AMCHP 2005 ANNUAL CONFERENCE
DELIVERING RESULTS, IMPROVING PREGNANCY & BIRTH
February 19-23, 2005
NAN STREETER: I’m thrilled to see how many people are here this morning. And as Betsy mentioned, you know, for 8:00 o’clock on a Sunday morning, this is great. And I have to say, you know, I see some familiar faces out there. Those of you who have worked in Title V for a number of years and I also see some new faces. And I have to acknowledge Meg McDonald over here. Meg and I traveled across the aisle from Salt Lake City to Washington on Friday, and Meg is from Nevada and is one of the family scholars. And I just think it’s great that you’re here and I know this is your first time. And I just was excited to hear what Meg has been up to. She’s the Director of, I’m sorry, I don’t remember the name of the organization.
Okay. Thanks. And I just am so glad you’re here. And Bob, your mentor, I met Bob the other day and I’m glad you’re here too, as well. All right, one thing I do want to clarify is Betsy was kind enough to, how can I say, indicate that I took Peter Van Dyke’s position in Utah and I did not. Actually, my boss took his position. So I just want to make sure everybody knows I’m not trying to be more than I am. Anyway, I’m really glad to be here this morning and I hope that--I think that you’ll find that the three presentations kind of build on each other. We tried to be very careful about not duplicating as we were planning this session. Betsy and I, or at least I realized I was duplicating a lot of what Betsy was saying and so we made some adjustments so that, hopefully, it’s not repetitive. And so what my goal this is morning is to talk about how states and territories, one of the experiences I had being on the AMCHP Board, excuse me, was one of the other board members was from one of the territories. And she educated me to remember that it’s not just the 50 states, but also the territories that receive Title V Block Grant money from the federal government. So I always try to be sensitive to that, so I want to acknowledge that.
Anyway, I want to talk about how we use Title V dollars in the states, in territories, and some of this, obviously, will come from my experience in Utah . But I also looked at some other states in terms of what they were doing. So as Betsy mentioned, you know, Title V of the Social Security Act has provided the foundation and structure for ensuring health of mothers and children in this country for more than 65 years. And the other comment I want to make is when I mention children, I’m also including children with special healthcare needs. We cannot forget those children and youth and their families. So I’m not trying to be excluding them, it’s just easier sometimes to say mothers and children and families of course. So, as Betsy mentioned, Title V is administered by The Maternal and Child Health Bureau, and in most states the Title V Block Grant funding is awarded to the state department of health.
Now some states are organized differently and so some states may have a Department of Health and Human Services, some states may have a Department of Social Services, whatever. But basically, the Title V money is awarded to the state agency that’s responsible for health, in the state. Now some states are organized even differently in that some states have their children and youth with special healthcare needs in a separate agency. And so what happens in those states is that the Title V funding is divided between the two agencies, so that each agency has funding capacity to provide the services that are needed. So the other thing that’s important is that as we all have been challenged with budget cuts and consolidation of staff, et cetera, that you will find that a lot of Title V agencies are not just administering Title V Block Grant, but they’re also administering other federal funding sources, such as the WIC program that’s funded by the Department of Agriculture and immunizations which is funded by The Centers for Disease Control and Prevention, and Part C, which is your early intervention programs. And so there’s a wide range of, how can I say, administration of Title V funding along with other funding streams in states and territories. I think a lot of times when we think about, you know, who provides public health services for mothers and children and families.
And sometimes I think we forget that private providers and community health centers are actually the primary providers for services for mothers, children and families. And so I always like to make sure that we’re inclusive of, you know the providers that we don’t necessarily automatically think of when we’re thinking about providing public health services. I look at any provider who provides services to the Medicaid population for example, as a provider of public health services. Betsy mentioned that every year, July 15 th is the magic date every year that states and territories have to submit their annual plan, what they’re going to be doing for the upcoming year. And the annual report, which is a report on what was done or what has been done, that details exactly what we have done to address the national and the state performance measures.
So, just to give you some examples of what the national performance measures cover and again, as Betsy mentioned, Healthy people 2010 that a lot of these measures do show up in the Healthy people 2010 objectives. So a lot of these are taken from the Healthy people 2010 so that there actually is an overlap between the national performance measures and Healthy people 2010. So these are some examples of the national performance measures. I haven’t worded them the way they’re worded as performance measures, but just to give you some idea of the topical areas that are covered in the national performance measures. And what I did with these is I took them out of order, Betsy mentioned that the first few performance measures are related to children and youth with special healthcare needs, and I tried to take it more from a chronological perspective. It’s just kind of how my mind works. So, you can see that they cover a wide range of areas related to healthcare for mothers and children. And you can see family involvement, as Betsy had mentioned, is one of the performance measures.
Okay. And those are in your handout, so I won’t address them specifically. Betsy had mentioned that each state and territory is asked to select up to 10, between 7 and 10 state performance measures. And because we are going through our needs assessment this year, this is an opportunity for states to look at the state performance measures that they’ve been working on for the previous five years, and determine whether or not those need to be changed, deleted, added to or et cetera. And so I went through the website that Betsy had mentioned to you--you can go through and look at what states have selected for their state performance measures. And these are just examples of some areas that states have identified as priorities for them to address, that they then went on and developed a state performance measure.
So some of these performance measures are obviously not represented in the national performance measures, but certainly, you know, play a significant role in the health of mothers and children and families. For example, mental health is by and large a significant issue for states to be looking at. And we’ll probably see more of that over time, quality childcare, birth defects, so on and so forth. So it just gives you an example of what states have identified as priorities that are not represented in the national performance measures. There also are national outcome measures that states are required to report on, not annually, but during the five year needs assessment. And these outcome measures by and large are--well they are mortality data to look at the rate of infant mortality, the disparity between black infant mortality and white infant mortality, which is significant in the United States .
Child mortality, oops I skipped--okay. And then states are also allowed to select a state outcome measure. And so for example, what we did in Utah , we felt very strongly that the maternal piece is under represented in the national performance measures and outcome measures. And so our state outcome measure was to measure maternal mortality rates and to do work on maternal mortality. All right. In terms of the federal funding requirements, Betsy had mentioned that there’s the 30-30-10 distribution. And I’ll put in my soapbox here, I think that’s great, but my concern is what about moms. If we’re going to have healthy children and we have to look at what happens before the children are born. And so preconception and pregnancy, inter pregnancy healthcare is extremely important in terms of working to reduce morbidity among children. States are required to provide the nonfederal match; Betsy had mentioned that.
This gives you an example of the wide range of funding allocations between the territories, Palau gets the lowest amount at $162,320. And you think about what you could do with about a $160,000. It’s tough. And I think, you know, what we found in our state, in Utah , is that we have large, we’re largely a rural and frontier state and the challenge is that even though you have small numbers in rural communities, your over head is still high because you still have to have that infrastructure to provide those services. And so you know obviously, you know, if you live in Palau , taking a $160,000 could be two full-time positions, if you chose to put the money into, you know, personnel. And then Guam is about $900,000 and then the lowest of the states in terms of funding is Alaska at $1.2 million and California at $48 million. Now, excuse me, we didn’t talk a lot about how the funding is allocated, but its allocated based on a funding formula.
So every year we know how much we are going to get. And I don’t know all the variables that are involved in that funding formula, but it is based, in part, the number of children living in poverty in the states and territories. And so this is partly what’s factored in in that funding formula. So as I say, you can see a wide discrepancy, you know, where wide gaps in funding from the territories and the states. It’s also important to keep in mind, you know, as Betsy mentioned, that there are many other sources of funding for Title V programs and we are required to provide the match. And these are some examples of some other sources of funding, obviously other federal grants; states put large amounts of money, you know, state dollars into Title V programs; private funding from foundations, private non for profit; city, county, local health departments put in money to support Title V programs in the local areas. And then there may be income sources for Title V programs such as billing for clinic services.
Well some of the comments that I want to make in terms of the federal funding requirements, since 9/11 occurred, states and territories, the nation, we have faced tremendous challenges in trying to meet the non federal match because what we have experienced is that state legislatures, in trying to find, you know, make their budgets work have wound up cutting state funding to health programs. And so this has been a significant challenge for many of us. Oops, did I go to the wrong--oh, all right. And then I had already mentioned this, so we’ll skip over that. So there are some restrictions on Title V funding. We can’t just take it and use it for anything. So building improvement, purchase of land, those are not permitted. We cannot make cash payments to recipients and inpatient services; payment for inpatient services is limited.
So it’s more to fund outpatient services. So we do have a lot of flexibility however, but it also is important to remember that Title V does not cover all programs and services to mothers and children and children with special healthcare needs. But services, the structure for states and territories to be able to provide them and as Betsy mentioned the pyramid comes into play here. Now every state is allowed to decide how they’re going to allocate their funding, and they do it in very different and creative and innovative ways. And as Betsy mentioned there has been a shift in philosophy about use of the Title V dollars in states moving away from direct services such as provision of prenatal care, or well-child care that we often times have seen states do. And some of the shift has actually been from states providing the services directly by the state agency to states contracting with local health departments or local public health agencies to provide the services in the community. And so, you know, that’s one way to expand, you know, the capacity within a state.
Title V funds may not go directly to finance specific services, but may provide the resources to make these happen. So, as Betsy mentioned relative to the pyramid, some states have chosen to put greater amounts of dollars to support the population of mothers and children and children with special healthcare needs in states, rather than allocating the dollars to fund smaller numbers of, you know, services for individuals, which has a much smaller impact. So some examples of state services and I’m going to run through kind of an example of what we did in Utah in our shift from direct services and how we reallocated that funding, which, hopefully, make this kind of a little more graphic, is that states often times had maternal and infant programs that provided prenatal services to pregnant as well as well-child follow-up services to their children.
One of the things that we did in Utah is as we shifted our funding from direct services to population based services, um, and again the whole intent with population based services is to impact a large population, is developing educational programs. And one of the things we did in Utah was we developed what we called the 13-13 Campaign. Utah has the notorious distinction of being 49 th in the nation for adequacy of prenatal care. And we studied this issue, we don’t understand why. But what we did was we decided that we needed to educate women that they need to get into prenatal.
NAN STREETER: --that states are required to have a hotline for families to call in and get information on where they can get services and how. And so these are some examples of some population-based services. Some other examples include newborn screening, immunizations, programs that promote the importance of good oral health, good nutrition, and physical activity. Also, states may put their dollars into investigating issues that lead to poor outcomes for moms and children. And as I mentioned before, what we did in Utah was trying to address the late or no prenatal care issue, which is associated with higher rates of prematurity in infant deaths, which obviously is concerning. And then mortality review projects, that help identify system issues, such as hospitals that are keeping very high-risk pregnant women, rather than transferring them to a prenatal center prior to their delivery.
Establishing policies and standards, working with licensing to work on hospital rules that require hospitals to meet certain requirements in order for them to be categorized as a high-risk prenatal center. We have one hospital in Utah --actually we’ve had two, but one since has made the change that call themselves a high-risk center, but all they have is a NICU. And I’m saying to myself, now how can you call yourself a high-risk center when you don’t have the provisions for high-risk prenatal care? Or, you know, pregnancy care? And, to me the two go hand-in-hand. And so one of the hospitals actually has brought on a perinatalogist. And so I look as that as, yes, that’s a high-risk center. You’ve got the infrastructure in place to make sure the mother is healthy and make sure that the baby’s healthy. Death reviews. Going on with the death reviews is, also children who are not treated appropriately for signs of infection.
Betsy had mentioned services that enable families to get to services, so I won’t go into that. Other support services, childcare services, healthcare coverage. So, talking about building the infrastructure. And, as Betsy mentioned, you know, this has been very frustrating, I think, for states. It’s been frustrating for local public health agencies, and it’s been frustrating for families, in that, why can’t we use all of our Title V dollars to fund direct services? Well, the bottom line is that there’s not enough money, and that if we used all of our funding for providing services to those in need, there’d never be enough funding to be able to work on impacting health outcomes. So, as Betsy mentioned, infrastructure is a foundation on which the rest of healthcare system relies. And I’d like to think of infrastructure as a house. And you think about a house, you buy a house, and you’ve invested all this money, and maybe you have a house inspection done before you bought it.
For example, I did when I bought my house, only to discover when the gas company came, the gas company would not turn the gas on for me because my furnace--well, anyway, there was a key part to the furnace that was broken. And as a result of that, we could have resulted in high levels of carbon monoxide. So, from a safety perspective, they were saying, “No, we won’t turn on the gas until you get your furnaces replaced.” And, so, what am I to do? Well, I only have one thing I can do. Well, actually, I could do two, I guess. I could live in the house without the heat, in the middle of winter, or, I could pay for new furnaces. And so I look at infrastructure in that way, is that you buy this house and you find out that it’s got some problems. And let’s say you’re furnace isn’t completely broken, the gas company’s willing to turn on your heat, but because of the way the house is built, you’re paying through the nose for leakage of heat because you have a lot of drafts in your house. And so, you can choose to spend your money paying for those monthly power bills or water bills, if you have a leaky facet, or you can invest the money upfront, which oftentimes cost more initially, and get those problems fixed, and save money down the road. And that’s how I look at infrastructure building.
So, anyway. So what do states do? States identify needs through their needs assessment. And the needs assessment really looks at services for the three populations that Betsy had talked about. Looks at gaps in services. Looks at gaps, you know, whether it’s because you’re a large rural frontier state like Utah is, or you don’t have enough pediatric specialists, et cetera. So we look at that, and then we develop strategies to address those issues. Information systems are critical to looking at and evaluating what we’re doing and trying to improve it, and then quality assurance. And one of the projects that we’re involved in Utah that we modeled after projects in Vermont and North Carolina , is working with our American Academy and Pediatric Chapter in Utah , and with our university folks. And we have a collaborative that we’re working on where we work with pediatric practice teams to help them identify--or actually, they identify themselves, what parts of their practice they want to improve, whether it’s making sure that BMI’s are measured in children, body mass index, to determine whether or not children are underweight or overweight, and work with them to develop strategies to improve the kind of healthcare they deliver in their practices.
And an example of what one practice did in this initiative was that they had their computer programmer re-program their computer system so that when a child comes in, and the height and weight is measured, which is pretty typical in a pediatric practice, the computer automatically calculates the BMI, so that the physician then, can look at that and determine, just like that, whether or not the child is on target or not, and then can counsel the family, as needed. So, there’s a lot of those kinds of activities going on, in which Title V is involved. Now, just to give you an example of what we did in Utah in terms of shifting from direct services, we had a maternal and infant program that provided services to high-risk pregnant women and their children. And in 1999, we closed it. Because when the program was first started, there were no high-risk specialists in Utah , or very few. And so this was a mechanism to provide services to a group of women who were very high-risk, and provide them with multidisciplinary care, including psychological counseling, nutrition, social work, et cetera. But we were only serving a small number of families every year. And this program was very expensive.
So, what we did was, we looked at how many families we were serving. We were serving about 200 families a year. And the program cost about a half one million dollars every year. So, what we did was, we looked at how we could take those dollars and reallocate them. So what we did with those dollars was we provided state match to increase the reimbursement rates for Medicaid for the prenatal enhanced services, such as care coordination, because we wanted to improve that throughout the state. So that had a statewide impact. And then we contracted with a local health department and community health center, so that they could provide direct services to some of the women that previously had been seen in our clinic. And then we had money left over to start our state PRAMS program. And for those of you who are not familiar with PRAMS, it’s a CDC-sponsored program. It's Pregnancy Risk Assessment Monitoring System, and it’s a wonderful tool to collect data from women who have recently delivered, about their experiences before, during, and after pregnancy. And so, one of my goals was to have a Utah PRAMS project, CDC didn’t have funding available for us at the time, and so we took our state dollars that were left over from the MNI project, and started our own state PRAMS program. We since have obtained funding from CDC, so. So, we wound up increasing the reimbursement rates.
So again, that was to increase, throughout the state, better access to care coordination, so that local health departments would be more willing to provide those services, because the rates were more reasonable. And I mentioned funding to local agencies, so that they could provide prenatal care, and then the PRAM system. So, for funding that previously only served about 200 families a year, that funding now provides the opportunity for all Medicaid pregnant women in the state to have better access to enhanced services. So we’re talking about approximately 15,000 women per year. Prenatal care for more than 200 women per year and local clinics, and then data for all mothers and newborns in the state, which is approximately 90,000 mothers and babies per year, that benefit from the PRAMS data that we then turn into action. So you can see the shift from, you know, half a million dollars, providing services to 200 women, versus what the money is now being used for.
So, as I mentioned, the funding decisions are usually based on needs assessment. And that’s why this year is so critical for states and territories. And so, one of the things that we had wanted to do was to get more information about women who give birth, so that we could work to improve, you know, the health of mothers as well as children. All right, so, why did we put Title V funding into PRAMS rather than services, other than what I’ve already suggested to you? Well, first of all, the oversight of the project is funded with Title V funds. For example, my salary comes out of Title V, and I do play a role in some of the project activities. So, Title V does play a role in PRAMS. And then we also take the data that we get from PRAMS and we put it into action. And, when I mentioned earlier, the 13-13 Project, the data that we used to develop that particular project came from PRAMS.
We already knew that we had poor adequacy of prenatal care in Utah . But what really was, you know, provided us with good information that enabled us to embark on that 13-13 campaign was that women reported that the primary reason why they didn’t get into prenatal care as early as they wanted to was money. And so our thinking was, well, if they don’t have money to get into prenatal care, are we doing a good enough job of getting the word out about our baby-to-baby program, which actually was started by Pierre Van Dyke, back in the ’80s, so that women could call our hotline and get linked with services. And so, the PRAMS data really played a significant role in the development of that particular campaign.
So, the TV spots kind of focus on, you know, 13 being a lucky number. And the marketing folks came up with some creative strategies about the mad scientist and the fortuneteller. So they were really eye-catching and ear-catching spots. And we’re in the process now of evaluating that campaign to determine the impact that it’s had. So, the other thing is that we have identified factors related to prematurity that help us discover, help us understand the problem better. We’ve determined that some of the issues around prematurity involve provider education on appropriate infertility treatment standards, educating women on the importance of planning for healthy pregnancies because we know that unintended pregnancies do have poorer outcomes, and the importance of previous pregnancy history.
Because oftentimes a mother who delivers a pre-term baby is more, more at-risk for having another pre-term birth. We have also been able to identify factors related to the high percentage of women who report experiencing moderate to severe depression during the months after birth of their infant. And so what we’re embarking on now is some provider education on the importance of screening for depression during pregnancy and between pregnancies, before pregnancy, and some public education on the signs of depression. We soon are going to be publishing an analysis of PRAMS data that will provide some information on obesity issues related to pregnancy. We have discovered that women who are obese or overweight have poorer outcomes in pregnancy. And so we will be embarking on some education of providers about counseling and also public education about the importance of good nutrition and physical activity.
So, by allocating the funding to work on healthcare issues and barriers to care, we’re able to impact the healthcare system for more individuals. And, Betsy had mentioned the reporting requirements, and so I’m not going to go over that again. I do want to talk a little bit about family involvement in Title V programs. Betsy had mentioned that, and obviously, some of you are funded by Title V, which is wonderful, we also have a staff person who is funded by Title V in our agency. And we involved, and I’m sure other states do too, family members on our advisory committees. One of the things we did this year for our five-year needs assessment was we developed what we called a key informant survey. It was an online survey that the public could participate in and help us identify what they viewed as the top priorities for the three populations served by Title V, as well as some of the healthcare system issues. And interestingly enough, the largest percentage of respondents were parents.
So, we’re really proud of that because, I don’t think in the past, we have really been able to get a lot of good parent-family input. So we were very pleased with that. And as Betsy mentioned, family member participation on Block Grant review. So I just want to end up with some of the challenges that we face, and I think everybody’s very familiar with concerns about funding, with the federal deficit and the federal budget allocations. They really are cutting into funding for public health programs. Some of the cuts that are being proposed in the president’s budget will cut into Title V, even though Title V, in and of itself, has been level funding. There are other programs that are being proposed to be cut that then would have to be picked up by Title V, thereby reducing Title V dollars. Obviously, we have increasing population needs with decreasing resources. And we need to focus on prevention. And of course it’s always hard to measure prevention, in terms of how effective it is.
The differences among states and territories, you’ve got large states versus small rural states versus the territories, the political climate regarding, you know, the mindset of, or the view of what public-health does, and the view of, about disadvantage populations. We’ve not done a good job marketing ourselves. I know in Utah , many people don’t know what the Utah Department of Health does. Access to coverage, increasing populations of women, men and children who are uninsured or underinsured, particularly those of undocumented citizenship status, access to oral-health and mental-health are big, big overriding issues. Increasing OB malpractice rates leading to decreased OB providers, low Medicaid reimbursement rates, workforce development needs. Some of us are getting older. And--just some of us--And, you know, we need to make provisions for staff to follow us. And so, we need, we need to develop our workforce. Salaries for public health workers and others. All right. I am done, and, I guess we probably want to; do we want to hold off on questions?
Betsy Anderson: Well, if we want to, why don’t we take one question now, and then we’ll take a break, and then it will be time.
Nan Streeter: Okay. Right. Okay. Good. Yes?
Mary: Nan , I’m Mary (inaudible), I’m from Minnesota .
Nan Streeter: Great, hi, Mary.
Mary: I'm one of the newbies here.
Nan Streeter: Oh, great, good.
Mary: I was very curious about your 13-13 Campaign.
Nan Streeter: Uh-huh.
Mary: Is that available to view in the public domain anywhere? On a website, or—
Nan Streeter: You know, I don’t know, to be honest with you, but let, let’s talk afterwards, and I’ll get your information, and I’ll connect you.
Mary: It looks great.
Nan Streeter: Yeah, it’s a fun campaign.
Mary: It’s catchy.
Nan Streeter: Yeah, it’s very catchy. It’s very catchy. And like I say, 13, everybody associates with an unlucky number, and so we just decided to capitalize on that.