Baby boom: what financial impact is the uptick of multiple births having on health plans?

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In July 31, Rachelle Wilkinson of Cedar Park, Texas, delivered three girls and two boys weighing a combined 21 pounds, 7.2 ounces--thus setting (by six ounces) the American record for giving birth to the heaviest quintuplets.

Kassidy, Kaydence, Kyndall, Rustin and Ryder were delivered by Caesarean section at Banner Good Samaritan Medical Center in Phoenix.

While gestations of four, five and even more babies remain extremely rare, the incidence of twins and triplets is on the rise in the United States.

Older age at childbearing and increased use of fertility therapies and ovulation-inducing drugs are driving the spike in multiple gestations. But with multiple births come hefty medical costs.

And with the bills still rolling in, Wilkinson's insurer will face a costly final tab, not just for the delivery, but also for respirator costs for two babies, neonatal intensive care unit expenses and several-day hospitalization stays for the quints.

Multiple-birth events have health carriers scrambling for ways to curb ever-rising expenses, particularly those involving complications and hospitalization stays of premature babies.

Potential Problems

One of the most significant problems associated with multiple gestations is the risk of preterm birth, said Dr. Joanne Armstrong, senior medical director for women's health at Aetna.

"The rate of preterm birth in women carrying a single baby was about 10% in 2004," she said. "During the same year, the likelihood that a woman carrying twins would deliver preterm was over 60%."

Premature birth results in a number of medical and societal problems, including infant death, illness and disability, Armstrong said. Preterm birth is the leading cause of infant death and a major underlying cause of illness in babies born prematurely.

The medical consequences of premature birth extend into childhood and adulthood, she said. "There are also consequences for families, including disability, lost workplace productivity and preterm medical expenses," Armstrong said. "The problem of multiple gestation, especially its impact on prematurity, is something many health groups are grappling with"

Mothers of "multiples" face their own challenges. They are at higher risk for pregnancy-induced hypertension; hyperemesis, or severe morning sickness; gestational diabetes and loss of pregnancy.

"The greater the number of fetuses, the higher the chance of risk and more complications, and the greater the amount of care needed as a result," said Dr. Tracy Flanagan, director of women's health for Kaiser Permanente's Northern California region. "Preterm birth itself has huge implications from the standpoint of hospital days for mothers and babies. About 30% of twins, 70% of triplets and 100% of quad babies are admitted to the NICU for more intensive care."

The American College of Obstetricians and Gynecologists reports the average NICU length of stay for twins is 18 days, for triplets 30 days and for quadruplets 58 days, she said. The March of Dimes reports that a preterm baby costs about 15 times more during his or her first year than a full-term baby.

"Infants born at around 24 weeks' gestation can frequently cost more than $500,000 and can exceed $1 million; said Jane Johnson, director of medical and managed care services for ING Reinsurance. She manages two company programs, ROSE and ROSEBUD, designed to improve health outcomes and reduce costs associated with high-risk pregnancies and infants.

"Twins and triplets also have higher complication rates for pre-eclampsia and gestational diabetes--factors that add to both the morbidity experience of women and adverse effects on their babies" said Armstrong. "All of those things snowball into higher medical costs"

Delivery costs also add up. The CDC's 2000 ART Surveillance report said that delivery costs for in-vitro fertilization pregnancies soar from $39,000 for singletons to $340,000 for triplets.

Added to that are higher costs stemming from increased Caesarean section deliveries. Among the 73 sets of twins born to Blue Cross Blue Shield of Florida members in 2006, 64 were delivered via C-section.

Dr. F. Mignel Fernandez, senior medical director of health-care services for the Florida Blues plan, said there are also numerous "softer" costs, including at-home care, services to assist in developmental issues and ongoing medical bills.

Future costs are more difficult to pinpoint, said Flanagan. "It's often unclear if there will be long-term neurological or functional deficits in these premature babies that will require more intensive treatment and follow-up and affect quality of life."

As for insurers' bottom line, most plans said they haven't quantified the total annual financial hit they're taking from gestation-related costs involving multiple fetuses.

There's good news for plans, however. Despite the increase in multiple births, longer-term expenses that may be associated with them have started to decrease, said Dr. Paul Kaplan, chief medical director of Blue Cross Blue Shield of Delaware.

"Part of that's occurring because NICU doctors and neonatologists are doing an exceptionally good job of treating premature babies, Kaplan said.

"Typical complications related to prematurity that we used to see with these babies are occurring less frequently now; he said.

Even with rising costs, most women delivering multiples generally don't exceed their policy limits, said Dr. Laura Long, chief medical officer of BlueChoice Health Plan, a subsidiary of BlueCross BlueShield of South Carolina.

"Most of our plans have $1 million to $2 million limits, so we don't see women hitting those kinds of numbers'. However, they usually have some out-of-pocket costs and that can 'be challenging for some families; she said.

Jennifer Fugel of New York, a new mother of twin girls, knows that first-hand. While her health plan covered many expenses, such as extra ultrasounds and specialist visits, she and her husband were left with nearly $30,000 in medical bills, she said.

"The cost of care is so high, there's always the potential to exceed medical coverage if someone has a very early delivery," said Dr. Tom Paulson, medical director for Premera. "But moms are the best incubators. The cost aspect is almost a byproduct of helping members with better outcomes"

Fernandez, with the Florida Blues plan, said the better the knowledge that high-risk women have about their condition, the more empowered they are to manage it and arrive at a better outcome.

That's something health plans have been helping women with for years, said Susan Pisano, a spokeswoman for America's Health Insurance Plans.

"Plans are reaching out to women to ensure they understand the signs and symptoms of preterm birth and see if there are risk factors that can be modified and addressed; Pisano said.

Many plans also help women locate providers and perinatologists--obstetricians who specialize in high-risk maternal-fetal medicine. The plans coordinate home-health services, put expectant moms in touch with community resources such as local mothers-of-multiples groups, and encourage them to seek care at "centers of excellence" that have preferred NICUs.

The first step for most carriers--Aetna's Beginning Right maternity management program is an example--is to identify women in high-risk pregnancies through a combination of risk and member self-assessment tools, data mining and predictive modeling.

"We can then educate them about symptoms of preterm birth, and offer services like our nurse intervention program where women are taught how to identify signs and how to palpate for contractions" said Armstrong.

Dr. Cathy Dratman, medical director for Pennsylvania-based Independence Blue Cross, said, "After early identification, between 6% to 10% of women in our program come out as moderate- to high-risk."

According to Dratman, "If they're experiencing problems, the nurse case-manager works with the woman and her obstetrician to put together a care plan that keeps mothers at home safely as long as possible, provides assistance with family issues and puts services like nurses, nutritionists and social workers into the home as appropriate."

BlueChoice's maternity management program goes a step further by sending women information about postpartum depression symptoms. The plan recently collaborated with a local university's postpartum depression focus group to identify resources and support groups for women.

For health-plan-sponsored case management outreach, the payoffs are big. Dratman said the average length of hospital stay for multiple babies has decreased because "babies are healthier and are being delivered later in pregnancy." Neonatal case managers also are monitoring infants' care.

Plans also report significant cost savings.

"We continuously look at ways to help members stay well, which helps to control costs." said Kaplan, of the Delaware Blues plan.

"With our prenatal program, there are fewer hospital readmissions for complications related to pregnancy and higher percentages of women carrying babies to term," he said.

Nearly two years ago, Premera built a robust technology that uses predictive modeling to assess claims.

"We can get a claim from women having multiples in the late first trimester or early second trimester, and can identify them as potential targets for case management even before they become symptomatic," Paulson said.

"It's in everyone's interest to strive to prevent preterm births in terms of cost and quality of life," said BlueChoice Health Plan's Long.

"One day in the womb is worth three days in the NICU," she said. "The longer you can keep babies in gestation, the better the outcomes for the child, less stress on parents and the lower the health-care expenses for plans and employers."

Assisted reproductive technologies continue to become more sophisticated, she said.

"Doctors are refining those advances, and now fewer eggs are implanted with each cycle, reducing the risk of multiple birth" said Long.

"As an insurer, we have to look at technology and new research to prevent preterm births and expand coverage as new things come along to support physicians in delivering those services."

* The Trend: Fertility treatments and women having babies later in life are increasing the number of multiple births.

* The Significance: Preterm births, longer hospital stays and complications from multiple gestations are sending health-plan costs over $1 million.

* What Needs to Happen: Education and intervention by health plans can help lessen complications and promote long-term savings.

Learn More

Aetna Health and Life Insurance Co. A.M. Best Company # 08189 Distribution: Brokers, consultants, retail network (pharmacy products)

BlueChoice HealthPlan of South Carolina A.M. Best Company # 68593 Distribution: Agents, brokers, consultants, direct

BCBSD Inc. (Blue Cross Blue Shield of Delaware) A.M. Best Company # 68578

Blue Cross Blue Shield of Florida Inc. A.M. Best Company # 68174 Distribution: Independent agents, consultants, direct

Independence Blue Cross A.M. Best Company # 64553 Distribution: Direct sales representatives, brokers, association administrators, consultants, direct

ING Reinsurance A.M. Best Company # 06846 (ReliaStar Life Insurance Co.) Distribution: Direct, brokers

Kaiser Foundation A.M. Best Company # 64585 Distribution: National consulting houses, regional brokers and brokerage firms, membership exchanges, direct

Premera Blue Cross A.M. Best Company # 60076, 64764 Distribution: Agents and brokers

For ratings and other financial strength information visit www.ambest.com.

RELATED ARTICLE: Keeping delivery charges in line.

Many small and midsize U.S. health insurers use reinsurance and case-management programs to mitigate the high costs of multiple-birth pregnancies.

The costs of neonatal claims, which are highly correlated with multiple births, represent "the biggest single diagnostic category of reinsurance claims that we see," said Alden Skar, vice president and senior actuary for ING Reinsurance. This means more than for cancer, transplants, heart attacks and strokes, he said.

Most of the claims ING Re pays out are associated with premature babies, said Julaine Cross, ING Re's marketing underwriter. "Multiple births lead to premature babies," she said. "You're not going to have quadruplets and have them go to term."

Skar said less than 2% of single births fall into the very-low-birth-weight category--less than 1,500 grams--according to national published data by the Centers for Disease Control and Prevention. Similarly, less than 2% of single births are "very preterm," meaning less than 32 weeks' gestation, Skar said.

Cathy Sussman, vice president at Minneapolis-based Collins, a reinsurance broker specializing in health plans, said when the company meets with a health insurer, it looks at the insurer's past claims experience to identify trends, such as the number of multiple-birth claims it's incurred in a given year. Not every health plan is interested in reinsurance; it depends on their experience and risk tolerance, Sussman said.

Health insurers also can turn to case-management programs to help manage their catastrophic health claims.

ING Re's ROSEBUD program, for example, has a staff of perinatal registered nurses who work directly with their high-risk insureds, such as pregnant women expecting multiple births, said Jane Johnson, ING Re's director of medical and managed care services.

They tell the morns what to expect throughout their pregnancies and about healthy lifestyles aimed at prolonging the pregnancy as close to term as possible.

"Each day closer to full term that the unborns stay in utero increases the chances for a healthy outcome and saves the health plan thousands of dollars," she said.

After the babies are born, a ROSEBUD neonatal nurse helps teach the parents what to expect in the neonatal intensive care trait. The nurse also prepares parents to care for the babies when they go home--often achieving an earlier discharge, Johnson said.--Fran Matso Lysiak

RELATED ARTICLE: Shedding light on infertility coverage.

Couples struggling to overcome infertility often turn to reproductive therapies and ovulation-inducing drugs. But are these services covered by health plans?

Most carriers offer varying levels of coverage for infertility treatment, ranging from diagnosing the cause of the problem to more complex and expensive therapies, said Dr. Joanne Armstrong, Aetna's senior medical director for women's health. "There's a hierarchy of infertility treatments that gets more complicated as you go up the scale" she said.

"At Aetna, advanced infertility benefits, such as in-vitro fertilization and menotropin injections to stimulate ovulation, are available by rider for employer groups to purchase on behalf of employees," Armstrong said.

Several states, including New Jersey, Massachusetts and Illinois, now mandate infertility coverage.

"Fertility treatments are now accepted options, reachable by the average patient or couples with economic resources to pay for that, plus the fact that more women are waiting to have children later in life," said Dr. Tom Paulson, medical director for Premera.

But some women "go into this with stars in their eyes because they're so happy to be pregnant" that they block out potential consequences of a multiple pregnancy, said Independence Blue Cross Medical Director Dr. Cathy Dratman.

"We have a number of in-network obstetricians who perform fetal reduction (a procedure used to reduce the number of embryos in a multifetal pregnancy). If the situation in which unexpected higher-order multiples is found, most of our plans permit the procedure to be covered," she said.

However, other expenses and problems could still result. "They could put in two embryos and end up with triplets because one embryo splits in utero, or there are complications, like one shared placenta in multiples," she said.

Dratman said one of the most recent changes in assisted reproduction is the definition of success for infertility. "It's no longer a pregnancy, but a take-home baby."

RELATED ARTICLE: Seeing double.

In 2004, the birth rate for twins reached 32.2 per 1,000 live births--a record high, according to the National Vital Statistics Reports prepared by the Centers for Disease Control and Prevention.

Triplet and other multiple births also have increased substantially over the years, from 37 per 100,000 live births in 1980 to 194 per 100,000 live births in 1998, the CDC reports.

Many health plans have seen the same trends in multiple gestations among their members.

Of the 125,000 babies born in Kaiser Permanente's Northern California region between 2003 and 2006, two in 100 deliveries were twins and one in 1,000 were triplet births, said Dr. Tracy Flanagan, director of women's health for the region. Five sets of quadruplets were delivered during that time.

Blue Cross Blue Shield of Delaware has noticed a 10% spike in the number of multiple gestations over the past five years; however, there's been a reduction in higher-order multiple births, said Chief Medical Director Dr. Paul Kaplan.

Some women seeking in-vitro fertilization now are having selective reduction in the number of eggs being implanted. Some reproductive societies that control IVF and other types of artificial insemination now have strict guidelines, based on the patient's age, for physicians to follow when deciding how many eggs should be implanted into the uterus.

Assisted reproductive treatments offer women a chance to have children, said Flanagan.

"But as that becomes more successful, the number of multifetal births increases," Flanagan said. "There are cost implications from that across the board, but also health implications for mothers and their babies, particularly for the fetuses, which are all tied together."