You asked (1) for an explanation of how the Department of Social Services (DSS) provided for the care of women with high-risk pregnancies after April 1, 2008 when managed care organizations dropped out of the HUSKY program and (2) how DSS plans to care for women with such pregnancies when a new managed care system begins on July 1, 2008. You also wanted data showing birth outcome trends over the past 25 years.

SUMMARY

When Governor Rell terminated the contracts of four managed care organizations (MCOs) serving the HUSKY Program on April 1, 2008 recipients were given the choice of obtaining service through two of the MCOs' networks (with the MCO acting purely in an administrator, not insurer, capacity) or moving to fee-for-service (FFS) Medicaid and choosing a provider.

Women who did not switch to FFS continued to receive case management through the remaining MCOs. Of the pregnant women who switched to FFS from the other two MCOs, the Department of Social Services (DSS) referred 14 it determined posed high-risk pregnancies to five Healthy Start contractors. Healthy Start is a prenatal outreach program that operates in 17 communities whose rates of infant mortality

and low-birthweight babies are disproportionately high. It is jointly funded and managed by DSS and the Public Health Department (DPH). DSS added approximately $29,000 to each contractor's budget for taking these new clients.

Beginning July 1, DSS will resume offering the HUSKY program through full-risk MCOs; HUSKY recipients will not be served under the FFS model. Healthy Start contractors will have the option of referring case management responsibility for high-risk pregnant women to the MCO the woman chooses.

The percentage of low-birthweight babies (under 2,500 grams) has fluctuated over the 25-year period we examined (1981 to 2006); the trend over the past 10 years has been upward. The percentage has been consistently high among mothers under age 20, minority and Hispanic mothers of all ages, and urban residents, while it fluctuates in suburban and rural areas.

The total number and percent of premature births has nearly doubled over the past 25 years. The total has nearly tripled for mothers over age 20, while it has declined for mothers under age 20. Higher percentages of prematurity are also linked to race and ethnicity.

Fetal deaths have decreased over the past 25 years overall, for both age groups, and among racial groups. They have risen among the Hispanic population, probably because of that group's growth.

HANDLING HIGH-RISK PREGNANCIES SINCE APRIL 1

Exiting MCOs and New HUSKY Structure as of April 1

On April 1, the health care landscape changed when Governor Rell terminated the four contracts between DSS and HUSKY MCOs. As of that date, two of the MCOs, HealthNet and Preferred One, stopped providing any services while the other two (Blue Cross Family Plan and CHNCT) continued to maintain a HUSKY role. HUSKY members from the terminated MCOs were given the option either to enroll with Blue Cross or CHNCT or to be placed in traditional FFS Medicaid. Members who failed to choose a plan defaulted into FFS.

Blue Cross and CHNCT act essentially like administrative service organizations (ASOs) and handle only HUSKY's administrative functions. They bill DSS for all medical services their network providers perform based on the department's fee schedules and in turn pay the providers. In return, DSS has paid them a much-reduced monthly fee per HUSKY member.

Treatment of High-Risk Pregnant Women

DSS's goal, outlined in a March 14, 2008 advisory letter, was to minimize the number of pregnant women in traditional FFS Medicaid (presumably, because the MCOs would have better provider networks). It directed its HUSKY enrollment broker, ACS, Inc., to call pregnant women who had previously received or were receiving case management from HealthNet or Preferred One and had either chosen, or defaulted into, FFS to see if they wanted to switch to Blue Cross or CHNCT.

HealthNet and Preferred One identified approximately 150 pregnant women who switched to FFS. Six were already labeled as at high-risk by one of the plans, and DSS determined another eight were at high risk because the MCO had been providing them with either case management or disease management services. DDS decided to refer the women to Healthy Start because its responsibilities include case management and health education. Table 1 provides a breakdown of the 14 referrals, by Healthy Start contractor.

Table 1: High-Risk Pregnancy Referrals to Healthy Start Contractors

Blue Cross and CHNCT continued to provide case management under their ASO arrangements to women with high-risk pregnancies who they had previously served and those who moved from the other two MCOs, according to Rose Ciarcia, the HUSKY program's manager. We do not know how many such women they are serving. The administrative services fee DSS pays the plans includes services such as case management, call center customer services, and utilization management.

Funding

According to Ciarcia, DSS added roughly $29,000 to each Healthy Start contract (which included Maternal and Child Health funds it had just received and a cost-of-living adjustment) as compensation for the referrals.

PLANS FOR JULY 1

On July 1, DSS will again offer full-risk health insurance under the HUSKY program through MCOs. Three MCOs have been chosen to serve HUSKY clients—Aetna Better Health, Americhoice, and CHNCT. At that time, HUSKY recipients will no longer be able to be served under FFS Medicaid.

The MCOs will provide case management services, and pregnant women enrolled in Healthy Start will receive their medical services through them. Ciarcia reports that MCOs' standard practice is to contact new members and do a risk assessment either by phone or through a questionnaire they send with the member handbook and card. They offer case management to members they identify as high risk. A member who is receiving case management through Healthy Start can continue to do so or can choose to have the MCO take over case management. Ciarcia expects that the 14 women transferred to Healthy Start will have delivered by the time the transition to the new MCOs is completed.

BIRTH OUTCOME TRENDS

The following tables show trends from 1981 to 2006 for low-birthweight babies (Table 2), low-birthweight for selected towns (Table 3), premature deliveries (Table 4), and fetal deaths (Table 5). The data are broken down by race and ethnicity, mothers' age (under or over 20), and, in Table 3, by residence.

Table 2 shows that the percentage of low-birthweight babies (< 2,500 grams) fluctuated over the 25-years from 7.3% in 1981, to 6.5% in 1986, and then upward in the next 20 years, reaching 8.2% in 2006. The rate of low-birthweight is highest among African-American women, always over 12%. It is also high among mothers under age 20—over 10% until 2001 when it dropped to 8.7% before rising again to 9.7% in 2006. The percentage is considerably higher among African-American and Hispanic mothers under age 20.

We selected three types of towns to show in Table 3. One is those with the highest percentages of low-birthweight babies for all racial groups over the entire period. These are urban and larger suburban communities with high percentages of minority and Hispanic mothers (Bridgeport, East Hartford, Hartford, New Haven, New Britain, and Waterbury). The second type are suburban and rural towns where more than 8% of births in 1981 were low-birthweight (Avon, Rocky Hill, Winchester); the third type are similar towns whose percentage grew to that level over the 25 years (Berlin, Clinton, Killingly).

Because they have fewer total births, the percentage of low-birthweight babies in the rural and suburban towns fluctuated considerably. The percentage of low-birthweight babies in the urbanized areas was consistently high, especially among minority and ethnic mothers.

The data show a steep increase in the number and percent of premature births (<37 weeks gestation) between 1986 and 1991. The total number and percent of premature births has nearly doubled over the past 25 years. The total has nearly tripled for mothers over age 20, but it has declined among younger mothers. The data also show significantly higher percentages of prematurity among mothers under age 20 and African-American mothers of all ages.

Fetal deaths have decreased significantly over the past 25 years overall and for both age groups and among racial groups. Fetal deaths have risen among the Hispanic population, probably because of that group's growth.

All data are derived from DPH's Annual Registration Report.

Table 2: Low Birthweight, By Mother's Race and Ethnicity and Age, 1981 to 2006

Table 3: Birthweight, By Mother's Race and Ethnicity, Age, and Town Of Residence, 1981 to 2006

Table 4: Prematurity¹, by Mother's Race and Ethnicity and Age, 1981 to 2006

1. <37 weeks gestation

2. % of all births for group

3. Total includes births of unknown ethnicity, consequently components below sum to less than total % of births where gestational age is known

Table 5: Fetal Death, by Mother's Race and Ethnicity and Age,

1981 to 2006

SS:ts