Launched less than a year ago, Gray's program, called pregnancy medical homes, is showing promise. "The reason I wanted to do it had nothing to do with finance," Gray says. "I wanted to get better babies and better moms, knowing that good care pulls the finance piece along with it."
North Carolina's approach borrows medical practices used for years by managed care companies to improve birth outcomes and lower costs. Organizations such as the March of Dimes and the American College of Obstetricians and Gynecologists promote similar practices nationwide. And this month, the U.S. Department of Health and Human Services announced a $43 million grant program aimed at lowering premature births in the Medicaid program.
It's the states that have been slow to catch on. A few, including Ohio, Vermont and South Carolina, have incorporated one or more research-based methods to improve prenatal care under Medicaid, but North Carolina is the first to combine multiple techniques in a statewide program.
How pregnancy medical homes work
To qualify, primary care doctors, obstetricians, nurse midwives and public health clinics must agree to screen every Medicaid-eligible woman who tests positive for pregnancy to determine whether she is at risk for complications. Among other things, a written survey determines whether the woman has had a previous preterm or low-birth weight delivery, whether she smokes or uses drugs, is homeless or lives in an unsafe environment, has a chronic disease that could complicate pregnancy or is late in seeking prenatal care.
When a woman is determined to be at risk, the doctor alerts a case manager from the staff of the North Carolina Public Health Department to coordinate her care throughout pregnancy. Case managers set up meetings with women anywhere that works — in the grocery store, in their homes, at the local health clinic or social services office or in their doctor's office.
The program is succeeding in part because it gives doctors an incentive to make contact with women early in their pregnancy. The doctors are paid based on the number of pregnant women enrolled. "We expect them to aggressively market, pull in, corral, capture that population if they even smell pregnant," Gray says. "It's no longer a case of waiting for the woman to come to them."
Under the program, health care participants must agree not to perform so-called "elective" deliveries prior to 39 weeks of gestation (a full-term pregnancy is 40 weeks), aim for a first-time cesarean delivery rate of no more than 20 percent and provide the drug 17 alpha hydroxyprogesterone caproate, commonly called 17P, to all women at risk of preterm delivery.
Even though all three of these procedures are generally approved by medical researchers, they are not always practiced. Out of convenience, for example, nearly 10 percent of all births are scheduled as induced or surgical deliveries before 39 weeks without medical justification. That is despite research showing that immediate and long-term complications can occur for both mother and infant from any elective delivery earlier than 39 weeks.
The drug 17P has also been shown to be safe and effective at staving off early births. But because it must be injected in the hip once a week, which can cause soreness, some doctors and patients opt to forgo the treatment. As for cesarean deliveries, doctors are not precluded from using the surgery when medically necessary. But if the 20 percent target is exceeded, the Medicaid program will ask the physicians to explain.
As an encouragement to participate in pregnancy medical homes, the Medicaid program pays doctors an additional fee of up to $400 per patient. Once the high-risk questionnaire is filled out, the practice receives the first $50. The remainder is paid after the woman has had her first postpartum visit, in which doctors must screen for depression, discuss plans for future pregnancies and direct the woman to further medical care when necessary.
Another "carrot" offered to doctors is a waiver of the normal Medicaid pre-authorization required for use of ultrasound imaging. Instead, doctors simply register each use of the diagnostic tool without filling out paperwork beforehand.
For the state, the financial gains from the new program could be significant. Initially, funding was accomplished without an appropriation by moving around line items in the state's existing biennial budget. From now on, the funding is expected to come from Medicaid money saved by the new techniques. In the first year, North Carolina is budgeting to save close to $1 million. In the second fiscal year, which ends July 1, 2013, the savings are projected to total $9 million.
In the long term, Gray and other medical experts expect the state will see significant collateral effects by avoiding the health care and special education costs that result from medical and cognitive problems suffered by children who are born too early.
Nationwide, more than half a million infants are born prematurely each year, a trend that has spiked by 36 percent in the last two decades. Studies by the Institute of Medicine, a federal agency, conclude that poor birth outcomes cost $26 billion annually. Both infant and maternal mortality rates are higher in the U.S. than in any European country.
In the Medicaid program, it is estimated that medical care in the first year of life for preterm babies averages $20,000, compared to about $2,000 for full-term infants, according to the U.S. Department of Health and Human Services. Of the more than 4 million births in the U.S., about 42 percent are paid for by Medicaid, a joint federal-state program.
In North Carolina, 13 percent of the state's approximately 50,000 annual live births are premature, a rate substantially higher than the national average. In 1988, North Carolina had the highest infant mortality rate in the country — 13 deaths per 1,000 births. Since then, the rate has fallen to 8 per 1,000, still well above the national average.
Creation of pregnancy medical homes was a natural step for North Carolina. The state was already providing primary care medical homes through its existing non-profit health care network, Community Care of North Carolina. That program has made significant inroads in improving the health of people with chronic diseases such as asthma and diabetes.
It took 18 months to get everyone involved, including the federal government, to agree on the pregnancy medical home experiment. But once doctors overcame their resistance to change, recalls project director Kate Berrien, the politics were pretty straightforward. "No one wants to have sick babies," Berrien says, "and sick babies cost a ton of money."
So far, 800 of the state's 1,000 obstetricians have signed up for the program, as have at least 80 percent of primary care doctors and others who provide maternity care. In the first nine months, about 60 percent of all pregnant women in the Medicaid program were screened. Of those, 70 percent were deemed to have high-risk pregnancies.
Although final results for the first year will not be available until the end of next month, Gray says data collected so far seem to indicate fewer emergency room visits by pregnant women and less use of neonatal intensive care units. But it will take at least two years to see real results, says Berrien. "After all, pregnancy itself takes nine months."