Risk assessment promotes healthy pregnancies
Drop in low birth weight babies in first year
When Regence Blue Cross Blue Shield of Oregon (BCBSO) started its prenatal risk assessment and case management program, some physicians balked.
Now, the physicians love the program, the plan’s members are reaping the benefits of having healthier babies, and employers and the health plan are saving money.
For instance, in the baseline year, before the prenatal risk-assessment program began, 1.5% of babies covered by the plan had very low birth weight. At the end of the first year, 0.6% had very low birth weight.
In the baseline group, 5% of mothers had low birth weight babies. The figure dropped to 3.5% the first year. Before the program began, 93.5% of pregnant members had normal pregnancies and deliveries. The figure rose to 95.9% after the first year.
"We all know how much healthier babies are when they are born full-term. Since it costs about $500,000 for a 26-week infant, we don’t have to alleviate very many problems to make the program cost efficient," says Melanie Westrick, RN, BSN, supervisor of healthcare services at Regence BCBSO.
The insurer made it a point to maintain a close working relationship with obstetrics providers in the area as one avenue for getting the names of pregnant patients.
Because the fees are paid on global billing, the insurer often didn’t find out a woman was pregnant until after delivery, when it got a bill. Now, about half of the women recruited for the program are referred by physician offices. Other sources are pregnancy tests from laboratories and employer advertising, including brochures in new members’ packages.
"When we first started in June 1997, we met quite a bit of resistance from physicians. They felt like they already provided education in their office," Westrick says.
Now physicians are enthusiastic about the program because they are kept involved and because a special 24-hour nurse line for participants helps them avoid some 3 a.m. telephone calls and ensures that a problem with the pregnancy isn’t ignored because the patient is reluctant to call her physician.
"This is one of the things the doctors like. Somebody can call us at 2 a.m. and ask if they should be concerned about something. They wouldn’t call their doctor because they would be afraid it was a stupid question," Westrick says.
When a woman enrolls, Regence BCBSO sends out a letter to the physician explaining the program. They receive a full set of telephone protocols that detail what answers the nurse line nurses give when a patient calls in.
Physicians are asked to send back information on how they want the calls handled. For instance, the patient may be told to call the physician directly in certain instances.
"We don’t want to get in the way of relations between the member and the obstetrics provider. We see ourselves as support," Westrick says.
In fact, every time a patient calls the nurse line, the physician gets a report, even if it’s something trivial.
Assessing risk
Participation in the program is voluntary. Pregnant women are asked to fill out a two-page risk assessment form that includes demographic information, information about past pregnancy, and lifestyle factors such as eating habits, support systems, and history of physical, emotional, or sexual abuse.
Women who return the questionnaire are placed in low-, medium-, or high-risk categories.
Participants receive a packet of information geared to their situation and reading level and are given the opportunity to choose a book about pregnancy. Some of the books are for mothers of twins; others are for first-time pregnancies, or people who have been pregnant before. The other materials they receive are based on their answers to the questions. For instance, someone who has had a lot of morning sickness would receive literature on that subject.
Regence BCBSO mails out another assessment at 26 weeks followed by telephone calls to all enrollees, and educational material that includes information on what is normal at that particular stage of pregnancy and what they can expect in the following weeks. Patients may be moved to high-risk status based on the second assessment or telephone call.
All patients are invited to call the 24-hour nurse line as often as they want with questions.
Patients who are at low-risk are called once a trimester by a case manager.
Medium-risk patients may be those who don’t have a good support system or who have a history of something like gestational diabetes that may or may not recur in their current pregnancy. They are called once a month.
In the case of low- and medium-risk patients, the same case manager typically calls them throughout the pregnancy, but it doesn’t always work out that way.
If the patients are high-risk, a specific nurse case manager is assigned to follow them through their pregnancy. In some cases, the nurse case manager may call every day if the patient needs it.
The case managers help the high-risk patients manage their care and help them get the services they need. For instance, if high-risk patients need to be on bed rest, the case managers try to help them find community resources for childcare.
After the patients deliver, Regence BCBSO sends a follow-up questionnaire and a gift certificate from a local department store as an incentive for participating.
Some employers give larger incentives, such as car seats or waiving co-pay for participants.
Regence BCBSO offers the program free of charge to all patients for whom they are the reinsurer. If the patient’s employer is its own reinsurer, the company can purchase the prenatal risk assessment program as an add-on.
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