Why outsource NICU UM and CM?

Why outsource NICU UM and CM?

That’s the question all of our health plan partners had at one point, and it’s a valid one…

Many plans already have robust and innovative UM/CM programs serving their broad member populations. But it’s also a critical cost question, since nearly half of a health plan’s total costs for infant hospitalizations are NICU cases.

NICU case csots nationwide

Here’s the answer: NICU cases represent a high-complexity, high-cost challenge that requires specialized knowledge to manage effectively

Health plans often don’t have sufficient case volume to develop the programs required to impact total NICU cost-of-care, while also maintaining strong network provider relationships. Employers have a similar problem and are impacted heavily by catastrophic claims from these cases.  

That’s where we come in. ProgenyHealth is the only national company dedicated exclusively to NICU UM and CM.  Our data-driven, clinical best-practices approach uniquely supports newborns and their families during the first crucial months of life.  

  • 70,000+ NICU managed cases to-date. More than most health plans see in 10 years.
  • 6,000+ provider contacts in 1,400+ facilities throughout the US, including major children’s hospitals.
  • National, regional, and state Medicaid managed care and commercial plan client experience.
  • Success in all payment environments.

ProgenyHealth has a proven solution for the high-cost challenge of covering NICU infant care. And while such case volume may seem relatively small, NICU admissions, as a percentage of all births, continue to increase as a result of many societal factors, including Neonatal Abstinence Syndrome (NAS) and lack of access to, or compliance with, good prenatal care.

NICU population trends

The US prematurity birth rate is nearly 10%, and climbing.

As cited in this Fact Book from the March of Dimes, the earlier a baby is born, the higher the risk of death or serious disability. On an average day in the US:

  • 1,045 babies are born preterm (less than 37 weeks gestation)
  • 874 babies are born with low birth weight

That often means these babies begin their life in a neonatal intensive care unit (NICU) battling a variety of medical complications common to premature infants.

How the nationwide opioid epidemic impacts infants

The devastating implications of opioid addiction among adults are now well publicized. But the implications for infants are equally troubling.  According to a recent Vanderbilt University Medical Center study, one infant is born every 15 minutes with NAS — withdrawal symptoms after exposure to opioids before birth.

And because the opioid epidemic is hitting rural populations very hard, many mothers suffering from this problem lack access to healthcare facilities with the resources and expertise needed to treat NAS infants effectively. The result is potentially worsening medical complications and prolonged length of stay.

ProgenyHealth’s clinical team are recognized thought leaders in the utilization and care management of infants suffering from NAS. We collaborate with our provider colleagues by discussing cases specialist-to-specialist, as well as developing best practices documents, which help to share our insights gained from working with NICU’s across the country.  

Get our Best Practices for Management of Infants with NAS

Integrated NICU UM/CM that improves infant outcomes and lowers costs

Every day, our team of neonatologists, pediatric nurses, and social workers take on the many unique challenges of NICU case management across the country. 

But the drive to improve infant health outcomes doesn’t end at discharge.  Too often, mom and baby are going from the hospital to an unstable home environment where basic needs of food, shelter, and safety are unmet.  From day one, ProgenyHealth’s comprehensive model has encompassed management of these social determinants of health as vital to the success of our mission.

Making a difference one baby at a time, one family at a time, across the country, and beyond…

Partner with us now to begin improving outcomes for your most vulnerable members.

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ProgenyHealth has helped to reduce our ALOS, reduce outlier days, and keep our readmission rates low. Testimonials from our members are full of praise.

- Health Plan CMO

Progeny has been an outstanding partner. Their clinical expertise in the NICU arena has helped us to manage the care of these infants effectively, and they are completely committed to identifying and addressing the social determinants of health often found in this fragile population.

- Marge Angello, Amerihealth Caritas’ Market President

Our medical management team worked closely with the experts at ProgenyHealth to deploy this integrated and very effective program. Their singular focus on NICU babies and their families was crucial to the program’s success, and especially vital in building a collaborative relationship with our providers. We’re very pleased with the outcomes of this initiative and the role it plays in our ongoing efforts to help members most at risk of developing serious chronic conditions.

- Dr. Michael Genord
Chief Medical Officer of Health Alliance Plan