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Minimizing Prematurity in a High-Risk Obstetrical Population


The health status of a high-risk newborn population is determined by the days per thousand and its average length of stay (ALOS) in the NICU. In 2001, the contracted HMO’s neonatal intensive care unit (NICU) days per thousand averaged 87 days per thousand admits. Its average length of stay for newborns in the NICU was 14 days.


To reduce the HMO’s days per thousand and the ALOS of newborns in the NICU by ten percent (10%) annually through its contracted relationship with Alpha Maxx Healthcare Inc. (AMAXX) and its OB population health management services.

Study Design

The organization performs annually an on-going longitudinal populationbased review of its birth outcomes using the latest data available (2002 through 2004). The year 2001 is the base for comparison. The study focuses on days per thousand and the average length of stay in the NICU. The source used for the study is the HMO’s Board Reports as validation of its success.

AMAXX’s success is also measured using the denominator of 5,545 pregnancies, which represent the total number of the HMO’s pregnancies throughout the region (2,178 of those were assigned to AMAXX). The numerator represents the total number of admits to the NICU. However, the data is not adjusted for ‘rule-outs’ (i.e. admits to rule out sepsis, beta strep, etc.). It is diffi cult to get an accurate measure for lowering the incidence of prematurity using the admission data as the only criteria. So, if the days per thousand and the ALOS are decreasing in spite of the ‘rule-outs,’ this becomes a true indicator of a healthier newborn population.

AMAXX is held accountable for all premature deliveries in Shelby County, whether the member was referred or not. Most of the HMO’s ‘critically’ high risk pregnant patients are referred to Shelby County late in their pregnancies to be followed by a high-risk OB provider (perinatalogist) and deliver in a hospital with a level three NICU. The tertiary hospital and high-risk physicians are all located in Shelby County.

Overview of the Patient Population

Medicaid recipients have many risk factors that signifi - cantly affect the birth outcomes of low-income women, including medical comorbidities, preterm birth, substance abuse issues, smoking, domestic violence, low literacy, and homelessness. According to the latest March of Dimes data for Shelby County, Tennessee, the percentage of low birth weight African American infants per 1,000 live births is 14.3 compared to 7.0 for whites. The percentage of preterm births for African Americans is 18.9 compared to 11.4 for whites.

The Medicaid population is defi ned by the presence of chronic conditions, disability, and poor health. There are specifi c risk factors that are common among this population and act as a barrier to a healthy outcome.

Most of these risk factors are exacerbated during a woman’s pregnancy. Interventions to reduce risk factors include early identifi cation and stratifi cation of potentially high-risk members using a variety of disciplines. Interventions include nursing and social work coordination of care for all members—low-risk and high-risk. Members are given support during their pregnancy through our telephonic care coordination contacts and outreach, incentive programs, patient education, home visits, hospital rounds, transportation, and connection with other community-based organizations.

Members receive individualized care plans based upon risk factors. The initial and subsequent routine assessments identify medical, mental health, economic, and psychosocial issues that might impede the member from experiencing the optimal outcome of a healthy newborn. AMAXX’s software system supports its care management program. The system is a repository for all information necessary to manage the obstetrical system of care for our members.


Prior to the implementation of AMAXX’s population health management program, the HMO had an outreach program that involved indirect contact only through mail and member services. Early in the implementation process, AMAXX began working with the HMO’s provider network. The goal of the organization’s outreach efforts was to encourage each provider to follow evidence-based clinical guidelines to ensure optimal outcomes. AMAXX also assisted providers to better serve their HMO patients by instituting the following services:

  • Assist with transfer of patients between levels of care.
  • Assist with non-compliant patients.
  • Issue loaner pagers to transient members to enhance communication between the physician and his patient.
  • Provide information on member’s emergent care to her provider as a result of AMAXX hospital rounds.
  • Quarterly meetings with university-affi liated providers (major high-risk providers in the community) to review trends, complaints, opportunities for improvement, and on-going concerns.

      In stark contrast, before 2002, the HMO’s contracted providers were not required to give a notifi cation of pregnancy or get an authorization for payment of services. It must be noted that the Plan is co-owned (50/50) by a university-affi liated medical group and the region’s safety-net and the university’s teaching hospital.

      Identifi cation of High-Risk Members

      As stated in the preceding section, providers were not required to have an authorization to be paid for providing OB services to the HMO’s members. In order to have a successful OB population health management program, the providers had to be provided incentives to change their procedures. The HMO instituted a timely payment program. A global payment was paid to any participating provider who agreed to the following:

      • Follow the HMO’s evidence-based clinical guidelines in caring for its members.
      • Submit a Pregnancy Risk Notifi cation (PRN) and report patient work-ups and lab results within 14 days of the initial encounter.
      • Submit “zero” balance claims for encounter data to elicit treatment information from the provider for each OB encounter.
      • Complete proper paperwork for high-risk referrals to perinatalogists or other specialists.
      • Will not “drop” patients after two missed appointments, as is the habit with many private physicians. They must contact AMAXX to initiate the transfer to another provider.

      AMAXX also assisted the providers by pre-processing claims to minimize the number of rejections on claims (stop the “ping-pong” factor). If there were issues associated with the claims, AMAXX’s staff ‘tracked down’ the problem and checked the remittance advice to make sure the provider was paid properly. This interaction with the physician and his staff fostered a good working relationship with AMAXX.

      AMAXX has initiated an incentive program for provider’s offi ce staff. Appreciation luncheons are offered semi-annually for participating providers’ offi ce staff. Quarterly luncheons are also offered to providers’ offi ce staff that have consistently provided updated and correct information on members (demographics and high-risk clinical data).


      The study was conducted using the HMO’s Board Reports and independent review of hospital data. The reduction of the HMO’s NICU days per thousand was from 87 days per thousand admits in 2002 down to 50 days per thousand admits in 2004, a 45% reduction in days per thousand. Correspondingly, its NICU length of stay was 14 days in 2002 and in 2004 the average length of stay was 9.8 days, a 31% reduction in the average length of stay for neonates in the NICU. These fi gures were a result of our study of the HMO’s NICU admits, and the length of stay.

      Our fi ndings were borne out by the HMO’s Board Reports that illustrated the fact that in late 2001, when AMAXX’s contract was implemented, over 20% of its population was premature, and in late 2004 the prematurity rate had dropped to six percent (6%) in Shelby County. This 6% fi gure is almost two-thirds lower than the county rate of 18% (according to the March of Dimes latest—2003—data for African Americans). In 2001 the HMO spent $20 million for OB care for 76,000 members. By 2004 they spent $6 million for OB care for a population of 176,000. Concomitantly, a by-product of lowering prematurity is lowering admits to the Pediatric Intensive Care Unit. Each year that a healthy versus a premature baby is delivered, the cost of care is driven down.


      AMAXX far exceeded its objective of reducing the HMO’s days per thousand and ALOS by 10% annually. This was accomplished primarily through AMAXX’s relationship with the physicians, including the initiation of the global payment. The interaction with the physician and his offi ce staff fostered a good working relationship and ensured more coordinated care for AMAXX’s members. Another factor was the collaborative relationship and quarterly meetings with the university- affi liated OB providers, who handle the majority of the HMO’s high risk pregnant members in Shelby County.

      A program that interfaces with the entire OB delivery system and addresses issues of providers, hospitals, clinics, provides face-to-face and telephonic care for all its members, will signifi cantly affect birth outcomes for this population. It is fair to say that you must not only modify the behaviors of the members, but also initiate change in the health care delivery system. AMAXX has focused on system-wide changes to ensure care delivery improvements for its members.


      Results of the longitudinal study:

      1. Neonatal Intensive Care Unit Trended Results, 2001-2004 (Days per Thousand and Average Length of Stay)
      2. Trended Membership Results, 2000-2004 (Illustrates lowering of days per thousand as membership rises)
      3. Trended Cost Statistics—NICU and PICU Costs, 2002-2004
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