At $25 BILLION annually, the pre term birth crisis is roughly equal in cost to the Avoidable Readmissions problem. The solution is to utilize post acute providers like home health nursing to care for expectant mothers in the community.
The emergence of health care "ecosystems" -- that operate efficiently and coordinate care effectively among providers -- provides signifcant new opportnities for post acute providers. Home Health Nursing, HME / DME companies, physical therapy agencies, Private Duty Home Care agencies and others have opportunities before them to partner with health systems and Accoutable Care Organizations, or ACOs, to develop new revenue while simultaneously improving patient care in the community. As more care is delivered outside of hospitals, post acute providers will serve as the primary delivery channel.
Ankota is often asked for guidance to help post acute care providers identify new opportuities and new programs to leverage. Here is one tremendously valuable opportunity to improve care and reduce costs for an expensive, high risk population. Post acute providers should partner with local health systems to address the pre term birth crisis.
Ankota's Chief Medical Officer, Dr. J. Hunter Young, points out that premature births in the US cost the healthcare system $25 Billion annually. Additionally, the "cost tail" is a long one, where pre-term babies who consume expensive care at birth tend to consume a disporportionate share of healthcare services for the rest of their lives. This is an entirely addressible problem during pregnancy, but is best suited to be addressed in the community using post acute providers and community based staff as the delivery channel.
Dr. Young is Ankota's Chief Medical Officer, and serves jointly as Assistant Professor of Medicine at the Welch Center for Prevention, Epidemiology, and Clinical Research, and Core Faculty of Johns Hopkins Bloomberg School of Public Health. In these roles, Dr. Young is involved in population health programs and community based initiatives that are aimed at decreasing readmissions and lowering the overall cost of care.Nearly 500,000 babies are born too early in the US every year.1 As the leading cause of infant mortality and long-term disability in children, the preterm birth rate between 12 and 13% extracts a very high cost on infants and families. This burden is not equally shared. In 2007, the preterm infant mortality was almost 3.5 times higher among infants of African American mothers compared to white mothers.1 In addition, the societal cost of preterm birth is considerable, estimated at more than $26 billion per year.2 Approximately $17 billion of this total goes to the medical care of the infant, accounting for approximately 50% of birth-related spending.2 A significant proportion of this cost supports the frequent admission of the preterm infant to the neonatal intensive care unit.
The good news is that we know many of the risk factors for preterm birth3 and, therefore, we can identify women in time to intervene. Just as important, we have an intervention that has been proven effective in preventing preterm birth among women with certain risk factors.4 Progesterone is a naturally occurring hormone that is involved in maintaining pregnancy. There is very strong evidence that progesterone administration significantly reduces the risk of preterm birth in women who have had a preterm birth in the past.5 There is also very good evidence that progesterone reduces the risk of preterm birth in women who have evidence of a shortened cervix on ultrasound.4 Given this evidence, progesterone administration has become the standard of care in the prevention of preterm birth in women with a history of preterm birth.
The use of progesterone has the potential to significantly reduce the burden of infant mortality and disability in children. In addition, its use has the potential to significantly reduce health care costs. In a paper published in 2007, the authors found that the universal treatment of eligible women with progesterone would save approximately $2 billion in annual direct medical expenses.6 The financial data is old and, therefore, this is likely a significant underestimate of the true cost savings.
Despite the proven benefit, progesterone is still underutilized. The data is sparse but a survey of Maternal-Fetal Medicine specialists in 2005 found that only 67% used progesterone to prevent preterm birth.7 The rate of use by non-specialists is likely substantially lower. Furthermore, progesterone administration is inconvenient, requiring weekly injection or daily vaginal suppositories. Therefore, adherence among women prescribed progesterone is likely low.
Given the proven benefit of progesterone treatment on birth outcomes and costs, it is important that health systems improve the process of identifying, treating, and supporting women at risk for preterm birth. Approaches to improve adherence to progesterone treatment include education of care providers, facilitation of progesterone compounding and delivery, the administration of progesterone in the patient’s home, periodic assessment of adherence, and patient support through education and other efforts such as motivational interviewing. Once implemented, a systematic approach to the care of women at risk for preterm birth could have a substantial impact on birth outcomes and costs. Given the very high direct medical cost for an infant born early, approximately $33,000 by one estimate,2 a small decrease in the rate of preterm birth can have a substantial impact on birth-related expenses.
1. Preterm Birth. 2012; www.cdc.gov/reproductivehealth/maternalinfanthealth/PretermBirth.htm. Accessed March 11, 2013, 2013.
2. Behrman R, Butler A. Preterm birth: causes, consequences, and prevention. Nataional Academy Press. Washington DC: Institute of Medicine; 2006.
3. Goldenberg RL, Culhane JF, Iams JD, Romero R. Epidemiology and causes of preterm birth. Lancet. Jan 5 2008;371(9606):75-84.
4. Ransom CE, Murtha AP. Progesterone for preterm birth prevention. Obstetrics and gynecology clinics of North America. Mar 2012;39(1):1-16, vii.
5. Dodd JM, Flenady VJ, Cincotta R, Crowther CA. Progesterone for the prevention of preterm birth: a systematic review. Obstet Gynecol. Jul 2008;112(1):127-134.
6. Bailit JL, Votruba ME. Medical cost savings associated with 17 alpha-hydroxyprogesterone caproate. American journal of obstetrics and gynecology. Mar 2007;196(3):219 e211-217.
7. Ness A, Dias T, Damus K, Burd I, Berghella V. Impact of the recent randomized trials on the use of progesterone to prevent preterm birth: a 2005 follow-up survey. American journal of obstetrics and gynecology. Oct 2006;195(4):1174-1179.