Neonatology has become a prime target for specialty care management or population management services. As the cost of caring for the neonatal intensive care unit (NICU) population steadily rises, with no accompanying increase in quality information, health plans and large self-insured groups have increasingly taken notice. Some plans have attempted to manage this challenging population on their own; others have sought outside solutions. One such program is that developed by Paidos Health Management Services, founded in 1996. This article identifies the key issues surrounding neonatology and medically complex newborns and suggests factors that need to be addressed by a comprehensive neonatal care management program. It explains elements of the Paidos program and how this model becomes operational. Using key program elements including a specific patient grouper system, clinical management guidelines, physician advisory boards, outcome measurements and family satisfaction, the success of the program is described. Wide variation in clinical practice is demonstrated by the duration of methylxanthine therapy with a 2-fold difference seen in various regions. The cornerstone of improvement in practice is the use of sound clinical management guidelines. As documentation that improvement can be made, a revised feeding guideline improved the time to first feeds by as much as 50% at certain gestational ages. Guideline compliance overall averaged greater than 90%. This success was achieved by developing these evidence-based guidelines in cooperation with practicing physicians. With a fully implemented program, cost savings can reach 10% but vary depending on hospital contracts. Absolute reduction in length of stay and leveling of care are components of cost reductions. For those health plans lacking different contracted levels, there exist opportunities in future contracting with the level-of-care approach. Timely discharge of an infant depends on competent, high quality home care services being available. The high degree of family satisfaction with the program indicates that measures to contain utilization as part of the care management process are not burdensome. There are significant barriers and challenges to overcome when establishing a neonatal care management program. These include the relatively closed practice style of neonatology, financial concerns of physicians and hospitals and the issues of `control' over what is best for the patient. However, given the current climate of managed care, a comprehensive, integrated approach can offer a successful solution.
Disease management programmes, Intensive care units, Neonates, Pharmacoeconomics
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