Even though the health risks to babies born before they reach full term at 39 weeks have long been recognized, nearly 1 in 10 babies in the United States is born prematurely. Texas decided to try to change that.
In 2011, the Texas Medicaid program was the first in the country to take steps to curb elective early deliveries by refusing to pay providers who induced early labor or performed a cesarean section that wasn't medically necessary before 39 weeks. In the first two years after that, Texas reduced the rate of unnecessary early delivery by as much as 14 percent. The state's efforts also led to an increase in the length of pregnancies by nearly a week, with infants weighing on average nearly half a pound more, a new study found.
Those reimbursement changes were part of a Texas Medicaid payment reform law. Before it took effect, 10.63 percent of Medicaid single births in the state were early elective deliveries, according to the study, which was published in the March issue of Health Affairs. After the law passed, the percentage of unnecessary early deliveries declined 2.03 percentage points.
About half of the decline was due to the payment reforms, while the rest could be attributed to other efforts to reduce early deliveries, unrelated trends and the economy, said Heather Dahlen, a research associate at Medica Research Institute in Minnetonka, Minn., and the study's lead author.
Still, "in order for the rate to fall that much, there was a relatively significant effect on the target population," Dahlen said.
The impact on early elective delivery was greatest for Latinos, whose rate declined 1.77 percentage points to 8.14 percent. The rate for non-Latino blacks declined 1.4 percentage points to 9.57 percent, while non-Latino whites saw a much smaller decline -- 0.72 percentage point, to 8.43 percent.
Infants born before 39 weeks are more likely to have a range of health problems, including respiratory disorders, sepsis and feeding issues, and to be admitted to hospital neonatal intensive care units. Doctors and expectant mothers who opt for early delivery may not realize the risk or choose to go ahead for convenience. In some rural areas, women may be encouraged to schedule early deliveries to ensure they're able to get to the hospital in time.
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For the study, researchers analyzed data from 2009 to 2013 on the national Vital Statistics System's Natality Detail Files, which is derived from information reported on birth certificates.
The federal-state Medicaid program for low-income people pays for roughly half of all births in the United States. After Texas passed its law, five other states passed similar laws in 2013: Georgia, Michigan, New Mexico, New York and South Carolina.
Reducing preterm births generally, and early elective deliveries in particular, is a priority for many groups, including health care providers, hospitals and patient-advocacy organizations. In addition to payment reform, these groups have employed other strategies such as educational programs for health care providers and patients and "hard-stop" policies that prohibit doctors from scheduling early elective deliveries unless they meet medical necessity standards.
"The Medicaid program was paying doctors for doing things that actually harm babies," said Dr. Paul Jarris, chief medical officer at the March of Dimes, which publishes an annual report card that ranks states based on their preterm birth rates. "These payment changes actually make huge differences if they're done right."