Plans, NGA examine infant mortality

July 1, 2013

Japan and the UK outrank the United States in infant mortality measures

When it comes to infant mortality, the United States continues to report higher rates than other countries. But new efforts by states, health plans and providers aim to lower infant mortality, improve birth outcomes and reduce costs to the healthcare system.

According to the Central Intelligence Agency's World Fact Book, the United States has approximately 5.90 deaths per 1,000 births each year, earning it the 174th ranking in infant mortality rates. Comparatively, the United Kingdom is ranked 189th and Japan is 223rd with a rate of 2.17 deaths per 1,000 each year.

The Centers for Disease Control and Prevention defines infant mortality as the death of a baby before his or her first birthday. The National Center for Health Statistics reported that in 2010, 57% of all infant deaths in the United States could be attributed to serious birth defects, babies born too small or too early, sudden infant death syndrome, maternal complications during pregnancy or injury.

Comparisons to other countries birth rates can be difficult because evaluation depends on the data's accuracy. In addition, a bulletin from the World Health Organization (WHO) noted that European countries often use different practices for stillbirth and live birth registration, and some countries only register live births after the infant has been alive for a specified period. The United States, however, uses the WHO’s definition of live birth that registers anything that breathes or shows evidence of life.

But despite these difficulties in comparing countries, healthcare experts agree that the United States still has room for improvement.

Infant mortality, preterm births and high-risk pregnancies can have costly implications for the healthcare system. According to the March of Dimes, preterm births cost the United States at least $26.2 billion in 2005, or approximately $51,600 for every premature infant born that year. In addition, it reports that the average first-year medical cost to care for premature infants is approximately 10 times higher than the average cost for full-term infants ($32,325 versus $3,325, respectively).

According to the National Center for Health Statistics, in 2010 there were 325,563 babies born with a low birth weight-less than 2,500 grams, or approximately 5 pounds, 8 ounces.

To combat infant mortality rates and low birth weights, health plans are turning to programs that offer education, early intervention, assessment and case management services. The goal of these programming efforts is to improve the overall health of mom and baby by increasing average birth weights, preventing preterm labor and encouraging healthy habits before, during and after pregnancy.

"We look at helping deliver healthy babies as helping deliver healthy members," says Janet Johnson-Yosgott, Health Net's manager of health promotion.

In January, Health Net teamed with a vended partner to expand its healthy pregnancy program to include obstetric risk assessment and education. The program includes an initial assessment to identify high-risk participants, a follow-up assessment midway through the pregnancy and 24-hour access to a "BabyLine" staffed with experienced perinatal nurses.

While women with healthy pregnancies and no signs of high-risk conditions are placed in a healthy pregnancy program, Health Net also offers case management services for those members with high-risk obstetrical conditions. Coordinators work to create care plans for these high-risk individuals that incorporate goals, support and periodic assessment.

"There's much more customized education and problem solving," Johnson-Yosgott says, adding that the health plan also works collaboratively with providers to ensure everyone is on the same page.

To encourage participation in the programs, Health Net provides the services at no-cost and promotes its benefits through annual mailings and by improving provider awareness.

Centene, a health plan that provides managed care services to government sponsored programs including Medicaid, has found that one of the biggest challenges to promoting healthy pregnancies is early identification. It has reported that 21.5% of pregnant women in its health plans are not enrolled until the third trimester.

"We felt that there really was a  problem where many of these women on Medicaid were coming in late to the system," says Mary Mason, MD, senior vice president and chief medical officer at Centene.

The company knows from their data that they need about 90 days during a pregnancy to make a difference, so they've developed a comprehensive pregnancy notification system that uses proprietary algorithms to maximize early identification and triage patients to the right level of case management. Their efforts include a  standardized form which not only identifies a pregnancy but also identifies possible risk factors. The form can be filled out by the member, physician or health plan. To encourage participation in the pregnancy identification, Centene offers incentives to each group for reporting a pregnancy.

One critical aspect of the program, according to Dr. Mason, was to change the culture within the health plan so that everyone, not just medical management staff, understood it was their responsibility to identify a pregnancy, including health coaches, call center staff or other employees who interact with members.

"It's amazing how many women we’re able to catch right now," she says.

In addition to early identification, the company's Smart Start for your Baby Program includes wellness and disease management, case management and care coordination for pregnant mothers and extends from preconception to the first year or two after birth.

Centene has found that there was a decreased likelihood of a low birth weight event for those who participated in the program compared to those who didn't, which has translated to some significant cost savings for the health plan, not only for costs initially associated with caring for a premature baby but also for costs during the first few years of life.

The plan estimates that it saved more than $43.4 million from 2009 to 2011 in prevented NICU days and additional costs for low birth weight babies. While the program carries a cost of $75 per pregnancy, it has been found to save $3,354 per pregnancy.

"The cost savings on this is tremendous," Dr. Mason says.

In addition to case management and care coordination, the company has taken a hands-on approach to education, even writing and co-writing parental books on topics such as the first year of care for a baby, the mother's recovery or dad's parenting role. Teams decided to produce the resources after discovering that many of the books available at local book stores did not address issues women who have limited financial resources.

"We try to take our materials and make them something that's relevant and engaging," Dr. Mason says.

States across the country are also joining in on the discussion. The National Governors Association (NGA) is leading the Learning Network on Improving Birth Outcomes, an effort to help states develop, align and implement policies and initiatives to improve birth outcomes.

The NGA plans to conduct three different rounds of the network, with four states participating in each round. During the learning network, which is currently in its second round, NGA convenes in-state sessions where states can choose to either hold a session for senior-level officials to talk in frank terms about the issues surrounding infant mortality in their state or open the discussion to community stakeholders. Participating states also get the opportunity to speak with other state leaders to benchmark.

"They often find the same obstacles, so it's nice to talk through how they can overcome them," says Krista Drobac, director of the health division for NGA. 

According to Drobac, one of the advantages of the program is that it ensures that the governor's office in each selected state will be part of the discussion, an often essential ingredient to moving initiatives beyond public health departments.

"When we come to a state we require that the governor's office has got to be there. The senior leadership has got to be there," she says.

While the second round is just beginning, Drobac says there were some valuable take-aways from the completed first round. One observation was the need for good, quality data to be able to trigger the appropriate interventions. States also saw the need for personalized case management in the home as much as possible; eliminating voluntary inductions before the 39-week mark of a pregnancy; and making sure incentives are properly aligned in reimbursement structures.

Aligning incentives will be an ongoing challenge for health plans.

Jill Sederstrom is a freelance writer based in Kansas City