Maternity CM saves costs, prevents heartache

Cost of a preterm infant can last a lifetime

The old saying "An ounce of prevention is worth a pound of cure," couldn't be more appropriate than when it comes to preterm births.

A report by the Institute of Medicine — Preterm Birth: Causes, Consequences, and Prevention — estimates the cost of preterm births in the United States in 2005 totaled at least $26.2 billion. The March of Dimes estimates that the average cost for a preterm infant is $49,000 compared with an average of $4,500 for full-term infants.

A stay in the neonatal intensive care unit (NICU) costs an estimated $2,000 to $3,000 a day, depending on the needs of the infant, says Angela Glyder, RN, CCM, director of integrated case management for Select Health of South Carolina, a Charleston-based health plan. "The cost adds up quickly when you consider the extended inpatient stays we see with these NICU babies," she says.

The initial costs of preterm births are staggering, but they often continue long after infants are discharged from the neonatal intensive care unit (NICU), adds Catherine M. Mullahy, RN, BS, CRRN, CCM, president and founder of Mullahy and Associates, a case management consulting firm in Huntington, NY.

"So many preemie babies have long-term problems, and the cost of their care continues for over a lifetime," she says.

Preterm babies have a higher prevalence of cerebral palsy, mental retardation, vision problems, and hearing loss than their full term counterparts and require medical care throughout their lifetime. In addition, premature and low birth weight infants often face development delays that impact them for many years. "They start from behind and it takes them a long time to catch up with their peers," Glyder says.

Cost is just one reason case managers should focus on preventing preterm deliveries, Mullahy says. Helping parents avoid the heartbreak and disappointment of coping when a child is in the NICU and needs extra care at home is another reason. "Case managers are involved in managing and preventing an array of medical conditions, but preterm deliveries is one of the most compelling," she adds.

Each year, almost 500,000 babies are born prior to 37 weeks gestation. That's one in every eight births, according to the Atlanta-based Centers for Disease Control and Prevention. Preterm delivery is the leading cause of infant death, the CDC adds.

"While preterm births comprise only 12% of all births nationwide, the staggering costs for early delivery are high," says Heather Jarrett, RN, BSN, senior vice president of government programs for Alere Health. Research shows that pregnancy case management programs can reduce pregnancy-related hospitalizations, she says. She recommends pregnancy management plans that include management for women during pregnancy and NICU case management for premature babies.

Early and consistent prenatal care identifies potential problems, and case management can engage pregnant women and educate them on how to stay healthy during pregnancy and identify warning signs that could indicate preterm labor, says Sherry Rumbaugh, RN, BSN, director of care coordination and quality for Passport Health Plan, with headquarters in Lexington, KY.

Passport's Mommy Steps Program, which focuses on three steps to a healthy pregnancy—regular doctor visits, healthy eating, and making good choices — consistently exceeds the state of Kentucky's goals for managing the care of at-risk pregnant women.

Case managers are in a position to educate women to have healthy pregnancies and avoid delivering premature babies, but first they have to identify them, Mullahy says. She advises case manager to look beyond the usual clues, such as a previous preterm birth or pregnancy-induced hypertension, to identify other women who may not be at risk.

For instance, women who conceive by in vitro fertilization, teenagers, and those over 35 should be in a high-risk program. Data from a wellness program can also indicate women at risk. For instance, cigarette smoking, poor nutrition, excessive alcohol use, and substance abuse can also put women at risk, Mullahy says.

"Obesity is another factor that often gets overlooked, but women who are obese have a much higher instance of Type 2 diabetes and hypertension, both of which can put a pregnancy at risk," she says.

Pregnant women who are Medicaid recipients experience a higher percentage of adverse outcomes than those covered by commercial insurance, she says.

Case managers who work with pregnant Medicaid recipients should have a lower caseload than those working with a commercial population, Mullahy suggests.

"Patients in Medicaid plans tend to have a disproportionately large share of preterm births. In addition to other risk factors, these women may not have transportation or they may be in a rural area or inner city neighborhoods where physicians don't accept Medicaid. They need the best in medical care, and their lack of access to a provider could be a barrier," she says.

Roanna Williams, RN, CCM, supervisor of case management for BlueCross BlueShield of Tennessee, points out that Medicaid members have tremendous needs that include basic resources such as adequate food, shelter, utilities, and transportation to appointments. The health plan's CaringStart program provides face-to-face case management for women treated at a large obstetrical practice. (For details, see related article below).

"In some cases, Medicaid members may live in a rural area, or even an inner-city neighborhood where physicians don't accept Medicaid. They need the best in medical care during their pregnancy but often, they don't have access," Mullahy says.