Maternal and infant mortality rates within the U.S. are far increased than these in equally massive and rich international locations, with individuals of coloration at elevated threat for poor maternal and toddler Health outcomes in comparison with their White friends. Because of this, coverage makers at each the federal and state ranges are more and more specializing in bettering maternal and toddler Health outcomes and lowering disparities. On the federal stage, the Consolidated Appropriations Act made everlasting the choice for states to increase Medicaid postpartum protection to 12 months. As of April 2024, 46 states have carried out the 12-month extension. As well as, the Biden administration has recognized maternal Health as a Health-Blueprint.pdf”>precedence, and their latest price range proposal consists of enhanced efforts to enhance maternal care. The nation’s governors, performing via the Nationwide Governors Affiliation, have acknowledged the pressing want for motion releasing the Tackling the Maternal and Toddler Health Disaster: A Governor’s Playbook in July 2023. Additionally, within the 2023 Medicaid price range survey, carried out by KFF and Health Administration Associates (HMA), almost a 3rd of all responding states talked about initiatives to enhance maternal and baby Health as a prime precedence for the yr forward.
The Medicaid program has potential to affect maternal and toddler Health outcomes as IT funds about 4 in 10 U.S. births. Whereas Medicaid’s protection of maternity care has historically targeted on prenatal and postpartum doctor visits and labor and supply care, a rising variety of states have added new being pregnant or postpartum advantages in recent times, equivalent to doula providers, lactation providers, and residential visiting packages, to advertise higher maternal and toddler Health outcomes and scale back racial/ethnic Health disparities.
To higher perceive state initiatives to broaden Medicaid protection of those much less generally coated pregnancy-related providers, the 23rd annual Medicaid price range survey, carried out by KFF and HMA requested states about methods and challenges in selling entry to “non-traditional pregnancy-related care and providers” and included childbirth training courses, doula providers, house births, and residential visits by lactation consultants as examples. The price range survey query was restricted to providers that have been individually reimbursed as of July 1, 2023, exterior of a hospital bundled payment and never as a element of an workplace or clinic go to. Maternity care is commonly reimbursed as a bundled cost that covers all skilled providers supplied throughout the perinatal interval, together with prenatal care, labor and supply, and postpartum care. These bundled funds do not typically cover non-traditional providers. A earlier KFF survey collected further element on pregnancy-related providers included in bundled charges as of July 2021 and likewise recognized particular pregnancy-related providers supplied by every state – element that was not collected by the 2023 price range survey.
Forty-eight states (together with DC) responded to the survey, though response charges for particular questions various. The total report highlights state motion to broaden being pregnant and postpartum advantages together with doula providers, lactation helps, and residential visiting packages.
What sorts of non-traditional (much less generally coated) pregnancy-related providers are states individually reimbursing for?
As of July 1, 2023, greater than two-thirds of responding states (32 of 47) reported protection of a minimum of one individually reimbursed, non-traditional pregnancy-related service. The next checklist describes providers talked about in state responses. A broader group of states might present these providers (like doula providers) via a bundled cost.
- Doula providers. Doula providers have been probably the most continuously talked about non-traditional service. Doulas are professionals who assist pregnant and postpartum individuals by offering a wide range of providers all through the being pregnant and postpartum interval, together with visits throughout the prenatal interval, labor teaching and assist on the time of supply, and postpartum care and help. Doula providers are linked to extra constructive supply outcomes, together with reductions in C-sections, untimely deliveries, and size of labor.
- Childbirth and/or parenting courses. There are a selection of education-related assist providers that may support pregnant and postpartum people with being pregnant, supply, and childrearing. These embody childbirth training courses, toddler and parenting training courses, and group prenatal care (e.g., Centering Pregnancy group prenatal care). Whereas some states cowl these providers via their Medicaid packages, some states supply these providers via different public Health packages.
- Outpatient lactation helps. Lactation assist will be supplied in a number of settings within the postpartum interval, together with within the hospital earlier than discharge, at outpatient visits, or at house. Many Medicaid enrollees are additionally eligible for WIC, which supplies lactation assist.
- Lay or “direct entry” midwife providers as a non-traditional coated service. Midwives use a holistic, person-centered care mannequin that has been linked to higher maternal and toddler outcomes. Most states solely embody licensed nurse-midwives (CNMs) of their supplier networks, as required by federal law, however latest state motion has extended Medicaid coverage to different midwife suppliers, together with midwives who could also be credentialed to offer childbirth assist and providers regardless of not having a proper nursing training. States use numerous phrases to consult with midwives with out a nursing diploma, together with licensed midwife, direct entry midwives, licensed lay midwife, licensed midwives, licensed skilled midwives, conventional midwife, and verifiable midwife.
- House births. International studies recommend that house births could also be as protected as hospital births for low-risk pregnant people and infants when they’re a part of an built-in and controlled system. However, house births account for a small share of births within the U.S., though there was growing interest because the begin of the COVID-19 pandemic. Doulas, midwives, or physicians could also be in attendance for house births.
- Different providers. Different coated pregnancy-related providers talked about by a minimum of one state as “non-traditional” embody specialised care administration or care coordination packages, house visiting packages, and being pregnant care by way of telehealth.
Along with state efforts, there are federal efforts to broaden entry to non-traditional pregnancy-related providers. In June 2022, the White Home recognized workforce enlargement and diversification as one in every of its Health-Blueprint.pdf”>5 objectives for addressing the nation’s maternal Health disaster. This aim consists of, partly, promotion of doulas, midwives, and neighborhood Health employees. Subsequently, CMS introduced the Health-tmah-model”>Reworking Maternal Health (TMaH) Mannequin in December 2023. The brand new mannequin goals to enhance maternal and toddler Health outcomes and scale back disparities by offering technical help and grant funding to as much as 15 state Medicaid businesses. TMaH will assist collaborating states enhance entry to care, together with care from doulas and perinatal neighborhood Health employees. The Biden Administration’s just lately proposed budget additionally directs greater than $300 million to bettering maternal Health, together with a further $5 million to develop and diversify the doula workforce. The proposed price range additionally consists of an elective Medicaid maternal Health assist profit aiming to deal with fairness points in maternal Health outcomes. The profit would come with protection of doulas, neighborhood Health employees, and peer assist employees. Nonetheless, with a divided Congress, these price range proposals are usually not prone to be handed this yr.
What are challenges and techniques to broaden entry to non-traditional pregnancy-related providers?
Whereas non-traditional pregnancy-related providers have the potential to enhance maternal Health outcomes and scale back disparities, access-related challenges might restrict utilization, regardless of state efforts to ascertain protection and encourage take-up. Documented access-related obstacles embody workforce shortages, restrictive provider training/licensure requirements, low reimbursement rates, billing complexities, and amount limitations. The 2023 Medicaid price range survey requested states about these challenges and initiatives to deal with them. The survey divided these challenges into six classes: 1) workforce shortages, 2) supplier enrollment//coaching/certification/licensing wants, 3) low reimbursement charges, 4) billing challenges, 5) amount limitations on hours/visits allowed, and 6) “different.”
Twenty-five states reported a problem in a minimum of one specified class. The next part describes the challenges most continuously talked about by states and the approaches cited for addressing these challenges, if any. In some instances, initiatives to answer challenges contain collaborative efforts between Medicaid businesses and managed care organizations (MCOs), state-level supplier licensing boards, and/or non-public licensing entities.
Essentially the most continuously cited challenges associated to supplier enrollment, coaching, certification, or licensing. Eighteen states reported challenges on this class. States have various approaches and requirements for certifying or licensing non-traditional suppliers. For instance, doulas haven’t traditionally obtained state medical board licenses, although many do obtain certifications from non-public entities (which can contain important coaching and price). Nonetheless, to obtain Medicaid reimbursement, doulas should enroll as Medicaid suppliers and meet the state Medicaid division’s related qualification requirements. Some doulas discover this course of to be challenging as IT can contain expensive and administratively burdensome coaching requirements. Additionally, midwives can have various ranges of training and coaching (as described above) which might impression their means to satisfy Medicaid enrollment necessities or restrict the settings for which they will obtain Medicaid reimbursement, particularly those that haven’t obtained nursing levels.
Only some states talked about initiatives to deal with these challenges: Michigan has developed supplier assist supplies, trainings, and toolkit Information; Montana reported creating an outreach and training plan; New Jersey Medicaid workers are working with MCOs and the New Jersey Division of Health-funded Doula Studying Collaborative to offer technical help; in Virginia the Division of Health and the Virginia Certification Board are working to extend the variety of doula coaching entities; and Wisconsin reported that IT deliberate to replace the state’s administrative code to permit further non-traditional suppliers to turn into licensed.
Seventeen states reported workforce scarcity challenges. A number of states reported that broader Health Care workforce shortages have been additionally affecting the non-traditional pregnancy-related providers workforce. States particularly talked about shortages of doulas, lactation consultants, and suppliers of childbirth courses. Along with widespread shortages introduced on by the COVID-19 pandemic, states cited coaching necessities (mentioned above) as a barrier to rising the non-traditional workforce. Just a few states famous particular initiatives to deal with workforce shortages in rural areas. For instance, Kansas permits entry to lactation consultants by way of telehealth to assist enhance entry in rural areas, and New Mexico makes use of midwife providers to enhance entry to care in rural areas with present doctor/OBGYN shortages.
At the least 4 states described efforts to extend their doula workforce: New Jersey is working with non-profits, MCOs, and their sister businesses to extend entry to accepted doula trainings; Virginia is recruiting extra doulas to create an adequately sized doula workforce for his or her anticipated variety of pregnant enrollees; Michigan is financing doula coaching programs, and Maryland is collaborating with their state’s Maternal and Youngster Health Bureau to recruit extra doulas.
Fifteen states cite billing challenges for non-traditional pregnancy-related service suppliers. A number of states famous that these suppliers are usually not accustomed to Medicaid and MCO billing processes, which can be complicated and time-consuming leading to delays in funds in addition to frustrations working with Medicaid businesses and MCOs. For instance, Michigan reported that suppliers don’t at all times have the Technology wanted for Medicaid billing and New Jersey reported that doulas are usually not accustomed to the quantity of paperwork for Medicaid billing. Some states are offering technical help, assets, and coaching to assist suppliers navigate billing. For instance, New Mexico reported exploring methods to streamline the billing course of and Virginia is working with MCOs to offer assist to doulas in Medicaid and MCO billing.
Eleven states reported low reimbursement charges for non-traditional suppliers as a problem. Low reimbursement charges can disincentivize suppliers from enrolling in Medicaid, limiting entry for Medicaid enrollees. This has been a barrier for perinatal professionals for a few years. For instance, in California implementation of Medicaid protection for doula providers was delayed as a consequence of disputes between the state and doula organizations over reimbursement charges. Non-traditional suppliers emphasize affected person training and assist, which implies that they usually spend intensive time with sufferers, and lots of have reported that Medicaid charges are usually not adequate for protecting their prices. Some states reported actions to deal with low reimbursement charges. Iowa and Indiana are evaluating their present reimbursement charges; Ohio is matching reimbursement charges to different packages, just like the federal Maternal, Infant, and Early Childhood Home Visiting (MIECHV) Program; Kansas has plans to extend reimbursement charges for lactation providers, and Wisconsin just lately elevated charges for prenatal care coordination services.
5 states reported challenges associated to amount limitations on hours or visits for doula providers, childbirth training courses, and/or lactation helps. For instance, whereas Virginia Medicaid presently reimburses doula providers for as much as eight prenatal/postpartum visits (90 minutes for the preliminary prenatal go to and one hour for different visits), the state reported that doulas have expressed the need to have extra allowed visits – e.g., a complete of 12-16 visits, 6-8 prenatal and 6-8 postpartum visits — and longer visits. Additionally, Indiana reported that efforts have been underway to develop doula-specific service limitations because the Group Health Employee profit presently used to reimburse doula providers was topic to go to limits that have been “not conducive to doula actions.”
4 states commented on “different” challenges: California commented on working with hospitals to permit doulas entry throughout delivery; Georgia cited entry to providers in rural areas as a problem; Missouri famous as a problem the necessity to disenroll members from MCOs for a house delivery to be coated via fee-for-service reimbursement cost; and Oklahoma commented on the problem of structuring the doula providers profit in a manner that enables doulas and sufferers to be matched on the premise of race, ethnicity, and language.
This transient attracts on work performed beneath contract with Health Administration Associates (HMA). Kathleen Gifford is an skilled on state Medicaid packages and a Principal at HMA.