The Spectrum of State Approaches to Medicaid Maternity Care Contracting.

Policy Points Maternal health is influenced by the quality and accessibility of care before, during, and after pregnancy. Nationwide, Medicaid covers nearly one in two births and uses managed care as a central means for carrying out these responsibilities. Thus, managed care plays a fundamental role in assuring timely, equitable, quality care and improving maternal health outcomes. A close review of managed care contracts makes evident that the absence of a national set of maternal health standards has caused challenges in setting expectations for managed care performance. State Medicaid agencies adopt a variety of approaches and underlying philosophies for contracting. CONTEXT: Managed care is how Medicaid agencies principally furnish maternity care. For this reason, the contracts that Medicaid agencies enter into with managed care organizations have attracted strong interest as a means of improving maternal health access, quality, and equity. However, limited research has documented the extent to which states use these agreements to set binding expectations across the maternal health continuum and how states approach the task of maternal health contracting. METHODS: To explore maternal health contracting within Medicaid Managed Care, this study took a three-phase, sequential approach: (1) an extensive literature review to identify clinical guidelines and expert recommendations regarding maternal health "best practices" for people with elevated health and social needs, (2) a review of the managed care contracts in use across 40 states and Washington, DC, to determine the extent to which they incorporate these best practices, and (3) interviews conducted with four state Medicaid agencies to better understand how states approach maternal health when developing their contracts. FINDINGS: The evidence on maternal health best practices reveals nearly 60 "best practices," although the literature review also underscored the extent to which these recommendations are fragmented across numerous professional bodies and government agencies and are thus difficult for Medicaid agencies to ascertain. The contracts themselves reflect an approach to the maternal health continuum in a fragmented and incomplete way. Thematic analysis of interviews with state Medicaid agencies revealed three key approaches to contracting for maternity care: an "organic" approach, an "intentional" approach, and an approach "grounded" in state strategy. CONCLUSIONS: The absence of comprehensive, integrated guidelines reflecting the full maternal health continuum likely complicates the contracting task and contributes to incomplete, ambiguous contracts. A major step would be the development of a "best practices tool" that helps state Medicaid agencies translate evidence into comprehensive, clear contracting expectations.

Mapping the Location of Health Centers in Relation to "Maternity Care Deserts": Associations With Utilization of Women's Health Providers and Services.

BACKGROUND AND OBJECTIVES: The aim was to explore the association between community health centers' (CHC) distance to a "maternity care desert" (MCD) and utilization of maternity-related health care services, controlling for CHC and county-level factors. MEASURES: Utilization as: total number of CHC visits to obstetrician-gynecologists, certified nurse midwives, family physicians (FP), and nurse practitioners (NP); total number of prenatal care visits and deliveries performed by CHC staff. RESEARCH DESIGN: Cross-sectional design comparing utilization between CHCs close to MCDs and those that were not, using linked 2017 data from the Uniform Data System (UDS), American Hospital Association Survey, and Area Health Resource Files. On the basis of prior research, CHCs close to a "desert" were hypothesized to provide higher numbers of FP and NP visits than obstetrician-gynecologists and certified nurse midwives visits. The sample included 1261 CHCs and all counties in the United States and Puerto Rico (n=3234). RESULTS: Results confirm the hypothesis regarding NP visits but are mixed for FP visits. CHCs close to "deserts" had more NP visits than those that were not. There was also a dose-response effect by MCD classification, with NP visits 3 times higher at CHCs located near areas without any outpatient and inpatient access to maternity care. CONCLUSIONS: CHCs located closer to "deserts" and NPs working at these comprehensive, primary care clinics have an important role to play in providing access to maternity care. More research is needed to determine how best to target resources to these limited access areas.

Choosing between medical management and liver transplant in urea cycle disorders: A conceptual framework for parental treatment decision-making in rare disease.

Urea cycle disorders (UCD) are rare inherited metabolic disorders caused by deficiencies of enzymes and transporters required to convert neurotoxic ammonia into urea. These deficiencies cause elevated blood ammonia, which if untreated may result in death, but even with optimal medical management, often results in recurrent brain damage. There are two major treatments for UCD: medical management or liver transplantation. Both are associated with mortality and morbidity but the evidence comparing outcomes is sparse. Thus, families face a dilemma: should their child be managed medically, or should they undergo a liver transplant? To (a) describe the factors that contribute to treatment choice among parents of children diagnosed with UCD and to (b) organise these factors into a conceptual framework that reflects how these issues interrelate to shape the decision-making experience of this population. Utilising grounded theory, qualitative data were collected through semi-structured interviews with parents (N = 35) and providers (N = 26) of children diagnosed with UCD and parent focus groups (N = 19). Thematic content analysis and selective and axial coding were applied. The framework highlights the life-cycle catalysts that frame families' personal perceptions of risks and benefits and describes the clinical, personal, social, and system factors that drive treatment choice including disease severity, stability, and burden, independence, peer experiences, and cost, coverage and access to quality care. Findings equip providers with evidence upon which to prepare for productive patient interactions about treatment options. They also provide a foundation for the development of patient-centred outcome measures to better evaluate effectiveness of treatments in this population.

Supporting Physical-Behavioral Health Integration Using Medicaid Managed Care Organizations.

This paper describes key findings of two states that sought to integrate physical and behavioral health services by delivering them through one Medicaid managed care contract. The purpose was to explore how managed care organizations (MCOs) could improve physical and behavioral health integration. Promising practices include leveraging data accumulated by MCOs about beneficiaries to support providers and enhanced case management, encouraging MCOs to pay providers for care coordination and care collocation, and offering protections to providers and beneficiaries. Finally, in the absence of a shared vision among key stakeholders regarding how to best promote integrated care, a state can make progress by promoting stakeholder innovation.

Predicting the Impact of Transforming the Medicaid Program on Health Centers' Revenues and Capacity to Serve Medically Underserved Communities.

Policy Points Recent federal proposals to use block grants or per capita caps to fund Medicaid would likely lead to cuts in Medicaid funding for health centers, which are an important source of care for Medicaid enrollees. Recent Medicaid §1115 waivers are seeking to change state-level enrollment and eligibility requirements in ways that are expected to adversely affect health center revenues. Proposed Medicaid funding cuts are expected to lead to reductions in service capacity across all health centers over the long term. State policymakers should understand the likely impacts of proposed Medicaid program changes on health centers in their states and allocate funding to help offset lost federal financing. CONTEXT: In 2017, Congress considered implementing block grants or per capita caps to significantly reduce federal financing of the Medicaid program. Medicaid plays a key role in supporting health centers in their provision of care to patients with Medicaid coverage. Consequently, changes to the program could have serious implications for health centers and their ability to fulfill their mission. METHODS: We used a mixed-methods approach to (a) test a model simulating the effect of block grants and per capita caps on health centers' total revenues and general service capacity, and (b) augment model assumptions by using information collected from official Medicaid documents and interviews with health center leadership staff. Data came from the Uniform Data Systems (UDS), state- and county-level population projections, structured analyses of waiver documents, and interviews with health center leaders in seven states with approved or pending Medicaid §1115 waivers. FINDINGS: By 2024, in states where Medicaid coverage was expanded under the Affordable Care Act, block grant funding for Medicaid would decrease total health center revenues for the expansion population by 92%, and by 58% for traditional enrollees. In nonexpansion states, block grants would decrease health center revenues for traditional Medicaid enrollees by 38%. In expansion states, a per capita cap would, by 2024, decrease health center revenues for the expansion population by 78%, and for traditional Medicaid enrollees by 3%. The per capita cap would reduce health center revenues for traditional Medicaid enrollees in nonexpansion states by 2%. Eliminating the Medicaid expansion population would not fully compensate for health center revenue deficits in expansion states. Health center executives in all sample states expressed significant uncertainty around federal plans to reduce Medicaid funding as well as the financial implications of §1115 waiver requirements. Many interviewees anticipate cutting back on services and/or staff as a result. CONCLUSIONS: Both block grants and per capita caps would have a detrimental effect on health centers. Although health center leaders anticipate a reduction in services and/or staff, the uncertainty around federal and state proposals hinders health centers from making concrete strategic plans. States should prioritize communicating changes to health centers in a timely manner and be prepared to set aside dedicated funding to address anticipated shortfalls.

Maternity Leave Access and Health: A Systematic Narrative Review and Conceptual Framework Development.

Background Maternity leave is integral to postpartum maternal and child health, providing necessary time to heal and bond following birth. However, the relationship between maternity leave and health outcomes has not been formally and comprehensively assessed to guide public health research and policy in this area. This review aims to address this gap by investigating both the correlates of maternity leave utilization in the US and the related health benefits for mother and child. Methods We searched the peer-reviewed scholarly literature using six databases for the years 1990 to early 2015 and identified 37 studies to be included in the review. We extracted key data for each of the included studies and assessed study quality using the "Weight of the Evidence" approach. Results The literature generally confirms a positive, though limited correlation between maternity leave coverage and utilization. Likewise, longer maternity leaves are associated with improved breastfeeding intentions and rates of initiation, duration and predominance as well as improved maternal mental health and early childhood outcomes. However, the literature points to important disparities in access to maternity leave that carry over into health outcomes, such as breastfeeding. Synthesis We present a conceptual framework synthesizing what is known to date related to maternity leave access and health outcomes.

The Influence of Social Determinants on Cancer Screening in a Medicaid Sample.

INTRODUCTION: Little attention has been paid to the influence of individually measured social determinants of health on cancer screening tests in the Medicaid population. METHODS: Analysis was conducted on 2015-2020 claims data from a subgroup of Medicaid enrollees from the District of Columbia Medicaid Cohort Study (N=8,943) who were eligible for colorectal (n=2,131), breast (n=1,156), and cervical cancer (n= 5,068) screening. Participants were grouped into four distinct social determinants of health groups on the basis of their responses to social determinants of health questionnaire. This study estimated the influence of the four social determinants of health groups on the receipt of each screening test using log-binomial regression adjusted for demographics, illness severity, and neighborhood-level deprivation. RESULTS: The receipt of cancer screening tests was 42%, 58%, and 66% for colorectal, cervical, and breast cancer, respectively. Those in the most disadvantaged social determinants of health group were less likely to receive a colonoscopy/sigmoidoscopy than those in the least disadvantaged one (adjusted RR=0.70, 95% CI=0.54, 0.92). The pattern for mammograms and Pap smears was similar (adjusted RR=0.94, 95% CI=0.80, 1.11 and adjusted RR=0.90, 95% CI=0.81, 1.00, respectively). In contrast, participants in the most disadvantaged social determinants of health group were more likely to receive fecal occult blood test than those in the least disadvantaged one (adjusted RR=1.52, 95% CI=1.09, 2.12). CONCLUSIONS: Severe social determinants of health measured at the individual level are associated with lower cancer preventive screening. A targeted approach that addresses the social and economic adversities that affect cancer screening could result in higher preventive screening rates in this Medicaid population.

Financial impacts of the Medicaid expansion on community health centers.

OBJECTIVE: To determine the impacts of the Medicaid expansion on revenues, costs, assets, and liabilities of federally funded community health centers. DATA SOURCES: We combined data from the Uniform Data System, Internal Revenue Service nonprofit tax returns, and county-level characteristics from the Census Bureau. Our final dataset included 5841 center-year observations. STUDY DESIGN: We used difference-in-differences model to estimate the fiscal impacts of the Medicaid expansion on community health centers. We employed event study models, state-specific trend models, and placebo law tests as robustness checks. DATA COLLECTION METHODS: Not applicable. PRINCIPAL FINDINGS: On the revenue side, we found a $2.08 million relative increase (p = 0.002) in Medicaid revenues, offset by a $0.44 million decrease (p = 0.015) in total grants among community health centers in expansion states compared with centers in non-expansion states. On the expenditure side, we found a large but not statistically significant $0.98 million relative increase (p = 0.201) in total expenditures among centers in expansion states. Uncompensated care for health centers in expansion states decreased by $1.19 million (p < 0.001) relative to their counterparts in non-expansion states. CONCLUSIONS: Community health centers in expansion states benefited from the increased, stable revenue stream from Medicaid expansions. While Medicaid revenue increased as a result of the policy, we find no major evidence of substitution away from other revenue lines, with one notable exception (i.e., substitution away from state and local government grants). From a policy perspective, these results are encouraging as the Biden Administration starts to implement the safety-net enhancements from the American Rescue Plan Act of 2021 and as more non-expansion states are considering opting into Medicaid expansions. It is anticipated that these added revenue streams will help to sustain health centers in the delivery of health care services to the underserved population.

Community Health Centers' Practices, Barriers, and Facilitators for Providing a 1-Year Supply of Oral Contraception on Site.

INTRODUCTION: High-quality family planning services help women to achieve their preferred family size and birth spacing, which in turn leads to improved health outcomes and better quality of life. This study investigates whether women have access to a 1-year supply of oral contraceptives (OCs) on site when they receive care at community health centers and whether states require coverage for a 1-year supply. METHODS: This study used a concurrent, mixed-methods approach, with a single phase of quantitative research (survey of health centers) and two phases of qualitative research (50-state policy environment scan and in-depth interviews). RESULTS: Only three states require coverage for a 1-year supply of OCs under all Medicaid and private insurance coverage mechanisms; the majority of states limit it through at least one mechanism. The survey found that 50.9% of health centers provided OCs on site, and of these, only 29.9% offered up to a 1-year supply at a time. An analysis of interviews revealed that clinician and pharmacist preferences and the organization's overall approach to family planning played a role in these practices. CONCLUSION: This study finds that that only a minority of health centers provide a 1-year supply on site and that a minority of states have rules requiring coverage for a 1-year supply of OCs. To remedy these gaps, change is needed at multiple levels, including health center practices, clinician knowledge and beliefs, federal agency guidance, and state-level insurance policy.

An Analysis of Payment Mix Patterns of Preterm Births in a Post-Affordable Care Act Insurance Market: Implications for the Medicaid Program.

BACKGROUND: The United States has a relatively high preterm birth rate compared with other developed nations. Before the enactment of the Affordable Care Act in 2010, many women at risk of a preterm birth were not able to access affordable health insurance or a wide array of preventive and maternity care services needed before, during, and after pregnancy. The various health insurance market reforms and coverage expansions contained in the Affordable Care Act sought in part to address these problems. This analysis aims to describe changes in the patterns of payer mix of preterm births in the context of a post-Affordable Care Act insurance market, explore possible factors for the observed changes, and discuss some of the implications for the Medicaid program. METHODS: We applied a repeated cross-sectional study design to explore payment mix patterns of all births and preterm births between 2011 and 2016, using publicly available National Vital Statistics Birth Data. We included an equal number of years with payment source available in the dataset before and after January 1, 2014, when the coverage expansions became effective. RESULTS: We found a small relative change in payment mix during the study period. Private health insurance (PHI) paid for a higher percentage of all births and this rate increased steadily between 2011 and 2016. Preterm births paid by PHI increased by 1.4 percentage points between 2011 and 2016 and self-pay/uninsured preterm births decreased by 0.3 percentage points over the same time period. Medicaid had the highest, and a relatively stable, preterm birth coverage percentage (48.9% in 2011, 49.2% in 2014, and 48.9% in 2016). Medicaid was also more likely to pay for preterm births than PHI, but this likelihood decreased by more than one-half after 2014 (8.2% in 2013 vs. 3.8% in 2014). CONCLUSIONS: After the 2010 reforms, Medicaid remained a constant source of coverage for the most vulnerable women in society when faced with the high cost of a preterm birth. Nationwide, of the 64 million women ages 15 to 44, 4% gained PHI (directly purchased or employer sponsored) and another 4% Medicaid, with a concomitant 8% decrease in uninsured women of reproductive age between 2013 and 2017. More research is needed to conclude with certainty that the reforms worked as intended, but the important role of Medicaid as a financial safety net is undeniable.

Adoption of health center performance measures and national benchmarks.

This study examines the adaptability of standardized performance measurement tools in 3 community-based health centers. Although health centers have considerable experience in the area of performance reporting, they do not currently participate in a national reporting system that is transparent and standardized. The analysis of the data collected from health centers indicates that not only can these safety net providers readily integrate standardized measures, the quality of care being provided compare favorably to national benchmarks. With evidence of solid performance may come the types of financial adjustments essential to permitting health centers to move more decisively into the broader private health insurance markets that may exist in their service areas.

Cost-effectiveness of an Evidence-Based Childhood Asthma Intervention in Real-World Primary Care Settings.

We present an incremental cost-effectiveness analysis of an evidence-based childhood asthma intervention (Community Healthcare for Asthma Management and Prevention of Symptoms [CHAMPS]) to usual management of childhood asthma in community health centers. Data used in the analysis include household surveys, Medicaid insurance claims, and community health center expenditure reports. We combined our incremental cost-effectiveness analysis with a difference-in-differences multivariate regression framework. We found that CHAMPS reduced symptom days by 29.75 days per child-year and was cost-effective (incremental cost-effectiveness ratio: $28.76 per symptom-free days). Most of the benefits were due to reductions in direct medical costs. Indirect benefits from increased household productivity were relatively small.

Effectiveness of Evidence-Based Asthma Interventions.

BACKGROUND AND OBJECTIVES: Researchers often struggle with the gap between efficacy and effectiveness in clinical research. To bridge this gap, the Community Healthcare for Asthma Management and Prevention of Symptoms (CHAMPS) study adapted an efficacious, randomized controlled trial that resulted in evidence-based asthma interventions in community health centers. METHODS: Children (aged 5-12 years; N = 590) with moderate to severe asthma were enrolled from 3 intervention and 3 geographically/capacity-matched control sites in high-risk, low-income communities located in Arizona, Michigan, and Puerto Rico. The asthma intervention was tailored to the participant's allergen sensitivity and exposure, and it comprised 4 visits over the course of 1 year. Study visits were documented and monitored prospectively via electronic data capture. Asthma symptoms and health care utilization were evaluated at baseline, and at 6 and 12 months. RESULTS: A total of 314 intervention children and 276 control children were enrolled in the study. Allergen sensitivity testing (96%) and home environmental assessments (89%) were performed on the majority of intervention children. Overall study activity completion (eg, intervention visits, clinical assessments) was 70%. Overall and individual site participant symptom days in the previous 4 weeks were significantly reduced compared with control findings (control, change of -2.28; intervention, change of -3.27; difference, -0.99; P < .001), and this result was consistent with changes found in the rigorous evidence-based interventions. CONCLUSIONS: Evidence-based interventions can be successfully adapted into primary care settings that serve impoverished, high-risk populations, reducing the morbidity of asthma in these high-need populations.

State purchasing and enforcement quality care for children in Medicaid and SCHIP managed care.

State Medicaid/Children's Health Insurance Program (SCHIP) agencies play pivotal roles in ensuring that participating health plans provide quality care. In 2003, researchers interviewed SCHIP officials with oversight responsibilities in nine states and found that all agencies had formal monitoring procedures and that all of them regularly collected data that measured health plans' compliance with quantifiable standards. Several states designed a graduated incentive and penalty system, which they believed favored compliance. Many agencies also stressed the need for collaboration with participating plans, because of underlying systemic barriers. None of the surveyed states considered their contractual agreements with health plans as all-encompassing on quality improvement, which underscores the importance of additional, noncontractual strategies to improve the quality of care. The survey found a disparity between state expectations for health plan performance and the realities of the delivery system, including the priorities of health plans and providers. The sample states were good monitors who enforced general contractual standards of pediatric quality of care; however, one shortcoming was found. Few of the surveyed states focused on oral disease or lead poisoning as part of their overall quality improvement efforts.

Defining and determining medical necessity in Medicaid managed care.

OBJECTIVES: In 2013, the American Academy of Pediatrics published a policy statement calling for pediatricians to be informed about the need for specific pediatric medical necessity language because children deserve "the intent embedded in Medicaid." This study aims to explore the definitions and determinations of medical necessity in Medicaid Managed Care (MMC), document the relevant language used throughout Medicaid, and investigate whether the federal standard of medical necessity for children is replicated in related state documents. METHODS: We conducted a desk review of state statutes, model MMC contracts, and 2 provider manuals per state, for 33 states with a full-risk MMC model. RESULTS: The federal "to correct and ameliorate" standard was replicated in 100% of state regulations, 72% of MMC model contracts (n = 13 of 18 MMC model contracts available online), and 54% of provider manuals (n = 30 of 56 available and sampled online). Only 9 states had an explicit "preventive" pediatric medical necessity standard in their state regulations that exemplified "the intent imbedded in Medicaid." CONCLUSIONS: The federal medical necessity standard for children is not replicated consistently within MMC programs from the state, to health plans, to network providers. Although the majority of the documents reviewed included the standard, the presence of the standard decreased by almost half between state-level and network-provider-level regulations. Having a single, explicitly defined pediatric medical necessity definition replicated at all levels of the health system would reduce confusion and increase the ability of pediatricians to apply the standard more uniformly.

Medicaid covered births, 2008 through 2010, in the context of the implementation of health reform.

BACKGROUND: Medicaid is a major source of public health care financing for pregnant women and deliveries in the United States. Starting in 2014, some states will extend Medicaid to thousands of previously uninsured, low-income women. Given this changing landscape, it is important to have a baseline of current levels of Medicaid financing for births in each state. This article aims to 1) provide up-to-date, multiyear data for all states, the District of Columbia, and Puerto Rico and 2) summarize issues of data comparability in view of increased interest in program performance and impact assessment. METHODS: We collected 2008-2010 data on Medicaid births from individual state contacts during the winter of 2012-2013, systematically documenting sources and challenges. FINDINGS: In 2010, Medicaid financed 45% of all births, an increase of 4% [corrected] in the proportion of all births covered by Medicaid in 2008. Percentages varied among states. Numerous data challenges were found. CONCLUSIONS/IMPLICATIONS FOR RESEARCH AND POLICY: Consistent adoption of the 2003 birth certificate in all states would allow the National Center for Health Statistics Natality Detail dataset to serve as a nationally representative source of data for the financing of births in the United States. As states expand coverage to low-income women, women of childbearing age will be able to obtain coverage before and between pregnancies, allowing for access to services that could improve their overall and reproductive health, as well as birth outcomes. Improved birth outcomes could translate into substantial cost savings, because the costs associated with preterm births are estimated to be 10 times greater than those for full-term births.

Medicaid Statistical Information System (MSIS): a data source for quality reporting for Medicaid and the Children's Health Insurance Program (CHIP).

Section 401 of the Children's Health Insurance Program Reauthorization Act of 2009 (CHIPRA) requires the Department of Health and Human Services (HHS) to identify and publish healthcare quality measures for children enrolled in the Children's Health Insurance Program (CHIP) or Medicaid. CHIPRA also requires core measures to identify disparities by race and ethnicity, among other factors. State Medicaid and CHIP programs are currently facing significant budgetary pressures that are likely to increase with eligibility expansions and programmatic changes resulting from the Patient Protection and Affordable Care Act (PPACA). To limit the burden on states and increase the likelihood of states' voluntarily reporting on core pediatric quality measures, HHS may consider utilizing existing data sources. This article examines the feasibility of utilizing Medicaid Statistical Information System (MSIS) data to identify and analyze the core children's healthcare quality measures required by CHIPRA. Five key themes related to the feasibility of using MSIS as a data source for quality measures are identified: states have significant experience with data collection, performance measurement, and quality oversight for children in Medicaid and CHIP; CHIPRA provisions related to reporting of quality measures will be implemented at a time when states are facing major fiscal constraints; MSIS provides potential opportunities as it offers a rich source of data, but the difficulties in obtaining clean data should not be underestimated; MSIS has limitations; and states, the federal government, providers, and enrollees benefit from standardization in data and quality measurement.