Medicaid wants fewer early births
Everyone who looks at the high cost of health care worries about the expense at the end of life.
But what about at the beginning?
Turns out there’s one deceptively simple change in obstetric care that can save millions of dollars and lead to healthier babies and healthier moms: stopping women and their obstetricians from inducing births before 39 weeks without a pressing medical reason.
That could be a tough sell though because early induction has become part of the culture.
About one in 10 births in the United States is intentionally early, and some estimates are higher. It’s a matter of choice and convenience, and sometimes efficiency, for both women and their doctors. A baby born at 38 weeks — a common time for early induction — isn’t premature. It sounds safe.
But mounting evidence shows that planned early births put babies at risk: more infants staying in neonatal intensive care units, more complications, more permanent damage and a higher death rate. Respiratory and digestive problems occur, and scientists are learning how early delivery can disrupt brain development.
There’s “an explosion of brain development in the last few weeks of gestation,” Billie Short, division chief of the Neonatal Intensive Care Unit at Children’s National Medical Center in Washington, said in a presentation about the costs and consequences of elective early births.
So private insurers, health quality groups, the March of Dimes, some large hospital organizations and now Medicaid — which pays for more than 40 percent of births in the U.S. — have teamed up to spread the word to women who are expecting. Their message: If nature intended for babies to be born at 38 weeks, pregnancy wouldn’t last 40 weeks.
“This is something that has got to change,” said Cindy Mann, Medicaid director at the Centers for Medicare & Medicaid Services — which along with its state partners could save hundreds of millions of dollars a year if such births were less common.
A baby born at 37 or 38 weeks isn’t premature, these groups tell women and doctors. But maybe they aren’t quite “full term,” either. The phrase being introduced is “early term.”
The message isn’t always getting through.
“We live in a culture of convenience and a culture of planning,” said Sue Gullo, managing director of the Institute of Healthcare Improvement, “Our whole culture is about making things neat and tidy,” she added.
A woman might want to avoid a particular birth date or choose to deliver when she knows it’s convenient for grandma to watch the older kids. She might try to maximize her maternity leave or improve the odds of having a specific obstetrician in a group practice when she delivers. Or she may just get tired of being hugely pregnant.
Obstetricians might like pre-planned births as a way of keeping more of their nights and weekends free. It might help make their practice more efficient if they can plan to be in the hospital delivering five babies on Tuesday, for instance, and be able to tend to their patients in the office on Wednesday.
Mann told POLITICO the trend must be reversed — not just on economic grounds but to protect newborns’ health. Early induction doesn’t mean quick or uncomplicated delivery; women who are induced early are also at increased risk for cesarean section. Some hospitals and medical practices have brought their early induction rates down sharply.
The Seton Family of Hospitals in Austin, Texas, has been a pacesetter by basically stopping the practice cold. It has seen a corresponding drop in birth traumas. In Ohio, a statewide collaboration on perinatal health in hospitals prevented an estimated 8,236 early deliveries and about 250 NICU admissions from September 2008 through March 2010 based on numbers researchers anticipated for births without intervention.
But elsewhere, the rate hasn’t budged, and in some hospitals, it’s a whopping 40 percent, according to the Leapfrog Group, a data-driven health care quality organization. Some outlier medical centers are even higher.
“There are pockets of success,” Mann said. “We know that the reduction can be accomplished. But it needs a lift.”
Getting doctors and women to bring the early induction rate down by half could save Medicaid $483 million a year — and several billion over a decade — and that figure doesn’t even include care that a child may need weeks, months or years after birth. Such efforts would be a lot less painful — and a lot better for the newborns and their families — than some of the other cost cutters that hard-pressed state Medicaid directors are contemplating.
A few states have imposed or are considering financial penalties for elective early births, but federal Medicaid officials aren’t considering such policies, Mann said.
Early deliveries aren’t unique to Medicaid. They happen across the country, in all socioeconomic groups, said Barbara Rudolph, senior science director for Leapfrog, which works with businesses and big health plans to address cost and quality.
And it’s one reason so many hospitals have NICUs. Early births keep them full — and profitable.
Gullo says it’s sort of a catch-22. Hospitals have NICUs, in part, because so many early-term babies end up needing them. And they go ahead and deliver the early babies because as long as they have NICUs, they can treat the infants if there’s a problem.
But some hospitals, like Seton, have changed that pattern quickly. Hospitals that have laid down the law, telling doctors they can’t deliver babies early without a compelling medical reason — a sort of zero tolerance — have seen the deepest and fastest drop in induction rates, Rudolph said.
Health and Human Services has targeted hospitals as a good starting point to leverage change. HHS Secretary Kathleen Sebelius earlier this year announced the Strong Start initiative to improve prenatal care, reduce preterm births and address the elective inductions.
The initiative is part of the Partnership for Patients quality improvement drive under the Center for Medicare and Medicaid Innovation, which was created under the health care reform law. About 3,200 hospitals are participating in the voluntary quality program.
“Women need to understand what they are asking for,” Gullo said.
“ If we help them understand the new evidence, people will make intelligent decisions,” Gullo said.
© 2012 POLITICO LLC