Amerigroup Community Care of Georgia (AGP GA) C-Section Focus Study 1 William Alexander, M.D. Chief Medical Officer July 2, 2012

AGP GA C-Section Focus Study Contractually required by the Georgia Department of Community Health AGP 2011 rate % DCH C-section 2011 goal- 31% Primary study question-What factors drive the CMO’s C- section rate trends? Study indicator-AHRQ C-section rate 2

AGP GA C-Section Focus Study Day of the Week The majority of deliveries take place from Monday to Thursday ( % %, %). The highest C section rate was Friday in 2009 and 2011 and Monday in 2010 The rate differences support the relationship between physician scheduling and member convenience and the lower overall number of deliveries and C-sections on weekend days. 3

AGP GA C-Section Focus Study Month of the Year C-section rates were highest for June, July and December in 2009, May, August and October in 2010 and February, June and August While there is some variation there does seem to some evidence that C-sections are more likely scheduled during the summer months however no real statistical significance was found between months for We also analyzed the percentage of deliveries for the year by month and did not find a direct correlation between an increased number of deliveries and higher C-section rates. 4

AGP GA C-Section Focus Study Region and County The Southeast region has a statistically higher rate than Atlanta and the North (p value ≤0.0001). No differences were found between regional rates for Atlanta Metro and the North region. As Amerigroup served only 4 regions in 2011 comparisons to the Central and Southwest region were not available. Analysis of differences for rural counties vs. urban counties was conducted. Urban counties had a lower rate than rural counties. This difference was found to be very statistically significant (p value < ) AMERIGROUP used DCH’s categorization of rural and urban counties for this analysis. 5

AGP GA C-Section Focus Study Member C-section rates varied across different age groups. Of all the age groups only members aged had a C-section rate less than state target. Members aged were just above state target at 31.9%. All other age group exceeded the DCH goal. These variations in age were found to be statistically significant. Analysis was also conducted by member’s language and no statistically significant differences were found between mothers that spoke primarily English vs. Spanish. Ethnicity yielded statistically significant differences in Hispanics vs. Blacks and Caucasians with Hispanic moms having lower C-Section rates. These differences may not be meaningful as members who identified themselves as Hispanic was very low. Blacks and Caucasians had the highest number of deliveries and both had rates over the state target (Blacks 35.1%, Caucasians 33.5%). 6

AGP GA C-Section Focus Study Member It appears that age is likely the biggest driver of C-sections, as older moms were more likely to receive a C-section than younger mothers with the exception of the youngest age group. AMERIGROUP reviewed claims data from 2011 to review diagnosis codes submitted with a cesarean procedure code. The most frequent diagnosis was previous C-section (93.4%) which is in line with March of Dimes state data. The low rate of VBAC’s in Georgia correlates to the high repeat C- Section rate. Interventions to encourage VBAC’s or to decrease C-section rates for younger mothers may help to facilitate decreasing the C-section rate. 7

AGP GA C-Section Focus Study 2011 Top Diagnoses Previous C Section Delivery with or without mention of Ante partum Condition (93.6%) Abnormal fetal heart rate (56.5%) Transient Hypertension of pregnancy with delivery (22.8%) Early onset delivery without mention of Ante partum Condition (21.6%) Post term pregnancy delivery with or without mention of Ante partum condition (20.3%) 8

AGP GA C-Section Focus Study Nulliparous vs. Multiparous Data on parity is not included in claims data and therefore not reliable in drawing inferences for purposes of this study. In other states, birth record data from vital statistics is used to obtain this information. The health plan did however review VBAC rates and cesarean section after vaginal try with a previous cesarean using professional claims associated with the hospital claim. For the 2011 population pulled for the AHRQ measure only 3% of deliveries for Amerigroup were coded as VBAC’s and only 1.3% was coded as cesarean sections after vaginal try with a previous cesarean. 9

AGP GA C-Section Focus Study Hospital Hospital performance varied widely. Rates of hospitals that contained at least 3.8% of the C-sections ranged from a low 25.6% at Athens Regional to 40.9% at Candler Hospital. The rates were not only varied but statistically different from hospital to hospital (P value.0001 from Athens to Candler). 10

AGP GA C-Section Focus Study Delivering Provider Of the providers with more than 30 deliveries, 22 obstetricians had C-section rates over 32%. This represents 20.9% of all high volume obstetricians. (22 of 109) There was no correlation found between number of deliveries and C-Section rates. We also looked at providers who were part of a group practice vs. solo providers. The difference was not found to be statistically significant ( p value ) however within the group of providers not affiliated with a group practice the C- section rate ranged dramatically from 7.3%-63.8%. 11

AGP GA C-Section Focus Study The results of our Focus Study clearly support the need for the GHA’ HEN EED Adverse Events Learning Collaborative and the Georgia Obstetrical and Gynecological Society’s proactive efforts earlier in the year to decrease elective cesareans and inductions prior to 39 weeks. 12

Questions? questions 13