Current Commentary
Improving Maternal and Infant Health Outcomes in Medicaid and the Children’s Health Insurance Program Mary Applegate,
MD, FACP,
Rebekah E. Gee,
MD, MPH,
Maternal and infant health is critical to our nation’s health. Disparities remain unacceptably high, particularly in the areas of prematurity and infant mortality. In 2012, traditionally distant partners such as federal and state governments, Medicaid and commercial payers, patients, public health and private clinicians, and multiple advocacy groups collaborated to focus on improving birth outcomes. To catalyze the alignment, the Centers for Medicare and Medicaid Services convened an Expert Panel on Improving Maternal and Infant Health Outcomes in Medicaid and the Children’s Health Insurance Program. Over a year’s time, the Expert Panel assimilated the best available evidence in clinical science and policy from content leaders and patients. These recommendations culminated in the present report, which challenges us as a nation to implement strategies to help all children have the best chance to survive and thrive comparable to that of other westernized nations. (Obstet Gynecol 2014;124:143–9) DOI: 10.1097/AOG.0000000000000320
From the Ohio Department of Medicaid, Columbus, Ohio; the Departments of Health Policy and Management and Obstetrics and Gynecology, Louisiana State University, Schools of Public Health and Medicine, New Orleans, and the State of Louisiana, Baton Rouge, Louisiana; and Department of Obstetrics and Gynecology, the University of Mississippi Medical Center, Jackson, Mississippi. The Expert Panel, cochaired by Drs. Applegate and Martin, was created by the Center for Medicare and Medicaid Services with project direction by Lekisha Daniel-Robinson, Coordinator, Maternal and Infant Health Initiatives for the Center for Medicaid and Children’s Health Insurance Program Services. The Expert Panel was convened by Centers for Medicare and Medicaid Services’ contractor Provider Resources, Inc whose membership included Dr. Gee and state Medicaid medical directors, Medicaid providers, consumer representatives, and other experts in the areas of maternal and child health, Medicaid, advocacy, and research. Corresponding author: James N. Martin, Jr, MD, Department OBGYN-UMMC, 2500 N State Street, Jackson, MS 39216-4505; e-mail: [email protected]. Financial Disclosure The authors did not report any potential conflicts of interest. © 2014 by The American College of Obstetricians and Gynecologists. Published by Lippincott Williams & Wilkins. ISSN: 0029-7844/14
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and James N. Martin, Jr,
MD
I
nfant mortality rates long have been considered a measure of the health of a nation.1 There have been multiple efforts to reduce the infant mortality rate in the United States, resulting in a reduction from 9.2 per 1,000 live births in 1990 to 6.2 per 1,000 live births in 2010. The decline is a significant achievement, driven by factors such as wider availability of neonatal care and expanded access to maternity and infant care through Medicaid coverage. At the same time, racial and ethnic disparities in infant mortality remain, and preventable infant deaths remain unacceptably high. Moreover, the United States lags compared with other industrialized nations; in 2004, the United States ranked 29th among developed nations2 and 27th in 2008 with a national infant mortality of 6.05 per 1,000 live births.1 These low rankings may be related partially to systems issues. Our current fragmented system divides the care of women into artificial segments based on payment policies, phases of pregnancy, and reproductive health status. In recent years, clinical, public health, and academic experts have documented the multifaceted nature of the challenge and the multiple factors that affect birth outcomes. One example is the identification of Perinatal Periods of Risk as advocated by Peck and colleagues.3 There is a great need for effective interventions, financing, and delivery systems that address a continuum of needs among women before, during, and after pregnancy as well as to both newborns and older infants. The Affordable Care Act, including Medicaid expansions, provides an opportunity for improved coverage, payment, and health care provider strategies. Medicaid programs pay for an estimated average of 40–50% of the 4.3 million births that occur every year in our country rendering pregnancy and delivery and newborn care the most common hospital condition for Medicaid. More births will be financed by Medicaid after implementation of the
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Affordable Care Act. Despite this level of coverage, accountability through data collection or quality monitoring has been low for the maternal and infant population. Given that Medicaid serves some of the most vulnerable women, there is an urgent need for Centers for Medicare and Medicaid Services and states to improve Medicaid perinatal practices, report on Medicaid perinatal outcomes, and enhance the quality of services financed. This report of the Expert Panel on Improving Maternal and Infant Outcomes in Medicaid and the Children’s Health Insurance Program offers strategies and policy options Centers for Medicare and Medicaid Services can use in the short term to improve maternity-related outcomes. The Expert Panel suggestions align with professional guidelines, the recommendations of the Department of Health and Human Services Secretary’s Advisory Committee on Infant Mortality and other federal, state, and private sector initiatives.4
EXPERT PANEL ON IMPROVING MATERNAL AND INFANT HEALTH OUTCOMES IN MEDICAID AND THE CHILDREN’S HEALTH INSURANCE PROGRAM An Expert Panel was convened for a year beginning June 2012 to identify strategies for achieving better policies, care, and outcomes for mothers and infants and to reduce the cost of perinatal care in the Medicaid program. The process of the panel entailed reviewing existing efforts for synergistic and collective effects, identifying gaps in performance measurement and performance improvement. Subject Matter Experts engaged in initial brain storming and months of structured deliberation. The Expert Panel’s work groups focused on four unique but interrelated themes: 1) measurement and data; 2) enhanced maternal services for high-risk women; 3) payment reform; and 4) effective reproductive (health) enablers. Each of the four groups identified several more detailed strategies for full panel consideration. Panel members rated the identified shortterm strategies by weighted criteria, including relationship to birth outcomes (0.2); potential effect on reducing disparities (0.2); feasibility of implementation within 2 years (0.5); and availability of supporting measurement approaches (0.1). Resulting ratings highlighted major cost drivers and opportunities for maximum population effects. As cochairs, Drs Applegate and Martin consider the following six major cross-cutting areas to constitute the most important recommendations of the group.
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Action Area 1: Reduce Unintended Pregnancy and Improve Birth Spacing by Increasing Contraceptive Access and Use Medicaid should reimburse for all contraceptive methods and support women in their family planning efforts through coverage of education and all methods without copays in the Medicaid benefit package, including long-acting reversible contraception (LARC) in all (inpatient and outpatient) clinical settings. Key Challenges Medicaid has long been criticized for burdening clinicians and other health care providers with administrative requirements and policies that pose barriers to the provision of effective and evidence-based reproductive health care services. Not all states provide Medicaid reimbursement for all the Department of Health and Human Services-recommended family planning methods and Affordable Care Act definitions within women’s clinical preventive services will not apply to Medicaid. Most states allow for reimbursement of the full range of LARC in the outpatient setting; however, if this service is done in the hospital after delivery, the cost of the device is included in the hospital Diagnosis-Related Group payment, rendering this service inaccessible to some mothers that desire this method of contraception.5 Potential Strategies Within State Medicaid Programs Education and Quality
• Prevent unintended pregnancy through patient engagement, education, and shared decisionmaking. • Provide coverage for education and access to contraceptives and family planning services before pregnancy (preconception) and between pregnancies (interconception). • Hold health systems and health care providers accountable for educating patients through payment reform and incentives, performance measurement, and measurement that includes patient activation. • Emphasize the postpartum visit as an important component of total obstetric care. Financing and Coverage
• Develop policies (including separate hospital payment for LARC) to support the use of LARC, especially for high-risk women and adolescents in keeping with patient preferences.5
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• Urge states to consider coverage of LARC as a medical rather than a pharmaceutical benefit if this fits better to meet their particular requirements. Data and Measurement
• Develop and adopt measures to track progress in birth spacing. • Develop and adopt family planning measures that reflect other Department of Health and Human Services standards from Title X family planning program, Centers for Disease Control and Prevention, and others. • Adopt preconception and interconception care measures from the model state measurement set promoted by the Association of State and Territorial Epidemiologists and the National Preconception Health and Health Care Initiative.6,7
Action Area 2: Expand and Enhance Breastfeeding Improve implementation of policies to provide coverage for education and support related to breastfeeding throughout pregnancy, inclusive of the prenatal, intrapartum, and postpartum periods of patient care. Key Challenges Rates of successful breastfeeding within the Medicaid population lag significantly behind other women despite the positive effect on health outcomes.8,9 Public policy, including payment policies, can lead to higher rates of breastfeeding, improved health, and likely lower costs for Medicaid. Potential Strategies Within State Medicaid Programs Education and Quality
• Encourage and support quality improvement projects in cooperation with perinatal improvement collaboratives to enhance breastfeeding support best practices such as those defined by the Centers for Disease Control and Prevention Best Fed Beginnings, 10 steps to a Baby Friendly Hospital Initiative, and similar models. Financing and Coverage
• Include breastfeeding education and expect breastfeeding implementation and accountability in all managed care program contracts in states that have managed care and ensure interagency referrals to
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state and community partners such as Women, Infants, and Children. • Provide coverage and rental for high-quality electric breast pumps. • Incentivize breastfeeding and provision of breast milk at both the patient and health systems levels, especially in circumstances of preterm birth. Data and Measurement
• Develop measures and data reporting mechanisms for population-level monitoring at the state level of breastfeeding by mothers of infants with Medicaidfinanced births.
Action Area 3: Reduce Preterm Birth and Adverse Pregnancy Outcomes Implement policies and procedures to encourage the earliest possible appropriate patient risk screening for preterm birth and other adverse pregnancy outcomes. For patients identified, support and encourage integrated systems of prenatal care that reflect both medical and psychosocial risk factors. Finance and create incentives for the appropriate administration of progesterone and 17a-hydroxyprogesterone caproate for patients at risk of preterm birth as well as enhanced prenatal care for those at risk for significant medical complexity and other adverse pregnancy outcomes. Key Challenges Lack of access to risk-appropriate prenatal care and recommended interventions affects pregnant women covered by Medicaid in every part of the country. Despite decades of national recommendations, our profession is slow to adopt new evidence basedguidelines. Moreover, it has been difficult to reliably implement best practices such as antenatal steroids and 17a-hydroxyprogesterone caproate for appropriately indicated patients. There are barriers to optimal use of 17a-hydroxyprogesterone caproate or progesterone in clinically eligible, Medicaid beneficiaries, including adherence to the weekly injection schedule, variability in state Medicaid financing of progesterone, late presentation for prenatal care, lack of identification of eligible recipients, cumbersome Medicaid enrollment processes, and obligatory 60-day free-choice-of-plan processes. Distribution barriers also exist related to a reluctance of clinicians to be at risk for the cost of unadministered doses and the challenges of coordinating home visits for the injections with specialty pharmacies. Until recently, 17a-hydroxyprogesterone caproate was an inexpensive, compounded drug, but after a formal U.S. Food and Drug Administration approval process for its indicated
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provision to prevent recurrent preterm delivery, the expense is prohibitive to take to scale. The provision of progesterone, including 17a-hydroxyprogesterone caproate, must be seamless and frustration-free for all those with prior preterm births inclusive of stillbirths, live-born neonates at 16–24 weeks of gestation, and all women with a shortened cervix detected early in pregnancy by standardized ultrasonography techniques. If preterm births were prevented in one-third of the 30,000 patients eligible for 17a-hydroxyprogesterone caproate and at least half were Medicaid recipients, an estimated 5,000 premature births annually could be prevented by this intervention in the United States.10 Other key challenges to reduction of preterm birth and adverse pregnancy outcomes (and lowered health care costs) derive from several chronic medical conditions (especially obesity, hypertension, and diabetes), which predate pregnancy and compromise successful maternal and perinatal outcomes. Obesity, eg, is a significant health concern in the United States where 34% of women 20–39 years of age are obese, 60% are overweight, and 8% are extremely obese.11 Maternal obesity potentiates diabetes and hypertension during pregnancy. Indeed, obese pregnant women are at an increased risk for poor maternal and neonatal outcomes including spontaneous abortion, gestational hypertension, preeclampsia, higher cesarean delivery rates, higher postoperative cesarean delivery complication rates, and thromboembolism compared with nonobese patients.12–14 Potential Strategies Within State Medicaid Programs
•
•
•
• • •
Education and Quality
• Based on the recommendations of national professional organizations such as the American College of Obstetricians and Gynecologists and the Society for Maternal-Fetal Medicine, create sample policies and encourage implementation of appropriate screening and use of 17a-hydroxyprogesterone caproate for eligible women. • Pursue programmatic efforts to deliberately and methodically keep many of the most vulnerable and high-risk mothers engaged and working on improved outcomes. Financing and Coverage
• Collaborate with manufacturers and others to ensure that all state Medicaid programs and health care providers have timely access to 17a-hydroxyprogester-
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•
one caproate with understanding of the manufacturing, distribution, payment, and enrollment issues. Improve payment policies for monitoring cervical length in at-risk pregnancies in accordance and consistent with professional guidelines for best care. Allow this identification of high-risk mothers through standardized clinical and ultrasound guidelines without the burden of additional prior authorization. Provide financing for an enhanced, expanded level of prenatal care for patients recognized early in gestation as high risk for preterm birth and adverse perinatal–maternal outcomes and regionalizing the care of these patients where possible in a group prenatal care format. This should include separate funding to support consultation by a team of dietitians, physical therapists, diabetic educators, social workers, and patient care coordinators with leadership ideally from a maternal-fetal medicine subspecialist or, if not available, an obstetrician–gynecologist with special expertise and interest in high-risk pregnancy care. Incentivize and support regionalized maternal, perinatal, and newborn care with early referral of mothers with complications likely to require preterm delivery and enhanced maternal-fetal and neonatal care. Develop waivers or other programs to provide care for women between pregnancies and improve interconception patient care. Increase emphasis and programmatic support for expansion of mental health and substance use, abuse, and addiction attention and funding support. Incentivize Medicaid plans and health care providers (through contracts and payments, for example) to perform a standardized pregnancy risk assessment to identify mothers at risk for preterm birth and medical complexities before or at the first prenatal visit and thereafter during prenatal care to plan prevention strategizes accordingly. Incentivize Medicaid plans and health care providers (through contracts and payments, for example) to identify women at risk for preterm birth based on her history of a prior preterm birth and devise risk appropriate care plans (this relates to Action Area 6 subsequently).
Data and Measurement
• Develop improved data and measurement approaches that monitor not just the timing and number of prenatal visits, but also the content, quality, and risk-appropriate level of prenatal care. • For states with a pharmacy carve-out, provide managed care programs with data on which
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members are receiving 17a-hydroxyprogesterone caproate so that these individuals can be tracked and outreached.
Action Area 4: Unbundle Global Maternity Services and Change Payment to Promote Appropriate Regionalization of Maternal and Neonatal Care and Develop Perinatal Care as a Value-Based Purchasing Bundle With Quality and Performance Measures Tied to Outcomes That Include Cost Key Challenges The current payment mechanisms for maternity care are perverse, paying more for volume and intervention rather than for value as defined by reliable adherence to best practice standards, health outcomes, and shared decision-making. One example is the reluctance of some hospitals or obstetrician–gynecologists to transfer an undelivered obstetric patient with an impending preterm delivery to a tertiary care center because of the threat of relinquishing higher reimbursement. Medicaid billing and reimbursement policies are complex. Some programs include several managed care plans with variable prior authorization and other requirements that differ substantially from private industry. There is little or no financial alignment across health systems and little or no transparency in the costs or quality that define value. The field of maternity care is ripe for payment reform that may accelerate achieving improved pregnancy outcomes because these are evident in a relatively short period of time, maternity care quality measures are fairly mature, and accountable entities can be identified for care. Payment reform can be achieved through fostering innovation with novel partners and reshaping the cost curve with potential gain and risk-sharing with health care providers. Potential Strategies Within State Medicaid Programs
Data and Measurement
• Develop measurement and data processes that enable states to integrate data systems related to service use, quality measurement, and cost as well as develop feedback mechanisms to connect those involved in all parts of the system.
Action Area 5: Implement Policies and Procedures to Drive Early and Regular Adolescent and Adult Well Checks Key Challenges Adolescents may not be seen routinely for well checks, representing lost opportunities for addressing reproductive health issues. Before the Affordable Care Act, preventive services for women were not covered uniformly. Visits with a medical provider during adolescence can address medical, behavioral, and reproductive topics during a vulnerable time before pregnancy becomes a possibility. Potential Strategies Within State Medicaid Programs Education and Quality
Education and Quality
• Develop systems of quality assessment of care or content measures in each bundle of pregnancy care listed previously. Financing and Coverage
• Divide reimbursement of the global obstetrics fee into components that include the first prenatal visit and risk assessment with referral for high-risk care if appropriate or to make plans and arrangements for
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program of preterm birth prevention and management of other high-risk patients, subsequent prenatal care, labor and delivery, and immediate postpartum care up to 60–90 days. • Tie reimbursement to satisfaction of the quality indicators identified for satisfactory implementation of the unbundled areas of prenatal care, labor and delivery, and postpartum care provision. • Continue refining, testing, and reporting all components of the Physicians Consortium of Performance Improvement measures that include postpartum and reproductive health as well as a source of data from electronic health records.
• Permit adolescents to receive confidential reproductive health information without a requirement for parental permission inasmuch as this conforms with the law in most states. • Encourage health plans and health care providers to conduct quality improvement projects related to use and content of the adolescent health well visit. Financing and Coverage
• Coverall annual preventive health visits including mental health screening, reproductive services, and recommended immunizations for adolescents. This
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Age at fetal or infant death
Birth weight
500–1,499 grams
1,500+ grams
Maternal health/Prematurity: points of impact of expert panel guidance • Long-acting reversible contraception/contraception/birth spacing • Breastfeeding supports • Progesterone/17α-hydroxyprogesterone caproate • Adolescent and adult women well-check visits • High-risk identification data systems
Maternal care: points of impact of expert panel guidance • Breastfeeding supports • Progesterone/17αhydroxyprogesterone caproate • High-risk identification data systems
Newborn care: points of impact of expert panel guidance • Breastfeeding supports
is recommended in Bright Futures and required for most non-Medicaid plans under the Affordable Care Act. • Improve access to sexual health counseling, possibly through school clinics, e-visits, or both. • Provide incentives at the consumer, clinician, and health plan levels for improved rates of adolescent well checks. Data and Measurement
• Use existing adolescent health measures (eg, Healthcare Effectiveness Data and Information Set, Children’s Health Insurance Program) and develop or adapt new measures as needed, including patient activation measures.
Action Area 6: Develop Population-Based Perinatal Data Systems to Enable Health Care System and Health Care Provider Performance Measurement and Reporting, Which Will Provide a Foundation to Identify High-Risk Women, Provide Feedback to Health Care Providers, and Monitor Health Outcomes Key Challenges Many perinatal data systems such as vital records are independent and lack connectivity to both health care providers and payers. These data isolation prevents the sharing of information to enhance evidence-based care across multiple systems, which otherwise might be used to show large-scale improved outcomes. In addition, to truly get to value-based purchasing, data systems that link both quality and cost information are required. The current global-based payment system has perverse incentives to drive ever increasing obstetric intervention regardless of clinical indication or outcomes.
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Infant health: points of impact of expert panel guidance • Breastfeeding supports
Fig. 1. Perinatal period of risk map. Applegate. Improving Maternal and Infant Health Outcomes. Obstet Gynecol 2014.
Potential Strategies Within State Medicaid Programs Financing and Coverage
• Develop mechanisms to identify women at risk for preterm birth or complex pregnancies based on prior preterm birth or maternal complications at the time of the index pregnancy with emphasis on the first prenatal visit or encounter as a significant event and one that is unbundled from the global obstetrics fee. Data and Measurement
• Develop and test the ability to link Vital Statistics, Medicaid claims, and eligibility data to use in a health care provider feedback loop as well as performance measurement and monitoring of patients and health care providers. • Create a registry for 17a-hydroxyprogesterone caproate candidates, which could be particularly helpful in states that have a pharmacy carve-out. Perinatal quality collaboratives or other entities could serve this function as well.15
OTHER CONSIDERATIONS Embedded in the assessments of the previously mentioned six major areas of action are a number of concerns that merit important mention. Patient education for patient empowerment (“knowledge is power”) and engagement in decision-making deserve continued emphasis and encouragement in practice. Health care disparities affect most, if not all, of the six categories of concern. Continued emphasis on eliminating elective inductions of labor before 39 weeks of gestation merits serious consideration for extension beyond that marker to await spontaneous labor in uncomplicated
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pregnancy with a deemphasis on elective inductions of labor at any gestational age. Testing of any new program is emphasized before general implementation so that unintended consequences are identified and dealt with before widespread introduction into general use.
5. Long-acting reversible contraception: Implants and intrauterine devices. Practice Bulletin No. 121. American College of Obstetricians and Gynecologists. Obstet Gynecol 2011;118:184–96. 6. Core State Preconception Health Care Indicators—Council of State and Territorial Epidemiologists. Available at: http://www. cste.org/?PreconIndicators. Retrieved July 2013. 7. Johnson KA, Floyd RL, Humphrey JR, Biermann J, Moos M, Drummonds M-K, et al. Action plan for the national initiative on Preconception Health and Health Care (PCHHC). CDC.gov. Available at: http://www.cdc.gov/preconception/documents/ actionplannationalinitiativepchhc2012-2014.pdf. Retrieved July 2013.
CONCLUSION Many of the major areas of focus address preterm birth, chronic medical conditions, and health behaviors that directly affect health outcomes within the Medicaid program. The Expert Panel discussions have shed light on six key areas ripe for immediate action that are intended to significantly improve outcomes for mothers and infants in the Medicaid program. Perhaps the best way to illustrate the thrust of these actions is to show the Perinatal Period of Risk graphic (Fig. 1), which visually demonstrates the critically important role of upstream work necessary to significantly affect downstream infant mortality and maternal and newborn health outcomes.3 REFERENCES 1. Macdorman MF, Hoyert DL, Mathews TJ. Recent declines in infant mortality in the United States, 2005–2011. NCHS Data Brief 2013:1–8. 2. Macdorman MF, Mathews TJ. Recent trends in infant mortality in the United States. NCHS Data Brief 2008:1–8.
8. Breastfeeding initiation and duration at 4 weeks. Available at: http://www.cdc.gov/prams/PDF/Snapshot-Report/Breastfeeding.pdf. Retrieved July 2013. 9. How do experiences of childbearing women on Medicaid and private insurance compare? A Listening to Mothers III data brief. Transforming maternity care. Available at: http://transform. childbirthconnection.org/reports/listeningtomothers/medicaid/. Retrieved July 2013. 10. Petrini JR, Callaghan WM, Klebanoff M, Green NS, Lackritz EM, Howse JL, et al. Estimated effect of 17 alphahydroxyprogesterone caproate on preterm birth in the United States. Obstet Gynecol 2005;105:267–72. 11. Flegal KM, Carroll MD, Kit BK, Ogden CL. Prevalence of obesity and trends in the distribution of body mass index among US adults, 1999–2010. JAMA 2012;307:491–7. 12. Cedergren MI. Maternal morbid obesity and the risk of adverse pregnancy outcome. Obstet Gynecol 2004;103:219–24. 13. Baeten JM, Bukusi EA, Lambe M. Pregnancy complications and outcomes among overweight and obese nulliparous women. Am J Public Health 2001;91:436–40.
3. Peck MG, Sappenfield WM, Skala J. Perinatal periods of risk: a community approach for using data to improve women and infants’ health. Matern Child Health J 2010;14:864–74.
14. Weiss JL, Malone FD, Emig D, Ball RH, Nyberg DA, Comstock CH, et al. Obesity, obstetric complications and cesarean delivery rate-a population-based screening study. Am J Obstet Gynecol 2004;190:1091–7.
4. IOM (Institute of Medicine). Crossing the quality chasm: a new health system for the 21st century. Washington (DC): National Academy Press; 2001.
15. Bettegowda VR, Lackritz E, Petrini JR. Epidemiologic trends in perinatal data—toward improving the outcomes of pregnancy III. White Plains (NY): March of Dimes; 2010.
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Improving Maternal and Infant Health Outcomes in Medicaid and the Children’s Health Insurance Program Mary Applegate,
MD, FACP,
Rebekah E. Gee,
MD, MPH,
Maternal and infant health is critical to our nation’s health. Disparities remain unacceptably high, particularly in the areas of prematurity and infant mortality. In 2012, traditionally distant partners such as federal and state governments, Medicaid and commercial payers, patients, public health and private clinicians, and multiple advocacy groups collaborated to focus on improving birth outcomes. To catalyze the alignment, the Centers for Medicare and Medicaid Services convened an Expert Panel on Improving Maternal and Infant Health Outcomes in Medicaid and the Children’s Health Insurance Program. Over a year’s time, the Expert Panel assimilated the best available evidence in clinical science and policy from content leaders and patients. These recommendations culminated in the present report, which challenges us as a nation to implement strategies to help all children have the best chance to survive and thrive comparable to that of other westernized nations. (Obstet Gynecol 2014;124:143–9) DOI: 10.1097/AOG.0000000000000320
From the Ohio Department of Medicaid, Columbus, Ohio; the Departments of Health Policy and Management and Obstetrics and Gynecology, Louisiana State University, Schools of Public Health and Medicine, New Orleans, and the State of Louisiana, Baton Rouge, Louisiana; and Department of Obstetrics and Gynecology, the University of Mississippi Medical Center, Jackson, Mississippi. The Expert Panel, cochaired by Drs. Applegate and Martin, was created by the Center for Medicare and Medicaid Services with project direction by Lekisha Daniel-Robinson, Coordinator, Maternal and Infant Health Initiatives for the Center for Medicaid and Children’s Health Insurance Program Services. The Expert Panel was convened by Centers for Medicare and Medicaid Services’ contractor Provider Resources, Inc whose membership included Dr. Gee and state Medicaid medical directors, Medicaid providers, consumer representatives, and other experts in the areas of maternal and child health, Medicaid, advocacy, and research. Corresponding author: James N. Martin, Jr, MD, Department OBGYN-UMMC, 2500 N State Street, Jackson, MS 39216-4505; e-mail: [email protected]. Financial Disclosure The authors did not report any potential conflicts of interest. © 2014 by The American College of Obstetricians and Gynecologists. Published by Lippincott Williams & Wilkins. ISSN: 0029-7844/14
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and James N. Martin, Jr,
MD
I
nfant mortality rates long have been considered a measure of the health of a nation.1 There have been multiple efforts to reduce the infant mortality rate in the United States, resulting in a reduction from 9.2 per 1,000 live births in 1990 to 6.2 per 1,000 live births in 2010. The decline is a significant achievement, driven by factors such as wider availability of neonatal care and expanded access to maternity and infant care through Medicaid coverage. At the same time, racial and ethnic disparities in infant mortality remain, and preventable infant deaths remain unacceptably high. Moreover, the United States lags compared with other industrialized nations; in 2004, the United States ranked 29th among developed nations2 and 27th in 2008 with a national infant mortality of 6.05 per 1,000 live births.1 These low rankings may be related partially to systems issues. Our current fragmented system divides the care of women into artificial segments based on payment policies, phases of pregnancy, and reproductive health status. In recent years, clinical, public health, and academic experts have documented the multifaceted nature of the challenge and the multiple factors that affect birth outcomes. One example is the identification of Perinatal Periods of Risk as advocated by Peck and colleagues.3 There is a great need for effective interventions, financing, and delivery systems that address a continuum of needs among women before, during, and after pregnancy as well as to both newborns and older infants. The Affordable Care Act, including Medicaid expansions, provides an opportunity for improved coverage, payment, and health care provider strategies. Medicaid programs pay for an estimated average of 40–50% of the 4.3 million births that occur every year in our country rendering pregnancy and delivery and newborn care the most common hospital condition for Medicaid. More births will be financed by Medicaid after implementation of the
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Affordable Care Act. Despite this level of coverage, accountability through data collection or quality monitoring has been low for the maternal and infant population. Given that Medicaid serves some of the most vulnerable women, there is an urgent need for Centers for Medicare and Medicaid Services and states to improve Medicaid perinatal practices, report on Medicaid perinatal outcomes, and enhance the quality of services financed. This report of the Expert Panel on Improving Maternal and Infant Outcomes in Medicaid and the Children’s Health Insurance Program offers strategies and policy options Centers for Medicare and Medicaid Services can use in the short term to improve maternity-related outcomes. The Expert Panel suggestions align with professional guidelines, the recommendations of the Department of Health and Human Services Secretary’s Advisory Committee on Infant Mortality and other federal, state, and private sector initiatives.4
EXPERT PANEL ON IMPROVING MATERNAL AND INFANT HEALTH OUTCOMES IN MEDICAID AND THE CHILDREN’S HEALTH INSURANCE PROGRAM An Expert Panel was convened for a year beginning June 2012 to identify strategies for achieving better policies, care, and outcomes for mothers and infants and to reduce the cost of perinatal care in the Medicaid program. The process of the panel entailed reviewing existing efforts for synergistic and collective effects, identifying gaps in performance measurement and performance improvement. Subject Matter Experts engaged in initial brain storming and months of structured deliberation. The Expert Panel’s work groups focused on four unique but interrelated themes: 1) measurement and data; 2) enhanced maternal services for high-risk women; 3) payment reform; and 4) effective reproductive (health) enablers. Each of the four groups identified several more detailed strategies for full panel consideration. Panel members rated the identified shortterm strategies by weighted criteria, including relationship to birth outcomes (0.2); potential effect on reducing disparities (0.2); feasibility of implementation within 2 years (0.5); and availability of supporting measurement approaches (0.1). Resulting ratings highlighted major cost drivers and opportunities for maximum population effects. As cochairs, Drs Applegate and Martin consider the following six major cross-cutting areas to constitute the most important recommendations of the group.
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Action Area 1: Reduce Unintended Pregnancy and Improve Birth Spacing by Increasing Contraceptive Access and Use Medicaid should reimburse for all contraceptive methods and support women in their family planning efforts through coverage of education and all methods without copays in the Medicaid benefit package, including long-acting reversible contraception (LARC) in all (inpatient and outpatient) clinical settings. Key Challenges Medicaid has long been criticized for burdening clinicians and other health care providers with administrative requirements and policies that pose barriers to the provision of effective and evidence-based reproductive health care services. Not all states provide Medicaid reimbursement for all the Department of Health and Human Services-recommended family planning methods and Affordable Care Act definitions within women’s clinical preventive services will not apply to Medicaid. Most states allow for reimbursement of the full range of LARC in the outpatient setting; however, if this service is done in the hospital after delivery, the cost of the device is included in the hospital Diagnosis-Related Group payment, rendering this service inaccessible to some mothers that desire this method of contraception.5 Potential Strategies Within State Medicaid Programs Education and Quality
• Prevent unintended pregnancy through patient engagement, education, and shared decisionmaking. • Provide coverage for education and access to contraceptives and family planning services before pregnancy (preconception) and between pregnancies (interconception). • Hold health systems and health care providers accountable for educating patients through payment reform and incentives, performance measurement, and measurement that includes patient activation. • Emphasize the postpartum visit as an important component of total obstetric care. Financing and Coverage
• Develop policies (including separate hospital payment for LARC) to support the use of LARC, especially for high-risk women and adolescents in keeping with patient preferences.5
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• Urge states to consider coverage of LARC as a medical rather than a pharmaceutical benefit if this fits better to meet their particular requirements. Data and Measurement
• Develop and adopt measures to track progress in birth spacing. • Develop and adopt family planning measures that reflect other Department of Health and Human Services standards from Title X family planning program, Centers for Disease Control and Prevention, and others. • Adopt preconception and interconception care measures from the model state measurement set promoted by the Association of State and Territorial Epidemiologists and the National Preconception Health and Health Care Initiative.6,7
Action Area 2: Expand and Enhance Breastfeeding Improve implementation of policies to provide coverage for education and support related to breastfeeding throughout pregnancy, inclusive of the prenatal, intrapartum, and postpartum periods of patient care. Key Challenges Rates of successful breastfeeding within the Medicaid population lag significantly behind other women despite the positive effect on health outcomes.8,9 Public policy, including payment policies, can lead to higher rates of breastfeeding, improved health, and likely lower costs for Medicaid. Potential Strategies Within State Medicaid Programs Education and Quality
• Encourage and support quality improvement projects in cooperation with perinatal improvement collaboratives to enhance breastfeeding support best practices such as those defined by the Centers for Disease Control and Prevention Best Fed Beginnings, 10 steps to a Baby Friendly Hospital Initiative, and similar models. Financing and Coverage
• Include breastfeeding education and expect breastfeeding implementation and accountability in all managed care program contracts in states that have managed care and ensure interagency referrals to
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state and community partners such as Women, Infants, and Children. • Provide coverage and rental for high-quality electric breast pumps. • Incentivize breastfeeding and provision of breast milk at both the patient and health systems levels, especially in circumstances of preterm birth. Data and Measurement
• Develop measures and data reporting mechanisms for population-level monitoring at the state level of breastfeeding by mothers of infants with Medicaidfinanced births.
Action Area 3: Reduce Preterm Birth and Adverse Pregnancy Outcomes Implement policies and procedures to encourage the earliest possible appropriate patient risk screening for preterm birth and other adverse pregnancy outcomes. For patients identified, support and encourage integrated systems of prenatal care that reflect both medical and psychosocial risk factors. Finance and create incentives for the appropriate administration of progesterone and 17a-hydroxyprogesterone caproate for patients at risk of preterm birth as well as enhanced prenatal care for those at risk for significant medical complexity and other adverse pregnancy outcomes. Key Challenges Lack of access to risk-appropriate prenatal care and recommended interventions affects pregnant women covered by Medicaid in every part of the country. Despite decades of national recommendations, our profession is slow to adopt new evidence basedguidelines. Moreover, it has been difficult to reliably implement best practices such as antenatal steroids and 17a-hydroxyprogesterone caproate for appropriately indicated patients. There are barriers to optimal use of 17a-hydroxyprogesterone caproate or progesterone in clinically eligible, Medicaid beneficiaries, including adherence to the weekly injection schedule, variability in state Medicaid financing of progesterone, late presentation for prenatal care, lack of identification of eligible recipients, cumbersome Medicaid enrollment processes, and obligatory 60-day free-choice-of-plan processes. Distribution barriers also exist related to a reluctance of clinicians to be at risk for the cost of unadministered doses and the challenges of coordinating home visits for the injections with specialty pharmacies. Until recently, 17a-hydroxyprogesterone caproate was an inexpensive, compounded drug, but after a formal U.S. Food and Drug Administration approval process for its indicated
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provision to prevent recurrent preterm delivery, the expense is prohibitive to take to scale. The provision of progesterone, including 17a-hydroxyprogesterone caproate, must be seamless and frustration-free for all those with prior preterm births inclusive of stillbirths, live-born neonates at 16–24 weeks of gestation, and all women with a shortened cervix detected early in pregnancy by standardized ultrasonography techniques. If preterm births were prevented in one-third of the 30,000 patients eligible for 17a-hydroxyprogesterone caproate and at least half were Medicaid recipients, an estimated 5,000 premature births annually could be prevented by this intervention in the United States.10 Other key challenges to reduction of preterm birth and adverse pregnancy outcomes (and lowered health care costs) derive from several chronic medical conditions (especially obesity, hypertension, and diabetes), which predate pregnancy and compromise successful maternal and perinatal outcomes. Obesity, eg, is a significant health concern in the United States where 34% of women 20–39 years of age are obese, 60% are overweight, and 8% are extremely obese.11 Maternal obesity potentiates diabetes and hypertension during pregnancy. Indeed, obese pregnant women are at an increased risk for poor maternal and neonatal outcomes including spontaneous abortion, gestational hypertension, preeclampsia, higher cesarean delivery rates, higher postoperative cesarean delivery complication rates, and thromboembolism compared with nonobese patients.12–14 Potential Strategies Within State Medicaid Programs
•
•
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• • •
Education and Quality
• Based on the recommendations of national professional organizations such as the American College of Obstetricians and Gynecologists and the Society for Maternal-Fetal Medicine, create sample policies and encourage implementation of appropriate screening and use of 17a-hydroxyprogesterone caproate for eligible women. • Pursue programmatic efforts to deliberately and methodically keep many of the most vulnerable and high-risk mothers engaged and working on improved outcomes. Financing and Coverage
• Collaborate with manufacturers and others to ensure that all state Medicaid programs and health care providers have timely access to 17a-hydroxyprogester-
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one caproate with understanding of the manufacturing, distribution, payment, and enrollment issues. Improve payment policies for monitoring cervical length in at-risk pregnancies in accordance and consistent with professional guidelines for best care. Allow this identification of high-risk mothers through standardized clinical and ultrasound guidelines without the burden of additional prior authorization. Provide financing for an enhanced, expanded level of prenatal care for patients recognized early in gestation as high risk for preterm birth and adverse perinatal–maternal outcomes and regionalizing the care of these patients where possible in a group prenatal care format. This should include separate funding to support consultation by a team of dietitians, physical therapists, diabetic educators, social workers, and patient care coordinators with leadership ideally from a maternal-fetal medicine subspecialist or, if not available, an obstetrician–gynecologist with special expertise and interest in high-risk pregnancy care. Incentivize and support regionalized maternal, perinatal, and newborn care with early referral of mothers with complications likely to require preterm delivery and enhanced maternal-fetal and neonatal care. Develop waivers or other programs to provide care for women between pregnancies and improve interconception patient care. Increase emphasis and programmatic support for expansion of mental health and substance use, abuse, and addiction attention and funding support. Incentivize Medicaid plans and health care providers (through contracts and payments, for example) to perform a standardized pregnancy risk assessment to identify mothers at risk for preterm birth and medical complexities before or at the first prenatal visit and thereafter during prenatal care to plan prevention strategizes accordingly. Incentivize Medicaid plans and health care providers (through contracts and payments, for example) to identify women at risk for preterm birth based on her history of a prior preterm birth and devise risk appropriate care plans (this relates to Action Area 6 subsequently).
Data and Measurement
• Develop improved data and measurement approaches that monitor not just the timing and number of prenatal visits, but also the content, quality, and risk-appropriate level of prenatal care. • For states with a pharmacy carve-out, provide managed care programs with data on which
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members are receiving 17a-hydroxyprogesterone caproate so that these individuals can be tracked and outreached.
Action Area 4: Unbundle Global Maternity Services and Change Payment to Promote Appropriate Regionalization of Maternal and Neonatal Care and Develop Perinatal Care as a Value-Based Purchasing Bundle With Quality and Performance Measures Tied to Outcomes That Include Cost Key Challenges The current payment mechanisms for maternity care are perverse, paying more for volume and intervention rather than for value as defined by reliable adherence to best practice standards, health outcomes, and shared decision-making. One example is the reluctance of some hospitals or obstetrician–gynecologists to transfer an undelivered obstetric patient with an impending preterm delivery to a tertiary care center because of the threat of relinquishing higher reimbursement. Medicaid billing and reimbursement policies are complex. Some programs include several managed care plans with variable prior authorization and other requirements that differ substantially from private industry. There is little or no financial alignment across health systems and little or no transparency in the costs or quality that define value. The field of maternity care is ripe for payment reform that may accelerate achieving improved pregnancy outcomes because these are evident in a relatively short period of time, maternity care quality measures are fairly mature, and accountable entities can be identified for care. Payment reform can be achieved through fostering innovation with novel partners and reshaping the cost curve with potential gain and risk-sharing with health care providers. Potential Strategies Within State Medicaid Programs
Data and Measurement
• Develop measurement and data processes that enable states to integrate data systems related to service use, quality measurement, and cost as well as develop feedback mechanisms to connect those involved in all parts of the system.
Action Area 5: Implement Policies and Procedures to Drive Early and Regular Adolescent and Adult Well Checks Key Challenges Adolescents may not be seen routinely for well checks, representing lost opportunities for addressing reproductive health issues. Before the Affordable Care Act, preventive services for women were not covered uniformly. Visits with a medical provider during adolescence can address medical, behavioral, and reproductive topics during a vulnerable time before pregnancy becomes a possibility. Potential Strategies Within State Medicaid Programs Education and Quality
Education and Quality
• Develop systems of quality assessment of care or content measures in each bundle of pregnancy care listed previously. Financing and Coverage
• Divide reimbursement of the global obstetrics fee into components that include the first prenatal visit and risk assessment with referral for high-risk care if appropriate or to make plans and arrangements for
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program of preterm birth prevention and management of other high-risk patients, subsequent prenatal care, labor and delivery, and immediate postpartum care up to 60–90 days. • Tie reimbursement to satisfaction of the quality indicators identified for satisfactory implementation of the unbundled areas of prenatal care, labor and delivery, and postpartum care provision. • Continue refining, testing, and reporting all components of the Physicians Consortium of Performance Improvement measures that include postpartum and reproductive health as well as a source of data from electronic health records.
• Permit adolescents to receive confidential reproductive health information without a requirement for parental permission inasmuch as this conforms with the law in most states. • Encourage health plans and health care providers to conduct quality improvement projects related to use and content of the adolescent health well visit. Financing and Coverage
• Coverall annual preventive health visits including mental health screening, reproductive services, and recommended immunizations for adolescents. This
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Age at fetal or infant death
Birth weight
500–1,499 grams
1,500+ grams
Maternal health/Prematurity: points of impact of expert panel guidance • Long-acting reversible contraception/contraception/birth spacing • Breastfeeding supports • Progesterone/17α-hydroxyprogesterone caproate • Adolescent and adult women well-check visits • High-risk identification data systems
Maternal care: points of impact of expert panel guidance • Breastfeeding supports • Progesterone/17αhydroxyprogesterone caproate • High-risk identification data systems
Newborn care: points of impact of expert panel guidance • Breastfeeding supports
is recommended in Bright Futures and required for most non-Medicaid plans under the Affordable Care Act. • Improve access to sexual health counseling, possibly through school clinics, e-visits, or both. • Provide incentives at the consumer, clinician, and health plan levels for improved rates of adolescent well checks. Data and Measurement
• Use existing adolescent health measures (eg, Healthcare Effectiveness Data and Information Set, Children’s Health Insurance Program) and develop or adapt new measures as needed, including patient activation measures.
Action Area 6: Develop Population-Based Perinatal Data Systems to Enable Health Care System and Health Care Provider Performance Measurement and Reporting, Which Will Provide a Foundation to Identify High-Risk Women, Provide Feedback to Health Care Providers, and Monitor Health Outcomes Key Challenges Many perinatal data systems such as vital records are independent and lack connectivity to both health care providers and payers. These data isolation prevents the sharing of information to enhance evidence-based care across multiple systems, which otherwise might be used to show large-scale improved outcomes. In addition, to truly get to value-based purchasing, data systems that link both quality and cost information are required. The current global-based payment system has perverse incentives to drive ever increasing obstetric intervention regardless of clinical indication or outcomes.
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Infant health: points of impact of expert panel guidance • Breastfeeding supports
Fig. 1. Perinatal period of risk map. Applegate. Improving Maternal and Infant Health Outcomes. Obstet Gynecol 2014.
Potential Strategies Within State Medicaid Programs Financing and Coverage
• Develop mechanisms to identify women at risk for preterm birth or complex pregnancies based on prior preterm birth or maternal complications at the time of the index pregnancy with emphasis on the first prenatal visit or encounter as a significant event and one that is unbundled from the global obstetrics fee. Data and Measurement
• Develop and test the ability to link Vital Statistics, Medicaid claims, and eligibility data to use in a health care provider feedback loop as well as performance measurement and monitoring of patients and health care providers. • Create a registry for 17a-hydroxyprogesterone caproate candidates, which could be particularly helpful in states that have a pharmacy carve-out. Perinatal quality collaboratives or other entities could serve this function as well.15
OTHER CONSIDERATIONS Embedded in the assessments of the previously mentioned six major areas of action are a number of concerns that merit important mention. Patient education for patient empowerment (“knowledge is power”) and engagement in decision-making deserve continued emphasis and encouragement in practice. Health care disparities affect most, if not all, of the six categories of concern. Continued emphasis on eliminating elective inductions of labor before 39 weeks of gestation merits serious consideration for extension beyond that marker to await spontaneous labor in uncomplicated
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pregnancy with a deemphasis on elective inductions of labor at any gestational age. Testing of any new program is emphasized before general implementation so that unintended consequences are identified and dealt with before widespread introduction into general use.
5. Long-acting reversible contraception: Implants and intrauterine devices. Practice Bulletin No. 121. American College of Obstetricians and Gynecologists. Obstet Gynecol 2011;118:184–96. 6. Core State Preconception Health Care Indicators—Council of State and Territorial Epidemiologists. Available at: http://www. cste.org/?PreconIndicators. Retrieved July 2013. 7. Johnson KA, Floyd RL, Humphrey JR, Biermann J, Moos M, Drummonds M-K, et al. Action plan for the national initiative on Preconception Health and Health Care (PCHHC). CDC.gov. Available at: http://www.cdc.gov/preconception/documents/ actionplannationalinitiativepchhc2012-2014.pdf. Retrieved July 2013.
CONCLUSION Many of the major areas of focus address preterm birth, chronic medical conditions, and health behaviors that directly affect health outcomes within the Medicaid program. The Expert Panel discussions have shed light on six key areas ripe for immediate action that are intended to significantly improve outcomes for mothers and infants in the Medicaid program. Perhaps the best way to illustrate the thrust of these actions is to show the Perinatal Period of Risk graphic (Fig. 1), which visually demonstrates the critically important role of upstream work necessary to significantly affect downstream infant mortality and maternal and newborn health outcomes.3 REFERENCES 1. Macdorman MF, Hoyert DL, Mathews TJ. Recent declines in infant mortality in the United States, 2005–2011. NCHS Data Brief 2013:1–8. 2. Macdorman MF, Mathews TJ. Recent trends in infant mortality in the United States. NCHS Data Brief 2008:1–8.
8. Breastfeeding initiation and duration at 4 weeks. Available at: http://www.cdc.gov/prams/PDF/Snapshot-Report/Breastfeeding.pdf. Retrieved July 2013. 9. How do experiences of childbearing women on Medicaid and private insurance compare? A Listening to Mothers III data brief. Transforming maternity care. Available at: http://transform. childbirthconnection.org/reports/listeningtomothers/medicaid/. Retrieved July 2013. 10. Petrini JR, Callaghan WM, Klebanoff M, Green NS, Lackritz EM, Howse JL, et al. Estimated effect of 17 alphahydroxyprogesterone caproate on preterm birth in the United States. Obstet Gynecol 2005;105:267–72. 11. Flegal KM, Carroll MD, Kit BK, Ogden CL. Prevalence of obesity and trends in the distribution of body mass index among US adults, 1999–2010. JAMA 2012;307:491–7. 12. Cedergren MI. Maternal morbid obesity and the risk of adverse pregnancy outcome. Obstet Gynecol 2004;103:219–24. 13. Baeten JM, Bukusi EA, Lambe M. Pregnancy complications and outcomes among overweight and obese nulliparous women. Am J Public Health 2001;91:436–40.
3. Peck MG, Sappenfield WM, Skala J. Perinatal periods of risk: a community approach for using data to improve women and infants’ health. Matern Child Health J 2010;14:864–74.
14. Weiss JL, Malone FD, Emig D, Ball RH, Nyberg DA, Comstock CH, et al. Obesity, obstetric complications and cesarean delivery rate-a population-based screening study. Am J Obstet Gynecol 2004;190:1091–7.
4. IOM (Institute of Medicine). Crossing the quality chasm: a new health system for the 21st century. Washington (DC): National Academy Press; 2001.
15. Bettegowda VR, Lackritz E, Petrini JR. Epidemiologic trends in perinatal data—toward improving the outcomes of pregnancy III. White Plains (NY): March of Dimes; 2010.
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