State Health Policymakers Look to Washington and Each Other to Fight the Opioid Epidemic
In the last two weeks, there has been a flurry of federal and state activity focused on the nation’s opioid epidemic that currently kills more Americans than guns or car accidents.
- In Washington, the President’s Commission on Combating Drug Addiction and the Opioid Crisis released its final report featuring 56 recommendations to stem opioid and substance abuse and improve treatment, followed by a State Medicaid Director Letter from the Centers for Medicare & Medicaid Services (CMS), outlining expanded flexibility for states seeking Section 1115 Waivers to address the problem.
- At the annual National Academy for State Health Policy (NASHP) conference, it was standing room only at a day-long session entitled State Innovations and Interventions in America’s Opioid Crisis. State health officials from across the country shared their new approaches, which ranged from treatment improvements, innovative use of data, and coalition-building between public safety, businesses, and communities to stem the epidemic that claimed more than 64,000 lives in 2016.
| For more details about how states are combatting the opioid crisis, explore NASHP’s State Innovations and Interventions in America’s Opioid Crisis Preconference resource book. |
While it’s unclear whether the Trump Administration will adopt all of the commission’s recommendations, which include additional block grant funding and federal incentives for evidence-based programs, the state Medicaid directors’ letter offered guidance for state officials interested in using Section 1115 Waivers to create innovative or experimental programs that meet the goals of Medicaid. In this case, states could use Section 1115 Waivers to expand or create new prevention and treatment initiatives in order to provide a fuller continuum of services to address opioid use disorders within their states.
Section 1115 of the Social Security Act permits CMS to waive certain federal Medicaid requirements so states have more flexibility to innovate and test new models of care, including providing services and expanding Medicaid in ways not typically permitted under current Medicaid rules. States must show that their initiatives still align with the purposes of the Medicaid program, and their waiver applications can be far-reaching or narrowly tailored, and usually require discussion and negotiation with federal partners.
The recent Medicaid letter reiterates the ability of CMS to waive the restrictive “Institutions for Mental Disease” or IMD exclusion, which would enable state Medicaid programs to receive federal financial participation (FFP) support for those facilities that treat opioid use disorders. The guidance notes that IMD costs do not include room and board unless those settings qualify as inpatient facilities.
Additionally, while states may submit an implementation plan after they apply for the waiver, IMD costs will only be paid prospectively once the plan has been approved. Moreover, interested states will need to demonstrate their ability to make improvements on a number of additional goals and milestones, and, as with other 1115 Waivers, the cost of the waiver initiative must be budget-neutral, and incur no costs beyond what the federal government would otherwise have paid.
States may access technical support and resources from the Innovation Accelerator Program to develop their 1115 Waivers. The administration recently approved its first substance use disorder-focused waiver application from West Virginia, which provides additional insight for states looking to go in this direction.
West Virginia’s 1115 Waiver enables the state to expand its substance use disorder (SUD) treatment to include methadone treatment services, peer recovery support services, withdrawal management services, and short-term residential services to all Medicaid enrollees.
“In implementing the SUD demonstration, West Virginia is delivering SUD services through comprehensive managed care plans for managed care enrollees and introducing new policy, provider and managed care requirements to improve quality of the care delivered to West Virginia Medicaid beneficiaries and to ensure that SUD treatment services are delivered consistent with national treatment guidelines established in the American Society of Addiction Medicine Criteria,” CMS officials wrote in their letter announcing the waiver.
“In addition, West Virginia is taking steps to improve the quality and access to care for West Virginia Medicaid beneficiaries with SUD, such as introducing new care coordination features and collecting and reporting quality and performance measures,” they noted. While obtaining financial support for services in IMD may help support a full continuum of services for SUDs, states are also moving forward with innovative community-based approaches, using other funding and policy levers. Examples from the NASHP preconference include:
- The Drug Free Moms and Babies Program in West Virginia, spearheaded by that state’s Office of Maternal and Child Health. The program is decreasing the presence of illicit substances at delivery through screening and comprehensive care, including long-term follow-up.
- Connecticut’s multi-pronged approach incorporates increased use of medication-assisted treatment in corrections settings, a statewide access line with transportation, and targeted supports in emergency departments to initiate treatment, including recovery coaches.
- Ohio’s Episodes of Care payment model measures share data on opioid prescribing in connection with dental extraction, a common pathway for opioid access.
Federal focus on the opioid crisis is expected to produce tangible supports for state policymakers who are on the frontlines of the opioid epidemic. In the meantime, policymakers attending the NASHP conference concurred that they will continue to serve as the leaders, innovators, and problem-solvers in their battles against this devastating epidemic.
Success Spurs Growth of Medicaid Managed Care for Children with Special Health Care Needs
Two decades ago, the majority of state Medicaid programs that served children and youth with special health care needs (CYSHCN) relied on a traditional, fee-for-service model to pay for the complex mix of health care services that this group of children often need. But as states became more adept at designing new health care delivery programs, they have begun enrolling Medicaid beneficiaries with chronic and complex medical needs into Medicaid managed care (MMC) programs.
Some states are discovering that MMC can provide greater opportunities for coordinating care, controlling costs, and improving health care quality and outcomes for CYSHCN.
To implement these programs, state Medicaid agencies are contracting with managed care organizations (MCOs) to provide care and support services for a set price (per member, per month) with the goal of providing high-quality care at lower costs. These state programs are unique, with each state creatively designing plans to serve specific CYSHCN populations. Knowing what plans and policies states have adopted, outlined in a 50-state scan, provides important insights into national trends and new approaches that states can use to transform their MMC models to serve CYSHCN.
A recent NASHP nationwide analysis found 47 states and Washington, DC, now use some form of managed care to serve all or some children and adults enrolled in Medicaid today. Of the states with managed care delivery systems, all enroll at least some or all of their CYSHCN into some type of Medicaid managed care. Most enrollment is in risk-based managed care, where the MCO assumes financial risk.
NASHP’s issue brief, and 50-state map and chart provide an easy-to-use reference guide to learn what individual states are doing as they redesign health care for their CYSHCN. NASHP’s analysis found that enrollment in MMC varies by state and subpopulation of CYSHCN:
- 42 states enroll children in the Medicaid Aid to the Aged, Blind and Disabled (ABD) category of assistance in MMC;
- 42 states enroll foster care youth in MMC;
- 22 states enroll children who receive Supplemental Security Income (SSI) in MMC; and
- 14 states enroll children in 1915(c) Medicaid waiver programs in MMC.
Most states with MMC enroll CYSHCN on a mandatory basis and serve CYSHCN in standard health plans that serve all Medicaid beneficiaries. A small number of states have developed specialized managed care plans for CYSHCN.
In addition to rapidly expanding MMC, states are also evaluating if this health care delivery model is truly improving the quality of care for Medicaid beneficiaries. Two-thirds of states (33) have incorporated quality measurement requirements specifically for CYSHCN into their managed care contracts to assess how well these systems are serving children’s needs. These and other findings about enrollment of CYSHCN in MMC are summarized in a new issue brief and a 50-State Chart and Map. NASHP has also taken an in-depth look at Medicaid managed care delivery systems for CYSHCN in six states, and state use of Medicaid quality metrics for CYSHCN. These and other resources will be released in the next two
State Medicaid Payment Reform Strategies Promote Improved Birth Outcomes
Improving birth outcomes, including reducing infant mortality, is a priority for state Medicaid agencies that finance nearly half of all births each year. Three states have proven to be creative and effective laboratories in developing initiatives that use Medicaid payment and delivery reform strategies to lower costs, improve access to postpartum care, reward high-quality care, and reduce unnecessary cesarean sections (C-sections).
On average, C-sections financed by Medicaid cost nearly $5,000 more than vaginal births, and the average payment for maternal and newborn care, including neonatal intensive care unit stays, is about $6,100 higher for C-sections than vaginal births. Oklahoma, Tennessee, and Wisconsin, as highlighted in three case studies, employed payment strategies, performance incentives for providers, and quality improvement initiatives to improve birth outcomes and patient experience while reducing overall health care costs.
Earlier this year, the National Academy for State Health Policy (NASHP), in partnership with the National Institute for Children’s Health Quality (NICHQ), conducted a 50-state environmental scan of Medicaid or Children’s Health Insurance Program (CHIP) strategies designed to improve women’s access to high-quality preventive and perinatal care. The scan revealed a number of innovate state payment or delivery reform initiatives, including the three highlighted in the new case studies:
The Oklahoma Health Care Authority created the Cesarean Section (C-section) Quality Initiative to reduce elective C-sections with no medical indication. The initiative is designed to decrease the primary C-section rate performed without medical necessity to 18 percent or less by ensuring providers and hospitals followed best practices when performing C-sections. As of 2016, Oklahoma had reduced the rate of primary C-sections without medical indication to 15.6 percent, resulting in substantial cost savings to the state. Read the case study.
Tennessee’s Department of Human Services’ Division of TennCare (Medicaid) implemented a perinatal episode of care (EOC) payment strategy as part of its overarching Tennessee Health Care Innovation Initiative (THCII). The perinatal EOC focused on women with low- to medium-risk pregnancies and encompasses care provided during the span of the pregnancy, delivery, and postpartum care. This payment strategy is intended to control costs while focusing on patient-centered, high-value health care for pregnant women by rewarding providers who deliver cost-effective, quality care . As a result, Tennessee’s Medicaid program has experienced a 3.4 percent decrease in medical care costs — a total of $4,719,519 — from calendar year (CY) 2014 to CY 2015. Read the case study.
The Wisconsin Department of Health Services, which administers Wisconsin Medicaid, implemented the Obstetric Medical Home (OBMH) program, which targets high-risk pregnant women to reduce birth disparities through effective, comprehensive, coordinated, and quality maternity care. The goal of the OBMH program is to provide holistic care that addresses all health needs of the pregnant patient through care coordination and home visiting. The OBMH program results indicated an improvement in the rate of postpartum care visits from 61.4 percent in 2013 to 85.5 percent in 2015. Postpartum care has the potential to improve outcomes for women and infants, and support ongoing health and well-being. Read the case study.
Federal initiatives like the Collaborative Improvement and Innovation Network to Reduce Infant Mortality (IM CoIIN), led by NICHQ and supported by the Health Resources and Services Administration’s Maternal and Child Health Bureau help to advance state efforts to prevent and reduce infant mortality and eliminate disparities in birth outcomes. These three states are active members in the IM CoIIN. As the Oklahoma, Tennessee, and Wisconsin, case studies demonstrate, Medicaid payment and delivery reform presents an opportunity for cross-agency collaboration to support shared goals of improving maternal and infant health outcomes and reducing costs.
This blog and related publications are joint products of the National Academy for State Health Policy (NASHP) and the National Institute for Children’s Health Quality (NICHQ). This project is supported by the Health Resources and Services Administration (HRSA) of the U.S. Department of Health and Human Services (HHS) (under grant # UF3MC26524, Providing Support for the Collaborative Improvement and Innovation Network (CoIIN) to Reduce Infant Mortality, $2,918,909, no NGO sources).
Wisconsin and Oklahoma Case Studies Show Marked Maternal Health Care Improvements
State Medicaid agencies, which fund half of all births in the United States, are increasingly looking for ways to improve birth outcomes and maternal health while reducing costs by improving medical care and avoiding medically unnecessary cesarean sections. Two case studies from Wisconsin and Oklahoma show how these states successfully improved health care access and quality by creating pregnancy-focused medical homes and developing provider education and incentives to reduce unnecessary C-sections. The studies were developed in partnership with the National Institute for Children’s Health Quality with support from the Health Resources and Services Administration’s Maternal and Child Health Bureau.
Case Study: Oklahoma’s Cesarean Section Quality Initiative Promotes Improved Birth Outcomes
Case Study: Wisconsin’s Obstetric Medical Home Program Promotes Improved Birth Outcomes
Facing Budget Uncertainties, States Seek New Opportunities to Fund Successful Home Visiting Programs
States have a long history of using home visiting programs to deliver cost-effective interventions to vulnerable children and families, and recent federal investments have been instrumental in the expansion of evidence-based home visiting programs across the United States.
Due to budget uncertainties at the state and federal level, states are exploring opportunities to maximize investments through a variety of sources in order to maintain and expand evidence-based home visiting programs. A new National Academy of State Health Policy (NASHP) issue brief, Medicaid Financing of Home Visiting Services for Women, Children, and Their Families, examines existing and emerging Medicaid financing mechanisms that states are using to support home visiting.
Evidence-based home visiting programs provide a comprehensive array of in-home services and supports to families and young children on a voluntary basis, and have been found to promote positive child and family outcomes, such as improved child and maternal health, increased school readiness, improved family economic self-sufficiency, and reductions in child maltreatment.
While the various evidence-based home visiting models vary in intensity and scope, all of them use trained providers, such as nurses, social workers, child development professionals, and other paraprofessionals, to deliver services to young children and families. The services typically include screenings, case management services, and family support and counseling. Additionally, evidence-based home visiting programs that target high-risk families have been shown to save states up to $5.70 for every $1 invested in the long run. These savings result from reduced health services utilization — including emergency department visits — and decreased special education placements and grade repetition, which leads to higher educational attainment and economic success later in life.
States typically use public and private funds, including Medicaid, to support evidence-based home visiting programs. While home visiting is not a mandated or a fully-defined set of services under Medicaid, there are numerous Medicaid financing pathways that states are using to implement, sustain, and expand home visiting programs. The NASHP brief examines these funding pathways, which include targeted case management, Early and Periodic Screening, Diagnostic and Treatment (EPSDT), and 1115 and 1915(b) waivers.
The NASHP brief also explores emerging opportunities to support home visiting as part of state payment and delivery system reform efforts. Several states, including Minnesota and Virginia, have partnered with Medicaid managed care organizations to cover home visiting services through contract requirements or other arrangements. New York is providing funding to support evidence-based programs through its Delivery System Reform Incentive Payment (DSRIP) Waiver program, which is designed to restructure Medicaid’s care delivery system and shift to primarily value-based payments.
To support the comprehensive services, rigorous staff trainings, and development of quality controls that make evidence-based home visiting programs successful, states use an array of federal and state funding sources. This is even more critical given current funding challenges at the state and federal level. Many states are experiencing gaps in their budgets, and a range of programs are facing large funding shortfalls.
In particular, the future of the federal Maternal, Infant, and Early Childhood Home Visiting Program (MIECHV) is uncertain. MIECHV, created by the Affordable Care Act, has provided grants to 50 states, Washington, DC, and five territories to establish or expand evidence-based home visiting programs. MIECHV is currently up for reauthorization in Congress, with funding slated to end Sept. 30, 2017.
Two reauthorization bills have been introduced in the House of Representatives (Home Visiting Works Act of 2017 and Increasing Opportunity through Evidence-Based Home Visiting Act), and the Senate is expected to introduce a MIECHV reauthorization bill on September 19. However, as of mid-September, it is not known if MIECHV’s funding will be reauthorized. States’ ability to use, leverage, and coordinate multiple funding streams, including Medicaid, will be even more critical to the future of this public health intervention.
Medicaid Funding Opportunities in Support of Perinatal Regionalization Systems
Nearly 40 states have a system of risk appropriate perinatal care. A series of new resources explore Medicaid’s role as an important partner in developing perinatal regionalization policies and strategies given its significant investments in a disproportionate share of high-risk births and flexibility in the range and scope of services covered. Case studies of California and Georgia demonstrate how state Medicaid agencies have developed various approaches to support risk appropriate perinatal care. NASHP in partnership with the National Institute for Children’s Health Quality (NICHQ), developed these resources as part of the Health Resources and Services Administration’s Collaborative Improvement and Innovation Network to Reduce Infant Mortality (IM CoIIN).
Additional Resources
Blog post
New issue brief
California Case Study
Georgia Case Study
Interactive Chart
Selected State Initiatives on Medicaid Financing of Perinatal Regionalization
Today, nearly 40 states have a system of risk appropriate perinatal care. As the payer for nearly half of all births nationwide, Medicaid is a key partner in the financing of perinatal regionalization. Medicaid covers specific services that can maximize access to risk-appropriate care for mothers and infants, including the coverage of pre- and post-natal care, delivery, and other services such as transportation. Medicaid coverage of neonatal transportation is a critical component of timely provision of care and overall patient health, specifically for high-risk mothers and infants, and a core element of a comprehensive perinatal regionalization system. This chart includes selected state initiatives and highlights Medicaid as a key partner in financing perinatal regionalization systems.
For more information on Medicaid funding opportunities in support of perinatal regionalization systems, read the blog post and issue brief that further explore Medicaid’s role as an important partner in developing perinatal regionalization policies and strategies given its significant investments in a disproportionate share of high-risk births and flexibility in the range and scope of services covered. Case studies of California and Georgia demonstrate how state Medicaid agencies have developed various approaches to support risk appropriate perinatal care.
This resource was developed by NASHP in partnership with the National Institute for Children’s Health Quality (NICHQ) as part of the Health Resources and Services Administration’s Collaborative Improvement and Innovation Network to Reduce Infant Mortality (IM CoIIN).
| California | The Regional Perinatal Programs of California (RPPC) were established in 1979 due to the need for a more comprehensive network of healthcare providers within specific geographic areas to promote access to high quality levels of maternal and infant care.[ii] Today, the RPPC has divided California into 9 separate regions, each of which include between 18-38 hospitals each.[iii]The California Perinatal Transport Systems (CPeTS) act of 1976 appropriated funds for the development of a dispatch service to facilitate transportation of mother and infants to NICUs.[iv] It also provides collection and analysis of perinatal and neonatal transportation data. |
| Florida | Developed in the 1970’s, Florida’s eleven Regional Perinatal Intensive Care Centers (RPICCs) provide access to high-risk perinatal care and are managed by FL’s Department of Health. Each facility provides community outreach education, and consultative support to other obstetricians and Level II and III NICUs in their areas, in addition to inpatient and outpatient services.[x] |
| Georgia | The Georgia Regional Perinatal Care Network Project (GRPCN) is a statewide initiative funded by the state Medicaid agency and state general funds appropriated to the Georgia Department of Public Health. Georgia’s six regional care centers are designated based on regional need and available funding.[xiii] |
| Illinois[xv] | First adopted in 1976, Title 77 created a perinatal regionalization system through Illinois Administrative code. [xvi] The Illinois Department of Public Health oversees the system and works with a Perinatal Advisory Committee (PAC) that offers recommendations relating to perinatal care. Today, Illinois’ perinatal regionalization system includes 10 administration Perinatal Centers that supervise 122 obstetric hospitals. In additional to a supervisory role, each Regional Perinatal Center has both clinical and administrative responsibilities.[xvii] |
| South Carolina | Established in the 1970’s, South Carolina’s regionalized perinatal system of care, is now made up of five perinatal centers in four regions that contract with the SC Department of Health. Key elements of the system include early risk assessment and referral to appropriate care; coordination and communication between hospitals and community providers; monitoring systems through data; and ensuring access to services from preconception through the first year of life.[xx] |
| California | Medi-Cal works with a variety of different partner programs to ensure coverage and access to services for pregnant women and neonates. These programs include the California Children’s Services Program (CCS),[v] The California Medi-cal Access Program (CMAP),[vi] and the Comprehensive Perinatal Services Program (CPSP).[vii] Through these programs, Medi-cal provides a variety of benefits, but the most notable is reimbursement for transportation services.[viii] |
| Florida | All RPICC Program patients are potential Medicaid Recipients. RPICC Medicaid reimbursement is inclusive for all services provided by the neonatology or obstetrical groups. [xi] The Agency for HealthCare Administration pays claims for inpatient-only services provided to Medicaid recipients by neonatologists and obstetricians enrolled in RPICC with Medicaid funds. |
| Georgia | Georgia Department of Public Health services for Medicaid members include: Perinatal Health Partners (PHP), Perinatal Case management, and Presumptive Eligibility Determination. [xiv] |
| Illinois[xv] | Two main programs offering coverage are available for pregnant women: Medicaid Presumptive Eligibility (MPE) which offers immediate temporary coverage for pregnant women who meet income requirements (outpatient care) and Moms & Babies, which covers healthcare during pregnancy and 60 days post-partum (inpatient, outpatient, and transportation).[xviii] Illinois’ Medicaid managed care plans are required to pay for and ensure the same level of care for pregnant women as in the fee-for-service benefit package. |
| South Carolina | Overall, the ability to link and contract with Medicaid providers has been difficult due to variations in policies and services of the Medicaid managed care plans. [xxi] |
| California | Funding for the RPPC and CPeTS is provided via Federal Title V Maternal and Child Health (MCH) Block Grant Funds.[ix] |
| Florida | The RPICC program is funded through a combination of Federal Title V MCH Block Grant Funds and Medicaid dollars. [xii] |
| Georgia | GRPCN is jointly funded by Georgia Medicaid and the Georgia Department of Public Health. |
| Illinois[xv] | IDPH allocates state funds to target preventative services, and provide grants to designated APCs responsible for the administration and implementation of the perinatal program.[xix] |
| South Carolina | Majority of the funding is through SC Department of Health and Hospitals. Additional funds are provided by the Title V MCH Block Grant.[xxii] |
| California | There is a neonatal transportation policy and it includes maternal transportation. Medicaid reimbursement policy exists for neonatal transportation. |
| Florida | There is a neonatal transportation policy and it includes maternal transportation and inter-hospital transportation. Medicaid reimbursement policy exists for neonatal transportation. |
| Georgia | There is a neonatal transportation policy and it includes maternal transportation, back transportation for infants, and inter-hospital transportation. Medicaid reimbursement policy exists for neonatal transportation. |
| Illinois[xv] | There is a neonatal transportation policy and it includes maternal transportation, back transportation for infants and mothers, and inter-hospital transportation. |
| South Carolina | There is a neonatal transportation policy and it includes maternal transportation, back-transportation for infants, and inter-hospital transportation. |
[i] E. M. Okoroh, C.D. Kroelinger, S.M. Lasswell, D.A. Goodman, A.M. Williams, and W.D. Barfield, “United States and Territorial Policies Supporting Maternal and Neonatal Transfer: Review of Transport and Reimbursement,” Journal of Perinatology 36 (2016):30, doi:10.1038/jp2015.109
[ii] “Regional Perinatal Programs of California Fact Sheet,” California Department of Public Health, Accessed August 24, 2016, https://www.cdph.ca.gov/healthinfo/healthyliving/childfamily/Pages/RPPC.aspx[i] E. M. Okoroh, C.D. Kroelinger, S.M. Lasswell, D.A. Goodman, A.M. Williams, and W.D. Barfield, “United States and Territorial Policies Supporting Maternal and Neonatal Transfer: Review of Transport and Reimbursement,” Journal of Perinatology 36 (2016):30, doi:10.1038/jp2015.109
[iii] California Department of Public Health- Maternal, Child, and Adolescent Health Program – Epidemiology, Assessment, and Program Development Branch, “Regional Perinatal Programs of California (RPPC),” October 2015, https://www.cdph.ca.gov/programs/rppc/Documents/RPPC_Regions_Oct2015.pdf
[iv] California Perinatal Transport System, “California Perinatal Transport System,” Accessed August 24, 2016, https://www.perinatal.org/
[v] California Department of Health Care Services, “Program Overview – California Children’s Services,” Accessed August, 29, 2016, https://www.dhcs.ca.gov/services/ccs/Pages/ProgramOverview.aspx
[vi] California Department of Health Care Services, Medi-Cal Access Program, “What Services are Covered in MCAP?,” Accessed August 24, 2016, https://mcap.dhcs.ca.gov/Services/?lang=en
[vii] County of Los Angeles Public Health, “Comprehensive Perinatal Services Program,” Accessed August 24, 2016, https://publichealth.lacounty.gov/mch/cpsp/CPSPwebpages/cpsp_rev.htm
[viii] “Medical Transportation – Ground,” in: California Code of Regulations, 2015, https://www.google.com/url?sa=t&rct=j&q=&esrc=s&source=web&cd=1&ved=0ahUKEwi7_PmV7trOAhXDHx4KHScUBtkQFggeMAA&url=https%3A%2F%2Ffiles.medi-cal.ca.gov%2Fpubsdoco%2Fpublications%2Fmasters-mtp%2Fpart2%2Fmctrangndcd_a05.doc&usg=AFQjCNFzBYxIjWfYOw5gAKxm32BkzRkHug&sig2=QFlVSnGrnpIL6_Y7Sjbd2Q
[ix] California Department of Public Health, “Maternal and Child Health Services Title V Block Grant – California,” 2015, https://www.cdph.ca.gov/programs/mcah/Documents/Title%20V%202016%20Application%202014%20Report%20final.pdf
[x] Children’s Medical Services (CMS), “Regional Perinatal Intensive Care Centers,” Accessed August 29, 2016, https://www.floridahealth.gov/AlternateSites/CMS-Kids/providers/rpicc.html
[xi]Florida Department of Health, Regional Perinatal Intensive Care Centers Handbook, August 2010, https://www.floridahealth.gov/AlternateSites/CMS-Kids/providers/documents/rpicc_handbook.pdf
[xii] Ibid.
[xiii] National Perinatal Information Center, “Medicaid Funding – The Georgia Regional Perinatal Care Network, Accessed August 24, 2016, https://www.npic.org/projects/MedicaidFunding.php
[xiv] Georgia Department of Community Health, “Georgia Public Health Services Available for Medicaid Members,” Accessed August 29, 2016, https://dch.georgia.gov/sites/dch.georgia.gov/files/Georgia_Public_Health_Services_for_Medicaid_Members.pdf
[xv] Bruce Rauner, Felicia F. Noorwood, and Teresa Hursey, Report to the General Assembly, January 2016 – Public Act 93-0536, (2016), https://www.illinois.gov/hfs/SiteCollectionDocuments/perinatalreport2016.pdf
[xvi] Joint Committee on Administrative Rules, Title 77, Chapter 1, Subchapter 1, Part 640: Regionalized Perinatal Health Care Code, Accessed August 29, 2016, https://www.ilga.gov/commission/jcar/admincode/077/07700640sections.html
[xvii] Illinois Department of Public Health, “Perinatal Regionalization,” Accessed August 29, 2016, https://www.dph.illinois.gov/topics-services/life-stages-populations/infant-mortality/perinatal-regionalization
[xviii] Illinois Department of Healthcare and Family Services, “Moms and Babies,” Accessed August 29, 2016, https://www.illinois.gov/hfs/MedicalPrograms/AllKids/Pages/MomsAndBabies.aspx#momsbabies
[xix]Joint Committee on Administrative Rules, Title 77, Chapter 1, Subchapter 1, Part 640, Section 640.80: Regional Perinatal Networks – Composition and Funding, Accessed August 29, 2016, https://www.ilga.gov/commission/jcar/admincode/077/077006400000800R.html
[xx] Association of State and Territorial Health Officials, “South Carolina’s Perinatal Regionalized System of Care: Reducing Premature Births and Infant Mortality,” (2013), https://www.astho.org/Presidents-Challenge-2013/SouthCarolina/
[xxi] South Carolina Department of health and Environmental Control, Healthy Mothers, Healthy Babies: South Carolina’s Plan to Reduce Infant Mortality & Premature Births, (October 2013), https://www.scdhec.gov/library/cr-010842.pdf
[xxii] The Title V Maternal and Child Health Block Grant funded components include: obstetric and neonatal outreach education, transport coordination, and physician consult and follow-up.
Association of Maternal and Child Health Programs, “South Carolina – Maternal and Child Health Block Grant 2016 State Profile,” Accessed August 29, 2016, https://www.amchp.org/Policy-Advocacy/MCHAdvocacy/Documents/South%20Carolina%202016.pdf
A Labor of Love: State Policies and Partnerships to Lower Infant Mortality
State agencies across the country, from Medicaid to public health, to social services and corrections, are deeply engaged in multi-sector initiatives to reduce infant mortality. And for good reason — the United States ranks 25th among industrialized countries in infant mortality with a disproportionate number of being African Americans.
Despite the gravity of the problem, infant mortality is responsive to policy and prevention strategies. There are recognized risks including smoking, limited pre/interconception care, unsafe sleep practices, and pre-term birth as well as evidence-based interventions that require a multi-sector approach.
NASHP’s 29th Annual State Health Policy Conference a session on infant mortality featured a snapshot of three state approaches: Colorado, Indiana, and South Carolina. Each of these states has developed a public/private partnership committed to comprehensive strategies that address both medical and social factors related to infant mortality. Each has participated in HRSA’s Collaborative Improvement and Innovation Network to Reduce Infant Mortality (IM CoIIN), identified state policy levers, and documented success stories.
Colorado:
Colorado’s Nurse-Family Partnership (NFP) has produced many positive outcomes. In fact, cumulative data as of December 31, 2015 shows that in 61 of the 64 counties served by the program, 90 percent of babies were born at a healthy weight and 91 percent of babies were born at full term . Because the NFP serves only first-time mothers, Health First Colorado, the state’s Medicaid program, offers Prenatal Plus to provide case management, nutrition counseling, and psychosocial services to all pregnant women at risk for negative maternal and infant health outcomes. These negative outcomes may be due to numerous lifestyle, behavioral, and non-medical factors that could affect pregnancy including a lost job or excessive debt, partner in jail, or prior low birth rate infant.
Health First Colorado has also devised strategies to ensure the accessibility of Long-Acting Reversible Contraception (LARC). The program pays full purchase price for LARC and a fee schedule rate for insertion at a physician’s office. Federally Qualified Health Centers (FQHC) are reimbursed through a Prospective Payment System (PPS) encounter rate based on full-costs for LARC devices and insertion. Health First Colorado received approval from CMS to pay free standing Rural Health Clinics (RHC) a separate payment for LARC devices because their PPS is not based on full cost methodology. The insertion of LARCs at an RHC is still paid at their PPS encounter rate. The state is also working with providers to reduce the rate of C-sections in low-risk, first time moms, and is considering options to provide physicians with information on their own C-section rates to encourage quality improvement.
Indiana:
Indiana’s Perinatal Quality Improvement Collaborative recognizes the value of multi-sector partnerships and data-driven evidence-based strategies. Through a public/private partnership, the state Medicaid agency was able to establish a policy for nonpayment for early elective delivery. A Management and Performance Hub collects information from a variety of state data sources, including Medicaid, the Department of Corrections, and multiple State Department of Health sources including HIV/STD and Maternal and Child Health. This collection of data sources has assisted the state in identifying three distinct high-risk subpopulations that account for only 1.6 percent of the sample population but nearly 50 percent of infant deaths. This information has enabled the state to target interventions. These high-risk subpopulations include low birthweight, preterm birth, and limited access to prenatal care, the most significant factor identified.
As a demonstration of state commitment, the Safety PIN (Protecting Indiana’s Newborns) grant program enacted by the Indiana Legislature in 2015 appropriates $13.5 million to reduce infant mortality: $2.5 million will support development of a two-way app for pregnant women to encourage better prenatal care and $11 million will be distributed through a competitive grant program to nonprofit organizations, local health departments, and health care entities for innovative approaches to address infant mortality.
South Carolina:
South Carolina’s Birth Outcomes Initiative is a public/private partnership of payers, providers, and other partners. Among its achievements are a dramatic reduction in early elective deliveries partly as a result of Medicaid nonpayment policies. Additionally through the initiative the state saw a 110 percent increase in LARC insertions in the past two years, and a decrease in infant mortality of 23 percent among non-white populations, and a 9 percent decrease overall.
South Carolina is the first state to initiate a pay for success model for birth outcomes, developed through a 1915(b) waiver in partnership with its NFP and the Children’s Trust. The program will enroll approximately 4,000 additional mothers in NFP evidence-based home visiting services over a four-year period. The waiver allows for “non-statewideness,” enabling the program to focus on communities most at risk. Through a combination of philanthropic support and Medicaid funding, the program provides upfront capital to expand services. Full success payments begin only if an independent randomized controlled trial finds that the NFP can meet the outcome targets: a reduction in preterm births by 15 percent, reduction in child injuries by 26 percent, and an increase in birth spacing by 20 percent. Other success payments will be made only if at least 65 percent of those enrolled reside within a set of targeted rural and underserved communities.
These states provide a snapshot of policy and financing levers that, as part of a comprehensive strategy, can make an impact on infant mortality. Questions remain about how best to capitalize on the momentum and develop complementary policy and programmatic approaches. For instance, what approaches can reduce the significant disparities as evidenced by an African American infant mortality rate that is two to three times higher than for the white population in each of the three states profiled? What are the most effective strategies for engaging African American communities in efforts to develop patient- and community-centered approaches? Some communities may be distrustful of LARC interventions unless they know the state policies for removal of the devices. In two of the three states profiled, Medicaid policies place limits on when removal is covered. In South Carolina they are covered when medically indicated and in Colorado coverage is provided when the medical provider and client are currently enrolled in the Medicaid program at the time of the LARC removal. What interventions are most effective in addressing social factors that contribute to infant mortality? Lessons will continue to emerge as all states continue to innovate and wrestle with these questions.
CHIP Coverage is Important for Pregnant Women Too
While the importance of the Children’s Health Insurance Program (CHIP) for children has been widely documented, it is also important to remember that states can and many do use CHIP to provide coverage to low-and moderate-income pregnant women. With federal-funding for CHIP due to run out by the end of this federal fiscal year (September 2017), there are again discussions at the national level about the future of this coverage program. The following are some of the concerns state CHIP directors have shared with NASHP for pregnant women if funding for CHIP is not continued.
Pregnant women are at risk of losing coverage. Currently, nineteen states have opted to cover pregnant women using CHIP funds. A recent NASHP poll of these states found that approximately 320,000 pregnant women were enrolled in CHIP-funded coverage at some point during the last state fiscal year. CHIP eligibility for pregnant women, as it is for children, is targeted towards those with low- to moderate family income and ranges from 185% to approximately 300% of the federal poverty level. This eligibility and enrollment data is broken down by state CHIP program and displayed on our CHIP Eligibility for Pregnant Women Map. Without CHIP some of the currently covered pregnant women may have access to other sources of coverage, such as private insurance through exchanges or through employer-sponsored coverage, but it could be very costly and ultimately unaffordable. Others who are uninsured and become pregnant may not be able to access exchange coverage if they try to enroll outside of open enrollment periods. And finally some women may not meet exchange eligibility rules that bar certain immigration statuses from enrolling in coverage.
Exchange coverage might not be enough. With the implementation of the Affordable Care Act, pregnant women have new choices when it comes to coverage, such as access to private coverage through Health Insurance Marketplaces. Women face many decisions when navigating their coverage options and must weigh costs, access to existing providers, penalties for gaps in coverage and the possibility of transitioning to different coverage options post-pregnancy depending on their state. Although many women may qualify for tax credits and subsidies to make exchange plans more affordable, such coverage may still be too expensive for some low-income pregnant women. This is compared to CHIP, which is low or no cost for qualifying low-income pregnant women. NASHP recently explored the coverage options and decisions that pregnant women face in a set of infographics. These infographics also highlight policy implications for states to consider to improve coverage for pregnant women.
Ensuring access to critical pre-natal care. Since 2002 states have had the option to use CHIP funds to provide coverage for income-eligible pregnant women regardless of their immigration status through the “unborn child option.” Currently 15 states operate coverage programs under the CHIP unborn child option. The services provided through this option can be more limited than the typical CHIP benefit package and are intended to support the growth and development of the unborn child. Because the coverage is targeted to the unborn child, who will be a citizen of the United States, the pregnant woman’s immigration status is not a determining factor for eligibility.
In addition to paying for delivery costs, the CHIP unborn child coverage allows states the option to provide access to important pre-natal care so lower income women are more likely to have healthier pregnancies. Healthier pregnancies lead to lower-risk, lower cost deliveries and an increased likelihood of healthier babies. State officials are concerned that without this coverage, there would be increased uncompensated care costs to hospitals for both delivering and caring for infants from potentially higher risk births. Ensuring pre-natal care reduces the risk for poor birth outcomes, which not only affect medical costs, but future costs to schools.
In the coming months as federal policymakers and state and national stakeholders consider the future of CHIP, pregnant women and their unique, important health care needs should be included in these discussions.
For individuals living with complex, often chronic conditions, and their families, palliative care can provide relief from symptoms, improve satisfaction and outcomes, and help address critical mental and spiritual needs during difficult times. Now more than ever, there is growing recognition of the importance of palliative care services for individuals with serious illness, such as advance care planning, pain and symptom management, care coordination, and team-based, multi-disciplinary support. These services can help patients and families cope with the symptoms and stressors of disease, better anticipate and avoid crises, and reduce unnecessary and/or unwanted care. While this model is grounded in evidence that demonstrates improved quality of life, better outcomes, and reduced cost for patients, only a fraction of individuals who could benefit from palliative care receive it. 
