1. Strategies to Increase Prenatal Volume in a Family Medicine Residency
Daniel J. Frayne, MD
E. Blake Fagan, MD
MAHEC Asheville, Family Medicine Residency Program
STFM Spring Meeting, Seattle, WA
April 26, 2012
Introduce self
OB/GYN curricular director, past 5 years working on enhancing resident experience in OB
Major hurdle is patient volume

2. Background Many FM residencies struggle for adequate prenatal volume
Inadequacies in maternity care frequently cited by RRC
Volume is associated with FM graduates’ likelihood to include obstetrics in future practice
Do any of you have this problem? This is not a unique problem to my program –
RRC deficiencies – I am not going to speak to the upcoming RRC changes
FM supervised prenatal deliveries are important – Ratcliffe demonstrated there is a relationship between volume and likelihood of graduates practicing maternity care
Key to continuing FM OB as part of scope of practice in rural areas

3. Background
What are the best strategies to increase prenatal volume in a family medicine residency clinic?
Collaboration with community programs
Marketing campaigns
Enhanced access
Efficacy of individual efforts largely unknown
How does one increase prenatal volume? No specific instruction manual or literature to direct efforts
Many programs take over care in resource poor settings
Business marketing and advertisement strategies and improving practice attractiveness are done and seem intuitively to make strategic sense
Family medicine residencies are not the same as private practices – constraints on marketing and financial resources
But what is the most efficient and effective strategy?

4. Methods
Multiple interventions aimed at increasing prenatal volume implemented
Prospective data collected on monthly new prenatal patient volume and referral source over 4 years
Data analyzed to determine effectiveness of strategies

5. Strategies employed Practice improvements
Enhanced appt access
Centering pregnancy
Improving language services – CLAS standards
Hispanic wellness case manager
Direct to consumer advertising
Brochure about pregnancy care at the FHC
Baby picture board in lobby
Fliers advertising free pregnancy testing (2011)

6. Strategies employed (cont)
Community referral collaborations
Health department
Private primary care practices
Local free clinic
Prenatal classes offered on site
Free access
Free pregnancy testing
Caring for uninsured moms sustained through caring for insured child (grant funded)

7. Monthly New Starts New prenatal starts
Monthly new prenatal starts varies significantly month to month, “patient base” is established and self referred, not as much variation – so what accounts for the overall big shifts?

8. Health Dept Referrals Commitment meetings
Shows influence of the health dept on the spikes in monthly volume
Taking away the health dept, the trend is positive, 14-19/month
Commitment meetings impact the success, but only for 2-3 months, then political landscape changed for 2010
However, taking the health dept out, the trend remains positive (self, estab, other) and has spikes in the times when there are no referrals from the health dept. Why?
Commitment meetings

9. Established and Self Referrals
New prenatal starts
Looking just at established and self referred – trend from /month
SO I am going to highlight 2 of the things we did – free pregnancy test and free care with a grant which may have the biggest impact on your practice
The first one is …
No health dept referrals

10. Free pregnancy tests Inexpensive
$1.05/each
Get ‘em in the door and they will stay
Battle the lack of community knowledge about what we do
Even our own patients often don’t know we deliver or do pediatric care!

11. Free Pregnancy Test: Preliminary Results May 2011-Feb 2012
Total tests = 106
Positives = 50
Negative = 56
Of positive tests:
Established OB care with us = 35
(19 new patients, 16 previously established)
Did not establish OB care with us = 15
Did minimal advertising: fliers, Craig’s list, United Way 211
So, for ~$115 in free preg tests we had 19 new patients we spent– not a bad ROI
The next one is how we supported free care…

12. Health Dept Collaboration
Non-contractual, referral to FHC
Benefit of quick access, uncompensated care, supporting education
Difficult to sustain
Ongoing troubleshooting, gains short lived
Staff turn-over, no stable champion
Political and community environmental factors
At the time, health department was overwhelmed, had a 6-8 week wait time for 1st OB appt
County supported idea of resident education

13. Unique position of FM
“Free” care CAN be recouped through care of insured children
Builds pediatric practice
Continuity of care is valued
Demonstrated with assistance from a BCBS Foundation grant

14. “Free Care” by Family Physicians
194 new pregnant, uninsured Hispanic moms began care with us over 2 years
145 newborns delivered, 18 deliveries pending
120 of these newborns continuing care with us
57 additional siblings/family members transferred care to us
Year 1 and 2 deficit $183,221
Projected deficits decrease Year 3-5
Fewer pregnant moms than desired, but more deliveries than anticipated and more of the newborns stayed with us (82%). Also, our hypothesis that family members would transfer care to us held true. Through this initiative and other innovative projects, over the past 4 years we have effectively doubled the amount of pregnancy care our practice has provided. Through the support of the grant, the financial loss in the first 2 years as been mitigated. Our projections show that the next 3 years we start to come close to breaking even. More on that to come.
bcbsncfoundation.org

15. Projected costs Projected bcbsncfoundation.org
So here are the numbers. Blue represents expected collections if all the moms had medicaid. Red is actual receipts. In the 1st two years as we are building the pediatric practice the defict is large. Each year, the pediatric practice grows, all of whom are insured. The pregnancy care is finite and remains static as a loss. Using the last 2 years average, we projected what the next 3 years would look like assuming our growth is the same. Although it does not equalize, it comes close. I know there are a lot of assumptions involved in this, but no one has ever tried to demonstrate this. It demonstrates a unique financial role that family physicians could play in other communities.
bcbsncfoundation.org

16. Conclusions
Multiple interventions to increase established and self referred patients
Trend from 14 to 19/month
Community education/advertisement
Innovative programs
“Attractiveness” and accessibility of practice
Most significant increases came from health department referrals
Difficult to sustain - BUT, highest yield
Offering free access and care might be sustainable and highly successful
Free pregnancy testing seems high yield
Average 5 patients per month from all the interventions – 60 patients/year – not bad

17. Implications Practice based improvements do have effect
Family physicians can capitalize on ability to care for children to offset costs
Direct collaboration with local health departments more effective
Collaborations may require more specific contractual relationships to be sustainable
Access this population directly
Access directly – take over care, Directed advertising? free pregnancy tests?
Changing the patient culture over time – preference, awareness, word of mouth, community memory and gradual change
Change the culture?