I recently had the honor of serving as a judge for URAC’s 2010 Awards for Best Practices in Health Care Consumer Empowerment and Protection. Although the title is quite a mouthful, what it boils down to are Awards for programs, usually developed and run by health plans and other health care organizations, that help patients and their families do better in our fractured health care “system.”

The winners of the Awards, about thirty of them, were invited to present at URAC’s XI Annual Quality Summit, held in Chicago on October 6 & 7. I moderated a series of presentations, all focused on improving outcomes for mom’s and their newborns,  particularly mom’s with high-risk pregnancies likely to result in a preterm delivery.


Preterm delivery problems

Preterm deliveries usually mean small or very small babies born weeks to months early.  The shorter the pregnancy, and the smaller the baby, the higher the number and severity of complications experienced by these tiny creatures. Baby’s lungs are often not fully developed requiring them to receive high dose oxygen therapy and, often, mechanical ventilation that can damage their eyes and their lungs respectively. These babes are also susceptible to brain bleeds, infections, and other serious disorders that put them at risk of dying before they are discharged from the hospital.

These vulnerable newborns are almost always managed in the NICU (neonatal intensive care unit) by highly skilled doctors, nurses, and other ancillary health professionals, such as respiratory therapists. These babies require, well, intensive care. This means that moms and dads may be separated from their tiny newborns for prolonged periods and even if they are encouraged to spend lots of time in the Unit, these are pretty daunting places for anyone either in or out of the health care field.  These families need lots of help.


Centene’s Start Smart for Your Baby

With that introduction to the problem, I want to describe one of the Award-winning programs that focuses on providing that help:  Centene’s Corporation’s “Start Smart for your Baby” program.

Centene is a health plan that provides managed care to individuals covered by government-sponsored programs (e.g, Medicaid, TANF, SSI, SCHIP, foster care, special needs plans.  Ok, guys, read that sentence again. Centene is a HEALTH PLAN that provides MANAGED CARE to people in government-sponsored programs. Aren’t those things supposed to be BAD according to common lore?? Well read on and you will learn about the good things that come from a motivated health plan that manages care and does it well.

The Start Smart program was spearheaded by three doctors: an internist (Mary Mason MD, SVP and Chief Medical Officer of Centene;  a pediatrician (Amy Pool-Yaeger, MD, Vice President of Medical Affairs for Centene);  and an ob-gyn (Brad Lucas, MD, another VP of Medical Affairs).  When I mentioned to them that they seemed to have covered all the bases, they responded, that it was “by design.” But they didn’t do it alone.  Not only were many other Centene employees involved but the group also collaborated with other organizations, such as the Centene Foundation, the American Academy of Pediatrics, and the March of Dimes, and the Wisconsin Women’s Health Foundation.

Start Smart provides services across the continuum of care for the women and babies eligible to enroll. That means well woman care, prenatal services, support for families while the baby is in the NICU, and follow-up to ensure good care after the baby goes home.  In fact, the babies remain enrolled for up to the age of two years.

What I like best about this program is that it is multi-faceted as opposed to the more simplistic single intervention programs often sponsored by health plans.  It was developed over time with new components added as needs were identified and results evaluated.  It has components targeting not only the health plan members (the patient and the newborn), but also doctors and, most unusual, a wide swath of employees of Centene.


Here are some of the key elements of the program:

  • Notification of pregnancy (NOP) questionnaire.   In order to identify eligible members, Centene culled claims data and sent out the questionnaire to the many thousands of women in their population that had a claim suggesting pregnancy.  In addition, they trained staff across the company to notify the Start Smart staff if they determined a member was pregnant of contemplating pregnancy (e.g., a member who asked the plan’s customer service representative about pregnancy benefits). Moms receive a free digital thermometer when they send in the NOP.  By January 2010, almost 60% of pregnancies were associated with a filled-out NOP.
  • Data from the NOP is used to identify high-risk pregnancies.  These women are provided with a nurse case manager to help them solve problems and coordinate their care.
  • All enrolled pregnant members receive educational information in a variety of formats:  print, via MP3 and on the web.)  The materials are in English and Spanish.
  • Incentives are used to reward healthy behaviors (such as keeping doctor’s appointments). These include Gift Cards and a special CentAccount card that can be used to buy things for the baby (e.g., diapers).
  • Members without cell phones are provided with them preprogrammed with their doctor’s phone number, their case manager’s phone number, the number to a 24-hour telenurse advice line, a line to call to arrange transportation, a domestic abuse hotline, and a health plan customer service number.  Members receiving newer smart phones will also find pre-loaded educational podcasts, healthy pregnancy guides, and relevant weblinks.
  • The Smart Start people have developed a “what to expect book” for moms and families as well as other educational materials.
  • Families receive stress reliever gifts while their babies are in the NICU (hand sanitizer, body lotion, healthy snacks) and at discharge, newborns receive gifts such as rattles and bibs.
  • The doctors of women identified as at risk for pre-term delivery (e.g., prior history of pre-term delivery) are offered help with implementing a 17-P program.  17-P is short hand for 17 hydroxyprogesterone, an “off label” injectable program, endorsed by the American College of Ob-Gyn, shown to delay the onset of labor.  Centene educates docs about this therapy and contracts with Alere, a disease management vendor, to administer the injections in the home.


And the results show…

Great news:  The program appears to be working. The three doctors showed results that suggest that over time there has been an improvement in the timeliness of prenatal care, in the percent of women going to their doctors more frequently, and getting timely post-partum care. Furthermore, in Centene’s patient population, the number of days in the NICU has decreased from 576/1000 births in 2007 to 386/1000 births in 2009.  The percent of babies born weighing less than 2500 grams has decreased from 11.3% of pregnancies in 2007 to 10.47% in 2009. These are all good things. One thing that was missing from the outcomes presentation was a good comparator, such as a national benchmark or a control group, so that you could be sure the improvements were the results of the program and not some other unrelated intervention such as a new medication or new vaccine.

The presenters estimate that the Start Smart program has saved money – approximately $10 million in 2009, primarily due to the reduction in NICU admissions. And it did so at a relatively modest cost of $5 per member per month for the pregnant population – or about $75 per pregnancy.

As we move away from the free-for-all of the no longer affordable model of fee-for service medicine into what I hope will be the era of Accountable Care (awful name) and Population Health, programs like Start Smart will be held up as shining examples of what MANAGED CARE can and should be.

All you nay-sayers who think that managing care is a bad thing need to read this post again.  Bad is unmanaged care where vulnerable families are on their own trying to deal with a complex scary situation they can barely understand. Good is proactive outreach to them.  Good is case management programs that provide that extra support during a trying time.  Good is healthier moms and fewer pre-term births. Good is better care at a lower cost.  What is not to like about that?