Savings achieved by giving WIC benefits to women prenatally.

The Special Supplemental Food Program for Women, Infants, and Children (WIC) provides supplemental food, nutrition and health education, and social services referral to pregnant, breastfeeding, and post-partum women, and their infants and young children who are both low-income and at nutritional risk. A number of statistically controlled evaluations that compared prenatal women who received WIC services with demographically similar women who did not receive WIC services have found WIC enrollment associated with decreased levels of low birth weight among enrolled women''s infants. Several also have found lower overall maternal and infant hospital costs among women who had received prenatal WIC services compared with similar women who did not receive prenatal WIC services. A meta-analysis of the studies shows that providing WIC benefits to pregnant women is estimated to reduce low birth weight rates 25 percent and reduce very low birth weight births by 44 percent. Using these data to estimate costs, prenatal WIC enrollment is estimated to have reduced first year medical costs for U.S. infants by $1.19 billion in 1992. Savings from a reduction in estimated Medicaid expenditures in the first year post-partum more than offset the cost of the Federal prenatal WIC Program. Even using more conservative assumptions, providing prenatal WIC benefits was cost-beneficial. Because of the estimated program cost-savings, the U.S. General Accounting Office has recommended that all pregnant women at or below 185 percent of Federal poverty level be eligible for the program.     

The cost of prematurity: a case-control study of twins vs singletons.

OBJECTIVES: This study evaluated the extent to which morbidity and costs at birth were associated with plurality, gestational age, and birth-weight with a sample of twins from a large urban hospital. METHODS: Each twin infant was matched to two singleton infants (control [ctrl]-singletons) for payor status and race, and to one singleton infant (gestation [ga]-singleton) for payor status, race, and gestational age; after exclusion of infants who were transferred, the study population included 111 twins, 242 ctrl-singletons, and 106 ga-singletons. Data were stratified by five gestational categories and compared across study groups. Outcomes included birthweight, neonatal diagnoses, infant length of stay, infant costs per day, and total infant and total birth costs. RESULTS: Total birth costs ranged from $280,146 at 25 to 27 weeks to $9,803 at 39 to 42 weeks, decreasing with advancing gestation to means of $88,891 (twins), $43,041 (ga-singletons), and $9,326 (ctrl-singletons). Twins did not differ from either group of singletons in prematurity-related diagnoses, length of stay, or costs until after 34 weeks' gestation. CONCLUSIONS: In this sample, prematurity, not plurality, was the predominant cost factor at birth. Compared with singletons, twins experienced increased morbidity and associated costs after 38 weeks' gestation.     

Use of Care, Outcomes and Costs of a Culturally-based Perinatal Program for Asian American and Pacific Islander Women in Hawaii

PURPOSE. This study examines whether psychosocial perinatal care services developed through community partnerships and cultural deference with attention to individual women's health issues, had an assocaited impact on use of prenatal care, birth outcomes and perinatal care costs for the three participating Asian Pacific Islander American ethinc groups. METHODS. The use of prenatal care visits and birth outcomes for women in the Malama program were compared to those for women of the same etnic groups in the community prior to the introduction of the program. Data on program participants from 1992 to 1994 were compared to birth certificate data on Hawaiian, Filipino and Japanese women from 1988 to 1991. Costs of providing Malama prenatal services were determined from data provided by cost accounting and encounter data systems for the program. SUMMARY OF IMPORTANT FINDINGS. The use of prenatal care visits and birth outcomes were significantly lower for Malama program participants than for women of the same ethnic groups prior to the introduction of the program. The costs of the prenatal program services were $846 to $920 per woman. The expected savings in medical costs per infant with the improved preterm birth rates were $680 per infant. Thus 75% to 80% of the costs of the services were likely to be saved in lower medical costs of the infants. MAJOR CONCLUSIONS. Programs that use community approaches and caring servies delivered in a cultural context, like the Malama model, have a potential for improving the use of prenatal care and birth outcomes at reasonable costs. RELEVANCE TO ASIAN PACIFIC ISLANDER AMERICAN POPULATIONS. The Malama approach to ascertaining cultural preferences for the content and delivery of care should prove useful in addressing public health goals of improved pregnancy outcomes for diverse groups of Asian Americans and Pacific Islanders. KEY WORDS. Asian Americans/Pacific Islanders, pregnancy, prenatal care, low birthweight, preterm birth, cultural competency, community partnerships, costs, cost effectiveness.     

Risk status and pregnancy outcome among medicaid recipients

Although Medicaid has increased access to medical care for low-income pregnant women, the Medicaid population remains at high risk for poor pregnancy outcomes. In 1983 the Michigan Department of Public Health conducted 1 week of in-hospital, postpartum interviews addressing risk factors for poor pregnancy outcome among 1,945 women. These births represented over 90% of the births during the study period and constituted a sample of approximately 1.5% of the yearly births in Michigan. Of these women, 24.6% reported receiving Medicaid during pregnancy. The demographic characteristics of the Medicaid women placed them at greater risk for poor pregnancy outcomes than either insured or uninsured women. In terms of medical services, Medicaid recipients began prenatal care later and had fewer visits. In terms of behavioral risks, more Medicaid recipients reported tobacco and alcohol use than did the other mothers. Finally, the infants of Medicaid recipients were 200 g lighter than the other infants. We suggest that the Medicaid program--the major source of prenatal health care for these women--is not adequate to address their risks for poor pregnancy outcomes.     

Neonatal health care costs related to smoking during pregnancy

RESEARCH OBJECTIVE: Much of the work on estimating health care costs attributable to smoking has failed to capture the effects and related costs of smoking during pregnancy. The goal of this study is to use data on smoking behavior, birth outcomes and resource utilization to estimate neonatal costs attributable to maternal smoking during pregnancy. STUDY DESIGN: We use 1995 data from the Center for Disease Control's (CDC) Pregnancy Risk Assessment Monitoring System (PRAMS) database. The PRAMS collects representative samples of births from 13 states (Alabama, Alaska, California, Florida, Georgia, Indiana, Maine, Michigan, New York (excluding New York City), Oklahoma, South Carolina, Washington, and West Virginia), and the District of Columbia. The 1995 PRAMS sample is approximately 25 000. Multivariate analysis is used to estimate the relationship of smoking to probability of admission to an NICU and, separately, the length of stay for those admitted or not admitted to an NICU. Neonatal costs are predicted for infants 'as is' and 'as if' their mother did not smoke. The difference between these constitutes smoking attributable neonatal costs; this divided by total neonatal costs constitutes the smoking attributable fraction (SAF). We use data from the MarketScantrade mark database of the MedStattrade mark Corporation to attach average dollar amounts to NICU and non-NICU nursery nights and data from the 1997 birth certificates to extrapolate the SAFs and attributable expenses to all states. PRINCIPAL FINDINGS: The analysis showed that maternal smoking increased the relative risk of admission to an NICU by almost 20%. For infants admitted to the NICU, maternal smoking increased length of stay while for non- NICU infants it appeared to lower it. Over all births, however, smoking increased infant length of stay by 1.1%. NICU infants cost $2496 per night while in the NICU and $1796 while in a regular nursery compared to only $748 for non-NICU infants. The combination of the increased NICU use, longer stays and higher costs result in a positive smoking attributable fraction (SAF) for neonatal costs. The SAF across all states is 2.2%. Across the states, the SAF varied from a low of 1.3% in Texas to a high of 4.6% in Indiana. CONCLUSIONS: These results further confirm the adverse effects of smoking. Among mothers who smoke, smoking adds over $700 in neonatal costs. The smoking attributable neonatal costs in the US represent almost $367 million in 1996 dollars; these costs vary from less than a million in smaller states to over $35 million in California. These costs are highly preventable since the adverse effects of maternal smoking occur in the short-run and can be avoided by even a temporary cessation of maternal smoking. These cost estimates can be used by managed care plans, state and local public health officials and others to evaluate alternative smoking cessation programs.     

Assessing the Economic Impact of Paternal Involvement: A Comparison of the Generalized Linear Model Versus Decision Analysis Trees

Lack of paternal involvement has been shown to be associated with adverse pregnancy outcomes, including infant morbidity and mortality, but the impact on health care costs is unknown. Various methodological approaches have been used in cost minimization and cost effectiveness analyses and it remains unclear how cost estimates vary according to the analytic strategy adopted. We illustrate a methodological comparison of decision analysis modeling and generalized linear modeling (GLM) techniques using a case study that assesses the cost-effectiveness of potential father involvement interventions. We conducted a 12-year retrospective cohort study using a statewide enhanced maternal-infant database that contains both clinical and nonclinical information. A missing name for the father on the infant’s birth certificate was used as a proxy for lack of paternal involvement, the main exposure of this study. Using decision analysis modeling and GLM, we compared all infant inpatient hospitalization costs over the first year of life. Costs were calculated from hospital charges using department-level cost-to-charge ratios and were adjusted for inflation. In our cohort of 2,243,891 infants, 9.2 % had a father uninvolved during pregnancy. Lack of paternal involvement was associated with higher rates of preterm birth, small-for-gestational age, and infant morbidity and mortality. Both analytic approaches estimate significantly higher per-infant costs for father uninvolved pregnancies (decision analysis model: $1,827, GLM: $1,139). This paper provides sufficient evidence that healthcare costs could be significantly reduced through enhanced father involvement during pregnancy, and buttresses the call for a national program to involve fathers in antenatal care.     

Expanding the Estimate of the Costs of Severe Maternal Morbidity to Include Readmissions,Physician Fees,and Infant Costs

Over the last 15 years, the United States has experienced major increases in the rates of severe maternal morbidity (SMM) or maternal “near misses.” Initial estimates of the costs of SMM have used delivery hospitalization data, which exclude physician costs and hospital readmissions from the estimates. The objective of this study was to expand existing estimates of the costs of SMM to include readmissions and physician costs and to examine whether SMM had an effect on infant costs. Secondary data analysis. We used the CDC definition of SMM, including readmissions up to 42 days postpartum. GLM models with a gamma distribution and a log link were used to estimate the effect of SMM on costs, controlling for race/ethnicity, cesarean delivery, type of insurance, parity, maternal age and BMI, multiple births, and an obstetric severity index. The infant models also controlled for gestational age, infant gender, and serious congenital anomalies. Models were estimated with and without hospital fixed-effects. California linked birth certificate-patient discharge data for mothers and infants for 2009-2011. About 200 000 were excluded for missing charge data (almost all insured by Kaiser Permanante). Cost-to-charge ratios were used to estimate costs from charges (including readmissions) and adjust for inflation to December 2017 dollars. Mean DRG-specific reimbursement was used to estimate physician payments. The final sample was 1 262 862. A case of SMM increases delivery costs to a mean of about three times those of a normal, uncomplicated delivery, $7014 vs $20 756. The added costs were $10 396 for vaginal deliveries and $15 838 for c-sections. Physician costs were over 20% of total SMM costs, $2290 (vaginal) and $3521 (cesarean), respectively. Including readmissions increased the SMM rate by 14.5%; these cases had a mean cost of $19 500, of which $4500 were MD costs. Mean infant costs were $23 318 with SMM and $6135 without, but this difference was much smaller for term deliveries ($5394 vs $2685). The risk-adjusted estimate was that SMM increased maternal costs by 72% and 71% and infant costs by 27% and 32%, with and without hospital fixed-effects, respectively. The per case maternal costs of SMM are triple those of a normal delivery. Further, readmissions and physician costs are important and previously unreported factors that add about $5000/case to the estimated maternal costs of SMM, increase the prevalence of SMM by 14.5%, and explain much of why our estimates are higher than previous reports ($6100-8600). SMM is also associated with modest increases in infant costs. Projecting our costs to the entire United States results in $825 million in addition maternal costs; adjusting for California’s higher costs still results in over $500 m in additional costs due to SMM. The costs of SMM extend well beyond those of the added costs of the delivery hospitalization. Failure to account for SMM-associated readmissions or physician costs result in a meaningful under-estimate of the costs of SMM. The additional infant costs associated with SMM need further investigation. National Institutes of Health.     

Racial Disparities in Economic and Clinical Outcomes of Pregnancy Among Medicaid Recipients

To explore racial-ethnic disparities in adverse pregnancy outcomes among Medicaid recipients, and to estimate excess Medicaid costs associated with the disparities. Cross-sectional study of adverse pregnancy outcomes and Medicaid payments using data from Medicaid Analytic eXtract files on all Medicaid enrollees in fourteen southern states. Compared to other racial and ethnic groups, African American women tended to be younger, more likely to have a Cesarean section, to stay longer in the hospital and to incur higher Medicaid costs. African-American women were also more likely to experience preeclampsia, placental abruption, preterm birth, small birth size for gestational age, and fetal death/stillbirth. Eliminating racial disparities in adverse pregnancy outcomes (not counting infant costs), could generate Medicaid cost savings of $114 to $214 million per year in these 14 states. Despite having the same insurance coverage and meeting the same poverty guidelines for Medicaid eligibility, African American women have a higher rate of adverse pregnancy outcomes than White or Hispanic women. Racial disparities in adverse pregnancy outcomes not only represent potentially preventable human suffering, but also avoidable economic costs. There is a significant financial return-on-investment opportunity tied to eliminating racial disparities in birth outcomes. With the Affordable Care Act expansion of Medicaid coverage for the year 2014, Medicaid could be powerful public health tool for improving pregnancy outcomes.     

Midwifery and Birth Centers Under State Medicaid Programs: Current Limits to Beneficiary Access to a High-Value Model of Care

Policy Points

• Birth center services must be covered under Medicaid per federal mandate, but reimbursement and other policy barriers prevent birth centers from serving more Medicaid patients.
• Midwifery care provided through birth centers improves maternal and infant outcomes and lowers costs for Medicaid beneficiaries. Birth centers offer an array of birth options and have resources to care for patients with medical and psychosocial risks.
• Addressing the barriers identified in this study would promote birth centers’ participation in Medicaid, leading to better outcomes for Medicaid‐covered mothers and newborns and significant savings for the Medicaid program.

ContextMidwifery care, particularly when offered through birth centers, has shown promise in both improving pregnancy outcomes and containing costs. The national evaluation of Strong Start for Mothers and Newborns II, an initiative that tested enhanced prenatal care models for Medicaid beneficiaries, found that women receiving prenatal care at Strong Start birth centers experienced superior birth outcomes compared to matched and adjusted counterparts in typical Medicaid care. We use qualitative evaluation data to investigate birth centers’ experiences participating in Medicaid, and identify policies that influence Medicaid beneficiaries’ access to midwives and birth centers.MethodsWe analyzed data from more than 200 key informant interviews and 40 focus groups conducted during four case study rounds; a phone‐based survey of Medicaid officials in Strong Start states; and an Internet‐based survey of birth center sites. We identified themes related to access to midwives and birth centers, focusing on influential Medicaid policies.FindingsMedicaid beneficiaries chose birth center care because they preferred midwife providers, wanted a more natural birth experience, or in some cases sought certain pain relief methods or birth procedures not available at hospitals. However, Medicaid enrollees currently have less access to birth centers than privately insured women. Many birth centers have difficulty contracting with managed care organizations and participating in Medicaid value‐based delivery system reforms, and birth center reimbursement rates are sometimes too low to cover the actual cost of care. Some birth centers significantly limit Medicaid business because of low reimbursement rates and threats to facility sustainability.ConclusionsMedicaid beneficiaries do not have the same access to maternity care providers and birth settings as their privately insured counterparts. Medicaid policy barriers prevent some birth centers from serving more Medicaid patients, or threaten the financial sustainability of centers. By addressing these barriers, more Medicaid beneficiaries could access care that is associated with positive birth outcomes for mothers and newborns, and the Medicaid program could reap significant savings.     

What price prematurity?

Data from a 1985 stratified sample of urban hospitals with neonatal intensive care units show that over half of the low-birth-weight infants in the United States are cared for in such centers. A cost analysis focusing on all infants who survive and go home from these hospitals revealed that those weighing from 500-2,500 g represent nine percent of the neonatal patient load, but consume 57 percent of the cost of their hospital care. Similarly, neonates in the 500-1,499 g range account for 1.6 percent of the infants cared for and over one-third or related costs in these urban facilities. If only 20 percent of infants moved from one birth-weight group (in 250 g intervals) to the next, this upward shift would result in an immediate savings of $70-$95 million. Estimates based on the published literature indicate that the programmatic expenditures for prenatal care needed to cause this shift would be $9-$28 million less than these immediate savings.     

Association Between Changes in Smoking Habits in Subsequent Pregnancy and Infant Birth Weight in West Virginia

West Virginia has one of the highest prenatal smoking prevalence rates in the nation. While overall national prenatal smoking rates have been declining, the prevalence rates in West Virginia continue to climb. Smoking in pregnancy has been associated with deleterious health outcomes in infants, including decreased birth weight. Yet, minimal research has been done on changes in smoking behaviors over time and the association of the changes in infant birth weights. The aim of the current study is to examine the change in prenatal smoking status of West Virginia women and the associated changes in infant birth weights. Population-based secondary data analysis was conducted using West Virginia birth certificates for all singleton infant siblings born between 1989 and 2006, linked based on mother. Infants born to women who smoked during pregnancy had significantly lower birth weights than infants born to non-smokers. Repeated measures analysis used to examine the changes with time showed that women who smoked during their first pregnancy but refrained from smoking during their subsequent pregnancy had significantly increased birth weight for the second infant, and conversely, infants born to women who initiated smoking with the subsequent pregnancy had significantly decreased birth weight compared to the previous infant. Findings of the study may be used to inform and to guide the development of population focused interventions to decrease maternal prenatal smoking in first and in subsequent pregnancies in an effort to improve infant birth weight outcomes.     

Second Births to Teenage Mothers: Risk Factors For Low Birth Weight and Preterm Birth

CONTEXT: Teenagers are more likely than older women to have a low-birth-weight infant or a preterm birth, and the risks may be particularly high when they have a second birth. Identifying predictors of these outcomes in second teenage births is essential for developing preventive strategies.
METHODS: Birth certificate data for 1993–2002 were linked to identify second births to Milwaukee teenagers. Predictors of having a low-birth-weight second infant or a preterm second birth were identified using logistic regression.
RESULTS: The same proportion of first and second infants were low-birth-weight (12%), but second births were more likely than first births to be preterm (15% vs. 12%). In analyses that adjusted for demographic, pregnancy and behavioral characteristics, the odds that a second infant was low-birth-weight or preterm were elevated if the mother smoked during pregnancy (odds ratios, 2.2 and 1.9, respectively), had inadequate prenatal weight gain (1.8 and 1.4), had an interpregnancy interval of less than 18 months (1.6–2.9 and 1.4–2.3) or was black (2.7 and 1.7). Women who had received an adequate level of prenatal care had reduced odds of both outcomes (0.6 and 0.4). Women younger than 16 also had increased odds of having a low-birth-weight second infant. Further adjustment for socioeconomic characteristics yielded largely the same results. In addition, women who were unmarried or did not identify a father were at increased risk of both outcomes (1.5 for each), and poor women were at risk of having a low-birth-weight infant (1.3).
CONCLUSIONS: Predictors of poor birth outcomes include modifiable behaviors. Prenatal interventions addressing these behaviors could help improve outcomes.     

Behavioral, health, and cost outcomes of an HMO-based prenatal health education program

This report presents the results of an evaluation of a prenatal health education program conducted within a health maintenance organization (HMO) setting. Specifically, the behavioral, birth, and treatment-cost outcomes for 57 women in an experimental group who received individual nutrition counseling and a home-correspondence smoking cessation program were evaluated against the outcomes for 72 women in a control group who received standard prenatal care. In comparison with the controls, a greater percentage of women in the experimental group quit smoking during pregnancy (49.1 percent versus 37.5 percent). Of those who smoked throughout their pregnancy, women in the experimental group had a greater reduction in their mean rate of daily smoking. A significantly greater percentage of experimental group women adjusted their diets during the prenatal period (91 percent versus 68 percent), and particular success was achieved in increased consumption of dairy products and vegetables, decreased consumption of coffee, and adequate weight gain during pregnancy. Analysis of birth outcome data revealed that infants born to the experimental group had a significantly higher mean birth weight than infants born to the controls (121.34 oz versus 113.64 oz). The experimental group also had fewer low birth weight infants (7.0 percent versus 9.7 percent for controls). Hospital treatment cost savings associated with the reduced incidence of low birth weight infants among experimental group women yielded an overall benefit-cost ratio for the prenatal program of approximately 2:1.     

Access to maternity care in rural Washington: its effect on neonatal outcomes and resource use.

OBJECTIVES: This study sought to ascertain the effects of poor local access to obstetric care on the risks of having a neonate diagnosed as non-normal, a long hospital stay, and/or high hospital charges. METHODS: Washington State birth certificates linked with hospital discharge abstracts of mothers and neonates were used to study 29809 births to residents of rural areas. Births to women from rural areas where more than two thirds of the women left for care were compared with births to women from rural areas where fewer than one third left for care. RESULTS: Poor local access to providers of obstetric care was associated with a significantly greater risk of having a non-normal neonate for both Medicaid and privately insured patients. However, poor local access to care was consistently associated with higher charges and increased hospital length of stay only if the patient was privately insured. CONCLUSIONS: These results indicate that local maternity services may help prevent non-normal births to rural women and, among privately insured women, might decrease use of neonatal resources.     

Care for veterans with mental and substance use disorders: good performance, but room to improve on many measures

In 2006 the Department of Veterans Affairs commissioned the Altarum Institute and the RAND Corporation to do an evaluation of its mental health treatment system. We found that veterans with mental illness and substance use disorders represented 15.4?percent of all veterans using Veterans' Health Administration (VHA) services in 2007 and that they accounted for 32.9?percent ($12?billion) of VHA costs, of which the majority was for non-mental health conditions. The average cost for a veteran with mental illness and substance use in our study was $12,337, or 2.7 times the cost for an average veteran without these conditions. The quality of care for the veterans in our study, although similar to or better than the care given to comparable privately insured patients or those enrolled in Medicare or Medicaid, varied by as much as twenty-three percentage points among regional service networks. Performance on some indicators, such as whether those with alcohol dependence received pharmacotherapy, was low. There is a need for substantial improvement in the care of these veterans, particularly with respect to ensuring the delivery of evidence-based treatments.     

A cost-benefit/cost-effectiveness analysis of smoking cessation for pregnant women

Research has shown that pregnant women who smoke cigarettes increase their risk of having low birthweight (LBW) infants. Recent randomized trials indicate that women who quit smoking early in pregnancy reduce their risk of delivering a LBW infant. Using various sources, we estimated the cost-effectiveness of a smoking cessation program for preventing LBW and perinatal mortality. Assuming the program would cost $30 a participant and that 15% of the participants would quit smoking, we determined that a program offered to all pregnant smokers would shift 5,876 LBW infants to normal birthweight and would cost about $4,000 for each LBW infant prevented. Since infants born to smokers are at 20% greater risk for a perinatal death, a smoking cessation program could prevent 338 deaths at a cost of $69,542 for each perinatal death averted. Compared with the costs of caring for these LBW infants in a neonatal intensive care unit (NICU), smoking cessation programs would save $77,807,054, or $3.31 per $1 spent. The ratio of savings to costs increases to more than six to one when we include reducing long-term care for infants with disabilities secondary to LBW in the benefits from smoking cessation programs. These findings argue for routinely including smoking cessation programs in prenatal care for smokers.     

An evaluation of the impact of maternity care coordination on Medicaid birth outcomes in North Carolina.

BACKGROUND. Care coordination is an important component of the enhanced prenatal care services provided under the recent expansions of the Medicaid program. The effect of maternity care coordination services on birth outcomes in North Carolina was assessed by comparing women on Medicaid who did and did not receive these services. METHODS. Health program data files, including Medicaid claims paid for maternity care coordination, were linked to 1988 and 1989 live birth certificates. Simple comparisons of percentages and rates were supplemented by a logistic regression analysis. RESULTS. Among women on Medicaid who did not receive maternity care coordination services, the low birth weight rate was 21% higher, the very low birth weight rate was 62% higher, and the infant mortality rate was 23% higher than among women on Medicaid who did receive such services. It was estimated that, for each $1.00 spent on maternity care coordination, Medicaid saved $2.02 in medical costs for newborns up to 60 days of age. Among the women who did receive maternity care coordination, those receiving it for 3 or more months had better outcomes than those receiving it for less than 3 months. CONCLUSIONS: These results suggest that maternity care coordination can be effective in reducing low birth weight, infant mortality, and newborn medical care costs among babies born to women in poverty.