Improving Maternal Health Access, Coverage, and Outcomes in Medicaid A Resource for State Medicaid Agencies and Medicaid Managed Care Organizations Preface Shortly after this project was completed, the first cases of COVID-19 in the United States were reported. As we go to press, the pandemic is bringing to the forefront the very issues this project was designed to address; never could we have anticipated such a need for attention to maternal health policy in Medicaid, particularly midwifery-led care at freestanding birth centers. COVID-19 is laying bare existing health inequities, the consequences of lack of health insurance coverage, as well as the limited capacity of existing birth centers, regulatory barriers and restrictive requirements for midwives. This moment presents an opportunity to address these inequities and barriers and fully incorporate the midwifery-led model of care into the Medicaid program. Acknowledgments We are grateful for the community of voices who have guided this project and the expertise, wisdom, and support of the many contributors and reviewers of this report and accompanying resources. The Institute for Medicaid Innovation also thanks the members of the national technical expert panel who helped to guide this project from its inception. Members of the panel challenged us to think beyond the obvious and volunteered their expertise in reviewing draft reports. In addition, we thank the organizations and individuals who responded to the national request for information to identify exemplars in the maternal model of care for Medicaid and who participated in extensive phone and in-person interviews. They included Birth Detroit, Boston Medical Center, Buffalo Prenatal-Perinatal Network, Community of Hope, Dasher Inc., El Rio Birth Center, HealthConnect One, HealthNet Community Doula Program, Mamatoto Village, Mountain Area Health Education Center, Penn Center for Community Health Workers, Roots Community Birth Center, San Francisco Support Sisters, and Uzazi Village. Their dedication to improving maternal and child health outcomes in the Medicaid population has resulted in the development of innovative programs and critical lessons learned that have the potential to assist other Medicaid stakeholders. Technical Expert Panel Members Expert Contributors Brenda Blasingame Zsakeba Henderson, MD Former Executive Director Medical Epidemiologist HealthConnect One National Network of Perinatal Quality Collaboratives Centers for Disease Control Carolyn J. Brooks, ScD, MA Maternal Child Health Program Director Vanessa Lee, MPH UnitedHealthcare Community and State Infant Mortality Collaborative Improvement & Innovation Networks Coordinator and Public Health Analyst Steven Calvin, MD Division of Healthy Start and Perinatal Services Maternal Founder and Medical Director and Child Health Bureau Minnesota Birth Center and the Birth Bundle Health Resources and Services Administration Amy Chen, JD Kacie McLaughlin, MPH Senior Attorney Public Health Analyst National Health Law Program Maternal and Child Health Bureau Health Resources and Services Administration Eugene Declerq, PhD Professor of Community Health Sciences Kimberly Sherman, MPH, MPP Boston University Division of Healthy Start and Perinatal Services Maternal and Child Health Bureau Blair Dudley, MPH Health Resources and Services Administration Senior Manager Transform Maternity Care Pacific Business Group on Health Authors Jordana Frost, DrPH, MPH, CPH, CD(DONA) Jennifer E. Moore, PhD, RN, FAAN Director, Maternal Child Health and Government Affairs Founding Executive Director March of Dimes Primary Investigator Institute for Medicaid Innovation Lisa Kane Low, PhD, CNM, FACNM, FAAN Associate Professor of Nursing and Women’s Studies Karen E. George, MD, MPH, FACOG University of Michigan Senior Women’s Health Fellow Project Director Jere McKinley Institute for Medicaid Innovation Acting Executive Director HealthConnect One Chloe Bakst Health Policy & Research Assistant Pooja Mittal, DO Project Manager Family Physician and Medical Director Institute for Medicaid Innovation HealthNet Karen Shea, MSN, RN Aza Nedhari, CPM, DHSc, MFT Senior Healthcare Management Consultant Founding Executive Director Institute for Medicaid Innovation Mamatoto Village This report was produced with support from the Yellow Chair Foundation. Amy Romano, MBA, MSN, CNM Copyright 2020 Improving Access, Coverage, and Outcomes in Medicaid: A Guide Independent Consultant for State Medicaid Agencies and Medicaid Managed Care Organizations Statement on Gender The Institute for Medicaid Innovation (IMI) recognizes that there are The document uses the pronouns “they/them/theirs” whenever possible individuals who become pregnant and give birth who might not identify in recognition of the gender-diverse population who may be included as women. Individuals who identify as women might also depend on a in maternal care. IMI has attempted to create a resource that is gender- diverse set of health care needs. The following report frequently uses the neutral, limiting gendered language and only using such terms when words “woman,” “women,” and “maternal.” This includes transgender, necessary to conform with language specified in Medicaid requirements, gender non-conforming, and non-binary individuals who might need the statutes/policy language, and cited research and data. IMI hopes to create suite of care services related to pregnancy, birth, and postpartum care. a resource that is inclusive of all individuals in the Medicaid community Also, “maternal care” in this document includes all individuals who require and their diverse health care needs. such services. Table of Contents Executive Summary 7 Coverage of Pregnancy Service in Medicaid 11 Disparities Among Maternal Health Outcomes Challenges in Accessing Pregnancy Services in Medicaid Eligibility and Coverage Gaps Unmet Social Needs Implicit Bias and Racism What is the Midwifery-Led Model of Care? 19 What is the Evidence on the Midwifery-Led Model of Care? Practice Settings 25 Hospital Births Case Study: BMC Birth Center Freestanding Birth Centers Freestanding Birth Center Outcomes in Medicaid Case Study: Birth Detroit Licensure & Scope of Practice 32 Medicaid Billing & Reimbursement 35 Billing and Service Codes Incident to Billing Establishing Reimbursement Rates for Midwifery-Led Care The Influence of Medical Loss Ratios on Reimbursement Equitable Compensation Medicaid Contract Considerations 41 Contracting with Freestanding Birth Centers Contracting Challenges with Freestanding Birth Centers Case Study: Baby and Company Alternative Payment Models 46 Bundled Payment Arrangements Federally Qualified Health Centers Case Study: Community of Hope Birth Center Monitoring & Evaluation 50 Challenges in Quality Measurement Measurement Development & Reporting Developing the Business Case 56 What is a Reasonable ROI? Business Case Scenarios to Consider Essential Elements for a Maternal Health Initiative Business Case 63 Opportunities Engagement in the State Medicaid RFP and Procurement Process Clinical, Research, and Policy Opportunities 70 Appendices Glossary Overview of CNM, CM, and CPM Education Credentialing, and Licensure State Regulations of Midwifery Practice & Medicaid Reimbursement 163 References Executive Summary U nder-utilization of high-value, evidence-based care, such as the midwifery-led model of care, and over-utilization of unnecessary care, such as cesarean deliveries without indication, are gaining attention in the U.S. as the nation attempts to address growing concerns about maternal health. These concerns include rising rates of maternal mortality and morbidity, increased costs of care, poor or even traumatic patient experiences, workforce shortages, and decreases in access to care in some regions of the country. The alarming trends of racial/ethnic, geographic, and socioeconomic disparities are necessitating local, state, and national conversations. These concerns are compounded by increased awareness of the role that unmet social needs, implicit bias, and structural racism have on maternal and infant outcomes. The factors contributing to poor maternal and infant outcomes in the U.S. are extensive and complex. There will not be only one intervention that will address all of these factors. As the nation considers the combination of potential interventions, it is important to fully consider opportunities to implement a high-value, evidence-based maternal model of care such as the midwifery-led model, both in hospitals and in freestanding birth centers. Midwifery-led care might be a means to improve health equity and ultimately, maternal and infant outcomes for pregnant individuals enrolled in Medicaid. Midwife-led continuity of care has been defined as care where “the midwife is the lead professional in the planning, organization, and delivery of care given to a woman from initial booking to the postnatal period.”1 www.MedicaidInnovation.org 8 This report reflects the Institute for Medicaid Innovation’s ambitious national project to answer critical questions that are needed to advance maternal health, specific to the midwifery-led model of care, for the Medicaid population: What is the current evidence on the midwifery-led maternity model of care 1 and freestanding birth centers? Are there differences between Medicaid and commercially insured populations? What are the state variations in access and coverage for the Medicaid 2 population specific to midwifery services and freestanding birth centers? What are the policy barriers by