In recent years, the idea of preconception care–education, counseling, and interventions delivered to women before they become pregnant–has gained traction as a critically important health promotion opportunity for women and their families. Employers, as purchasers of health care and as providers of wellness services, have an important role to play in the promotion of preconception care. Large, self-insured employers can craft their medical benefit plans to include evidence-informed preventive health benefits such as preconception care. Employers can also design and implement worksite health promotion programs that address preconception, pregnancy, and postpartum health. And employers of all sizes can educate women and their partners on pregnancy health through tailored communication. This article provides an overview of the business case for preconception care and concrete steps employers can take to support and incent preconception care among their beneficiaries. The article also includes suggestions on ways providers and health professionals support employers in these efforts.
Overview
Ever-increasing health care costs are taking their toll on businesses across the United States. As the Nation faces a recession, the health care cost crisis will continue to grow in importance for both the private and public sectors. As purchasers of health care, employers have developed a myriad of strategies to address the health care cost problem, including increasing employee cost-sharing, reducing or eliminating specific benefits, restricting eligibility, and implementing new plan designs, such as high-deductible health plans. Employers have also emphasized consumer education and engagement, and are supporting quality improvement initiatives at the provider and plan levels. Many employers now see disease prevention and health promotion as a promising opportunity for curbing health care costs and safeguarding employee productivity. In fact, employers consider promoting health improvement programs to be one of the 10 most effective cost-management tactics (
March of Dimes, Thomson Reuters Healthcare, 2008
).Pregnancy is a major cost and productivity concern for employers. Women of reproductive age (16–44 years) represented 46% of the US workforce in 2004 (
National Business Group on Health, 2006
). More than 6 million pregnancies were reported in 2004, and there were 4.11 million births, including 2 million births to women in the workforce (Campbell, 2007
, Centers for Disease Control and Prevention2008, 2008
, Centers for Disease Control and Prevention. (2008). Pregnancy rate drops for U.S. women under age 25. Retrieved March 27, 2008 from http://www.cdc.gov/nchs/pressroom/08newsreleases/pregnancydrop.htm
National Business Group on Health, 2006
). Two thirds of women aged 18–64 have job-based health coverage, either through their own employer or their spouse's employer (The Kaiser Family Foundation. (2007), 2007
). A substantial number of pregnancies result in complications or poor birth outcomes; this puts large employers, who are typically self-insured, at risk for catastrophic health care costs, short- and long-term disability claims, and substantial productivity declines. Employers must also contend with expected and unexpected turnover owing to pregnancy and pregnancy-related health problems. Employers are particularly concerned by the increasing rates of prematurity and low birth weight.The Kaiser Family Foundation. (2007). Women's Health Insurance Coverage Fact Sheet, December 2007. Retrieved September 13, 2007 from http://www.kff.org/womenshealth/6000.cfm
Between 1980 and 2000, the proportion of babies born preterm increased by 26% and the proportion of babies born at a very low birth weight (<1,500 grams) increased by 25.9% (
Atrash et al., 2006
). Approximately 11% of babies covered by employer-sponsored insurance are born prematurely, and each year employers pay for roughly half of the $18 billion in medical claims charged for the care of premature infants (National Committee for Quality Assurance, 2006
). Among privately insured women in 2005, the average total cost (in paid outpatient visits, hospital, and pharmacy claims) for a premature infant was $46,000. This figure includes the cost of the birth, neonatal care, and infant care through the first year of life. In comparison, an uncomplicated vaginal delivery cost $8,120 and an otherwise uncomplicated cesarean section delivery cost $11,666 (March of Dimes, Thomson Reuters Healthcare, 2008
, unpublished data). These figures include the cost of 9 months of prenatal care, labor and delivery, and 3 months of postpartum care for the mother.Poor birth outcomes are also a leading cause of lost productivity for women. “Complications of pregnancy” (e.g., gestational diabetes and hypertension, premature labor, antepartum or postpartum hemorrhage) is the second leading cause of short-term disability and the 6th leading cause of long-term disability for employed persons in the United States (
Met Life Disability, 2003
). The exact dollar cost of pregnancy-related disabilities depends on the causal condition and ensuing length of disability, but the March of Dimes estimates that on average, employers lose nearly $3,000 per premature birth owing to parents’ extended absence and mothers’ short-term disability claims (March of Dimes, 2007
).March of Dimes. (2007). Help reduce cost: The cost to business. Retrieved July 17, 2007 from http://www.marchofdimes.com/prematurity/21198_15349.asp
It is also important to remember that the cost of a poor birth outcome does not end with the neonatal period. Premature babies, for example, are at high risk for long-term impairment, including physical disability, cerebral palsy, mental retardation, and attention-deficit and hyperactivity disorder (
Dan and Marlo, 2008
). In fact, medical experts estimate that a quarter of infants leaving neonatal intensive care units have chronic and costly health problems (Dan and Marlo, 2008
, Hack et al., 2005
). Most large employers provide health coverage to qualifying dependents through age 18 or 19, and 43% provide coverage through age 25, so long as the child is enrolled in an accredited school. Furthermore, many large employers remove age limits for disabled dependents (NBGH, unpublished data, 2006). This means that employers pay the excess health care costs for children harmed by a poor birth outcome for many years.The Business Case for Preconception Care
Employers have struggled to find effective ways to prevent poor birth outcomes among their beneficiaries. In recent years, the idea of preconception care—education, counseling, and interventions delivered to women before they become pregnant—has gained traction as a critically important health promotion opportunity for women and their families.
Women of childbearing age face an alarming number of risk factors for poor birth outcomes. Data from the CDC's Pregnancy Risk Assessment Monitoring System show that in the 3 months before pregnancy, 23.2% of women used tobacco, 50.1% consumed alcohol, and only 35.1% took a multivitamin at least 4 times a week (
D'Angelo et al., 2007
). In the year before their pregnancy, 18.5% of women reported experiencing significant stress and 3.6% experienced physical abuse, 2 risk factors linked with preterm labor. In addition, 1.8% had diabetes, 6.9% had asthma, 2.2% had hypertension, and 10.2% had anemia (- D'Angelo D.
- Williams L.
- Morrow B.
- Cox S.
- Harris N.
- Harrison L.
- Posner S.F.
- Hood J.R.
- Zapata L.
Preconception and interconception health status of women who recently gave birth to a live-born infant–Pregnancy Risk Assessment Monitoring System (PRAMS), United States, 26 reporting areas, 2004.
MMWR Surveill Summ. 2007; 56: 1-35
D'Angelo et al., 2007
). Other research shows that among women who could get pregnant, 3% take prescription or over-the-counter drugs that are known teratogens, and 4% have preexisting medical conditions that could negatively affect a pregnancy if not appropriately managed before conception (- D'Angelo D.
- Williams L.
- Morrow B.
- Cox S.
- Harris N.
- Harrison L.
- Posner S.F.
- Hood J.R.
- Zapata L.
Preconception and interconception health status of women who recently gave birth to a live-born infant–Pregnancy Risk Assessment Monitoring System (PRAMS), United States, 26 reporting areas, 2004.
MMWR Surveill Summ. 2007; 56: 1-35
Adams et al., 2002
). Once pregnant, 11% of women continue to smoke and 10% continue to drink alcohol (Adams et al., 2002
). This information suggests that many women could benefit from preconception counseling to ameliorate or reduce prevalent risk factors for prematurity, birth defects, and other complications.The business case for investing in preconception care is growing. A recent 3-study meta-analysis showed that preconception care can be cost-saving (
D'Angelo et al., 2007
). One of the selected studies, a prospective analysis of a hypothetical comprehensive preconception care program, calculated that every $1 spent on preconception care could save $1.60 in maternal and fetal care costs, namely by reducing the need for maternal and infant hospitalization. In the second study, a matched retrospective analysis of a cohort from California, investigators observed reduced maternal and infant hospitalization costs of $5.19 for every $1 spent on preconception care. In the third study, women enrolled in a preconception care program (the intervention group) received 2 outpatient visits before pregnancy and then regular prenatal care. Pregnant women in the intervention group experienced fewer congenital malformations (4.2% vs 13.5%) compared with women in the prenatal care-only group. The infants of women in the preconception care program were also 50% less likely to require neonatal intensive care unit hospitalization (- D'Angelo D.
- Williams L.
- Morrow B.
- Cox S.
- Harris N.
- Harrison L.
- Posner S.F.
- Hood J.R.
- Zapata L.
Preconception and interconception health status of women who recently gave birth to a live-born infant–Pregnancy Risk Assessment Monitoring System (PRAMS), United States, 26 reporting areas, 2004.
MMWR Surveill Summ. 2007; 56: 1-35
Dye, 2005
, Grosse et al., 2006
). Studies like these help payers to understand the value of investing in preconception care.In addition, many of the interventions that support healthy pregnancies also benefit women's overall health. Obesity, alcohol and drug abuse, tobacco use, sexually transmitted infections, and many other issues addressed in preconception care are critical for women's health and well-being. Each of these conditions cost employers money in terms of medical and pharmacy claims, disability claims, and work loss; thus, many employers have already adopted specific programs to address these issues. Preconception care is in line with employer's larger objective of promoting employee health and productivity.
Unfortunately, despite CDC and professional association guidelines that strongly recommend ≥1 prepregnancy office visit for preconception services, preconception care is rarely provided in a systematic way. In fact, fewer than one third of women report speaking with a health care provider about preparing for a healthy pregnancy before they became pregnant (
D'Angelo et al., 2007
). Reasons for the low utilization of preconception care are manifold and include access, cost, and knowledge barriers.- D'Angelo D.
- Williams L.
- Morrow B.
- Cox S.
- Harris N.
- Harrison L.
- Posner S.F.
- Hood J.R.
- Zapata L.
Preconception and interconception health status of women who recently gave birth to a live-born infant–Pregnancy Risk Assessment Monitoring System (PRAMS), United States, 26 reporting areas, 2004.
MMWR Surveill Summ. 2007; 56: 1-35
NBGH Recommendations to Support Preconception Care
The NBGH is a nonprofit membership organization of large, self-insured employers. Collectively, these employers provide health care coverage to 55 million people in the United States. The NBGH advises its members on health care benefits and health promotion programs. In 2007, the NBGH released the Maternal and Family Health Plan Benefit Model, 1 component of a larger toolkit for employers on investing in maternal and child health (
March of Dimes, 2007
). The Plan Benefit Model includes recommendations on 34 evidence-informed benefits specifically designed for children and adolescents, as well as preconception, pregnant, and postpartum women. The Plan Benefit Model was developed by a Benefits Advisory Board that included corporate medical directors and benefit managers, health plan representatives, health care consultants, and experts from the American Academy of Family Physicians, American Academy of Pediatrics, and the National Association of Pediatric Nurse Practitioners. The Plan Benefit Model was also reviewed by a panel of 30 external experts. Preconception care was one of several innovative preventive benefits recommended in the Plan Benefit Model.March of Dimes. (2007). Help reduce cost: The cost to business. Retrieved July 17, 2007 from http://www.marchofdimes.com/prematurity/21198_15349.asp
The model's preconception care benefit was based on the CDC/Agency for Toxic Substances and Disease Registry Preconception Care Work Group and the Select Panel on Preconception Care Guidelines. It provides coverage for “medical services aimed at improving the health outcomes of pregnant women and infants by promoting the health of women of reproductive age before conception.” The benefit allows for up to 2 office visits per calendar year to address: 1) maternal assessment, including family history, behaviors, obstetric history, and a general physical examination; 2) vaccinations for rubella, varicella, and hepatitis B; 3) screening for HIV, sexually transmitted infections, and genetic disorders; as well as 4) counseling for folic acid supplementation, smoking and alcohol cessation, and weight management (CDC, 2008). To incent utilization and remove potential cost barriers, the NBGH recommended that employers provide 100% coverage for preconception care by eliminating copayment or coinsurance requirements and not subjecting the benefit to a deductible.
Current Coverage Challenges
Current Procedure Terminology (CPT) codes are developed by the American Medical Association for the purpose of providing a uniform language that accurately describes medical, surgical, and diagnostic services provided by physicians and other clinicians (
American Medical Association, 2008
). Employers and health plan administrators use these codes to define coverage, track utilization, and support payment and other claims algorithms. In 2007, there was not a specific or universal CPT code for the bundled set of services defined as “preconception care” by the CDC and professional associations.American Medical Association. (2008). CPT code search. Retrieved March 28, 2008 from https://catalog.ama-assn.org/Catalog/cpt/cpt_search.jsp
Currently, plans and providers who deliver preconception care services use longstanding well-exam codes (99381–99397) or general preventive health counseling codes (e.g., preventive medicine counseling/risk factor reduction, individual, 15–60 minutes, 99401–99404; administration/interpretation of health risk assessment instrument, 99420) in addition to codes for specific interventions or procedures (e.g., rubella immunization). These “substitution codes” do not adequately reflect the scope of services provided. Moreover, they do not allow for tracking or comparison across populations, because it is impossible to tell which women received services defined as preconception care and which women received general preventive services such as tobacco cessation counseling or immunizations. Both of these issues are problematic for employers: Employers typically only provide coverage for services with clear and unique codes, and they have a strong interest in tracking population-specific utilization.
Next Steps
Preconception care is an integral part of reproductive and women's health care. Preconception care should be attractive to employers from both cost and productivity standpoints because preconception care promotes healthy pregnancies, thereby reducing the rate of complications and poor birth outcomes. Barriers to preconception care, such as lack of coverage, cost, access problems, and women's lack of knowledge about the importance of prepregnancy interventions, can and should be addressed by employers.
However, before preconception care benefits can be widely adopted and promoted by employers and other purchasers, the coding issues must be resolved. Moreover, health plan administrators should work with their networked providers and facilities to ensure that preconception services are offered and delivered in a standardized way. Additional data in support of the business case for preconception care is also likely to spur benefit expansion. Medical and public health professionals should also work to proactively communicate the importance of preconception care to health plan administrators, health care consultants, and insurance brokers. Although large employers with self-funded health plans can design their own benefit plans, small and medium-sized employers typically purchase fully insured products from health plan administrators, and do not have the option of adding single or custom-designed benefits. Encouraging health plans to adopt preconception care as a standard offering may be the only way to ensure that this important health benefit is available to the millions of women who work for small and medium-sized businesses.
Other Ways to Support Preconception Health
In addition to offering a comprehensive preconception care benefit, employers can also provide worksite education and wellness initiatives that promote healthy pregnancies. The NBGH recommends that large employers adopt the following programs and policies to promote pregnancy health.
- •Offer pregnancy-related health promotion programs at the worksite or in the community.
- •Include pregnancy-related health issues in existing wellness programs or develop new programs specific to pregnancy concerns. Examples include nutrition, tobacco cessation, weight management, encouraging exercise through healthy lifestyle incentives, and stress management.
- •Provide incentives for healthy pregnancy behaviors and participation in pregnancy-related health promotion programs. For example, provide rebates or reimbursements for breast pumps or child car seats for participation in parenting/birthing classes.
- •Consider including basic preconception and prenatal care services in onsite medical facilities, when available.
- •Implement a campus-wide tobacco ban to protect women of childbearing age from secondhand smoke.
- •Educate beneficiaries on maternity leave, family medical leave, parental leave, and other support policies that may be available.
- •Support and promote breastfeeding by providing a worksite lactation program, rebates on breast pumps, and access to lactation consultants, onsite or by telephone.
- •Cover all Food and Drug Administration-approved prescription contraceptive methods at no cost to the employee to facilitate the prevention of unintended pregnancies and promote healthy approaches to family planning.
Conclusion
Employers have an important role to play in the promotion of preconception care. Large, self-insured employers can craft their medical benefit plans to include evidence-informed preventive preconception care. They can also design and implement worksite health promotion programs that address preconception, pregnancy, and postpartum health. And employers of all sizes can educate women and their partners on pregnancy health through tailored communication. To spur employers’ adoption of preconception care benefits, the field must develop standardized and specific codes, ensure that providers have the resources and training necessary to deliver high-quality services, and develop systems to monitor utilization, track progress, and report outcomes.
Acknowledgments
Development of the Maternal and Child Health Plan Benefit Model, a component of Investing in Maternal and Child Health: An Employer's Toolkit (2007), was supported by a grant from the Health Resources and Services Administration, Maternal and Child Health Bureau. The authors gratefully acknowledge the contributions of Ronald Finch and Leah Trahan of the National Business Group on Health and Steve Abelman of the March of Dimes.
Kathryn E. Phillips is currently with Qualis Health.
References
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March of Dimes. (2007). Help reduce cost: The cost to business. Retrieved July 17, 2007 from http://www.marchofdimes.com/prematurity/21198_15349.asp
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Biography
Ms. Phillips led the National Business Group on Health's Maternal and Family Health Initiative and Clinical Preventive Services Translation Project between 2004 and 2008. Her work focused on educating purchasers on the value of preventive care and translating scientific research into evidence-informed health benefits. Ms. Phillips holds a Master of Public Health (MPH) with a concentration in health behavior and health education from the University of Michigan's School of Public Health.
Ms. Flood currently works on the National Business Group on Health's Maternal and Family Health Initiative for the Maternal and Child Health Bureau. Her work currently focuses on educating employers about the benefits of the patient centered medical home and the value of immunizations. Ms Flood holds a Bachelors Degree in Psychology from James Madison University.
Article info
Publication history
Published online: November 03, 2008
Accepted:
July 21,
2008
Received in revised form:
July 17,
2008
Received:
April 30,
2008
Footnotes
The authors have no direct financial interests that might pose a conflict of interest in connection with the submitted manuscript.
Identification
Copyright
© 2008 Jacobs Institute of Women's Health. Published by Elsevier Inc. All rights reserved.
