North Carolina’s Medicaid program, Community Care of North Carolina (CCNC), has been using “medical homes” to coordinate and improve care for 1.1 million children and other people on Medicaid for more than a decade. Now the state is adding pregnant women to the medical home program in the hope of healthier babies and mothers, and savings to the state budget.
By Rose Hoban
Maricela Nash never knew you could get diabetes just from being pregnant, so when she went to her prenatal visit and found her blood sugar was up, she was really surprised.
“I had to be on a special diet, and had to prick my finger every so often to check the levels and if they were lower than what they should be I had to just get them higher, and if they were higher I had to do stuff to get them lower,” the 23-year-old new mother said.
Nash’s health care providers claim her as a victory. Women with gestational diabetes are at higher risk for a host of problems, from high blood pressure, to having overweight babies at risk for respiratory distress.
But Nash’s pregnancy was a success, and her son Brandon was born without complications. He’s 6-months-old, playing with his toes and babbling, and Nash is pregnant again. She returned to the prenatal clinic at Wake County Human Services where she’s a patient in the Medicaid “pregnancy medical home” clinic there.
“They’re monitoring me closely for (gestational diabetes), because they said once you have it with your first one, you’re much more likely to have it again with your second one. So, I didn’t know that either,” said Nash, who wants to make this baby her last.
North Carolina’s Medicaid program, Community Care of North Carolina (CCNC), has been using “medical homes” to coordinate and improve care for 1.1 million children and other people on Medicaid for more than a decade. According to an actuarial report released earlier this year, CCNS has saved the state more than a billion dollars over the past five years.
Now the state is applying the medical home model to pregnant women around the state in a parallel effort to improve the quality of pre- and post-natal care, and save North Carolina money.
Medicaid is the state and federal program that covers a total of 1.4 million low-income children, people with disabilities, and old people living in nursing homes in North Carolina. Medicaid also covers pregnant women, an attempt to give babies of low-income women a good start, and reduce the number of premature births.
More than half the pregnancies and births in North Carolina are covered by Medicaid annually.
“That’s about 76,000 births that the state and federal government effectively pays for,” said Al Delia, N.C. Secretary of Health and Human Services, during a tour of the clinic for reporters last month. “Right now, it’s about 11 percent of all births that are preterm. For every percentage point that you reduce preterm births, you save about $50 million.”
“That’s real money,” Delia said.
The hallmark of the medical home model is the combination of medical care, along with case management (CCNC calls it “care management”) for people who need it. For pregnant women, that means a 7-page risk screening form on their first visit to ask about everything from previous preterm births, to smoking or substance abuse, plus all of the medical concerns of a pregnant woman.
“The nice thing is using this risk screening form to try to find out as early as possible, the sooner you can have an impact,” said Kate Barrett, who coordinates the pregnancy program for CCNC. “We try to get them connected to care managers as early as possible so that they can intervene. it’s important to get them connected, and get them hooked up early enough in pregnancy. If you find a problem when she comes in just to have her baby there’s nothing we can do.”
That’s what happened for Karima Elqira, 29, who had a host of problems during her second pregnancy.
“I was sick, I was having some bad situation with my first baby and I was so sad,” Elqira said. “You have an appointment every month, so I missed my appointment for like, 3 months.”
In addition to her depression, Elqira had gestational diabetes and she was anemic, so the care managers at the clinic were concerned. Social worker Shantel White called Elqira, helped her arrange transportation, and gave her encouragement. Elqira made her appointments until she gave birth.
“Shantel… she became my best friend,” Elqira said, showing off her two-and-a-half-week-old son, who was born on time, without complications.
Preventing preterm births
“Screening happens on the very first visit,” said Cathi Weatherly-Jones, M.D. the physician in charge of the clinic. She said the women come in monthly at first and more frequently later in their pregnancies. The care focuses a lot on teaching the women about preterm labor, something that’s bad for babies, and is expensive.
“Everybody gets a little card that outlines the symptoms right there, we have it in English and we have it in Spanish, what symptoms to look for in terms of pre-term labor,” Weatherly-Jones said. “We give them the information at 24 weeks and we reiterate it at 28 weeks.”
CCNC also has a program to give a drug called 17-progesterone to women with a history of previously giving birth before 37 weeks. The drug has been found to reduce the rate of preterm births in women with a history of the problem by about a third.
“I think we’re seeing even better than that,” said Weatherly-Jones.
“It works wonderful, and doesn’t cost a whole lot,” she said. “We start giving it at 16 weeks and we stop giving it at 36 weeks, so she will get 20 or 21 injections at about $100 per injection versus… the cost of the baby being in the neonatal intensive care unit. Big savings. The biggest impact we are going to have is right there.”
Care for a preterm baby averages about $74,000 per year, according to Secretary Delia.
“For a normal pregnancy, it costs a little less than $3000 a year to provide that well babies medical need for the subsequent year,” Delia said. “It’s a big savings to the state.”
Delia said the pregnancy medical home program has been going for about a year, and he expects that in a few more months, all pregnant women getting Medicaid will be enrolled in a medical home.