New York insurer develops plan to improve outcomes and save money on at-risk births
Willie Sutton reportedly once said he robbed banks because “that’s where the money is.” Take a leap to health care and you’ll find that a good part of the money — re: Medicaid dollars — is in pregnancy. In a report in the March 2005 edition of the American Journal of Managed Care, pregnancy is listed as one of the primary events leading to eligibility for Medicaid, and deliveries account for almost 50% of Medicaid inpatient discharges.
For Rochester, NY, Monroe Plan for Medical Care, one area of concern was high-risk pregnancies among Medicaid clients that led to high-cost neonatal intensive care unit (NICU) stays. Women from lower socioeconomic groups experience poorer birth outcomes than those from higher socioeconomic groups, and thus delivery claims and high-cost NICU expenses consume a large portion of Medicaid managed care medical expenses, says Monroe chief medical officer Joseph Stankaitis.
By implementing a structured plan to help women deliver healthier babies and reduce NICU costs, Monroe has gained national attention and recognition for cutting its 1998 baseline of 108 NICU admissions per 1,000 births to 98 per 1,000 births in one year. By 2003, Monroe had reduced NICU admissions to 57 per 1,000 births and saved $1.8 million in projected NICU costs.
Mr. Stankaitis tells State Health Watch the plan concentrates on the NICU because “that’s where most of the costs are in prenatal care. We knew we wanted babies to be as mature as possible in terms of development, and we knew we had something that would be pretty easy to measure so we could see how we were doing.”
Monroe Plan for Medical Care is an independent practice association representing more than 3,000 providers in the Rochester region. It partners with Excellus BlueCross BlueShield as the Blues Plan’s delivery system for publicly financed programs targeting underserved populations.
Monroe provides care for nearly 48,000 Medicaid managed care Excellus enrollees in a program that covers the categories of individuals that include women and children (Temporary Assistance to Needy Families recipients, adults who are unable to work, and a segment of the disabled population). Monroe has 70% market share for Medicaid managed care in the region and is the exclusive community provider for 14,000 enrollees in Family Health Plus, an expansion of the New York State Medicaid managed care program for the working poor
It also is the exclusive community provider for 11,000 children enrolled in New York’s SCHIP program.
One of 11 pilot programs
Although Monroe’s enhanced quality improvement efforts began in 1997, they became more intense in 2000 when the Center for Health Care Strategies invited the organization to participate in its Best Clinical and Administrative Practices “Toward Improving Birth Outcomes” program, a nationwide group of 11 Medicaid managed care entities committed to developing and pilot-testing best practice models.
In a literature review and discussions with other Medicaid managed care organizations, Mr. Stankaitis said, it became evident there was no single magic bullet for improving birth outcomes. Thus, Monroe decided that sustained improvement would require change in the care delivery system to assist practitioners in doing the right thing at the right time. It adopted a quality improvement approach for its prenatal care improvement activities calling for use of learning cycles to plan and test changes in systems and processes. “Such cycles have been referred to as ‘plan-do-study-act’ cycles,” Mr. Stankaitis wrote, “which will guide improvement teams through a systematic analysis and improvement process.”
The focus of such quality improvement programs is to institute organizational system changes to ensure adherence to appropriate practice guidelines through the coordination of care. Such an approach emphasizes organizational and care delivery improvements using existing standards of care. Thus, there was no randomization of enrollees into intervention and control groups, and the services provided were available to all eligible enrollees, who at all times were able to refuse or terminate any services offered. Identification of high-risk individuals is through a prenatal registration form to be completed by practitioners. With the plan paying $30 per form submitted, there have been annual submission rates of 85% to 98%, but timeliness of submissions remained a problem — forms often came in during a patient’s late third trimester, when the ability to mitigate any significant risks was at a minimum.
Tiered payments get forms in
In April 2001, the plan’s Healthy Beginnings program implemented a tiered payment for submission of the forms, with a $50 payment for first trimester submission, $30 for second trimester, and $20 for third trimester. Also, program staff visited practitioners’ offices to educate personnel about the importance of submitting the form for managing high-risk pregnancies. This intervention led to submission rates consistently higher than 60% in the first trimester.
Staff input the form’s data into a care management database that scores the reported findings to reflect the risk for each patient and to engage members in needed medical, behavioral health, and social and support services as identified.
Through the quality improvement process, Healthy Beginnings has evolved its approach to outreach, from using generalized community outreach services (the local county community health care worker program and contracted home health agencies) to instituting a trial of using its own prenatal outreach workers, to finally engaging outreach services through the local BabyLove program in 2002.
“Whenever the Healthy Beginnings perinatal nurse coordinator identifies members at moderate-to-high risk, the coordinator manages these individuals through communications with the practitioners, outreach programs, and referral to Monroe’s internal social work program as needed,” Mr. Stankaitis writes.
“Individuals with medical complications of pregnancy receive complex care management, home care services, or skilled nursing services as required,” he notes.
BabyLove offers outreach
“The perinatal nurse coordinator refers all pregnant enrollees identified as high risk because of psychosocial problems to the BabyLove program. This community-based program has a strong history of working effectively with high-risk pregnant women, with the added feature of social work supervision that is necessary to effectively provide outreach,” he points out. “The BabyLove program offers home visits, arranges transportation, provides links to support services and social work services, and connects high-risk pregnant women with other critically needed services.”
Mr. Stankaitis reports that with enhanced outreach, Monroe Plan has been able to more effectively connect its pregnant women with medical, mental health, chemical dependency, community-based governmental and social services.
The measurement for program effectiveness is the NICU admission rate for all pregnant women in the plan. NICU admission rates have progressively declined relative to the chosen 1998 baseline rate of 107.6 per 1,000 births. At the same time, NICU admission rates for Medicaid patients in upstate New York have remained essentially the same during the same time period.
Mr. Stankaitis says Monroe officials theorize that implementation of its Healthy Beginnings enhanced prenatal care program in late 1997 and early 1998 has resulted in a marked decrease in the NICU admission rate. Other than this program, he says, there were no known external forces that would have caused a drop in the NICU admission rate, such as a change in NICU admission criteria or coding changes or evidence that the overall population experienced a drop in rates.
Synergistic improvements
The plan’s administrators say it is difficult to ascertain if any one intervention led to the improvements. The most likely scenario is that activities enhancing early identification, stratification, and outreach provided a synergistic effect on improving the outcomes.
In its latest activity, Monroe Plan has partnered with the county Department of Public Health on the Greater Rochester Area Smoking Prevention Program, targeting minorities for smoking cessation opportunities.
Smoking is a recognized major risk factor for poor birth outcomes and the rate of self-reported smoking among Monroe Plan pregnant women has been consistently well above 20%.
Mr. Stankaitis says that previous attempts to mitigate this risk were less than successful because of a combination of practitioner unfamiliarity with evidence-based approaches to smoking cessation and a lack of appreciation of the importance of providing culturally competent counseling.
He says the potential exists for this new effort, which deploys culturally competent peer counselors who have been trained in use of smoking cessation strategies endorsed by the federal Agency for Healthcare Research and Quality, to remedy the problem.
The keys to achieving a significant reduction in NICU rates, Mr. Stankaitis explains, involve these components:
1. having a structure for quality improvement efforts that emphasizes identification and stratification of at-risk patients, outreach to the patients, and interventions;
2. prompting practitioners to ask the right questions that they might otherwise forget about;
3. outreach to engage women to get the care they need.
The importance of outreach and the need for social supports and ancillary care is seen, he points out, in the major drop in NICU rates that occurred after the plan partnered with the BabyLove program.
[Contact Mr. Stankaitis at (585) 256-8425 or e-mail at [email protected].]
In a report in the March 2005 edition of the American Journal of Managed Care, pregnancy is listed as one of the primary events leading to eligibility for Medicaid, and deliveries account for almost 50% of Medicaid inpatient discharges.
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