Although President Clinton has made overhauling the health-insurance and health-care industries a priority, delays have been inevitable. The process of reform is expected to be lengthy and fractious, leaving U.S. businesses to fend for themselves in dealing with issues of cost and accessibility. Businesses must continue, at least for the time being, to supplement uncompensated care for the uninsured.
To improve the health of their employees and thus reduce company-related health-care costs, companies have implemented a variety of wellness programs. Some organizations have been disappointed because they haven't been able to evaluate outcomes effectively and verify the results that they had hoped to achieve.
One type of wellness program, however, has been proving itself repeatedly: the work-site prenatal program. This program offers to pregnant employees (and often to pregnant spouses of employees) information on birth risks, assessments for their risk factors, case-management intervention and educational materials for a healthy pregnancy.
Work-site prenatal programs have been developed to control birth-related costs.
Most of the prenatal work-site programs in existence today have been developed by or for insurance carriers. The insurance companies realized that a good portion of their health-care costs occurred as a result of women delivering preterm or having low-birthweight babies. Because many of these women are in the work force, or are insured through their spouses' medical plans, expenses related to childbirth have become the largest single component of total health-care costs for employers, according to a 1992 study conducted by Philadelphia-based CIGNA Corp. The study, titled The Corporate Cost of Poor Birth Outcomes, indicated that these childbirth-related expenses account for between 10% and 49% of employers' total health-care costs. Adding the expenses of absenteeism, disability, turnover and cost shifting compounds this cost further.
A 1987 report of the Southern Corporate Coalition to Improve Maternal and Child Health reported that the average cost of rehabilitation for a preterm infant was $20,000. CIGNA's recent study, however, found that its actual cost for preterm births and low-birthweight babies averaged $40,000, far higher than anticipated.
CIGNA commissioned the study, along with a second study, titled Impact of Uncompensated Maternity and Infant Care Costs on Employers, to determine the impact of preterm births on its organization. These studies verified the alarming facts about the costs associated with maternal and infant health care.
The first report found that U.S. businesses and their employees pay an estimated $5.6 billion annually for the health-care costs of mothers who deliver babies who are underweight or born prematurely. The second report found that U.S. businesses pay an additional estimated $4 billion annually for uncompensated health-care costs incurred by the nation's poorest mothers and infants.
CIGNA summarized its findings: "Put simply, infant mortality is taking an expensive toll on U.S. businesses." W. Allen Schaffer, senior vice president for CIGNA's Employee Benefits companies, takes it one step further by saying, "Poor maternal and child health is a subject that many people associate with the poorer segment of our society, and because of this, some have looked at maternal and child health as someone else's problem. Nothing could be further from the truth. These health-care problems have a real impact on the business community, as well as the community at large."
Many employers believe that because their workers are employed and have insurance coverage, they're seeking appropriate medical care. Unfortunately, that often isn't the case. "This isn't just a problem for the inner-city poor," points out Schaffer. He says that the CIGNA studies showed that among the population of employed people who have group health insurance, there's "a high percentage of less-than-best pregnancy outcomes."
Anne Serra, administrator of employee services and recreation for Pomona, California-based Hughes Missile Systems Co., concurs. She started a prenatal work-site program for her company's 4,000 employees and insured spouses as a result of lackluster prenatal attitudes. "Even though everyone here has insurance, not all our women sought care during their first trimesters, and quite a few weren't reporting their pregnancies until after the first trimester or just before delivery," she says.
The reports funded by CIGNA cited several reasons why insured women may not seek prenatal care, such as:
- Inadequate time off for doctor visits
- Extreme out-of-pocket coinsurance costs
- Severe shortages of practicing obstetricians in many parts of the country.
Atlanta-based Crawford & Company, a health-care-management corporation, found that participants of its Maternity Management Program faced similar barriers to effective prenatal care. "We found that many physicians require a percentage of professional fees for prenatal care and delivery payable within the first trimester," says Jeff Aycock, Crawford's vice president of health-care management. Because the cost for physician care from start to finish of a pregnancy can range from $2,000 to $4,000, the physicians required the pregnant women to pay anywhere from $500 to $1,500 up front. "Many of the mothers in our program were generally young and just starting their careers, and found it difficult to come up with that kind of money," says Aycock. "Consequently, we found that the women were delaying prenatal care for as long as possible, and some until just prior to delivery, based simply on financial factors."
In certain types of businesses, other factors also may play a role in determining how early an expectant mother seeks prenatal care. Serra discovered that some Hughes Missile Systems' employees weren't reporting that they were pregnant because they didn't want to be transferred—something that is mandatory for pregnant women who work in those areas of the business that have a potential for exposure to toxins. "Some of the women hid their pregnancies to avoid transfers or going on disability," she says.
Educate workers to seek care early.
Study after study demonstrates that U.S. businesses spend millions of dollars on back-end heroics to save the children of mothers who don't seek prenatal care. The money would be better spent at the front end for education and prevention.
According to the American Journal of Obstetrics and Gynecology (May 1987), 63% of private-sector preterm births and low-birthweight cases are preventable. "The key to prevention is early recognition of pregnancy," says CIGNA's Schaffer. "If we can encourage mothers to access prenatal care early in their pregnancy, and, equally important, educate them about the risks their lifestyles pose to their babies, we have a better chance of favorably impacting the outcome of their pregnancies."
Prenatal risk-management programs have been proven to reduce the risk, and related costs, of low-birthweight and preterm births. Debbie Nuttycombe's case illustrates this fact. Nuttycombe is the owner of USA Financial in Newport News, Virginia. When her physician determined that she was pregnant with triplets, Nuttycombe realized that she would need help through her pregnancy, which was deemed high-risk. She immediately joined a program called Baby Benefits by Richmond, Virginia-based Health Management Corp.
Baby Benefits provides pregnant women with nurses who consult with the women and with their participating physicians, coordinate appropriate care, conduct monthly follow-up phone visits and answer questions throughout the pregnancies. "The benefits nurse who was assigned to me knew about high-risk pregnancies and knew the best things to do relative to multiple-birth deliveries," says 33-year-old Nuttycombe.
Nuttycombe's pregnancy experience is evidence from the prospective mother's viewpoint of how effective such a focus can be. "The most important thing I got out of Baby Benefits is that the staff recognized that my pregnancy wasn't just affecting me, but that it was a family experience," says Nuttycombe. "They realized that for me to be taken care of properly, my family had to be taken care of properly." During Nuttycombe's pregnancy, a nurse helped her find a housekeeper, and convinced Nuttycombe's insurance carrier to pay for the service. Housekeeping service cost the company far less than hospitalization, which would have been the alternative for preventing preterm labor. The cost savings for the insurance company by avoiding hospitalizing Nuttycombe totaled approximately $28,000.
A Program Effectiveness Study prepared by Blue Cross and Blue Shield of Richmond, Virginia, on the Baby Benefits program that Nuttycombe used, provides tangible evidence of savings for companies offering the program. The actuarial study showed that women who participated in Baby Benefits had 20% fewer charges related to preterm and low-birthweight babies than those women who didn't participate in the program.
Many of the insurance carriers for which other prenatal work-site programs were developed also have reported significant savings as a result of the programs, even through programs that have been in place for only a short period of time. Their experiences support the theory that through early education, assessment for high risk, and appropriate case-management intervention, mothers and babies can have more positive outcomes more often.
Rick Dorazil, corporate director of benefits at Roselle, Illinois-based Motorola Inc., agrees. He says that in the first year of providing a prenatal educational, assessment and home-based care program, the consumer-electronics manufacturer saved twice as much in health-care costs as it spent for the program. The program cost the company between $200 and $225 per pregnancy. He says that the eventual savings from preventing preterm births and birth defects far outweigh the program's expense.
Haggar Apparel Co.'s experience with a prenatal work-site program is similar. The Dallas-based company introduced a broad program of coverage for prenatal care when it discovered that 95% of its female work force wasn't seeking prenatal care because of the expense. Haggar's program allows expectant mothers to receive full reimbursement if they see their physicians within the first trimester of their pregnancies.
Savings to the company have been significant, reports Anne Hunt, Haggar's health and wellness coordinator. "Health claims dropped from $2.3 million in 1991 to $1.8 million in 1992, a savings of more than a half-million dollars," says Hunt. "And this savings was realized even though the total number of births increased."
Find a prenatal program to fit your needs.
How does a corporation know which programs are best for its employees and for the overall health of the company? As a human resources professional trying to help your company and its employees, you need to know how to identify a prenatal program that has all the elements for successful implementation. Just what is a prenatal program and what should it include?
Programs available range from simple educational materials to comprehensive pregnancy case management for high-risk mothers. In all cases, prenatal medical care is provided by the patients' obstetricians, although not all the programs establish relationships with physicians or interact with doctors to share data.
Generally, companies make their programs available to all pregnant employees. Some also offer the program to the spouses of male employees, particularly if many are covered by their companies' insurance programs. By offering such broad coverage, the companies can screen for the high-risk pregnancies while still providing beneficial information to all expectant mothers.
To be most effective, a prenatal-education program should be as inclusive as possible, both in terms of participants and in the components of the program, says Connie Marshall, spokesperson for the national March of Dimes' campaign and author of From Here to Maternity, The Expectant Father and other prenatal-wellness materials. "Several elements are required in order to produce the desired outcome, which is delivering healthy babies," she says. "Comprehensive pregnancy-educational materials and risk assessment by qualified health-care professionals are the minimum requirements for a program that addresses corporate and employee goals and objectives."
Marshall considers education one of the most vital components of a successful prenatal health-management program. "Many of the factors contributing to low-birthweight babies are lifestyle issues," says the clinical OB nurse. "Recent studies show that women underestimate the impact that smoking, drinking and drug use have on unborn fetuses. They also are unaware of dietary recommendations and the necessity of weight gain during pregnancy."
Hughes' Serra concurs, pointing out that she was surprised at the number of women in her organization who weren't informed about lifestyle issues and the impact of lifestyle on pregnancy. "We wanted to target those women who needed information and weren't getting it," she says. "We wanted to ensure that they had the information they needed to make the right behavioral choices. We offered incentives, such as the opportunity to earn infant car seats or similar items, to entice them to join the program."
Materials to accompany work-site education programs are relatively inexpensive for employers to provide. Most programs include these materials with the price of the program. If purchased separately and in bulk, many of these materials cost as little as $5 each.
These accompanying materials can educate women on health issues that lead to lifestyle assessment and change. However, Marshall cautions that many companies, and consumers in general, have fallen into the trap of assuming that any book published on pregnancy is clinically correct and up-to-date. "You can't assume that just because a book is in a bookstore—and possibly is a best-seller—that it's accurate, and more importantly, up-to-the-minute. Obstetrics is a very specialized and rapidly changing field, and buyers need to be aware," Marshall says.
To be most effective, educational materials need to be complete, accurate, up-to-date and written in clear and understandable language, according to Thomas Garite, an obstetrician specializing in high-risk pregnancies, and professor and chairman of obstetrics and gynecology at the University of California, Irvine.
Most of the available programs recommend and use the March of Dimes' Babies and You work-site seminars as an enhancement to their educational component. The March of Dimes recently launched another national campaign, Men Have Babies, Too. The organization designed the campaign to help heighten men's awareness of the role they play in pregnancy, and to teach them how they can assist their partners in having a healthy baby. "We need to include the expectant father; he's very important to the outcome of the pregnancy, too," says Marshall. "It's been shown that when the expectant father is educated about pregnancy, the chances for a healthy baby increase."
Other important program components for which corporations should look are management of high-risk pregnancies and postnatal follow-up. All of the major programs available today offer a risk assessment for expectant mothers in order to screen for potential problems as early as possible. "One of the goals recommended by all groups concerned is to assure that women with high-risk pregnancies get into the health-care system as early as possible," says Donald M. Hayes, medical director for Chicago-based Sara Lee Corp. "Baby Benefits is of immeasurable help in identifying these women and helping them make this connection."
W. Jack Hudson, director of insurance and retirement for Indiana University, is equally pleased with the prenatal program that his university uses: Start Smart from Indianapolis-based Anthem Health Systems, Inc. "I'm aware of a number of pregnancies that had been identified as high risk and resulted in the intervention by prenatal nurses and case managers," he says. "I feel confident that this intervention has resulted in both employee satisfaction and in significant cost savings to the plan."
Keep track of outcomes data.
For most companies, data gathering will be a must in order to verify the cost-effectiveness of the program. Many of the vendors offer quarterly and annual reports on program use, costs, and so on.
Serra says that outcomes data and usage information are important. She has had difficulty tracking the success of Hughes' internal program, titled Maternity Fraternity. Because the company insures its employees through a self-funded plan, as well as a number of HMOs, Serra often can't obtain the information she needs to measure the effectiveness of her program, even though more than 200 women have used it in the two years during which it has been in place.
CIGNA's Schaffer agrees that outcomes data are vital. "Only when a health plan establishes benchmarks and has a system in place to continuously measure quality-management programs can we be satisfied that we have met the standards expected of us," he says.
Corporations can choose from programs that do all the administration, or can opt to manage the program themselves. Costs for the programs vary, and are subject to negotiation and customization. Some programs offer per-employee prices, or per-pregnant-employee prices. Prices can range from 30 cents to 50 cents per employee, or $200 to $250 per pregnant employee. Many programs add hourly charges as well for high-risk pregnancies. There may be additional implementation fees, which normally include posters, setup and customization of materials.
The size of the employee base and other factors can influence price as well. Corporations always should investigate what the cost of the program would be for the organization. Group demographics, managed-care arrangements and the program components used all can affect the pricing.
Dorazil of Motorola sums up his company's experience with Irvine, California-based Tokos Clinical Services' BabyLink program by saying, "There are certainly high-tech applications that are saving us hospitalization costs. What's even more important, however, is the component that allows us to identify potential problem pregnancies before they become expensive problems."
Advises Schaffer: "Prenatal care and well-baby programs are important components of an employer's health-plan offering, and these programs customarily are part of a managed-care plan. Managed-care programs offer an integrated, coordinated system of care that identifies individual medical needs and oversees all the care administered to a patient. Maternity care and case management of high-risk pregnancies are examples of how coordinated care can affect outcome and add value."
Serra points out that even if a company can't offer a comprehensive program, it should at least offer the educational component. Her commitment is unflagging, even though she lacks the hard data to back up this commitment. "Any information that a company can provide its employees is worthwhile," she says.
Corporations that make an investment in education and risk assessment are contributing to the well-being of their workers and taking positive steps toward changing the statistics on pregnancy outcomes and infant mortality—an issue that affects all of society. They also will benefit by lowering company health-care costs and increasing satisfaction among workers, resulting in reduced absenteeism, increased productivity and improved morale. Additionally, companies offering prenatal programs are making a commitment to future generations, helping ensure that as many babies as possible get the best start that they can.
Personnel Journal, October 1993, Vol. 72, No.10, pp. 39-48.