Managed Care - January 2008 - (Page 49) socioeconomic groups, considerable attention is focused on preventing poor birth outcomes and NICU admissions. Centene health plans have obstetric nurse case managers and social workers who provide support for pregnant mothers who are identified as being at high risk for complications during pregnancy. A notification system is in place to allow our health plans to identify members as early as possible in their pregnancy. However, because of a number of factors including members not accessing prenatal care in a timely manner, delays in state eligibility processes, and noncompliance with notification requirements, our plans frequently do not identify a woman’s pregnancy until she is well into her second or third trimester. For example, in 2006 over 15 percent of the pregnant mothers in Superior Health Plan, Centene’s Texas subsidiary health plan, joined after 21 weeks gestation. Availability From 2004 to 2007, 17P was not offered as a covered benefit in feefor-service Medicaid in any of the states (Georgia, Indiana, New Jersey, Ohio, Texas and Wisconsin) where Centene currently operates health plans. The fee-for-service Medicaid program is prohibited from paying for any drug product for which a rebate agreement has not been signed. Centene has verbiage in its contracts that allows its health plans to provide 17P as a benefit for the managed Medicaid population. The use of 17P treatment is voluntar y, and physicians have adopted its use at varying rates. Therefore, determining whether or not the introduction of the use of 17P, after the time period recommended by previous studies (16– 21 weeks gestation), would benefit these higher risk cases was a key motivating factor in conducting the present study. Indeed, if it could be demonstrated that 17P injections after 21 weeks gestation could have the same beneficial effects as revealed in other studies, better health outcomes could be provided to plan members, and plan care costs could be reduced. Identification of high risk members For this review, members who received 17P during their pregnancy were identified by reviewing claims and by collecting data from the obstetric (OB) case managers in each of the Centene health plans. Providing the 17P benefit Once a physician identified a member who is a candidate for 17P, the health plan made arrangements to administer the injections in the physician’s office or through a home health agency. Frequent contact with the health plan’s OB case managers provided the members with information and support to facilitate education and compliance with the treatment. The time frame for initiation of 17P treatment was determined by member enrollment in managed Medicaid, timing of the initial prenatal care visit, and when the health plan learned of the member’s pregnancy. Statistical test A chi-square analysis (2 x 2 contingency table), commonly used when comparing the number of occurrences between two groups or time frames, was conducted to determine the significance of reduction in NICU admissions and pregnancy outcomes between the two groups. Using statistical tests rules out the risk of chance being the contributing factor to reductions and/or improvements in outcomes and also accounts for variations in sample sizes. The p-value assigned to determine statistical significance and account for sample size variation at 95 percent confidence is less than 0.05. RESULTS We measured the effectiveness of 17P by analyzing and comparing results under two comparative conditions, onset of treatments (gestation) and number of treatments (injections). The first condition consisted of a two-group comparison between those members who were 1) treated with injections between 16 and 21 weeks gestation and 2) those members treated after 22 weeks gestation. The second condition consisted of a comparison between 1) those members who received fewer than five injections and 2) those members who received more than five injections during their pregnancy. To assess treatment effectiveness, we used a) the NICU admission rate, b) the rate of preterm delivery prior to 32 weeks, c) the rate of preterm delivery between 33 and 37 weeks gestation, and d) the total infant deaths related to preterm delivery. All members were enrolled in case management, as they had been identified by prenatal risk assessments as being at risk for preterm delivery. In addition to educational material, members in OB case management received ongoing followup services and support to help them comply with treatment and for continued prenatal care. Initiation of treatment comparison The sample consisted of 47 women who were administered 17P within the recommended time frame of 16–21 weeks gestation and 57 women who were administered treatment after 22 weeks gestation. Table 1 demonstrates the results. NICU admissions The group initiating 17P between JANUARY 2008 / MANAGED CARE 49
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