpatient mental health services is carefully managed through concurrent review that is based upon the criteria for medical necessity, the average number of days a member remains in the hospital will be minimized. Clinically appropriate utilization of mental health day/night services are a transitional resource for some members leaving the inpatient setting and for other members are a service that will be used in lieu of an unnecessary mental health hospitalization. Use of Services This table (The original document contain the tables) displays the number (N) and percentage of members who received Mental Health services during the measurement year. Mental Health services are broken down by Inpatient, Day/Night, Ambulatory, and then Any Service. Note that the denominator used to calculate these percentages is member years (i.e., member months divided by 12). All MassHealth members (Basic and non-Basic) are represented in this chart. (The original document contain the tables) Inpatient Discharges and Average Length of Stay This table shows the number of inpatient discharges associated with the use of Mental Health services, and the average length of stay (ALOS) for those admissions. All MassHealth members (Basic and non-Basic) are represented in this chart. (The original document contain the tables) Behavioral Health Care Chemical Dependency Services These data measure both access to care (members with at least one service) and utilization of chemical dependency services (discharges per 1000 members). The National Medicaid average rate for each measure appears below; average utilization rates for National and Massachusetts Commercial Plans appear on page esiii. Numerous epidemiological studies have documented that vulnerable populations are at particular risk for mental health or chemical dependency issues. When utilization of inpatient chemical dependency services is carefully managed through concurrent review that is based upon the criteria for medical necessity, the average number of days a member remains in the hospital will be minimized. Clinically appropriate utilization of chemical dependency day/night services are a transitional resource for some members leaving the inpatient setting and for other members are a service that will be used in lieu of an unnecessary hospitalization. Use of Services This table displays the number (N) and percentage of members who received Chemical Dependency services during the measurement year. Chemical Dependency services are broken down by Inpatient, Day/Night, Ambulatory, and then Any Service. Note that the denominator used to calculate these percentages is member years (i.e., member months divided by 12). All MassHealth members (Basic and non-Basic) are represented in this table. (The original document contain the tables) Inpatient Discharges and Average Length of Stay This table displays the number of inpatient discharges associated with the use of Chemical Dependency services, and the average length of stay (ALOS) for those admissions. All MassHealth members (Basic and non-Basic) are represented in this table. (The original document contain the tables) APPENDIX A: ANTIGEN-SPECIFIC IMMUNIZATION RATES Staying Healthy Childhood and Adolescent Immunization CIS Childhood Immunization Status Combo 1, Combo 2, and DTP. (The original document contain the tables) Staying Healthy Childhood and Adolescent Immunization CIS Childhood Immunization Status HBV, HIB, and IPV (The original document contain the tables) Staying Healthy Childhood and Adolescent Immunization CIS Childhood Immunization Status MMR and VZV AIS Adolescent Immunization Status Combo 1 (The original document contain the tables) Staying Healthy Childhood and Adolescent Immunization AIS Adolescent Immunization Status Combo 2, HBV, and MMR (The original document contain the tables) Staying Healthy Childhood and Adolescent Immunization AIS Adolescent Immunization Status VZV (The original document contain the tables) APPENDIX B: MENTAL HEALTH SERVICE UTILIZATION: BASIC AND NON-BASIC POPULATIONS Behavioral Health care Mental Health Services Basic Ages 18-64: Female, Male, and Total (The original document contain the tables) Use of Services and Inpatient Discharges and ALOS Behavioral Health care Mental Health Services Basic Ages Total: Female, Male, and Total (The original document contain the tables) Use of Services and Inpatient Discharges and ALOS Behavioral Health care Mental Health Services Non-Basic Ages 0-12: Female, Male, and Total (The original document contain the tables) Use of Services and Inpatient Discharges and ALOS Behavioral Health care Mental Health Services Non-Basic Ages 13-17: Female, Male, and Total (The original document contain the tables) Use of Services and Inpatient Discharges and ALOS Behavioral Health care Mental Health Services Non-Basic Ages 18-64: Female, Male, and Total (The original document contain the tables) Use of Services and Inpatient Discharges and ALOS Behavioral Health care Mental Health Services Non-Basic Ages Total: Female, Male, and Total (The original document contain the tables) Use of Services and Inpatient Discharges and ALOS APPENDIX C: CHEMICAL DEPENDENCY SERVICE UTILIZATION: BASIC AND NON-BASIC POPULATIONS Behavioral Health care Chemical Dependency Services Basic Ages 18-64: Female, Male, and Total (The original document contain the tables) Use of Services and Inpatient Discharges and ALOS Behavioral Health care Chemical Dependency Services Basic Ages total: Female, Male, and Total (The original document contain the tables) Use of Services and Inpatient Discharges and ALOS Behavioral Health care Chemical Dependency Services Non-Basic Ages 0-12: Female, Male, and Total (The original document contain the tables) Use of Services and Inpatient Discharges and ALOS Behavioral Health care Chemical Dependency Services Non-Basic Ages 13-17: Female, Male, and Total (The original document contain the tables) Use of Services and Inpatient Discharges and ALOS Behavioral Health care Chemical Dependency Services Non-Basic Ages 18-64: Female, Male, and Total (The original document contain the tables) Use of Services and Inpatient Discharges and ALOS Behavioral Health care Chemical Dependency Services Non-Basic Ages total: Female, Male, and Total (The original document contain the tables) Use of Services and Inpatient Discharges and ALOS APPENDIX D: SUMMARY OF MASSHEALTH PERFORMANCE (The original document contain the tables) APPENDIX E: DATA COLLECTION METHODOLOGY TABLE (The original document contain the tables) References 1) Gardner P, Pickering L, Orenstein W, Gershon A and Nichol K. (2002). "Guidelines for Quality Standards for Immunizations." Clinical Infectious Diseases September 35: 503-11. 2) Ekwueme D, Strebel P, Hadler S, Meltzer M, Allen J and Livengood J. (2000). "Economic Evaluation of Use of Diptheria, Tetanus, and Acellular Pertussis Vaccine or Diptheria, Tetanus, and Whole-Cell Pertussis Vaccine in the United States, 1997" Archives of Pediatrics and Adolescent Medicine August 154(8): 797-803. 3) White C, Koplan J and Orenstein W. (1985). "Benefits, risks and costs of immunization for measles, mumps and rubella." American Journal of Public Health July 75(7): 739-44. 4) Santoli J, Huet N, Smith P, Barker L, Rodewald L, Inkelas M, Olson L and Halfon N. (2004). "Insurance Status and Vaccination Coverage Among US Preschool Children." Pediatrics June 113(6): 1959-64. 5) US Department of Health and Human Services. (1999). "Vaccine-Preventable Diseases: Improving Vaccination Coverage in Children, Adolescents, and Adults." Morbidity and Mortality Weekly Report June 48 (RR-8). 6) Redd SC, Markowitz LE and Katz SL. Measles vaccine. In: Plotkin SA, Orenstein WA, eds. Vaccines. Philadelphia: WB Saunders, 1999:222-66. 7) Newacheck P, Hughes D, Stoddard J. (1996). "Children's access to primary care: differences by race, income, and insurance status." Pediatrics January 97(1):26-32 8) Halfon N, Newacheck P, Wood D, and St. Peter R. (1996). "Routine emergency departmet use for sick care by children in the United States." Pediatrics July 98(1): 28-34. 9) Weissman J, Gatsonis C and Epstein A. (1992). "Rates of avoidable hospitalization by insurance status in Massachusetts and Maryland." JAMA November 268(17): 2388-94. 10) Hakim R and Bye B. (2001). "Effectiveness of Compliance with Pediatric Preventive Care Guidelines Among Medicaid Beneficiaries." Pediatrics July 108(1): 90-97. 11) Ronsaville D and Hakim R. "Well Child Care in the United States: Racial Difference in Compliance with Guidelines." (2000). American Journal of Public Health September 90(9): 1436-43. 12) Grossman L and Humbert A. (1996). "Continuity of Care Between Obstetrical and Pediatric Preventive Care: Indicators of Non Attendance at the First Well-Child Appointment." Clinical Pediatrics November 35(11): 563-70. 13) Bethell C, Klein J and Peck C. "Assessing Health System Provision of Adolescent Preventive Services: The Young Adult Health Care Survey." Medical Care 39(5): 478-90. 14) Muscari M. (1999). "Prevention: are we really reaching today's teens?" American Journal of Maternal Child Nursing 24(2): 87-91. 15) Bethell C, Klein J and Peck C. "Assessing Health System Provision of Adolescent Preventive Services: The Young Adult Health Care Survey." Medical Care 39(5): 478-90. 16) Medicaid Access Study Group. (1994). "Access of Medicaid Recipients to Outpatient Care." New England Journal of Medicine May 330(20): 1426-30. 17) American Diabetes Association. (2002). "National Diabetes Fact Sheet." www.diabetes.org. 18) National Heart, Lung, and Blood Institute. "National Heart, Lung, and Blood Disease and Conditions Index." www.nhlbi.nih.gov. 19) Donahue J, Weiss S, Livingston J, Goetsch M, Greineder D and Platt R. (1997). "Inhaled Steriods and the Risk of Hospitalization for Asthma." JAMA March 277(11): 887-91. 20) Halterman J, Aligne A, Auinger P, McBride and Szilagyi P. (2000). "Inadequate Therapy for Asthma Among Children in the United States." Pediatrics January 105(1): 272-6. 21) Fuhlbrigge A, Carey V, Adams R, Finklestein J, Lozano P, Weiss, S and Weiss K. (2004). "Evaluation of Asthma Prescription Measures and Health System Performance Based on Emergency Department Utilization." Medical Care May 42(5): 465-71. 22) Halterman J, Aligne A, Auinger P, McBride and Szilagyi P. (2000). "Inadequate Therapy for Asthma Among Children in the United States." Pediatrics January 105(1): 272-6. 23) Eggleston P, Malveaux F, Butz A, Huss K, Thompson L, Kolodner and Rand C. (1998). "Medications Used by Children with Asthma Living in the Inner City. Pediatrics March 101(3): 349-54. 24) Legoretta A, Christian-Herman J, O'Connor R, Hasan M, Evans R and Leung K. (1998). "Compliance with National Asthma Management Guidelines and Specialty Care: A Health Maintenance Organization Experience." Archives of Internal Medicine March 158(5): 457-64. 25) Zoratti E, Havstad S, Rodriguez J, Robens-Paradise Y, Lafata J and McCarthy B.(1988). "Health Service Use by African Americans and Caucasians with Asthma in a Managed Care Setting." American Journal of Respiratory and Critical Care Medicine 158:371-7. Hedis 2004