12/20/22: Insights from State Strategies to Improve Maternal Health and Promote Health Equity

View the slides here and the recording here.

***

Heather Howard set the stage by sharing background on Medicaid’s role in maternal health. Medicaid accounts for 75 percent of all public expenditures for family planning services and covers close to half of all births nationally. Further Medicaid/CHIP play a key role in health care for pregnant and postpartum people of color, covering the majority of births among Black, American Indian/Alaskan Native and Latino(a) people. While Medicaid plays an enormous role, however, what is sometimes forgotten is that, the work of improving maternal health outcomes is also a significant focus of other state and federal agencies including public health departments, maternal and child health programs, and managed care organizations. The siloed nature of government agencies has led to fragmentation and disconnect within the system; thus one of the focus areas for SHVS is to identify strategies that will build stronger partnerships and learning collaboratives across federal and state government agencies.

In September, SHVS held a roundtable with five states that are innovating in the area of maternal health – California, Louisiana, Maryland, Minnesota, Tennessee – and the Center for Medicare and Medicaid Innovation (CMMI). Despite political and geographical differences across the states, all shared the same concern of the high rates of maternal health deaths due to overdose, mental illness, obesity, and traffic accidents. All states were eager to explore ways in which they could more effectively leverage not only Medicaid, but other public health funding streams, to expand access to diverse provider types such as doulas, peer support providers, and midwives.

Dr. Linda Elam shared the compendium developed by SHVS and Manatt Health, which is designed to offer a one-stop-shop for all activities relating to maternal health at the state level. The document is bucketed into four areas of state work:

• Maternal health models, including care delivery and payment models
• Quality Improvement, including maternal mortality review committees and QI initiatives
• Workforce and benefits, including reimbursement for improved outcomes and addressing racism in the workforce
• Eligibility and enrollment

The full document can be accessed here: https://www.shvs.org/resource/state-strategies-to-improve-maternal-health-and-promote-health-equity-compendium/.

The following serves as a summary of the discussion that followed the presentation:

• One participant asked if there are any state initiatives underway to address the silos between Medicaid and other departments and agencies that are funding maternal health initiatives.
  • Linda shared that it comes down to leadership. Strong leadership – such as that displayed by New Jersey First Lady Tammy Murphy or DC Mayor Muriel Bowser, both of whom have come out as strong advocates for maternal health – is critical for driving this work.
  • Heather shared that states with the Medicaid and public health departments in the same agency are more naturally geared toward collaboration.
• Another participant highlighted how important it is to build maternal health models that are designed and delivered by community members. The member queried if SHVS thought about this perspective in their work.
  • Heather shared that they are beginning to think about that. Virginia and Colorado both facilitate Medicaid member experience committees which could be a model for better understanding the community perspective. While these states’ committees are not specifically focused on maternal health, their experiences could provide best practices for the future.
• A participant noticed that Louisiana is opting not to pay for early-elective C-sections under Medicaid and was curious about reactions from hospitals in the state.
  • Linda and Heather did not know of any reactions from Louisiana specifically. They shared that both New Jersey and South Carolina have opted not to cover early elective C-sections under Medicaid, and this policy has been met with limited pushback. Using data to paint the picture is an effective tool.
• One participant asked about the accepted standard rate for C-sections, and if an algorithm could be developed to determine the necessity of a C-section.
  • The national target for C-sections is below 23 percent.
  • Other members clarified that there is a distinction between early elective C-section rates and NSTV C-section rates. Data supports early elective C-sections being unnecessary, which makes it easier to disincentivize those specifically as a practice. NTSV C-sections may be clinically necessary and therefore are more difficult to develop non-payment policies around.
• Another member brought up the importance of reimbursing for midwifery care at 100 percent of the Physician Fee Schedule. Although nurse midwifery is mandated through Medicaid, only 17 states pay at 100 percent of the fee schedule. They also pointed to the need to remove disincentives around midwifery care.
• A member shared in the chat that while reducing c-section rates is important, there will not be one magic solution to the maternal health crisis. Medicaid paying for longer visits with pregnant individuals, covering behavioral health providers and providing greater access to mental health for pregnant individuals, and using midwives and paying them fairly, are all important strategies as well.
• Last, a participant shared that bundles are moving in the direction of providing holistic care that encompasses community-based care. Insurance companies are working to develop episodes that provide meaningful data and tools to close gaps in maternal health outcomes.