Maternal mortality and morbidity have garnered recent attention in the face of growing disparities in perinatal outcomes across minority and at-risk, low-income populations. Medicaid programs, the primary source of health care for these populations, are poised to lead the charge in grappling with this striking crisis. States are now citing this disparity as a policy priority for their Medicaid agencies, leading Medicaid medical directors to meet this past September to discuss the challenges to perinatal care delivery. Their agenda included drivers such as addressing access and coverage barriers, opportunities to leverage Maternal Mortality Review Committees and Perinatal Quality Collaboratives, and potential innovative practices in delivery system reform—each focused on minimizing disparities, improving quality of care delivery, and ultimately saving women’s lives.
How Did We Get Here? What Factors Need To Be Addressed?
Medicaid programs play a pivotal role in providing maternal services, covering nearly half of all births in the United States, and thus are most familiar with the factors and related services needed to address this maternal health crisis. Severe maternal morbidity is a critical starting point, actionable through improved patient-centered, early maternal and post-natal care, which can both achieve long-term sustainable health improvements for mother and infant and result in decreased risks for maternal mortality.
Complications resulting from preexisting chronic conditions are the most common cause of maternal mortality and morbidity, with additional causes ranging from complications linked to surgical deliveries and access to care. One study identified that at least 10 percent of pregnant women in 2014 had one chronic condition. Additionally, the proportion of cesarean sections (c-sections) at US hospitals ranged widely from 7 percent to 70 percent, and most studies have indicated that women who have a c-section have a higher chance of maternal death.
These complications and risk factors are further increased for racial and ethnically diverse women. Compared to the 2016 national maternal mortality rate (16.7 deaths per 100,000 live births), African American and American Indian/Alaska Native (AI/AN) women had pregnancy-related death rates of 40.8 and 29.7 per 100,000 births, respectively. Access to care and quality reproductive services are a contributing factor in racial disparities. A 2010 Healthy People report found that approximately 25 percent of all pregnant women in the United States do not receive the recommended number of prenatal visits, with rates much higher for minority women (32 percent of African American women and 41 percent of AI/AN women, respectively).
Access To Care Is The First Step, But There’s More Medicaid Can Do
Additionally, there are geographic disparities. A study published in Health Affairs in 2017 found that more than half of all rural counties in the US, with 2.4 million women of reproductive age, have no hospital obstetric services and also face primary-care physician shortages. Maternal health care is necessary pre- and post-pregnancy; women who have continuous health coverage reduce their risk of pregnancy complications. The American College of Obstetricians and Gynecologists recommends women have access to uninterrupted care to increase preventive care, reduce avoidable adverse obstetric and gynecologic health outcomes, increase early diagnosis of disease, and reduce maternal mortality rates. A recent study highlighted how states that expanded Medicaid had healthier pregnant women due to an increase in access to preventive care and a reduction in adverse health outcomes before, during, and after pregnancies. Medicaid expansion also has an important role in reducing the significant and persistent racial disparities that come from lack of access to quality care.
In a recent convening of AcademyHealth’s Medicaid Medical Director Network, funded by the Agency for Healthcare Research and Quality, Medicaid clinical leaders shared their respective state priorities to address this crisis. In states that expanded Medicaid, many were implementing innovative practices to address access barriers and improve health equity to ensure enhanced coverage for disparate populations. Some measures included piloting doula, peer navigator, and home visit programs. New York implemented a doula pilot program a few months ago in two counties that is serving 80-plus mothers. Doulas, non-medical birth coaches for women during the prenatal, labor, and delivery as well as post childbirth phases, have been shown to improve health outcomes for pregnant women pre- and post-pregnancy. Wisconsin implemented an Obstetric (OB) Medical Home program that incentivizes optimal OB care with early data suggesting that infant birthweights have increased significantly. Ohio initiated an alternate payment model for home visiting and maternal/infant support.
In many of these innovation programs, the Medicaid medical directors noted persistent reimbursement issues, many of which remain unsolved. States that did not expand Medicaid demonstrated even larger access disparities and are currently exploring resourceful approaches to improve outcomes, including analysis of mining data and mortality and the development of maternal medical homes. Wyoming is leveraging surveys and screening tools, one of which is to screen for maternal depression. South Dakota received a grant to develop a state violent death review committee, which incorporates maternal and infant/child mortality review. To track deaths in the state the committee will be gathering data from participating hospital systems. They are also implementing a Centers for Disease Control and Prevention (CDC) 6|18 collaborative program in conjunction with their Department of Health to decrease tobacco use rates in pregnant and first-year, post-partum women.
Most Medicaid medical directors cited data collection and quality as one of the top priorities for their Medicaid agencies, to identify policy gaps. Additionally, many states are looking to ensure women have access to long active reproductive contraception (LARC) through efforts such as unbundling them from current payment approaches. Montana is promoting the use of effective methods of birth control by allowing LARCs to be unbundled at time of delivery, requesting federally qualified health centers and rural health clinics to be paid outside of their prospective payment system rate for LARCs, and removing restrictions to birth control access, such as the former limit on the number of LARCs a women can have over her reproductive lifetime. Increasing the use of LARC and other effective contraception can reduce unwanted pregnancies and increase birthing intervals. In addition, some states, such as Delaware, concerned with high rates of post-partum maternal morbidity, are looking to expand coverage for 180 days post-partum and implement standard trauma and depression screenings at well-baby visits. A recent Health Affairs blog post discussed how post-partum enrollment is a solution to combatting mortality rates. The pending Helping MOMS Act of 2019 would give states the option of extending coverage for pregnant women over a one-year postpartum enrollment period, which would reduce maternal morbidity, depression, and mortality.
Most Medicaid medical directors are also involved in their state perinatal quality collaboratives (PQCs) and Maternal Mortality Review Committees (MMRCs), or are establishing one in their state. MMRCs are the primary data source detailing pregnancy-associated and pregnancy-related death. There are 38 states and two cities with MMRCs, so making MMRCs obligatory could help with data collection. In addition, PQCs are state and multistate networks with many supported by the CDC that work to improve infant and maternal health by translating data and implementing evidence-based clinical practices.
Where Do We Go From Here?
In addition to various state Medicaid initiatives, there has been a call to action to address this maternal health crisis nationally. Congress enacted the Preventing Maternal Deaths Act of 2018, which aims to support states in their work to sustain the health of mothers during pregnancy, childbirth, and in the postpartum period and eliminate disparities in maternal health outcomes. Specifically, this act will support state and tribal maternal mortality review committees to improve data collection and reporting around maternal mortality. The Health Resources and Services Administration’s Maternal and Child Health Bureau (MCHB) supports at least 21 states and more than 650 hospitals with the Alliance for Innovation on Maternal Health (AIM). AIM currently promotes safe and consistent maternity care through clinical quality improvements and works directly with practitioners in health care facilities that perform approximately 45 percent of all US births. The MCHB currently looks to scale the initiative.
As momentum increases for state and federal policy makers to identify policy solutions, the Medicaid medical directors are focusing on investments in data collection and quality care delivery. States can leverage their MMRC and PQC to understand and identify problems related to mortality rates to assist both Medicaid and public health agencies as well as policy makers. For example, Washington State is working with its MMRC to collect and analyze Medicaid data to help understand the quality of care delivered prior to death, while Pennsylvania’s perinatal quality collaborative focuses on best care practices for women with opioid use disorder and substance-exposed infants.
As states continue to implement health transformation efforts, some will pursue other quality initiatives, including value-based payment models such as patient-centered maternity medical homes, bundled or episode payments, and pay-for-performance approaches to incentivize payers and providers to provide quality, cost-efficient maternal care. As states are addressing this priority, Medicaid medical directors and Medicaid agencies are primed to assist in implementing innovative strategies, standardizing solutions through national guidance and diverse legislation to ensure the safety and well-being of all women and their infants.