Association of Maternal and Child Health Programs Conference February 14, 2012

Healthy Babies Initiatives

David Lakey, M.D.CommissionerTexas Department of State Health Services

Infant Mortality 2008Preterm Births 2008*

Medicaid Costs>55% of all Texas births (225,000) paid by Medicaid$2.2 billion per year in birth and delivery-related services for moms and infants through first year ~70% of Medicaid costs for hospitalized newborns tied to billing codes for prematurityInfant care costs growing by ~10% per year50% are attributable to extremely preterm infantsNewborn costs (1st year)Extreme Preterm infant: $63,124Term infant: $404

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Preconception Health Health Behaviors Perinatal CarePrenatal Care High Risk Referral Obstetric CarePerinatal Management Neonatal Care Pediatric SurgerySafe Sleep Breast Feeding Injury PreventionPossible Points for Intervention**

Healthy Texas BabiesHealthy Texas Babies (HTB) is an initiative to decrease infant mortality in Texas

Goals of Healthy Texas Babies Initiative:

Provide local partnerships and coalitions with major roles in shaping programs in their communitiesUse evidence-based interventionsDecrease preterm birth rate by 8% over 2 yearsSave ~ $7.2 million in Medicaid costs over 2 years

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Healthy Texas Babies*

Legislature appropriated $4.1 million in General Revenue funds to DSHS to fund the Healthy Texas Babies Initiative

Legislature passed three related perinatal health billsHB 1983 Develop quality initiatives and implement cost-cutting measures to reduce elective inductions and c-sections before the 39th week in Medicaid HB 824 Creates an outreach campaign to promote fathers' involvement with their children before birthHB 2636 Creates a council to study neonatal intensive care units to develop standards and recommendations for Medicaid reimbursement2011 Texas Legislative Actions*

ASTHO 2011 Presidential Challenge Improve birth outcomes by reducing infant mortality and prematurity in the United States

Objectives:Focus on improving birth outcomes as SHOs and state leadership teams work with state partners on health and community system changesCreate a unified message that builds on the best practices from around the nationDevelop clear measurements to evaluate targeted outreach, progress, and return on investment

*S.M.A.R.T. Challenge:Reduce preterm births by 8% by 2014

One Roadmap to Reducing Prematurity by 8% by 2014Reduce non-medically indicated elective inductions and cesarean sections prior to 39 weeks gestation. Reduction of 25,000 PTBEnsure universal access to 17P for eligible women. Reduction of 10,000 PTBEliminate the incidence of higher order multiples due to assistive reproductive technologies, 97 percent of whom are born pretermReduction of 2,300 PTBReduce rates of smoking among pregnant women by 10 percent. Reduction of 1,300 PTB

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HRSA Region IV &VI Summit onInfant MortalityJanuary 12-13, 20127 member State Teams State Health Officials, MCH Directors and other MCH experts, State Medicaid Officials, March of Dimes, Hospitals, Legislative and Governors Office senior staffFederal partners HRSA, CMS, CDCRegional Goals and State Strategies

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DRAFT STRATEGIES FOR A REGIONAL APPROACH TO REDUCING INFANT MORTALITY AND PREMATURITY

Implement state policy change to eliminate elective inductions and c sections prior to 39 weeks gestationHospital PoliciesPayment Medicaid (Waivers)Individual, Provider EducationImprove access to care for all women o reproductive age including 17-P as clinically indicatedDevelop and implement a regional campaign to address the following aspects of womens health:Life Course Health preconception/pregnancy/inter-conceptionSmoking cessation, especially for pregnant womenChronic conditions obesity and diabetesInfluenza immunizations for pregnant womenSafe Sleep

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Since the SummitState Teams are continuing their workMeeting together to develop and implement next steps Alabama, Georgia, Kentucky, Texas

State Summit In the Works Oklahoma

Sharing practical tools like economic impact calculation formulas, hospital policies, legislative language

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ASTHO Current Activities Current CommitteesSteering CommitteeData and Best Practices/Policy CommitteesCommunication and Marketing CommitteeStrong CollaborationHRSA, AMCHP, March of Dimes, Leap Frog, National Association of Medicaid Directors, AHA, Secretaries Advisory Committee on Infant Mortality, CDC, CMS

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ASTHO WebsiteASTHO website with matrix of current emerging, promising and best practices will be available soon Facilitating use of a menu of strategies for varying levels of intervention linked to concrete implementation steps and detailed resource informationOther resources will include case studies and commentary from state leaders Guide, create or strengthen state partnerships and fine-tune current programs The ASTHO site will also link to tool kits on best practices created by AMCHP and March of Dimes

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ConclusionRates of prematurity and infant mortality are much higher then they should beThe cost of prematurity is very high, measured in both human and economic costsThere are proven methods states can use to combat these public health issuesWe will not be successful unless we work together

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Thank You!*

*Source: National Center for Health Statistics, final mortality data, 1990-1994 and period linked birth/infant death data, 1995-present.

*Texas Medicaid covers 3 million Texans primarily low-income families with children, pregnant women, the elderly and people with disabilities. Pregnant women are covered up to 185 percent of the federal poverty level. Non-citizens are not eligible for Medicaid (except emergency Medicaid). More than 55 percent (225,000) of all births in Texas are paid by Medicaid. Medicaid currently spends over $2.2 billion per year in birth and delivery-related services for moms and infants through their first year ($22 billion total program services costs in 2010).Also in Texas, Medicaid costs related to infant care are growing almost 10 percent per year. Neonatal Intensive Care Unit utilization is growing faster than expected. Over 50 percent of costs are attributable to extremely preterm infants, who account for about 2 percent of births. Extremely preterm infants are less than 28 weeks gestation or have a birth weight under 1,000 grams. The average cost per claim for extremely premature infants was $63,124, compared with $404 for a normal newborn claim, based on Medicaid diagnosis-related group billing codes.*Thank you for the opportunity to participate in our Healthy Babies Presidential challenge at the upcoming Association of State and Territorial Health Officials (ASTHO) meeting in Portland. As promised, I am providing a formulation of how a national goal of 8% reduction in rates of preterm birth (PTB) could be achieved by 2014.

Many of the causes of PTB remain unknown, but evidence is mounting that bold public health leadership can effect meaningful changes in communities among clinicians and consumers, that decrease the incidence of preterm birth and reduce its associated harms and costs. Extensive analytic work prepared by MODs Perinatal Data Center demonstrates that aggressive but reasonable activity in four areas of intervention could yield the 8 percent reduction in PTB rates that you envision. Models using national statistics, peer-reviewed findings on evidence-based interventions, and pre-published analyses by MOD on community-based interventions, yield the following blueprint that we believe can guide individual jurisdictions toward that 8 percent reduction. Considerations can, of course, vary by locale.

1.Ensure universal access to 17P for eligible women. (Reduction of 10,000 PTB)

Recently approved by the FDA for this purpose, 17 alpha hydroxyprogesterone caproate ( 17P) has been demonstrated to reduce subsequent PTB by 33% percent among women with PTB history who received prenatal care during weeks 16-20 of pregnancy (Meis, et al.,2003). Petrini and colleagues estimated that 10,000 of the nations half million preterm births would be prevented annually if all eligible women who sought prenatal care during the critical gestational period received 17P. Even more preterm births could be prevented if a higher proportion of women received early prenatal care. This study predated FDA approval of the injection form of 17P and the clinical trials of its vaginal gel form intended for women with short cervix, which could result in even greater reductions.

ASTHO leadership can increase the appropriate clinical use of 17P in two ways: first, by working with public and private payers to eliminate access barriers to this important drug; and second, by working through traditional means to get more pregnant women into prenatal care during the critical gestational stage. We believe that universal access to 17P, which may be within the reach of bold and effective ASTHO leaders in their own jurisdictions, together with higher rates of early prenatal care could yield 10,000 fewer preterm births annually across the nation if applied universally.

2.Eliminate the incidence of higher order multiples due to assistive reproductive technologies (ART), 97 percent of whom are born preterm. (Reduction of 2,300 PTB)

Nearly 35,000 preterm births annually are attributable to assistive reproductive technologies (ART) and non-ART infertility treatments that result in twins or higher order multiples. More than 65% of twins and 97% of triplets and higher order multiples that result from ART are delivered prematurely (CDC, 2009). While it may be difficult during this next three years for ASTHO leaders to effect sufficient change in the ART industry to reduce substantially the incidence of twins, we believe that there is sufficient political will to eliminate the triple (and higher) embryo transfers that result in nearly 2,300 preterm births annually. The state of the science has advanced in recent years to yield reasonably high rates of implantation success from single embryo transfer, and the evidence of harm from higher order multiples is adequately documented to launch a successful statewide campaign against the risky industry practice of triple embryo transfer. ASTHO leadership and activism, therefore, has a realistic probability of eliminating 2300 preterm births attributable higher order multiples. If successful, this campaign may also reduce the incidence of twins, who are also at higher risk for PTB.

3.Reduce rates of smoking among pregnant women by 10 percent. (Reduction of 1,300 PTB)

The linkage between smoking and PTB is well established, as is the benefit of smoking cessation for pregnant women. In its landmark demonstration project Healthy Babies are Worth the Wait (HBWW), conducted in Kentucky over the past four years, readily available community-based smoking cessation initiatives executed led by the Kentucky Department for Public Health, in partnership with participating hospitals, and March of Dimes resulted in a 10 percent reduction in smoking among women delivering over the study period. Based on estimates of the contribution of maternal smoking to preterm delivery (Shah and Bracken, 2000), an estimated 12,700 babies nationwide are born premature as a direct result of smoking during pregnancy. A 10 percent reduction in maternal smoking could prevent nearly 1,300 preterm births annually nationwide. Many of your ASTHO colleagues hold key positions in their jurisdictions to launch these initiatives in partnership with local hospitals and March of Dimes chapters. We learned from HBWW that such partnerships can be effective.

4.Reduce non-medically indicated elective inductions and cesarean sections prior to 39 weeks gestation. (Reduction of 25,000 PTB)

In 2010, the Joint Commission established a new perinatal care core measure set that includes the number of elective deliveries (both vaginal and cesarean) performed at >37 and