Collaborative program works to improve high-risk prenatal care

Medicaid plans seek healthier moms and babies

Collaboration among four competing HMOs? They said it could never happen in Philadel-phia until a nonprofit HMO, Health Partners, envisioned a cooperative approach to prenatal care for high-risk women on Medicaid.

After months of coalition building, beginning in 1997, Health Partners and its three for-profit competitors joined with numerous community service and government groups to form Healthier Babies Inc., a collaborative project run by "stakeholder governance." It is the first population-based effort to improve birth outcomes for women on Medicaid.

For providers in the five-county region surrounding Philadelphia, the project brings a measure of relief from paperwork. A universal prenatal encounter form (UPEF) replaces several sets of forms.

For expectant moms, the UPEF means better care. "The Medicaid population changes plans frequently," explains Deneen Vojta, MD, senior vice president for medical affairs and chief medical officer for Health Partners. "So when you have the same form from provider to provider, you have more continuity." (See sample UPEFs, inserted in this issue.)

The benefit of simplified paperwork reaches beyond continuity of care. It attacks administrative costs, the last remaining area of waste in the health care industry, according to Vojta.

"Cost savings on the medical side of the health care industry are over; hospitalization rates are about as low as they’re going to go. The savings have to come from the administrative side," she says. And in that area, opportunities abound. Like their counterparts from coast to coast, each of the Philadelphia Medicaid HMOs issued its own forms and provider numbers.

"If you simplify the administrative processes, as we have with Healthier Babies, you save money and you take better care of patients. I think that what we’ve done here is what you’ll see nationally in five years. While the forms may differ, the principles of simplification and collaboration will be similar to Healthier Babies," adds Vojta.

The story of a successful coalition

The project’s story highlights a rule of successful coalition building: Hurry and draw every interest group in early, and slow down to identify what it takes to earn their long-term loyalty and contributions, explains Richard Baron, MD, FACP, president and CEO of Health Partners and champion for the project.

Healthier Babies’ data collection model and growing database are promising prototypes for improving the care of high-risk patient populations. "We still have to develop therapies around these data," he notes. "But first, we had to get people to focus on using the forms. There is one clear message from our experience: If you want to get providers to give you high rates of good clinical information, a regional effort is your only hope. Our 90% completion rate for the encounter forms is significant. We would not have that if we asked providers to fill out nine or 10 different forms."

Katherine Lupton, operations manager for Healthier Babies, points out that the UPEF replaces three other forms, including the HMOs’ prenatal risk-assessment tools. "We did not want to make the providers’ task harder; we wanted to streamline it as much as possible."

Another provider perk is the elimination of several phone calls. "These forms go to Healthier Babies pretty much in real time, and that expedites the authorization of special services if issues are listed like homelessness or drug use, for example."

Competitive habits persist like weeds — a few bruised egos and hours of tough negotiation lie in the wake of this partnership. As the only nonprofit of four HMOs, Health Partners applied for and administered the $500,000 in grants from the Robert Wood Johnson Foundation and the Center for Healthcare Strategies, both in Princeton, NJ.

The grants, coupled with the vision of the Health Partners leadership, sustained the project through the building period of roughly one year. Confidentiality and control issues loomed as deal breakers throughout. Grant monies ran out in May 1998; the Healthier Babies board held its first meeting in July 1998.

The coalition builders’ foremost challenges, according to Baron, were:

1. Base of operations.

From the beginning, Health Partners expressed its willingness to spin off the data collection, processing, and housing piece to an outside entity. The choice was the Philadelphia Health Management Corporation (PHMC), a local nonprofit umbrella group providing management support for a number of small nonprofit agencies.

2. Confidentiality of the data.

Complex legal regulations surround collection, management, and use of information about HIV carriers and drug and alcohol users. Healthier Babies covered the concerns by including representatives of the consumer advocacy and legal communities.

3. Provider buy-in.

Clinicians are leery of forms and hold little warmth toward HMOs. The work simplification offered by the UPEF won them over.

4. Funding for data collection and processing activities after the grant period.

The HMOs were the logical source, and eventually they consented after seeing the organizational benefits awaiting them.

5. History of failure by similar cooperative efforts.

The power of the naysayers carried formidable force, Baron acknowledges. He credits the Health Partners representatives for prevailing, fired by an interest not in ownership, but in what cooperation could mean for clinicians and patients. Baron wielded enormous influence as former chief medical officer with Health Partners and as bearer of extensive knowledge of Pennsylvania’s Medicaid program.

Transferable lessons from Healthier Babies

Lupton describes the organizational building blocks that took months to stack into place, without which this collaborative would have joined its failed predecessors:

Think expansively as you identify key stakeholders.

In its present form, the Healthier Babies coalition represents clinical, consumer, health plan, government, advocacy, and legal groups.

Build a forum in which to bring the stakeholders together.

Identify common ground for cooperation.

In the case of the HMOs and providers, it was to improve the health of the vulnerable population of Medicaid women. "Primarily, we started with the chief medical officers of the HMOs, then we infiltrated their organizations, communicating with all the people who would eventually work with us — the claims departments, medical records, and case managers," Lupton says. Tailor your message to show all the players how cooperation can serve their professional and altruistic interests.

Forge a contractual arrangement with an outside entity.

The four HMOs contract with Healthier Babies Inc. for information management, analysis, and reporting to the state Medicaid agency.

Secure key stakeholders’ agreement on the database contents.

Resolve legal concerns related to the data collection.

Designate a centralized repository for the database and a governance structure for data ownership, data release, access, confidentiality, and use.

Make a connection with professional clinical organizations.

In this case, it was the American College of Obstetricians and Gynecologists (ACOG) in Washington, DC.

Establish compliance procedures for data collection from providers.

"The data collection and processing runs smoothly because it has simplified the administrative procedures," notes Vojta. On average, UPEFs are submitted and processed within two weeks of completion by the physician’s office.

Install a formal communication process to reach everyone who will be affected, including the media.

Press conferences are an effective way to convey your key message to the community and your target population.

Baron believes the Healthier Babies information management model could work for asthma populations as well as high-risk pregnancy.

Speaking from experience

An ambitious effort like Healthier Babies could hardly reach its present stature without a few missteps along the way. Baron shares two he believes others could avoid if forewarned:

1. "I wish we had tried to work with [members of] the organized provider community earlier. When we got to them, they were mad at us," he confesses. Healthier Babies now has ties with both ACOG and local physician groups.

2. "We started without a particular clinical improvement activity in mind, like smoking cessation," he notes. While the original encounter forms asked whether a woman smokes, the smoking cessation community explained that they should have asked whether she ever smoked or whether she smoked in the past 30 days. Version 2 UPEFs reflect the change.

Although Healthier Babies has a rich database, "people can ask what difference we have really made because of the project and the data collection. We would have been wiser to ask ourselves what outcomes we really wanted to achieve and to build even one outcome into the research design, like reducing homelessness or cocaine use or pregnancy-induced hypertension. I wish we had thought that through a little more and taken the advice of people who told us to build it in early," he says.

Unprecedented QI opportunities

If a fancy software package had been a top priority for the project planners, any number of commercial vendors could have filled the bill. Instead, they chose PHMC to mastermind the information management component. "They had experience in data collection from homeless and HIV-positive women. They understood that the hard part would be capturing information in the field and getting the providers to turn it in," Baron says. They also could offer a good home for the project and its data, he adds.

A 90% provider reporting rate soundly affirms the wisdom of the planners. "That means that more than 90% of the time, for pregnant women in five Pennsylvania counties [covered by] four Medicaid HMOs, we get a clinical report of that encounter," Baron says. As of March this year, that amounts to data from 156,000 encounters with 29,000 pregnant women.

As it turns out, the database package is no clunker. In one to two mouse clicks, you can sort out low birth weight babies, or cocaine-using or teen moms. "But that’s good news and bad news," Baron cautions. While the data enable the HMOs to easily identify high-risk mothers, "there’s not a lot of literature about what you can do to improve birth outcomes for this population."

By the same token, there’s a good chance that the Healthier Babies findings might answer some of those questions. "We’ve never had the opportunity to look at a population of 315 cocaine-using pregnant women in this city," explains Baron. The next task is to develop care practices based on findings from the data.

Currently, Healthier Babies is analyzing 1999 birth certificate data together with 1998 prenatal risk data. Baron says that if prenatal cocaine use proves to have as big an impact on low birth weight as people think, they can identify and target cocaine-using pregnant women for intensive interventions, as opposed to the typical referrals to drug treatment programs.

The following year, they could measure the impact.

"Having these data is like [being] a kid with a new microscope," he reflects. "We have the information, but we don’t know yet what it means. It’s like the first X-rays — they had the pictures but they didn’t know what they meant."

Need More Information?

For more on collaborative initiatives among Medicaid HMOs, contact:

o Katherine Lupton, Operations Manager, Healthier Babies Inc., c/o Philadelphia Health Management Corporation, 260 South Broad St., Suite 1800, Philadelphia, PA 19102-5085. Telephone: (215) 985-2517. E-mail: hbabies @phmc.org.