All it took was one look at their enrollment, and managers at Arizona Physicians IPA knew they needed a perinatal case-management program.
About 70% of the Medicaid HMO's 130,000 enrollees are age 21 or younger, and there is a "large volume" of pregnant women, says Judith Black, director of the independent practice association's medical management department and champion of the perinatal program.
"We have lots of young and single mothers in the plan, and that's a high-risk group," Black says. "Even in the most stable environment, a sick baby can be emotionally devastating for parents. Our members live in poverty, many on the fringes of society."
The program, which this year received an honorable mention in the Excellence in Healthcare Risk Management Awards, aims to provide case management of prenatal services for pregnant women who are very young and have substance-abuse problems or other high-risk factors.
Arizona Physicians started the program in 1993 by tracking "sick babies"-newborns with a low birth weight or gestational age, often born with medical problems. The plan quickly learned that identifying at-risk mothers-to-be and facilitating regular physician visits could dramatically lower its costs.
When an enrollee is confirmed to be pregnant, the plan sends a letter congratulating her and asking her to call the plan. When she calls, a representative asks her a prepared set of questions to determine if she has higher risks.
"We ask them if this is their first pregnancy and how far along they are," Black says.
But Arizona Physicians doesn't just send out letters. Case managers check emergency room utilization reports and review notices from community outreach agencies to find enrollees who might be pregnant.
When pregnant women are at risk, the health plan makes regular telephone calls and home visits to gauge possible problems such as signs of domestic violence or substance abuse.
"We call them, encourage them to make regular visits to the physician and teach them, getting them involved in some classes," Black says.
If problems are found, the plan acts. For example, mothers with a substance-abuse problem are referred to rehabilitation programs.
"Our sick-baby rate went way down when we did that," Black says.
Because of the plan's risk-management efforts, the percentage of deliveries resulting in sick babies has declined to 4.7% in 1997 from 7.4% in 1995.
That translates to big savings. The average cost of a sick newborn inpatient stay is $12,146 vs. a mere $386 for a healthy baby's inpatient stay, or one day following delivery.
"The real value-hundreds of newborns who begin life healthy and vigorous instead of sick and impaired-cannot be measured," says Jack Nock, Arizona Physicians' president and chief executive officer.