5/17/22: Embedding Health Equity in Medicaid Managed Care

In this month’s Maternal Health Hub Learning Community session on embedding health equity into Medicaid Managed Care Organization (MCO) contracts we heard from Dr. Nathan Chomilo (Medical Director for Medicaid and MinnesotaCare, Minnesota Department of Human Services), Patty Graham (Senior Quality Consultant at Health Partners), Vanessa Kittelson (Senior Quality Management Specialist at Hennepin Health), and Diana Crumley (Senior Program Officer, Center for Health Care Strategies).

View the recording here.

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Dr. Nathan Chomilo shared the initiatives at the Minnesota Department of Health related to health equity and maternity care. One of these is within the context of the state’s Integrated Health Partnership System, a partnership between providers and the state to improve the quality, and lower the cost, of care for Medicaid and MinnesotaCare enrollees. Through value-based contracting and incentives to improve delivery innovation, Integrated Health Partners (IHP) have flexibility to address their community’s needs. The Department of Human Services (DHS) acts as a facilitative partner by providing data analytics, reports, and ad hoc support to the IHP.

Several IHP interventions relate to maternal health: the access to care OB program, which focuses on providing parenting education to pregnant youth ages 11-24; and the First Step Collaborative, which provides interventions to expectant mothers and mothers with young children at high risk. Dr. Chomilo shared that these programs are evaluated using traditional quantitative metrics and a mixed methods evaluation looking at the process, scale and scope, and impact of the program.

Dr. Chomilo also spoke about how Minnesota is addressing health equity and anti-racism training in their RFPs for contracting with Medicaid Managed Care Organizations (MCOs).  The RFP now includes requirements that MCOs seeking to contract with Minnesota include their plans for addressing structural racism, using value-based purchasing to improve racial equity, and addressing social determinants of health (SDOH). One RFP question specifically requires the plan to discuss its strategies to address bias in maternity care.

This year, Minnesota DHS also included prenatal and postpartum care quality withholds in RFP contracts. In an effort to demonstrate a withhold related to decreasing disparities, the agency established prenatal and postpartum care quality withholds for 2022. The withhold measures include the timeliness of prenatal care (% of deliveries that received prenatal care visit in first trimester and postpartum care (% of deliveries that had postpartum visit on or between 7 and 84 days after delivery). Dr. Chomilo shared that these measures were chosen because they will push systems to change while being relatively easy to capture.

Patty Graham and Vanessa Kittelson shared the Medicaid MCO perspective on embedding health equity into RFPs. In Minnesota, the state and MCOs work together on Performance Improvement Projects (PIPs). The current PIP is Healthy Start for Mothers and their Children. Under this project, each MCO develops their own plan to improve outcomes for this population, and then the MCOs and state meet biweekly to discuss the various initiatives.

Currently, the MCOs in the state are working collaboratively to improve culturally congruent doula care for Medicaid members through improving access to Indigenous and Black centered programs. The MCOs and state are working together to develop a framework for certification, and then – with the help of community advocates – will look to specific curricula that aligns with this framework to recommend for approval. While Minnesota Medicaid does reimburse for doulas, Vanessa and Patty both acknowledge the challenges with low reimbursement and high certification costs, and how these impact access to a diverse doula community.

Each MCO also focuses on their own initiatives to target the PIP. Vanessa shared Hennepin Health’s work using prenatal peer support groups for minority communities, as well as clinical outreach in underserved areas through a mobile unit. Patty shared Health Partner’s implementation of analytics that flag when a member searches pregnancy related topics in their EHR, to alert the system to pregnancy as early as possible. Health Partners also provides grants to doula programs to cover certification and registration costs, as well as increased funding of doulas serving their Medicaid population.

One learning community member asked about collecting Race, Ethnicity, and Language data to use as a base for measurement. Patty shared that it has been a challenge to gather the needed data, but DHS has done work to impute data from other sources and share it with the health plans.

Another member asked about the plans’ efforts to make lactation support more accessible. Patty shared that Health Partners is involved with the MN Breastfeeding Coalition, all of their doulas are certified lactation consultants, and that the WIC program provides valuable support to low-income birthing individuals. Vanessa shared that the Strong Black Babies project in St. Paul recently released free downloadable posters and books to support breastfeeding in the Black community.

Diana Crumley shared CHCS’s recent toolkit highlighting how states are advancing primary care through Medicaid MCO contracts. Specifically, she spoke to the health equity chapter, which focuses on states employing four domains to address health equity: procurement, program planning, payment for providers, and payment for payers.

• Louisiana provides an example of procurement, as the state assesses an MCO’s health equity strategy through the RFP. Questions in the RFP require the plans to describe their strategies to improve pregnancy and birth outcomes for Black populations, data collection, community engagement, and their goals for value-based payment.
• Through their release of their Comprehensive Quality Strategy, California exemplifies the program planning component. The strategy includes goals on data collection and stratification, workforce diversity and cultural responsiveness, and reducing health care disparities. Under reducing disparities, the state has set bold goals around maternity care, including to reduce 50% of maternity care disparities in Black and Native American populations and increase maternal depression screening by 50%.
• Using payments to providers, Pennsylvania targets improving health equity. In their maternity care bundled payment, there is a health equity score (determined by providers reaching a certain percentile for the Black community) that informs the percentage of shared savings earned.
• Michigan provides an example of addressing health equity through payment to plans. Michigan has a multi-year pay for performance initiative to address birth weight, with a focus on decreasing disparities. Under this initiative, MCOs are expected to conduct literature reviews, perform analysis to identify disparities, and more.

Chat Questions:

Question: Did you have any push back from the MCOs on asking how they are addressing structural racism?

• The only questions I’ve fielded have been among plans who have less racial diversity among their members, wanting to know how to apply a racial equity focus. Overall I’ve heard appreciation for the focus on health equity through the lens of racial equity and specific areas like maternal health, early childhood and behavioral health.

Question: I’m curious how the plans are thinking about introducing measures that assess experiences of racism and discrimination.

• We have included questions around experiences of discrimination as well as proxies for that like showing up to clinic and being told they were too late to be seen in our CAHPS surveys.

Question: Please give an example race specific programs other than doulas?

• Here is the ICHRP program that is focused on African-American and Native American birthing persons and their communities – https://mn.gov/dhs/partners-and-providers/news-initiatives-reports-workgroups/minnesota-health-care-programs/integrated-care-high-risk-pregnancies/#:~:text=The%20Integrated%20Care%20for%20High%20Risk%20Pregnancies%20(ICHRP)%20initiative%20sponsored,by%20sharing%20services%20and%20knowledge

Question: In regards to giving grants to community doula programs, is the grant process competitive? A formal RFP? What are the amounts of the grants on average?

• Our ICHRP grant program has around $1.75 annually in our base budget, grants are distributed through a competitive RFP and awarded to perinatal care coalitions that work within specific geographic areas and with communities experiencing disparities in preterm birth and low birth weight which in MN are our African American and American Indian/Indigenous communities.

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