Health plan promotes better outcomes
Health plan promotes better outcomes
Corticosteroid program uses education, praise
Programs to standardize medical practice, such as physician profiling, often pit physicians against health plan administrators. But when Minneapolis-based United HealthCare recently sought to improve health outcomes, the managed care organization developed a different model one based on cooperation and partnership.
The program to increase the appropriate use of antenatal corticosteroids in preterm delivery was based on a 1994 National Institutes of Health (NIH) Consensus Statement.1 And the methods included physician education, reminders, and positive reinforcement.
United found a high level of appropriate use among its network physicians. Six-month data still are being analyzed to determine the program’s impact. United is using the educationally oriented model to boost adherence to other clinical guidelines, and the model could be adapted to any outcomes improvement program. (See related article, p. 35.)
"I think most health plans across the United States have realized that we have to work hand in hand [with physicians] in order to make a difference," says Cynthia A. Page, MS, United’s national manager of preventive and health improvement programs.
"We’re not coming down on the physicians and saying, This is what we want you to do,’" she says. "We’re inviting them to participate in this [program] to provide better care for our members."
Mark Brown, MD, an obstetrician in Columbus, OH, found it refreshing to hear from United about something other than cesarean rates, length of stay, and other physician profiling or cost management issues. "Obviously, there’s a bottom line to it. But in this case, they were doing something proactive and educational," he says. "There’s a benefit to them, but the benefit to families and babies is beyond doubt."
High cost in $, health
United began with a concern that had both serious cost and health implications. Although preterm delivery occurs in only 7% to 10% of all pregnancies, it is associated with $2 billion in annual health care costs and is responsible for the majority of neonatal deaths.1
When administered two to 24 hours before delivery, corticosteroids reduce incidents of respiratory distress syndrome, intraventricular hemorrhage, and mortality, without any long-term adverse effects.1 Yet when the NIH came out with its consensus statement in 1994, followed by a position statement from the Washington, DC-based American College of Obstetrics and Gynecology, only 12% to 18% of women delivering preterm infants received corticosteroids.
Making good practices better
United began a pilot project with five sites in 1996, working with obstetricians, neonatologists, family practitioners, and pediatricians. "Our intent was to focus on this specific behavior to try to obtain a significantly better performance [than the national average]," says Nelson Braslow, MD, national medical director of United in Hartford, CT.
The NIH Consensus Statement had already had a major effect; when United HealthCare retrospectively reviewed charts of preterm deliveries in 1995, corticosteroids had been used in 62% of the cases, says Braslow. Among the other 38%, in many cases corticosteroid use would not have been appropriate because of an existing infection or some other medical problem, he says.
"On balance, there’s probably close to 80% and 90% appropriate action taken [among the reviewed cases]," Braslow says.
Although that statistic is quite good, United HealthCare continued its program to promote corticosteroid use including a push to begin the treatment as soon as possible for women who are delivering preterm.
United HealthCare sent laminated, wallet-sized cards and letter-sized chart reminders outlining the specific treatment regimen recommended by NIH. (See copy of the chart reminder, inserted in this issue.) They also provided physicians with chart labels for high-risk patients.
The managed care organization also provided laminated reminders for hospital labor rooms.
The program was modeled after a chart reminder and educational intervention project developed by researchers at the University of Alabama at Birmingham as part of the patient outcomes research team on low birthweight of the Agency for Health Care Policy and Research, led by Robert L. Goldenberg, MD.
Those physicians who used corticosteroids for women in preterm labor received a letter of commendation from the medical director of their local health plan. "We applaud your effort to utilize effective treatment therapies based upon current scientific evidence," the letter states. "This demonstrates your commitment to providing the best possible treatment for your patients and their babies."
Physicians responded positively to the reminder cards and the compliments, says Braslow, who also is an internist and pulmonary critical care specialist.
"They said, We’re so used to having people telling us we did something wrong or we’re not doing things, it was nice to have someone tell us we’re doing something right,’" he says. "The physicians [also] liked the idea that the company was interested in doing something that improves fetal outcomes and health, rather than something oriented toward efficiency or management."
Plan takes soft approach
Those physicians who didn’t use corticosteroids also received a letter, but it had an educational tone, not a punitive one: "If you are not presently administering this therapy with your pre-term labor patients, we ask you to consider using ANCS, when appropriate," it says. "We invite you to join us in this effort to reduce the incidence of infant morbidity and long-term disability in infants affected by catastrophic complications of prematurity."
The company still is analyzing results to see if behavior among these physicians changed as a result of this outreach.
"It was a carrot and a piece of broccoli, instead of a carrot and a stick," explains Braslow. United officials realized that the physician may have had sound reasons for not using the corticosteriods with certain patients, he says.
While corticosteroid use is high among United HealthCare’s network physicians, the education campaign will continue in an effort to further improve the use and timing, Braslow says. "There’s always room for improvement," he says.
Reference
1. National Institutes of Health. NIH Consensus Statement: Effect of Corticosteroids for Fetal Maturation on Perinatal Outcomes. Rockville, MD; 1994.
Subscribe Now for Access
You have reached your article limit for the month. We hope you found our articles both enjoyable and insightful. For information on new subscriptions, product trials, alternative billing arrangements or group and site discounts please call 800-688-2421. We look forward to having you as a long-term member of the Relias Media community.