Closing the Disparity Gap in Premature Births and Infant Deaths: A Glimpse Into North Carolina’s Pregnancy Medical Home Program


By Sharita Thomas, Staff Editor

The United States has a higher incidence of premature birth than any developed nation, a factor that contributes to its abysmal ranking in the infant mortality rate. 12.2% of births in the U.S. are preterm, while only 5% to 7% of births in other developed nations are preterm.  The U.S. health care system clearly has a lot of ‘splainin’ to do.’ Additionally, preterm births and newborn deaths in the United States disproportionately affect Non-Hispanic Blacks and Hispanics. Non-Hispanic Blacks, Non-Hispanic Whites, and Hispanics have infant mortality rates of 15.2, 6.4, and 6.3 respectively. This problem is even more pronounced in North Carolina: Non-Hispanic Blacks account for 17.6% and Hispanics account for 12.1% of preterm births in the state.  Only seven states and the District of Columbia fare worse than North Carolina in the overall number of preterm births and number of infant deaths.

To combat this problem, the Director of North Carolina’s Division of Medical Assistance, Craigan Gray, launched a program over a year ago that brings together community leaders, the Division of Public Health, and Community Care North Carolina to provide a pregnancy medical home (PMH) for recipients of Medicaid. PMHs may particularly help Non-Hispanic Blacks and Hispanics because they make up 48% of the state’s Medicaid recipients.

North Carolina is the first to implement a statewide comprehensive managed care pregnancy model of this kind. A goal of PMHs is to reduce Medicaid spending through the achievement of improved perinatal care, which should result in improved birth outcomes. Medicaid is a primary payer for perinatal care in North Carolina, covering 56% of the 126,785 live births in 2009 alone. The focus on outcomes as an indicator for success makes the PMH a “value-added” model. Traditionally, the main purpose of medical homes has been to provide patient-centered, comprehensive, and coordinated care with increased access and a systems-based approach to quality. This program will be fee-for-service with additional monetary incentives to increase provider participation and streamline the outcomes.

The list of possible contributors to the poor infant outcomes for Non-Hispanic Blacks and Hispanics is long and may include inadequate care, lack of education, poverty, and stress.  Instead of focusing on how to reduce the cost of care directly, the PMH model aims to reduce the inadequacies in care that lead to pregnancy-related medical problems and higher Medicaid costs. The promise of reducing adverse outcomes and costs will lie in the ability of the program to identify high risk pregnancies and sufficiently coordinate and manage care up to and through delivery. Providers will be tasked with early outreach, as some incentives are based on the number of patients enrolled.

The question remains as to whether the significant cause of the disparities in pregnancy outcomes among racial and ethnic minorities is quality and access of care. Dr. Jennifer Culhane has noted that some studies have shown that common interventions, such as prenatal care, risk screening, and nutrition training have not been successful in preventing preterm births among racial and ethnic groups, specifically among Non-Hispanic Blacks.

It will be interesting to study the results of North Carolina’s PMH program when they become available next month to see just how much of an impact comprehensive care can have on reducing health outcome disparities. So far, 80 percent of North Carolina’s obstetricians have joined the program and have screened 60 percent of all pregnant women enrolled in Medicaid.

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