Testimony on House Concurrent Resolution 12
June 17, 2015
Brad Lucas, MD, MBA, FACOG
Chief Medical Officer
Buckeye Health Plan
Akron, Ohio
My thanks to the leadership of this Committee for the opportunity to provide this
testimony regarding this House Resolution and the need to ensure equitable access to
cervical length screening and progesterone intervention for all pregnant women as a
primary strategy to reduce preterm birth and infant mortality.
My name is Dr. Brad Lucas. I am a Board Certified Obstetrician/Gynecologist and Chief
Medical Officer of Buckeye Health Plan, an Ohio Medicaid managed care organization.
Buckeye covers approximately 7,500 pregnant women annually, striving to provide
comprehensive, high quality prenatal care to some of Ohio’s most vulnerable. From
conception, these expecting mothers – and their babies – are at risk of adverse outcomes
simply given their lack of social support and economic resources.
Many also face
challenges related to poor nutrition, smoking, or alcohol or drug abuse. Significant racial
disparities contribute to the higher rates of preterm birth and infant death, as do the
number of teen pregnancies.
I commend the State of Ohio for its attention to infant mortality: the Kasich Administration,
the legislators, many of you included, who have actively addressed infant mortality
throughout this session, and Dr. Mary Applegate, our Medicaid Medical Director.
Through the Ohio Perinatal Quality Collaborative (OPQC), Dr. Applegate and obstetrics
and public health experts around the state are tackling many issues that have real
potential improve birth outcomes.
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The Department of Health established the Ohio Collaborative to Prevent Infant Mortality
(OCPIM) in 2010. I have had the honor of serving on OCPIM since its inception and
working with the State, nonprofit organizations, other health plans, and many physicians.
I am on the Steering Committee and Co-Chair the Care Coordination Committee for
OCPIM. This Collaborative does great work bringing awareness to our State’s crisis of
infant mortality and educating stakeholders from all arenas and arming them with
prevention strategies across the continuum of maternal and child health. Our 2014 Infant
Mortality Summit is December 3-4 in Columbus.
We are not making enough progress. Ohio must do more. Three babies die every day in
Ohio before their first birthday. Our state is ranked 50th in infant mortality for African
Americans. Preterm birth is the leading cause of infant death. One of 9 babies in Ohio is
born too soon. These babies at increased risk of death, and many face a life of disabling
health, developmental, or neurological conditions.
The morbidity and mortality associated with preterm birth affect population health broadly,
and each family individually and deeply.
The economic impact is staggering.
Each
preterm birth is 10 times more expensive than a birth after 37 weeks gestation. Medical
costs in the first year of life for babies born very preterm, before 28 weeks, are 57 times
those of a full term baby – and the excess costs continue, still double at 7 years of age.
Neonatal Intensive Care Unit admissions can run into the millions for just one preemie.
Ohio Medicaid pays for 38% of babies born here, around 50,000 annually. You can
imagine the impact of preterm birth on the State budget.
One intervention proven to reduce the rates of preterm birth and infant mortality by 4050% in certain high risk pregnancies is progesterone.
Buckeye has encouraged our
providers for many years to use one form of progesterone, 17-OHPC, for pregnant
women with history of spontaneous preterm birth. Screening for this risk factor is simply
a review of obstetric history at the first prenatal visit.
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Since 2005, we have helped our providers improve appropriate use of 17-OHPC through
clinician and patient education as well as coverage policies. We’ve seen an increase in
the percentage of patients treated from less than 10% to over 60%, and we and will
continue our efforts to drive continued improvement.
In 2013, we expanded our education and outreach to encourage use of vaginal
progesterone as evidence based treatment for pregnancies diagnosed mid-pregnancy
with a short cervix. These pregnancies are at 10 times the risk of an early delivery. This
inexpensive, generic drug cuts that risk in half. NIH clinical trial data suggest that NICU
admissions can be cut by 25% among pregnant women with premature cervical
shortening if treated with vaginal progesterone.
To identify this high risk population, cervical length screening must be added to routine
prenatal care.
This risk screening and vaginal progesterone for these patients are
recommended by all three obstetrics professional societies: the Society for MaternalFetal Medicine (SMFM), the American College of Obstetricians and Gynecologists
(ACOG), and the American College of Nurse-Midwives.
Economic analyses have
proven the strategy cost saving; Ohio could save $10 million annually.
OPQC is now working to understand barriers associated with patient access to
progesterone and putting systems in place to remove those barriers. This is a step in the
right direction and is helping improve treatment for some pregnant women. We can do
more.
The main barriers are a lack of awareness and physician reimbursement. At Buckeye,
we have seen the power of education and relationship building with our providers in our
efforts to increase risk screening and use of progesterone. Because we know physicians
cannot add new procedures without reimbursement, we changed our policies to ensure
payment for cervical length screening. Buckeye covers screening with either transvaginal
ultrasound (TVU) or a cervicometer, to allow physician choice as well as provide
equitable access for patients.
We are eliminating pre-authorization requirements for
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these screening procedures, since those might limit physician adoption. Importantly, we
are also putting a tracking mechanism in place. Measuring an uptake in cervical length
screening, along with progesterone prescriptions, is critical to measuring success.
This resolution will play a valuable role in bringing greater attention to expanded preterm
birth risk screening and utilization of progesterone to reduce the risk of death for Ohio’s
babies. We must make this change to routine prenatal care to make progress reducing
early preterm birth, which accounts for more than half of infant deaths.
In respect to this resolution, I suggest the following three issues be considered:
1. Preventable preterm births continue to occur in Ohio, which means preventable
infant deaths also continue to occur. Without the addition of universal cervical
length screening, pregnant women for whom progesterone treatment could
prevent preterm birth will continue to go undiagnosed.
2. A collaborative effort among all stakeholders is needed to raise awareness of the
professional society guidelines on a comprehensive progesterone strategy.
All
obstetrics providers in Ohio should follow these recommendations. Doing so will
increase appropriate use of progesterone for both high risk groups (prior
spontaneous preterm birth and prematurely short cervix) to achieve greater
improvements in birth outcomes and cost savings.
3. Many physicians in Ohio are currently only offering cervical length screening to
patients for whom the procedure will be reimbursed. Coverage by all payers in
Ohio will help accelerate adoption of screening, and thus enable increased use of
progesterone treatment.
Consideration of both cervical length screening
modalities (TVU and a cervicometer) is important to allow screening in all health
care settings.
Thank you for your time.
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