Effects of changing health care financial policy on very low birthweight neonatal outcomes.Background. Our objective was to determine whether perinatal perinatal /peri·na·tal/ (-na´t'l) relating to the period shortly before and after birth; from the twentieth to twenty-ninth week of gestation to one to four weeks after birth. per·i·na·tal adj. referral patterns and clinical outcomes for very low birthweight infants changed in relation to changing Medicaid financial policies in coastal South Carolina South Carolina, state of the SE United States. It is bordered by North Carolina (N), the Atlantic Ocean (SE), and Georgia (SW). Facts and Figures Area, 31,055 sq mi (80,432 sq km). Pop. (2000) 4,012,012, a 15. . Methods. Referral patterns and outcome indicators for very low birthweight infants were compared during two periods in a cohort design. Results. A total of 520 infants were identified over two funding periods. A decrease in the proportion of nonwhite non·white n. A person who is not white. non  white adj. very low birthweight
infants was identified. There was an increase in very low birthweight
infants with Medicaid funding born outside our level III center.
Conclusions. Changes in financial public policy have been successful in the movement of low risk pregnancies into the private sector. However, an increased proportion of deliveries of very low birthweight infants occurred outside the level III center. ********** PREMATURITY has long been recognized as a public health problem. In a study by Rush et al, (1) mortality rates were 43 times higher for infants born before 37 weeks' gestation. According to according to prep. 1. As stated or indicated by; on the authority of: according to historians. 2. In keeping with: according to instructions. 3. Oppenheimer, (2) "For more than 30 years, federal, state, and local health agencies have played a dominant role in the creation of public policy concerning premature infants premature infant Prematurity, premie; preterm infant Obstetrics An infant born before the 37th wk of gestation and after the 20th wk, who weighs 500–2500 g. See Very-low birth weight. in the United States United States, officially United States of America, republic (2005 est. pop. 295,734,000), 3,539,227 sq mi (9,166,598 sq km), North America. The United States is the world's third largest country in population and the fourth largest country in area. , active in defining both the problem and solution." National and regional policies regarding the care of premature neonates are in a continuous state of evolution. Coastal South Carolina is characterized by a high perinatal mortality Perinatal mortality (PNM), also perinatal death, refers to the death of a fetus or neonate and is the basis to calculate the perinatal mortality rate. Variations in the precise definition of the perinatal mortality exist specifically concerning the issue of inclusion rate, a high rate of inadequate prenatal care prenatal care, n the health care provided the mother and fetus before childbirth. , and a high rate of very low birthweight (VLBW VLBW Very low birth weight, see there , <1,500 g) births. In South Carolina, VLBW infants constitute only 1.5% of births, yet encompass 40% of neonatal deaths. (3) In an effort to analyze the effects of governmental intervention, we investigated the clinical outcomes of VLBW neonates born in coastal South Carolina during two periods corresponding to changes in policy. Factors that may have contributed to changing neonatal/Perinatal care in coastal South Carolina include (1) a statewide program designed to encourage private-sector prenatal care of Medicaid patients by providing a financial incentive via increased reimbursement, (2) changing patterns of third-party reimbursement, with emphasis on cost-reduction, and (3) proliferation and expansion of level II services, in some circumstances working with nearby level III centers. These changes were intended to improve access to prenatal car e, thereby improving pregnancy outcomes without interfering with state regionalization regionalization Managed care The subdivision of a broadly available service–eg, a blood bank, into quasi-autonomous regional centers, capable of making decisions and providing more cost-effective and/or faster service to hospitals and health care facilities, policies. It was and still is the goal of South Carolina regionalization policies to deliver at least 90% of VLBW infants in level III centers. (4) The increased funding for prenatal care resulted in Medicaid reimbursement for obstetric ob·stet·ric or ob·stet·ri·cal adj. Of or relating to the profession of obstetrics or the care of women during and after pregnancy. obstetrical, obstetric pertaining to or emanating from obstetrics. care being comparable to that of many commercial insurance carriers. (3) This policy was not coupled with increased funding for neonatal care, however, nor did it include any financial disincentives for the delivery of VLBW infants outside the level III center. Our objective was to determine whether prenatal/perinatal referral patterns and clinical outcomes for VLBW infants were changed after the alteration of a financial health care policy within our catchment area catchment area or drainage basin, area drained by a stream or other body of water. The limits of a given catchment area are the heights of land—often called drainage divides, or watersheds—separating it from neighboring drainage . METHODS Under South Carolina classifications, level III centers are subspecialty subspecialty, n a limited portion of a narrowly defined professional discipline. E.g., surgery is a specialty of medicine and pediatric vascular surgery is a subspecialty. perinatal centers providing inpatient care inpatient care Managed care Services delivered to a Pt who needs physician care for > 24 hrs in a hospital for maternal and fetal complications. The Medical University of South Carolina “MUSC” redirects here. For Abel Santa María airport in Santa Clara, Cuba (ICAO code MUSC), see Abel Santa María Airport. The Medical University of South Carolina (MUSC MUSC Medical University of South Carolina MUSC Maritime and Underwater Security Consultants MUSC Memphis Union Station Company ) is an urban regional perinatal referral center in southern coastal South Carolina consisting of a level III neonatal intensive care unit Noun 1. neonatal intensive care unit - an intensive care unit designed with special equipment to care for premature or seriously ill newborn NICU ICU, intensive care unit - a hospital unit staffed and equipped to provide intensive care (NICU NICU abbr. neonatal intensive-care unit ). In addition to a full spectrum of neonatal medical and surgical subspecialty services, our center provides a comprehensive developmental follow-up program for neonatal intensive care graduates. In our role as the regional referral center, we provide a rapid-response transport service, furnish regular educational opportunities and evaluation activities consistent with Towards Improving the Outcomes of Pregnancy standards, (5) and have developed reliable methods of consultation and referral. In addition, in coastal South Carolina, we are the sole providers of maternal and fetal medicine fetal medicine n. The branch of medicine that deals with the growth, development, care, and treatment of the fetus and with environmental factors that may harm the fetus. subspecialty (perinatology perinatology /peri·na·tol·o·gy/ (-na-tol´ah-je) the branch of medicine (obstetrics and pediatrics) dealing with the fetus and infant during the perinatal period. per·i·na·tol·o·gy n. ) services, which have been shown to employ strategies that enhance outcomes of VLBW infants. (3) Level II centers are specialty perinatal centers providing management for certain high-risk pregnancies High-Risk Pregnancy Definition A high risk pregnancy is one in which some condition puts the mother, the developing fetus, or both at higher-than-normal risk for complications during or after the pregnancy and birth. , including maternal referrals from level I basic care centers, services for newborns with selected complications, and appropriate continuing education continuing education: see adult education. continuing education or adult education Any form of learning provided for adults. In the U.S. the University of Wisconsin was the first academic institution to offer such programs (1904). . Level II+ is a variation on the level II center, with increased availability of some neonatal intensive care services. (6) No centers provided level II+ services in our catchment area during this study. The standard of care in coastal South Carolina included transfer of all VLBW infants to MUSC. Using a prospectively collected data base, referral patterns for VLBW infants born inside our level III center (inborn inborn /in·born/ (in´born?) 1. genetically determined, and present at birth. 2. congenital. in·born adj. 1. Possessed by an organism at birth. 2. ) and those born outside our level III center (outborn) were compared during two funding periods: August 1990 through July 1992 (traditional funding period) and January 1995 through December 1996 (enhanced funding period). During the funding periods studied, MUSC was the only provider of level III services in coastal southern South Carolina. Regional referral patterns did not change between funding periods, as indicated by South Carolina Perinatal Regionalization Surveillance data, (6) showing that during reporting periods that approximate the traditional and enhanced funding periods investigated in this study, 94% and 95%, respectively, of VLBW infants surviving delivery in our region were transferred to MUSC. Furthermore, during state-reported time periods approximating traditional and enhanced funding periods, 95% and 96%, respectively, of VLBW infants born to mothers residing in our region were born within our region. South Carolina Perinatal Regionalization Surveillance reports include state-specific, region-specific, and hospital-specific data on births and deaths. State reports also contain race and birth-weight-specific data, as well as limited demographic population data. Comparison of the data contained in the MUSC prospectively collected data base and the state data base allowed the detection of any births or deaths occurring outside of the referral center, as well as providing information on the race and birthweight categories. Primary outcome variables identified were inborn or outborn status, ethnicity, and funding pattern. Covariates were identified as Apgar scores Ap·gar score n. A system of evaluating a newborn's physical condition by assigning a value (0, 1, or 2) to each of five criteria: heart rate, respiratory effort, muscle tone, response to stimuli, and skin color. , small for gestational age small for gestational age Intrauterine growth retardation Neonatology adjective Referring to an infant whose gestational age and weight gain are < expected for age. See Low birthweight. (SGA SGA abbr. small for gestational age Small-for-gestational-age (SGA) A term used to describe newborns who are below the 10th percentile in height or weight for their estimated gestational age. ) classification, and multiple births. Statistical Analysis Categorical variables were compared using chi-square or Fisher's exact tests Fisher's exact test a statistical test for association in a two-by-two table based on the exact hypergeometric distribution of the frequencies within the table. , as appropriate. Continuous variables were analyzed using Student's t tests. Key outcome indicators included demographic characteristics of infants delivered or cared for at MUSC, indicators of maternal complications, indicators of neonatal morbidity, and neonatal mortality Noun 1. neonatal mortality - the death rate during the first 28 days of life neonatal mortality rate death rate, deathrate, fatality rate, mortality rate, mortality - the ratio of deaths in an area to the population of that area; expressed per 1000 per year . RESULTS A total of 520 VLBW infant records were included in this study. No infants were excluded. The overall number of deliveries at MUSC was 6,292 during the traditional funding period and 3,839 during the enhanced funding period. Of the 255 VLBW infants evaluated during the traditional funding period, 218 (85%) were born at MUSC (inborn), and 37 (15%) were born at other centers with subsequent transfer to MUSC (outborn). Of the 265 VLBW infants evaluated during the enhanced funding period, 219 (83%) were inborn, and 46 (17%) were outborn. Table 1 includes patient demographics and location of delivery during both periods. The overall distribution of inborn vs outborn VLBW patients did not change (P = .38) between funding periods. In both study populations 1-minute (P .723) and 5-minute (P = .064) Apgar scores [less than or equal to]3 also remained constant. There was a significant decrease in the proportion of nonwhite VLBW infants born between funding periods (P = .037) (Table 1). During enhanced funding, there was an increase in the percentage of VLBW outborn patients in both nonwhite (P= .035) and Medicaid subpopulations (P = .01), as compared with traditional funding (Figure). The Medicaid population in VLBW patients remained predominantly nonwhite during both time periods (83.9% traditional funding; 70.3% enhanced funding). The nonwhite population consisted of 97% black, 2% Hispanic, and 1% other. Statistically significant changes in the pattern of funding between periods were seen in the out-born population over time (Table 2). A smaller proportion of patients with private funding and a larger proportion of patients with Medicaid funding were outborn (P= .003). As shown previously, the proportion of VLBW infants who were inborn did not change between periods. DISCUSSION The goal of regionalization is to eliminate disparities in chances for survival among infants born in hospitals with different levels of care. (7,8) South Carolina Department of Health and Environmental Control The South Carolina Department of Health and Environmental Control (also known as "SC DHEC" or simply "DHEC") is the government agency responsible for health and environment control in the American state of South Carolina. policy currently supports regionalization of neonatal and perinatal care. (9,10) Perinatal regionalization has been shown to be associated with improved outcomes. (3,8,11-16) It has been shown that lower mortality is achieved with delivery of the VLBW infants at a level III center. (8,11,17-20) This has also been shown to be true in South Carolina. It appears that recent changes in state Medicaid financial reimbursement policy had both positive and negative consequences. Our data show that although nonwhite VLBW infants remained overrepresented o·ver·rep·re·sent·ed adj. Represented in excessive or disproportionately large numbers: "Some groups, and most notably some races, may be overrepresented and others may be underrepresented" , the ratio of white to nonwhite VLBW infants became more reflective of the overall delivery population mix in coastal South Carolina. This might reflect improved access to prenatal care within this population, (21) a goal of the state policy being analyzed, but would require further analysis for conclusions to be drawn. According to South Carolina surveillance data, the racial mix of patients of all gestational ages in the period of traditional funding (white to nonwhite) is 1:0.70; however in VLBW infants, this ratio is 1:2.37. (6) During enhanced funding, the racial ratio (white to nonwhite) of all infants born is 1:0.61; in VLBW infants, this ratio is 1:1.86. If adjusted for the overall change in white to nonwhite mix between funding periods, we would expect a ratio of 1:2.06 if there were no change in racial mix. This represents an approximate 9% improvement from the period of traditional funding, though a significant discrepancy remains in the white to nonwhite ratio. Since more Medicaid-funded patients were outborn, it would indicate the goal to move low-risk pregnancies outside the tertiary care tertiary care Managed care The most specialized health care, administered to Pts with complex diseases who may require high-risk pharmacologic regimens, surgical procedures, or high-cost high-tech resources; TC is provided in 'tertiary care centers', often setting was successful. Possible detrimental effects were also found, however. The proportion of Medicaid-funded VLBW and nonwhite VLBW infants born outside our tertiary care center tertiary care center Hospital care A hospital or medical center for Pts often referred from secondary care centers, which provides subspecialty expertise Tertiary care center Surgery increased significantly with enhanced funding. This is disturbing, since mortality rates are consistently higher for black infants than for white infants among VLBW infants in South Carolina. (3) In effect, a high-risk subpopulation sub·pop·u·la·tion n. A part or subdivision of a population, especially one originating from some other population: microbial subpopulations. Noun 1. shifted from inborn to outborn, which is associated with higher mortality. (8,11,17-20) The state's goal to move Medicaid low-risk deliveries into the community was met, but with the concomitant negative consequence of increasing the proportion of VLBW deliveries occurring outside level m centers. The nonwhite subpopulation was disproportionately affected, based on the racial representation of Medicald. This would suggest that a portion of the state's goal to have VLBW del iveries occur in level III centers was not met for Medicaid-funded and nonwhite infants, but the goal was met for the indigent indigent 1) n. a person so poor and needy that he/she cannot provide the necessities of life (food, clothing, decent shelter) for himself/herself. 2) n. one without sufficient income to afford a lawyer for defense in a criminal case. , private, and white subpopulations of infants. While the mortality for both inborn and outborn VLBW infants improved with time, a discrepancy of 40 deaths per 1,000 VLBW births remained during enhanced funding. Because of this discrepancy, 14 additional Medicaid VLBW infants were now outborn; therefore, a potential improvement in the Medicald VLBW mortality rate of 3 deaths per 1,000 VLBW births was not realized. This is of particular importance, considering the local and national dismantling of regionalization programs. The use of financial incentives to encourage Medicaid-funded deliveries in the private sector was successful; however, financial disincentives for the delivery of a VLBW infant outside of a level III center or, conversely, financial incentives for the transfer of high-risk patients were lacking. We recommend that reimbursement strategies that penalize pe·nal·ize tr.v. pe·nal·ized, pe·nal·iz·ing, pe·nal·iz·es 1. To subject to a penalty, especially for infringement of a law or official regulation. See Synonyms at punish. 2. obstetricians for transferring established patients for delivery at a level III center be revisited. Additionally, incentives should be devised to encourage the transfer of such at-risk obstetric patients threatening delivery, which is more consistent with state goals of achieving delivery of at. least 90% of VLBW births in tertiary care centers. In conclusion, financial policies that increased funding for prenatal care were associated with an increase in the proportion of outborn Medicaid-funded VLBW infants, with associated mortality increases. [Graph omitted]
TABLE 1
Demographics of Very Low Birthweight Infants Studied During Periods of
Traditional and Enhanced Funding
Traditional Funding
Characteristic (n = 255)
Outborn 37 (14.5%)
Birthweight (g) (+) 1,078.0 [+ or -] 270.4
Gestational age (weeks) (+) 29.5 [+ or -] 2.9
No prenatal care (++) 16 (6.3%)
Small for gestational age 75 (29.4%)
Multiple gestation 44 (17.3%)
Apgar @ 1 minutes
[less than or equal to]3 (*) 86 (35.0%)
Apgar @ 5 minutes
[less than or equal to]3 (**) 24 (9.7%)
Medicaid-funded 124 (48.6%)
Nonwhite 179 (70.2%)
Black 175 (68.6%)
Hispanic 3 (1.2%)
Other 1 (0.39%)
Enhanced Funding P
Characteristic (n = 265) Value
Outborn 46 (17.4%) .375
Birthweight (g) (+) 1094.6 [+ or -]244.3 .462
Gestational age (weeks) (+) 29.1 [+ or -] 2.7 .107
No prenatal care (++) 8 (3.0%) .095
Small for gestational age 62 (23.4%) .120
Multiple gestation 59 (22.3%) .152
Apgar @ 1 minutes
[less than or equal to]3 (*) 87 (33.5%) .723
Apgar @ 5 minutes
[less than or equal to]3 (**) 14 (5.4%) .064
Medicaid-funded 155 (58.5%) .054
Nonwhite 163 (61.5%) .037
Black 157 (59.4%)
Hispanic 3 (1.1%) .793
Other 2 (0.8%)
Categorical data are presented as No. (%). Birth weight and gestational
age are presented as mean [+ or -] standard deviation.
(*)Based on n = 506; n = 246 during traditional funding and n=260 during
enhanced funding due to missing data.
(**)Based on n = 507; n = 247 during traditional funding and n = 260
during enhanced funding due to missing data. Birth weight, gestational
age, and racial distribution during enhanced funding is based on n = 264
due to missing data. Statistical analysis was done with chi-square
unless indicated by (+), which represents Student's t test, or (++),
which represents Fisher's exact test.
TABLE 2
Chi-Square Analysis of Funding Patterns of VLBW Infants During Both
Funding Periods Analyzed for All Patients, Inborn Patients and Outborn
Patients.
Traditional Funding Enhanced Funding P Value
All Private 96 (37.7%) 86 (32.5%)
(n = 520) Indigent 35 (13.7%) 24 (9.1%) .054
Medicaid 124 (48.6%) 155 (58.5%)
Inborn Private 81 (37.2%) 78 (35.6%)
(n = 437) Indigent 24 (11.0%) 17 (7.8%) .415
Medicaid 113 (51.8%) 124 (56.6%)
Outborn Private 15 (40.5%) 8 (17.4%)
(n = 83) Indigent 11 (29.7%) 7 (15.2%) .003
Medicaid 11 (29.7%) 31 (67.4%)
Acknowledgment. we thank Myla Ebeling, Medical University of South Carolina, Epidemiology Division, Department of Pediatrics, for data analysis. References (1.) Rush RW, Davey DA, Segall ML: The effect of preterm preterm /pre·term/ (-term´) before completion of the full term; said of pregnancy or of an infant. pre·term adj. delivery on perinatal mortality. Br J Obstet Gynaecol 1978; 85:806-811 (2.) Oppenheimer GM: Prematurity as a public health problem: US policy from the 1920s to the 1960s, Am J Public Health 1996; 86:870-878 (3.) Menard MK, Liu Q, Holgren EA, et al: Neonatal mortality for very low birth weight deliveries in South Carolina by level of hospital perinatal service. Am J Obstet Gynecol 1998; 179:374-381 (4.) US Public Health Service: Healthy People 2000: National Health Promotion and Disease Prevention Objectives. washington, DC, US Department of Health and Human Services Noun 1. Department of Health and Human Services - the United States federal department that administers all federal programs dealing with health and welfare; created in 1979 Health and Human Services, HHS , 1990 (5.) Toward Improving the Outcome of Pregnancy. White Plains, NY, National Foundation-March of Dimes, 1976 (6.) Perinatal Regionalization Surveillance Data: Report of Perinatal Indicators for 1983-1996. Columbia, SC, Department of Health and Environmental Control, 1997 (7.) Toward Improving the Outcome of Pregnancy. The 90s and Beyond. White Plains, BY, National Foundation-March of Dimes, 1993 (8.) Paneth N, Kiely JL, wallenstein S, et al: Newborn intensive care and neonatal mortality in low-birth-weight infants. N Engl J Med 1982; 307:149-155 (9.) South Carolina Department of Health and Environmental Control: Regulation number 61-16. Standards for licensing hospitals and institutional general infirmaries. South Carolina State Register, 16, 1992 (10.) Guidelines for Achieving Perinatal Care in South Carolina. Columbia, South Carolina Columbia is the state capital and largest city of South Carolina. As of 2006, estimates for the population of the city proper is 122,819[1]. Columbia is the county seat of Richland County, but a small portion of the city extends into Lexington County. Perinatal Association, 1994 (11.) Phibbs CS, Bronstein JM, Buxton E, et al: The effects of patient volume and level of care at the hospital of birth on neonatal mortality. JAMA JAMA abbr. Journal of the American Medical Association 1996; 276:1054-1059 (12.) Budetti PP, McManus P: Assessing the effectiveness of neonatal intensive care. Med Care 1982; 10:1027 (13.) Evans HE, Glass L: Regionalization of perinatal care. Pediatrics 1978; 7:154 (14.) Ferrara A: Evaluation of efficacy of regional perinatal programs. Semin Perinatol 1977; 1:303 (15.) Bowes WA: A review of perinatal mortality in Colorado, 1971 to 1978, and its relationship to the regionalization of perinatal services. Am J Obstet Gynecol 1981; 141:1045-1052 (16.) Usher R: Changing mortality rates with perinatal intensive care and regionalization. Semin Perinatol 1977; 1:309 (17.) Nugent RR: Perinatal regionalization in North Carolina North Carolina, state in the SE United States. It is bordered by the Atlantic Ocean (E), South Carolina and Georgia (S), Tennessee (W), and Virginia (N). Facts and Figures Area, 52,586 sq mi (136,198 sq km). Pop. , 1967-1979: services, programs, referral patterns, and perinatal mortality rate declines for very low birthweight infants. NC Med J 1982; 43:513-515 (18.) Goldenberg RL, Hanson S, Wayne JB, et al: Vital statistics data as a measurement of perinatal regionalization in Alabama, 1970 to 1980. South Med J 1985; 78:657-660 (19.) Goldenberg RL, Koski J, Ferguson C, et al: Infant mortality (hardware) infant mortality - It is common lore among hackers (and in the electronics industry at large) that the chances of sudden hardware failure drop off exponentially with a machine's time since first use (that is, until the relatively distant time at which enough mechanical : relationship between neonatal and postneonatal mortality postneonatal mortality Public health A standard indicator of health, defined as the number of infant deaths occurring between 28 days and 11 months of life. Cf Infant mortality. during a period of increasing perinatal center utilization. J Pediatr 1985; 106:301-303 (20.) Gortmaker S, Sobol A, Clark C, et al: The survival of very low-birth weight infants by level of hospital birth: a population study of perinatal systems in four states. Am J Obstet Gynecol 1985; 152:517-524 (21.) Herron MA, Katz M, Creasy crease n. 1. A line made by pressing, folding, or wrinkling. 2. Sports a. A rectangular area marked off in front of the goal in hockey and lacrosse. b. RK: Evaluation of a preterm birth prevention program: preliminary report. Obstet Gynecol 1982; 59:452-456 RELATED ARTICLE: KEY POINTS * Our objective was to determine whether prenatal/perinatal referral patterns and clinical outcomes for very low birth-weight infants were changed after the alteration of a financial health care policy. * Changes in state Medicaid financial reimbursement policy had both positive and negative consequences. * A potential improvement in the Medicaid-funded very low birthweight infant mortality rate infant mortality rate n. The ratio of the number of deaths in the first year of life to the number of live births occurring in the same population during the same period of time. was not realized. * Incentives should be devised to encourage transfer to level Ill centers of at-risk obstetric patients threatening delivery. From the Department of Pediatrics, Medical University of South Carolina, Charleston. Reprint requests to Karen Lessaris, MD, Carolinas Medical Center Carolinas Medical Center (CMC) is a public, not for profit hospital located in Charlotte, North Carolina. The hospital was organized in 1940 as Charlotte Memorial Hospital on Blythe Boulevard in the Dilworth neighborhood. , Division of Neonatology neonatology /neo·na·tol·o·gy/ (ne?o-na-tol´ah-je) the diagnosis and treatment of disorders of the newborn. ne·o·na·tol·o·gy n. , 1000 Blythe Blvd, Charlotte, NC 28232. |
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