Minnesota Title V MCH Needs Assessment Fact Sheets

Children and Adolescents

Access to Health Care, Well Child Care, Immunizations and Dental Care

November 2004

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Size of the Problem

Children and adolescents are Minnesota’s greatest resource. Assuring optimal health for all children, adolescents and their families through quality, comprehensive, well-child health care is a major goal for those interested in maintaining and improving the public’s health. According to the 2000 Census, almost 30% of Minnesota’s population is 19 years or younger. Minnesota 2000 census data reports 1,218,894 children 1 to 17 years old, and 284,191 youth aged18 to 21 years.

Approximately 68,000 children in Minnesota are uninsured [1].

Eighteen to 24 year olds have the highest uninsured rates of any age group at a rate of 21 percent [2].

National data indicate that more than one quarter of US children (< 18 years) do not receive the American Academy of Pediatrics-recommended visits for well-child care, and this outcome is associated with poor health status [3]. In addition, only 18% of US children receive all recommended immunizations without delay in the first 2 years of life [4].

In 2004, there are about 3,000 active practicing dentists in MN and only about 30 are in the specialty practice of pediatric dentistry [5].

Approximately 21,775 children under 18 years old received some type of mental health service through public dollars (county and state) in Minnesota in 1999. It is estimated that these services reached approximately 30% of the total number of children with emotional disturbance in Minnesota [6].

Seriousness

Access issues such as lack of insurance, discontinuous insurance coverage, lack of providers, and the structure of delivery systems become barriers to receiving health care services.

A recent Minnesota survey of parents showed that while the majority of children in Minnesota had health insurance coverage (95.5%) and dental coverage (79%) in 2002, there are significant variations by race and income.

  • Black children in Minnesota are about 2.5 times more likely to be uninsured than children overall, and Hispanic children are nearly four times more likely to be uninsured [7].
  • In Minnesota children with family incomes below 200% of poverty have uninsurance rates that are about three times higher than the rate for all children [8].
  • Younger children were more likely to have health insurance coverage than older children [9].
  • Nationally, when compared with other children, Hispanic/Latino children were most likely to have unmet needs and least likely to have a usual place of health care [10].

For each child without medical insurance, there are almost three children without dental insurance [11].

More than eight in 10 uninsured Americans come from working families. Nearly 70% of the uninsured are in families with one or more full-time workers [12].

Uninsured children are at risk for health problems. Uninsured children are less likely to receive proper medical care for childhood illnesses as well as preventive care.

Childhood mortality and infectious disease rates in America have decreased significantly over the past century. Despite these accomplishments, there are growing numbers of children with serious chronic diseases including childhood obesity, diabetes, asthma, mental health disorders, and intentional and unintentional injuries. The long-term consequences of these disorders are significant, because unhealthy children become unhealthy adults.

Economic Loss
Well-child care saves long term costs by encompassing a variety of health promoting and disease preventing services and by providing opportunities to detect and treat conditions early. Regular preventive health care for children is associated with fewer adverse health care effects, suggesting improved health outcomes [13,14]. For example, studies have shown that routine immunizations, only one component of well-child care, saves an estimated $10-$14 in health care for every $1 spent [15].

Screening and Early Identification
The federal Early Periodic Screening, Diagnosis and Treatment program’s 80% goal for screening and the 2004 Healthy Minnesotans objective to increase the number of children on Medical Assistance (MA) who receive Child and Teen Checkups (C&TC) according to the recommended schedule has not yet been met. The Department of Human Services (DHS) reports a 60% overall participation rate for C&TC in 2003 [16].

DHS 2003 C&TC Participation Rate
Year Percentage
All Ages
60%
1-2 Years
77%
3-5 Years
65%
6-9 Years
49%
10-18 Years
53%

The MDH 2002 Minnesota HMO Profile reports PMAP rates between 20 and 50 percent for well-child visits 0-15 months, and the rates for children receiving MinnesotaCare at about 45% [17].

Geographic disparities in children receiving well child visits also exist. Children living in the Twin Cities metropolitan area are more likely to receive well-child checkups than children living in Greater Minnesota [6]. DHS data for children on Medical Assistance and MinnesotaCare also confirm these trends with participation rates for children in Hennepin (67%) and Ramsey (60%) counties significantly higher than in many rural counties such as Big Stone (45%), Houston (45%), Mahnomen (45%), Roseau (45%) and Todd (42%) [4].

The quality of child health supervision at well-child checkups varies greatly among primary care practices as evidenced by a national survey of parents [18]. It appears that there are missed opportunities to screen for developmental delays and/or social-emotional issues. In this survey 36% of parents with infants 4-9 months and 56% of parents with children 10-35 months identified anticipatory guidance topics not discussed, which they would have found helpful. Topics included discipline strategies, toilet training, childcare, reading, vocabulary development and social development.

Although professional guidelines encourage the routine provision of developmental screening, a substantial proportion (57%) of parents with children 10-35 months of age do not recall their child ever being screened.

Immunizations
Families also frequently receive their immunizations outside of their customary medical home, resulting in fragmented immunization records and costly paper sharing of data across providers and schools.

While Minnesota’s rates of childhood immunizations have been steadily increasing, significant portions of Minnesota’s diverse communities and select cities/counties are substantially below the state target goal and lower by 8 to 19 percentage points than rates for white children [20].

Percent of Minnesota children not fully immunized by age two by race/ethnicity in 2001-02 [21]:

  • African American: 38%
  • American Indian: 27%
  • Asian: 34%
  • Hispanic: 35%
  • White: 15%

Certain areas of the state are significantly below the 81% immunization level of children up-to-date at 24 months of age. These areas include both urban cities and rural counties, reflecting varied barriers to age-appropriate immunization.

Mental Health
Children and adolescents in non-metro counties face additional barriers to mental health treatment as most of these counties have a shortage of mental health professionals; specifically child psychiatrists [22].

In Minnesota, there are 4.6 child psychiatrists for every 100,000 children, compared to 6.73 for every 100,00 children in the United States as a whole [23].

It is difficult to accurately measure how many children and adolescents receive treatment for mental health problems because of the fragmented mental health care system [24].

Adolescent Health Care
Adolescents and young adults are most likely to be without a usual source of care and have lower ambulatory visit rates. Foregone care is common among teens, especially among those who are older, low-income, uninsured, from minority backgrounds, or involved in high risk behaviors [25].

Too few adolescents have access to appropriately designed and delivered health screening, preventive counseling and medical treatment. Other challenges include:

  • Lack of health care providers who understand adolescent health and enjoy working with teens;
  • Lack of easy access to services at convenient times and places that are “youth-friendly;”
  • Lack of confidentiality for sensitive health services; and
  • Difficulties in health care service financing when youth seek services outside of the traditional health service system.

In general, adolescents use health care services the least of any age group and are the least likely to seek care through traditional office-based settings [26].

Nationally, the annual costs of preventable adolescent health problems were estimated in 2002 to be $51.5 billion or $1,152 per adolescent [27].

Interventions

Health Care Coverage
Advocate for adequate health insurance coverage in either public or private programs for all children and adolescents. Conduct public awareness and outreach programs to promote the importance and value of coverage.

Work with partners and communities to assure that services and systems of care reach targeted populations.
Methods for improvement include working with partners to increase beneficiary outreach and education through training, technical assistance, and the development of resources. Strategies include creating helpful and easy to understand materials, and working with programs to reach special populations such as children with disabilities and working with existing programs such as WIC [28].

  • Utilize peer educators to encourage adolescents to use health care services and become active participants in health care decision-making, with particular attention directed to adolescents with low utilization patterns, especially males, Hispanics, immigrants, and youth not in school [29].
  • The assignment of outreach workers to help inner-city physician practices track immunization status, contact families by mail, telephone, or home visits, and provide assistance with scheduling or transportation as needed result in the reduction of disparities [30].

Access to dental treatment cannot by itself eliminate the burden of dental caries. There must be multiple approaches that address family and community determinants of oral health. Healthy personal behaviors promote oral health, e.g. brushing the teeth with fluoride toothpaste at least once a day, eating healthy foods, helping parents learn about oral health and acquiring skills to prevent oral disease. Community programs such as water fluoridation and school-based dental sealant programs are very effective in reducing dental caries. All the determinants of oral health disparities – access to professional dental care and social, community, personal and familial factors must be adequately balanced to promote, improve, and maintain sound oral health [31].

Develop and promote health services and systems of care designed to eliminate disparities and barriers across the MCH population.
Strategies to decrease disparities include the promotion of:

1) Non-traditional health care providers/setting (e.g. school-based clinics) [32]. Studies show that access to school based primary health care is associated with increased use of services, decreased use of emergency rooms, and decreased hospitalization.
2) Education and employment of a diverse workforce [33].
3) A medical home [12]. The American Academy of Pediatrics supports a medical home that promotes access and coordinates care for children. Having a usual source of health care facilitates access to health care and is associated with higher rates of preventive care use as well as higher ratings of the patient-physician relationship and fewer unmet needs [34].

Improve tracking systems and participation in state and local immunization registries.
Immunization registries can be powerful tools to increasing age appropriate immunizations in an entire geographic area, regardless of where children go for their shots. An immunization registry combines immunization data from all immunization providers in a defined area and allows efficient sharing of that data on a need-to-know-basis. A registry can also send provider and/or parent reminder notices, and conduct both population- and practice-specific assessments of immunization level among current two year olds.

Immunization registries have been strongly recommended by the Centers for Disease Control and Prevention’s Task Force on Community Preventative Services. Additionally, the 1996-1997 statewide Retrospective Kindergarten Immunization Study revealed that most counties could increase their immunization levels by 15% by reducing missed opportunities for simultaneous administration.

Status

The importance of assuring access to quality health care, including quality well-child care, is reflected in numerous public health goals, including the Healthy Minnesotans 2004 [35] and Healthy People 2010 [36].

Minnesota’s public health system, including all local public health agencies, and tribal governments has programs and strategies that promote access to primary preventive health care and include the following:

  • Every Minnesota county and 4 tribes have a C&TC coordinator. C&TC coordinators provide timely information to eligible families/ children about the health care benefits of the C&TC Program. They assist families/children to access C&TC services, make appointments, and arrange for transportation and interpreters. They look for additional creative ways, beyond required activities, to provide effective outreach to the diverse populations within counties, CHB(s) and tribes. The Minnesota Department of Health contracts with the Department of Human Services to provide training and technical assistance for the C&TC Providers.
  • Home visiting programs available in some local communities have a program goal to increase access to well child health care for the families served.
  • The Cover All Kids initiative sponsored by Health Plans, the Children’s Defense Fund and the State of Minnesota promotes health care coverage and preventive care for Minnesota children and develops comprehensive, long-range plans to further improve preventive care and reduce health disparities for underserved children.

A statewide network of regional immunization registries is operating around the state, connecting a statewide web-based application known as the Minnesota Immunization Information Connection (MIIC). MIIC addresses the issues of fragmented records, adds the ability to target outreach efforts to those that are behind, greatly simplifies information exchange, and adds a level of security never before found with immunization records. As of August 2004, 55% of health care providers were participating in MIIC, as were 40% of children aged birth to 6 years.

Minneapolis and St Paul Public Schools have a number of school based health clinics serving primarily high school aged youth.

The Minnesota Department of Health, the Minnesota Board of Dentistry, and the Minnesota Department of Human Services have implemented programs and strategies that promote oral health for children and adolescents.

  • Establishment of a Dental Health Access Advisory Committee.
  • Promotion of Child and Teen Check-up, Early and Periodic Screening, Diagnostic and Treatment and Head Start programs.
  • Increased dental provider reimbursement rates for diagnostic examinations, dental radiographs, fluorides and sealants for children.

References

1. Compiled by the State Health Access Data Assistance Center, University of Minnesota School of Public Health, using US Census data, June 2004.
2. Minnesota Department of Health. (April 2002). Minnesota’s uninsured: Findings from the 2001 Health Access Survey.
3. Yu, S., Hilary A., Bellamy, H., Kogan, M., Dunbar, J., Schwalberg, H., Schuster, M. (2002). Factors that influence receipt of recommended preventive pediatric health and dental care. Pediatrics, 110(6).
4. Luman E., McCauley M., Stokley S., Chu S., & Pickering L. (2002). Timeliness of childhood immunizations. Pediatrics, 110.
5. Minnesota Department of Health. (2004). 2002 BRFSS child health module data book.
6. (Minnesota Department Human Services, Children’s Mental Health Division, 2000). (Action plan)
7. Minnesota Department of Health. (April 2002). Minnesota’s uninsured: Findings from the 2001 Health Access Survey.
8. Minnesota Department of Health. (April 2002). Minnesota’s uninsured: Findings from the 2001 Health Access Survey.
9. Minnesota Department of Health. (April 2002). Minnesota’s uninsured: Findings from the 2001 Health Access Survey.
10. Blackwell D.L., Tonthat L. (2002) Summary of Health Statistics for US Children: National Health Interview Survey, 1998. National Center for Health Statistics. Vital Health Stat 10(208).
11. U.S. Department of Health and Human Services. (2001). Trends in children’s oral health.
12. Kaiser Commission on Medicaid and the uninsured. (2003). The uninsured: A primer, key facts about Americans without health insurance.
13. Hakim R. & Bye B. (2001). Effectiveness of compliance with pediatric preventive guidelines among Medicaid beneficiaries. Pediatrics, 108:90.
14. Keller. (1983). Study of selected outcomes of the early and periodic screening, diagnosis and Treatment program in Michigan. Public Health Reports, 98:110.
15. Wagner,et al. (1992). Insurance coverage for preventive immunizations in children. New England Journal of Medicine, 768.
16. Minnesota Department of Human Services (2004). Medicaid management information system. Annual C&TC Participation Report, Federal Fiscal Year-2003.
17. Minnesota Department of Health Health Economics Program. (2002). The Minnesota HMO Profile – 2000.
18. Olson, M., Inkelas, M., Halfon, N., Schuster, M., O’Connor, K., Mistry, R., (2004). Overview of the Content of Health Supervision for Young Children: Reports from Parents and Pediatricians. Pediatrics, 133(6).
19. Halfon, N., Regalado M., Sareen H., Inkelas M., Peck Reuland, C., Glascoe F., & Olson ,L., (2004). Assessing development in the pediatric office. Pediatrics,113(6).
20. Children’s Defense Fund Minnesota. (2004). Minnesota kids: A closer look 2004 data book.
21. Children’s Defense Fund Minnesota. (2004). Minnesota kids: A closer look 2004 data book.
22. Children’s Defense Fund Minnesota. (2004). A special report from Minnesota KIDS COUNT, a project of Children’s Defense Fund Minnesota. Online resource: www.cdf-mn.org/PDF/KidsCountData_04/MentalHealthData.pdf Attn: Non-MDH Link
23. Children’s Defense Fund Minnesota. (2004). A special report from Minnesota KIDS COUNT, a project of Children’s Defense Fund Minnesota. Online resource: www.cdf-mn.org/PDF/KidsCountData_04/MentalHealthData.pdf Attn: Non-MDH Link
24. Children’s Defense Fund Minnesota. (2004). A special report from Minnesota KIDS COUNT, a project of Children’s Defense Fund Minnesota. Online resource: www.cdf-mn.org/PDF/KidsCountData_04/MentalHealthData.pdf Attn: Non-MDH Link
25. Ford, CA, Bearman, PS, & Moody, J. (1991). Foregone health care among adolescents. JAMA, 282(23): 2227-2234.
26. Klein, JD, Slap, GB, Elster, AB, Cohn, SE. (1993) Adolescents and access to health care. Bulletin of the New York Academy of Medicine, winter: 219-235.
27. Gans, JE, Alexander, B, Chu, RC, Elster, AB. (1995). The cost of comprehensive preventive medical services for adolescents. Archives of Pediatrics and Adolescent Medicine, 149(11):1226-1234. Converted to 2002 dollars using the US department of Labor’s Bureau of Labor Statistics’ Medical Care Consumer Price Index.
28. US General Accounting Office (2001). Medicaid- Stronger Efforts Needed to Ensure Children’s Access to Health Screening Services. GAO –01-749.
29. McManus, MA, Shejavali, KI & Fox, HB. (2003). Is the health care system working for adolescents? Maternal & Child Health Policy Research Center.
30.  Szilagyi, T., et al. (2002). Reducing geographic, racial, and ethnic disparities in childhood immunization rates by using reminder/recall intervention in urban primary care practices. Pediatrics, 110.
31. Partnership in Prevention. (2001). Oral health: Common and preventable ailments. Priorities in Prevention.
32. English A. (1993). Early periodic screening, diagnosis and treatment program (EPSDT): A model for improving adolescent’s Access to Health Care. Journal of Adolescent Health, 14.
33. McDonough, J., Gibbs, B., Scott-Harris. J., Kronebusch, K., Navarrd, A., Taylor, K., (2004). A State policy agenda to eliminate racial and ethic health disparities. The Commonwealth Fund: New York, NY.
34. Inkelas M., Schuster, M., Olson, L., Park C., & Halfon, N. (2004). Continuity of primary care clinician in early childhood. Pediatrics, 113(6).
35. MDH Healthy Minnesotans Public Health Improvement Goals 2004. Accessed 8-4-04. http://www.health.state.mn.us/divs/chs/phg/intro.html
36. Healthy People 2010. Accessed 8-4-04.
http://www.healthypeople.gov/Document/HTML/Volume1/01Access.htm#_Toc489432807 Attn: Non-MDH Link