HMOs, docs work together to target low-birth weight

Good health care should not be proprietary’

Competition shouldn’t get in the way of better medicine. That conviction led to a collaborative of four Philadelphia-based health plans and about 800 clinicians in a project to improve pregnancy outcomes among Medicaid women.

And while it’s still too early to measure the clinical impact of the project, the collaborative approach is already providing much better data than any single health plan could have gathered, says Richard J. Baron, MD, FACP. Baron is an internist and president and CEO of Healthier Babies Inc., the nonprofit corporation that maintains the database.

The health plans and providers are all using the same data collection form, which can be used to identify patients at risk for low weight births. Some 90% of providers are sending their forms to the Healthier Babies project, allowing for population-based information and broad interventions, says Baron.

"The core commitment was to gather comprehensive prenatal data on all deliveries in 1999 and to link that with birth outcome information from birth certificates," he says. Armed with data that describes, for example, what percentage of Medicaid patients are smokers, health plans and medical groups can design interventions. The Healthier Babies project plans to target smoking as a risk factor this fall.

Together, the health plans hope to lower the low birth weight rate in the Philadelphia area, which is about double that of the federal "Healthy People 2000" goal of 5% of live births.

Health Partners, a nonprofit Medicaid managed care organization owned by five Philadel-phia health systems, spearheaded the Healthier Babies project to identify and intervene with at-risk pregnancies in a five-county area of southeast Pennsylvania. But Health Partners officials quickly realized that one health plan couldn’t do it alone. Any single payer would be able to impact only a portion of the physicians’ panel.

The three other health plans serving the Medicaid population were willing partners.

"Good health care should not be proprietary," says Deneen Vojta, MD, FAAP, senior vice president of medical affairs, and chief medical officer of Health Partners. "Each HMO has a different flavor about them, and we may go about solving the problem in different ways. But we all agree that we need to solve the problem."

Designing a uniform data form

The first challenge for the collaborative was to create a uniform intake and risk assessment form that could be used for all Medicaid pregnancies. That alone was a daunting task.

Three of the health plans had distinct risk-assessment forms that asked similar questions but in a different format. The providers were also varied, encompassing private practice, academic centers, community health centers, and federally sponsored health centers.

Meanwhile, the concept of creating a database of clinical information to monitor the outcomes of a subgroup of patients was novel for many physicians.

"Everybody’s used to standard financial reports of business performance of a practice," says Baron, who was formerly chief medical officer at Health Partners. "But people haven’t gotten as good at understanding ways to standardize and work with clinical information at the practice level."

Some physicians wondered if they would be compensated for the extra time required to fill out forms. (Previously, the completion rate of the different health plan forms wasn’t high.) But Baron stressed the overriding goal of collaborating for better outcomes. "We’re going to need some different kind of effort; we’re going to need to mobilize resources you don’t have [alone]," Baron told physicians. "This is a team approach."

The Robert Wood Johnson Foundation in Princeton, NJ, provided a $400,000 start-up grant, and Health Partners invested almost twice that much. The form evolved with input from physicians and research of the medical literature.

With education of providers and some pressure applied from health plans, the intake, follow-up, and post-partum forms quickly gained acceptance. Healthier Babies now receives about 1,800 forms a week. (See sample form, inserted in this issue.)

Intake data from those forms revealed one important risk factor: 18% of the pregnant women were smokers. Healthier Babies plans to coordinate a broad-scale smoking cessation program that targets pregnant women who are members of the Medicaid plans.

Meanwhile, individual health plans are making use of the data in different ways. Health Partners is developing a method to identify low- and high-risk members. "We are reaching out to our high-risk members with an education program to make sure they understand the signs and symptoms of pre-term labor," says Vojta.

The health systems that are part of the health plan also received data and tailored their own interventions. For example, Temple Health System discovered that women missed prenatal care because of transportation problems. So the health system purchased a van and provides rides to enable women to receive the care they need.

Health Partners also identified HIV-positive pregnant members and cross-matched their names with a pharmacy database to see if they were taking AZT. "Women who take AZT and have good obstetrical care markedly decrease the risk of transmitting HIV to their babies," says Vojta.

Medical groups also will receive data on their Medicaid population, risk factors, and subpopulations. "They will understand more about their practice," says Baron. "They’ll know what percentage of their women smoke; they’ll know their low birth weight rates. They’ll understand some relationship between those things."

By working together and using these data, the health plans and providers can truly manage care for better outcomes, says Baron. "It feels like a good opportunity to make a difference in an important public health problem," he says.