issue brief EARLY ELECTIVE DELIVERIES IN MISSISSIPPI Impact on Health and Medical Care Costs PUBLISHED NOVEMBER 2013 A large body of evidence indicates early elective birth is a major risk factor for increased neonatal illness and death, as well as a driver of medical costs. This issue brief describes the impact of early elective deliveries and examines policies designed to improve birth outcomes through postponing elective deliveries. There are well documented benefits for newborn health and reductions in costly medical care services associated with postponing elective deliveries for non- medical reasons until at least 39 weeks of pregnancy. Figure 1 illustrates the significantly (p<.05) higher death rates found for all babies born just 1 to 2 weeks earlier than 39 weeks of pregnancy, elective or otherwise. There are significantly higher death and intensive care unit admission rates in the U.S. Figure 2 shows significantly (p<.05) higher intensive care unit admission rates for babies born electively during the for babies born before 39 weeks gestation. 37th and 38th week of gestation. Research shows elective deliveries are often scheduled early for non-medical reasons. Health experts advise delaying these non-medically necessary deliveries until at least 39 weeks. FIGURE 1. U.S. NEONATAL DEATH RATES PER 1,000 LIVE BIRTHS BY WEEK OF DELIVERY, 2001 EARLY ELECTIVE DELIVERIES 39 Weeks 0.8 Induced labor or C-section delivery by a health care provider before the 39th week of pregnancy for non-medical reasons. 38 Weeks NEONATAL 1.0 Infant age up to 28 days after birth. 37 Weeks 1.7 0.0 1.0 2.0 Source: Reddy et al. (2009). Pediatrics,124:234-240. HEALTH RISKS MEDICAL SERVICES FIGURE 2. U.S. NEONATAL INTENSIVE CARE ADMISSION RATES BY WEEK OF ELECTIVE DELIVERY, 2009 ASSOCIATED WITH NEEDED MORE 18.0 17.8 EARLY OFTEN FOR EARLY ELECTIVE BIRTHS ELECTIVE BIRTHS Breathing problems Ventilation Feeding problems Intravenious therapy 8.0 8.0 4.6 Infections Intensive care services Low body Incubation temperature 0.0 37 Weeks 38 Weeks 39 Weeks Source: Clark et al. (2009). Obstetrics & Gynecology, 200(156): e1-e4. 1 of 4 Center for Mississippi Health Policy � Brief: Early Elective Deliveries in Mississippi-Impacts on Health and Medical Care Costs � NOVEMBER 2013 Early Elective Deliveries in Mississippi Mississippi reflects trends found nationwide, as all the births during 37 and 38 weeks of pregnancy climbed significantly (p<.01) from 2001 to 2011. During the 37% same time frame, all the births at 39 weeks or later in pregnancy, elective or not, declined significantly (p<.01) in Mississippi. Births during 37 and 38 weeks There was also a statistically significant (p<.01) rise in early elective deliveries of pregnancy in Mississippi during 37 and 38 weeks of pregnancy in Mississippi from 2001 to 2011 increased 37% from 2001-2011 (Figure 3), which leveled off after 2008. However, over the span of the last decade, early elective deliveries doubled statewide. FIGURE 3. EARLY ELECTIVE LIVE BIRTH TRENDS FOR 37 AND 38 WEEKS OF GESTATION IN MISSISSIPPI FROM 2001-2011 28% 24% 20% 17.8% 17.0% 15.9% 16.3% 16.5% 15.0% 2x 16% 11.7% 13.3% 14.1% 12% 9.8% 8.5% Early elective deliveries during 8% 37 and 38 weeks of pregnancy 4% doubled from 2001-2011 0% 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 Source: Mississippi Department of Health. (2013). Office of Vital Statistics, 2001-2011. Figure 4 shows babies born electively in Mississippi during 37 and 38 weeks of gestation compared to babies born during 39 weeks of gestation had significantly (p<.05) higher death rates within the first month of life. FIGURE 4. EARLY ELECTIVE DELIVERY AND 39 WEEK DELIVERY NEONATAL DEATH RATES PER 1,000 LIVE BIRTHS IN MISSISSIPPI, 2007-2011 39 Weeks 0.6 3x Neonatal death rates over a 5 year 38 Weeks 1.0 period in Mississippi among elective deliveries are more than 3 times higher in week 37 than in week 39 of delivery 37 Weeks 2.1 0.0 0.5 1.0 1.5 2.0 2.5 Source: Mississippi Department of Health. (2013). Office of Vital Statistics, 2007-2011. 2 of 4 Center for Mississippi Health Policy � Brief: Early Elective Deliveries in Mississippi-Impacts on Health and Medical Care Costs � NOVEMBER 2013 Health and Medical Care Costs INSTITUTE OF MEDICINE The Institute of Medicine (IOM) estimated the average economic cost of early COSTS PER EARLY DELIVERY, 2005 deliveries was $51,600 per infant in 2005. Medical care services accounted U.S. ECONOMIC BURDEN COST PER for nearly three-quarters (71%) of these costs. A majority (85%) of the medical INFANT care costs are accumulated during early infancy. Upon release of the IOM Medical Care Services $33,200 study findings, a flurry of activity among states to reduce early births ensued, in part because state Medicaid programs finance about 45 percent of all births. Lost Productivity $11,200 (labor & household) To estimate the financial impact on the Texas Medicaid program, the Health and Maternal Delivery Costs $3,800 Human Services Commission reviewed early elective deliveries from Medicaid claims data. The Commission projected $7.2 million in cost savings over a two year Special Education $2,200 time frame if early elective deliveries were reduced by 8 percent. Early Intervention Services $1, 200 North Carolina estimated $2.4 million in cost savings by avoiding neonatal TOTAL COST PER INFANT: $51,600 intensive care unit admissions after successful reductions in early elective deliveries. Efforts to reduce early elective deliveries in Ohio resulted in fewer neonatal intensive care unit admissions. Estimated medical care cost savings were $24.8 million over 3 years, half of which were for mothers enrolled in Medicaid. More than half of Mississippi’s 40,000 births annually are covered by the state Medicaid program. These findings suggest altering early elective delivery patterns could return major cost savings. Policies Adopted by Other States HARD STOP POLICIES Many states are working to improve newborn health outcomes and reduce costs Strictly enforced hospital policy against associated with early elective deliveries– a modifiable risk factor. A few of the early elective deliveries at fewer states that have had success in lowering statewide rates of early births after policy than 39 weeks gestation. enactment are highlighted below: SOFT STOP POLICIES Policy in which health care providers agreed Louisiana hospitals adopted policies to end early elective deliveries in concert not to perform early elective deliveries before 39 weeks gestation. with medical malpractice carriers’ providing financial incentives. Carriers reduced provider premiums after receipt of education on reducing early elective deliveries. PROVIDER EDUCATION PROGRAM Education program that informs health care providers about the risks associated with Ohio implemented a public reporting program through the state’s health agency. delivery before 39 weeks of gestation. Each hospital’s individual early elective delivery rate is reported statewide. North Carolina participating hospitals adopted “hard stop” policies and used patient REDUCTIONS IN EARLY and provider education to reduce early elective births. ELECTIVE DELIVERIES BY POLICY TYPE POLICY TYPE CHANGE IN RATE Texas legislators mandated Medicaid non-payment for elective deliveries before the 39th week of gestation. Hard Stop 8.2% to 1.7%* Washington state’s Medicaid program pays reduced rates for early elective Soft Stop 8.4% to 3.3%** deliveries and pays increased rates to hospitals achieving lowered benchmark Provider Education Only NS delivery rates. Source: Clark, et al. (2010). American Journal of Obstetrics & Gynecology, 203:449, e1-6. *Statistically significant (P=.007).**Statistically signficant (P=.025). West Virginia developed public/private agency partnerships to collectively reduce NS = No statistically signficant change. early elective deliveries by targeting selected birthing hospitals across the state. 3 of 4 Center for Mississippi Health Policy � Brief: Early Elective Deliveries in Mississippi-Impacts on Health and Medical Care Costs � NOVEMBER 2013 Policy Considerations Due to the mounting evidence of the serious health consequences and health care costs documented, policies to reduce elective deliveries are being recommended by health organizations nationwide. Based on the evidence, the American College of Obstetricians and Gynecologists (ACOG) and the Association of State and Territorial Health Officials (ASTHO) suggest adoption of the following policies to reduce the incidence of early elective deliveries: Modify state payment policies to encourage health providers to postpone elective deliveries until at least 39 weeks of gestation (e.g. payment withholding, penalties, or bonuses). Encourage hospitals to adopt policies to end elective, non-medically necessary deliveries before 39 weeks of gestation. Partner with medical malpractice carriers to reduce premiums when providers receive education on the importance of reducing elective deliveries before 39 weeks of gestation. Collect and report data on early elective deliveries in order to measure and monitor progress of policy changes. Sources American College of Obstetricians & Gynecologists. (2013). Nonmedically indicated early-term deliveries. Committee Opinion, No. 561. Obstetrics & Gynecology, 21:911–915. Applegate, M. (2012). Improving care and proving it. 2nd Annual CMS Medicaid/CHIP Quality Conference, Baltimore, MD. Association of State and Territorial Health Officials. (2013). Improving birth outcomes position statement. Policy and postion statement as approved on March 15, 2012. http://www.astho.org. Behrman, R.E. & Butler, A.S. (2006). Preterm birth: causes, consequences, and prevention. Institue of Medicine of the National Academies. Washington, D.C. National Academies Press. Clark, S., Miller, D., Belford, M., Dildy, G., Frye, D., & Myers, J. (2009). Neonatal and maternal outcomes associated with elective term delivery. Obstetrics & Gynecology, 200(156):.e1-156.e4. Clark, S.L., Frye, D.R., Meyers, J.A., Belfort, M.A., Dildy, G.A., Kofford, S., Englebright, J., & Perlin, J.A. (2010). Reduction in elective delivery at <39 weeks of gestation: comparative effectiveness of 3 approaches to change and the impact on neonatal intensive care admission and stillbirth. American Journal of Obstetrics & Gynecology, 203:449, e1-6. Donovan, E.F., Lannon, C., Bailit, J., Rose, B., Iams, J.D., & Byczkowski, T. (2010). A statewide initative to reduce inappropriate scheduled births at 36(07)-38(6/7) weeks’ gestation. American Journal of Obstetrics & Gynecology, 202(3): 243 e1-e8. Gee, R.E., Alletto, M.M., & Keck, A.E. ( 2012). A window of opportunity: the Louisiana birth outcome initiative. Journal of Health Politics, Policy, and Law, Vol. 37(3): 551-557. King, V.J., Pilliod, R.P., & Little, A. (2010). Medicaid evidence based decisions project (MED) rapid review: elective inductions of labor. Portland: Center for Evidence-based Policy. http:// www.ohsu.edu /xd/research/centers-institutes/evidence-based-policy-center/med/index.cfm. McCaffrey, M.J. (2012). Perinatal quality collaborative of North Carolina. Neonatal Outcomes Improvement Project (NOIP) Technical Report. Perinatal Quality Collaborative of North Carolina. Mississippi State Department of Health. (2013). Vital statistics births, 2001-2011. Mississippi State Department of Health. (2013). Vital statistics births linked to deaths, 2007- 2011. Plaza Building, Suite 700 Texas Health and Human Services Commisssion. (2011). Medicaid and healthy babies. http://alt. 120 N. Congress Street coxnewsweb.com/statesman/politifact/012011_hhscmedicaidhealthybabiespresentation.pdf. Jackson, MS 39201 Texas Health and Human Services Commission. (2013). Chapter 2: Reduce Medicaid pre-39 week elective deliveries. Texas Medicaid and CHIP in Perspective, 9th edition. http://www.hhsc. state.tx.us/Medicaid/reports/PB9/3_PB_9th_ed_Chapter2.pdf. Phone 601.709.2133 National Governor’s Association. (2012). Case Study: Louisiana Birth Outcomes Initiative. http:// statepolicyoptions.nga.org. Fax 601.709.2134 Reddy, U.M, Ko, C.W., Raju, T.N., Willinger, M. (2009). Delivery indications at late-term gestations and infant mortality rates in the United States. Pediatrics, 124:234-240. www.mshealthpolicy.com West Viriginia HealthCare Authority. (2008). West Virginia quality collaborative for eliminating non-medically indicated elective deliveries prior to 39 weeks gestation. http://www.wvperinatal. org/reports.htm 4 of 4 Center for Mississippi Health Policy � Brief: Early Elective Deliveries in Mississippi-Impacts on Health and Medical Care Costs � NOVEMBER 2013