Maternal and toddler mortality charges within the U.S. are far greater than these in equally giant and rich international locations, with folks of shade at elevated threat for poor maternal and toddler well being outcomes in comparison with their White friends. Consequently, coverage makers at each the federal and state ranges are more and more specializing in enhancing maternal and toddler well being outcomes and decreasing disparities. On the federal degree, 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 well being as a precedence, and their latest finances proposal contains enhanced efforts to enhance maternal care. The nation’s governors, performing by way of the Nationwide Governors Affiliation, have acknowledged the pressing want for motion releasing the Tackling the Maternal and Toddler Well being Disaster: A Governor’s Playbook in July 2023. Additionally, within the 2023 Medicaid finances survey, performed by KFF and Well being Administration Associates (HMA), almost a 3rd of all responding states talked about initiatives to enhance maternal and youngster well being as a high precedence for the yr forward.
The Medicaid program has potential to affect maternal and toddler well being outcomes because 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 well being outcomes and scale back racial/ethnic well being disparities.
To higher perceive state initiatives to broaden Medicaid protection of those much less generally coated pregnancy-related providers, the twenty third annual Medicaid finances survey, performed by KFF and HMA requested states about methods and challenges in selling entry to “non-traditional pregnancy-related care and providers” and included childbirth schooling lessons, doula providers, residence births, and residential visits by lactation consultants as examples. The finances survey query was restricted to providers that have been individually reimbursed as of July 1, 2023, exterior of a hospital bundled cost 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 through the perinatal interval, together with prenatal care, labor and supply, and postpartum care. These bundled funds don’t usually cowl 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 finances survey.
Forty-eight states (together with DC) responded to the survey, though response charges for particular questions assorted. The total report highlights state motion to broaden being pregnant and postpartum advantages together with doula providers, lactation helps, and residential visiting packages.
What forms 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 not less than 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) by way of a bundled cost.
Doula providers. Doula providers have been essentially the most steadily talked about non-traditional service. Doulas are professionals who help pregnant and postpartum folks by offering quite a lot of providers all through the being pregnant and postpartum interval, together with visits through the prenatal interval, labor teaching and help on the time of supply, and postpartum care and help. Doula providers are linked to extra optimistic supply outcomes, together with reductions in C-sections, untimely deliveries, and size of labor.
Childbirth and/or parenting lessons. There are a selection of education-related help providers that may help pregnant and postpartum people with being pregnant, supply, and childrearing. These embody childbirth schooling lessons, toddler and parenting schooling lessons, and group prenatal care (e.g., Centering Being pregnant group prenatal care). Whereas some states cowl these providers by way of their Medicaid packages, some states provide these providers by way of different public well being packages.
Outpatient lactation helps. Lactation help might be supplied in a number of settings within the postpartum interval, together with within the hospital earlier than discharge, at outpatient visits, or at residence. Many Medicaid enrollees are additionally eligible for WIC, which gives lactation help.
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 legislation, however latest state motion has prolonged Medicaid protection to different midwife suppliers, together with midwives who could also be credentialed to offer childbirth help and providers regardless of not having a proper nursing schooling. States use numerous phrases to discuss with midwives with no nursing diploma, together with licensed midwife, direct entry midwives, licensed lay midwife, licensed midwives, licensed skilled midwives, conventional midwife, and verifiable midwife.
House births. Worldwide research counsel that residence births could also be as secure as hospital births for low-risk pregnant people and infants when they’re a part of an built-in and controlled system. Nonetheless, residence births account for a small share of births within the U.S., though there was rising curiosity because the begin of the COVID-19 pandemic. Doulas, midwives, or physicians could also be in attendance for residence births.
Different providers. Different coated pregnancy-related providers talked about by not less than one state as “non-traditional” embody specialised care administration or care coordination packages, residence 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 certainly one of its 5 targets for addressing the nation’s maternal well being disaster. This aim contains, partly, promotion of doulas, midwives, and group well being employees. Subsequently, CMS introduced the Remodeling Maternal Well being (TMaH) Mannequin in December 2023. The brand new mannequin goals to enhance maternal and toddler well being outcomes and scale back disparities by offering technical help and grant funding to as much as 15 state Medicaid companies. TMaH will assist taking part states enhance entry to care, together with care from doulas and perinatal group well being employees. The Biden Administration’s just lately proposed finances additionally directs greater than $300 million to enhancing maternal well being, together with an extra $5 million to develop and diversify the doula workforce. The proposed finances additionally contains an optionally available Medicaid maternal well being help profit aiming to deal with fairness points in maternal well being outcomes. The profit would come with protection of doulas, group well being employees, and peer help employees. Nonetheless, with a divided Congress, these finances proposals will not be prone to be handed this yr.
What are challenges and methods to broaden entry to non-traditional pregnancy-related providers?
Whereas non-traditional pregnancy-related providers have the potential to enhance maternal well being 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 limitations embody workforce shortages, restrictive supplier coaching/licensure necessities, low reimbursement charges, billing complexities, and amount limitations. The 2023 Medicaid finances 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 not less than one specified class. The next part describes the challenges most steadily 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 companies and managed care organizations (MCOs), state-level supplier licensing boards, and/or personal licensing entities.
Essentially the most steadily 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 acquired state medical board licenses, although many do obtain certifications from personal entities (which can contain vital coaching and value). 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 difficult as it might contain expensive and administratively burdensome coaching requirements. Additionally, midwives can have various ranges of schooling and coaching (as described above) which might impression their skill to fulfill Medicaid enrollment necessities or restrict the settings for which they’ll obtain Medicaid reimbursement, notably those that haven’t acquired nursing levels.
Just a few states talked about initiatives to deal with these challenges: Michigan has developed supplier help supplies, trainings, and toolkit info; Montana reported growing an outreach and schooling plan; New Jersey Medicaid employees are working with MCOs and the New Jersey Division of Well being-funded Doula Studying Collaborative to offer technical help; in Virginia the Division of Well being 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 out to be licensed.
Seventeen states reported workforce scarcity challenges. A number of states reported that broader well being 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 lessons. 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. A number of 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 current doctor/OBGYN shortages.
At the very least 4 states described efforts to extend their doula workforce: New Jersey is working with non-profits, MCOs, and their sister companies 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 Little one Well being 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 will not be 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 companies and MCOs. For instance, Michigan reported that suppliers don’t all the time have the expertise wanted for Medicaid billing and New Jersey reported that doulas will not be 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 help 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 result of disputes between the state and doula organizations over reimbursement charges. Non-traditional suppliers emphasize affected person schooling and help, which signifies that they typically spend in depth time with sufferers, and plenty of have reported that Medicaid charges will not be ample 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, Toddler, and Early Childhood House Visiting (MIECHV) Program; Kansas has plans to extend reimbursement charges for lactation providers, and Wisconsin just lately elevated charges for prenatal care coordination providers.
5 states reported challenges associated to amount limitations on hours or visits for doula providers, childbirth schooling lessons, and/or lactation helps. For instance, whereas Virginia Medicaid at present 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 Neighborhood Well being Employee profit at present 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 start; 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 start to be coated by way of 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 idea of race, ethnicity, and language.
This transient attracts on work accomplished below contract with Well being Administration Associates (HMA). Kathleen Gifford is an professional on state Medicaid packages and a Principal at HMA.
