AMCHP 2005 ANNUAL CONFERENCE
DELIVERING RESULTS, IMPROVING PREGNANCY & BIRTH
February 19-23, 2005
CHRISTOPHER BOTSKO: All right. My name is Chris Botsko, and I work fork Health Systems Research. And I commend Joshua for getting the name right because nine times out of ten, whenever I come somewhere, someone always changes it into Health Services Research or Health Research Systems. So I appreciate that.
My main role these days is working with states on the early childhood comprehensive systems grants, which is states have grants to kind of help them figure out ways to make their system of services for very young children work together better. But I also do some other things in terms of Title V. We're doing some Title V needs assessments for some states. And this relates to a project we did for the March of Dimes. It was actually a focus on prematurity, but it also ‑‑ there's some data from another study we did.
Donna did a great job on eligibility issues. My focus is going to be more on covered services and special programs designed to improve birth outcomes. And my plan is to describe some Medicaid policies and coverage that are designed to improve birth outcomes and then discuss some of the challenges of maintaining such coverage in the current political and economic environment.
The two sources of data, one is a survey of Medicaid coverage of perinatal services that we did for the Kaiser Family Foundation. I'd be the first to admit that this is a little dated now because the data is from 2000 and there may have been some changes. Probably more likely to be retrenchment issues than expansion issues. But, I mean, I did a little checking, and it's ‑‑ a, I couldn't find any more recent data, and, b, most of the places seem to confirm what we had found back then.
It also includes some case studies of comprehensive approaches to promoting positive birth outcomes that we conducted for the March of Dimes. As I said, this was part of a larger study on prematurity, and we did a literature review on prematurity, and one of the findings is that there's lots of things we simply don't know about why someone has a premature child and not. So when it came time to focus on the case studies, I mean, there's very few programs that focus specifically on prematurity issues. There are lots of things that focus on improving birth outcomes, including prematurity, so we've kind of broadened the focus for the case study part of it.
This is from the Kaiser study. What we found was what services the state Medicaid covered. 42 states covered case management or care coordination, 34 covered nutrition counseling, 37 covered psychosocial counseling. I mean, those are fairly high numbers.
When you get to things like smoking cessation and substance abuse treatment, the numbers come down some. These are things that are clearly associated with improving birth outcomes and which ‑‑ I mean, you have studies that show you can intervene in some of these areas and actually have an effect. I mean, women are ‑‑ if you can counsel women to give up smoking while they're pregnant, they're very likely to accept that. They're much more likely to do it than if nobody kind of steps in.
And substance abuse treatment, I mean, clearly this is a population you need treatment for. You also need kind of a specifically targeted treatment. A lot of substances still ‑‑ even to this, day a lot of substance abuse treatments programs aren't really targeted at women. They're kind of targeted at older males and in a lot of cases are simply not appropriate.
So those are the numbers. And as I said, they may have changed. And I guess I would add one other thing. These are coverage things. These are things that are covered. But it's important to realize, just because something is covered doesn't mean it's going to be well utilized. We've just been doing some work in this state, and when we ‑‑ we did an interview with the Medicaid office, and they said, well ‑‑ they started talking about enhanced coverage for prenatal care for high risk women. And we were a little puzzled because we'd already done a bunch of interviews and talked to people and we hadn't heard about this yet.
And we looked at the Medicaid rules, and it was there, but when you ask providers, they simply didn't know about it. I mean, it was kind of a tree falls in the forest. If Medicaid covers something and nobody knows about it, is it really covered?
And in this case, I mean, it really wasn't covered. Nobody knew about it. There was ‑‑ and part of it, I think, was the way it was done because there was no formal way of assessing high risk. There wasn't in here, here are some accepted instruments. So providers knew nothing about, you know, this is a state form to determine high risk, and they did not have the clear connection: If you have a high risk women, you can offer these services.
So, I mean, one of the important things is making sure this ‑‑ we do focus groups with families all the time, and far too often they say they have no idea what Medicaid coverage covers, and the only time that they usually find out is when they talk to another family and they say, well, we got that covered. And then they go and they try and fight, and sometimes they get the answer that, well, that's wrong. But a lot of times, if they persist, they find out that there are things covered that they weren't aware of.
I'm going to turn to the case studies of comprehensive approaches to promoting positive pregnancy outcomes. And most of these focus on Medicaid. There is one exception that I'll talk about as I move through.
The first is the Colorado Prenatal Plus Program, and that provides care coordination, nutrition, and mental health services for high risk pregnant women. There's 27 providers, which are heavily concentrated in the urban areas of the state. And it's not because the state simply decided that urban areas were where they wanted to focus. Anybody in the state can become a provider. They've just had a really hard time recruiting rural providers. And I think it's just partly capacity issues, that there's just not folks out there that can provide some of these services. And it's partly, as we'll talk about, reimbursement issues.
Most providers are county health departments or community health centers. There are a few other private non‑profit agencies thrown in. And there's a multi‑disciplinary team led by a care coordinator who works with a nutritionist and mental health specialist when warranted. So the care coordinator figures out what the issues are in the case, and they can bring in a nutritionist or a mental health specialist.
I put set reimbursement fee for full package of services, and I actually did some followup research, and the reimbursement fee changed. There was always a reimbursement fee, but they've actually made‑‑ now they have three layers. One of the issues was that for years they hadn't raised the reimbursement fee. And what it was, was it was $540. Now, $540 for ten visits, I mean, the immediate thing is this isn't covering the cost of these services. There was no way it was covering what these folks were providing. At least two of these had to be home visits. Essentially, providers were finding a way to cover the additional costs some other way.
And one of the reasons you didn't have providers is because with the $540 fee, people ‑‑ I mean, it was a loss. And if they couldn't find another program they took to cover part of those costs, they couldn't do it. So what happened was, actually, that there had been 34 providers in 2001, and folks started kind of slipping away.
And what the state said is that part of the issue was that a lot of other programs were being held steady or being cut so that providers who were piecing together kind of pots of money, which they do all the time, were suddenly figuring that they just couldn't ‑‑ the money wasn't there anymore. They couldn't pull those pots of money.
One of the things is, we work with states all the time, and we work with the federal government all the time, and one of the big issues when you talk about systems grants is blending and braiding funding. Well, the fact is that locals blend and braid funding all the time. I mean, for them, they can't survive unless (inaudible). Community health centers do it. I mean, very seldom is there one pot of money covering anything. And when it comes to extra services, Medicaid ‑‑ there are very few Medicaid programs that actually cover the full cost of services. Or for extra services, it's a rare occurrence. So people piece together the money. I think from the state and federal perspective, the issue isn't that this isn't being done, the issue is how to make it easier. I think people sometimes lose site of that.
But in any case, what they did was, recently, is they've changed the total to $750 for what was the old package of services. So if you do your ten visits ‑‑ actually, I said two had to be in person. It's ten visits, only one of which cannot be in person. So you can do one telephone call. So you essentially have to have nine visits, two of which have to be home visits, seven of which the person either has to come or you have to do home visits. And if you're actually wanting to generate these visits and you have a pregnant woman, you're probably doing more home visits than, just to kind of reflect the costs versus the reimbursement. So they changed that to 750. They also added a new thing where they can do 850 for 11 visits if the person is particularly high risk.
But in the process of doing so, they used to give ‑‑ they used to give $280 for partial payment. So if you got somebody into the program and they didn't get through the full package of services, they would reimburse the providers. And this, which I actually think may end up losing more providers than gaining providers, their decision was, well, we want people to comply with this program. So they cut back the partial payment to 150 when they increased the other payments from 280.
And just given population issues, given that pregnant women sometimes have other things on their mind, it may very well be that there's a lot of people getting partial payment, and by cutting that back, there's clearly a good policy goal, but the cost may end up being more than the benefits.
And so, I mean, the issues are reimbursement does not cover costs, and decline in number of providers. One of the ways this program has been able to keep and gain support ‑‑ I mean, it gains support to the extent that they increase the reimbursement. Clearly they haven't increased the reimbursement enough to cover full costs, but, nonetheless, the program has been able to kind of keep its support in the legislature at a time when the legislature was looking at these programs as kind of extras in trying to save some dollars on Medicaid is that they've done some costs benefit studies.
And what they found was that they saved $2.48 in Medicaid costs for every one dollar spent. And I actually reviewed one of their papers on this, and you can quibble with their cost analysis in terms of is this the exact figure, this $2.48? But what you couldn't quibble with is that they put together a convincing amount of data that this did save money, that, in fact, they were saving us a fair amount of money when they were providing these services, that women were having less complications, women were having less issues, that they were being connected to other things.
In terms of Medicaid, it was actually saving costs. Even with that, I mean, it's still very hard to get folks to increase coverage for services in this climate.
Another thing is the Montana Miami Program. Once again, it's care coordination and referrals for high risk pregnant women, targeted case management, home visits from nurse, social worker and nutritionist. And home visits in a place like Montana are very important because it's a long drive to come in for a lot of these things. So it's an essential pat of their healthcare system.
Their challenges in putting this together was that they required changes in the definitions of targeted case management services and rates. So they had to go and had kind of negotiate ‑‑ they have the Medicaid office sit down and talk about, well, what are we going to do as part of targeted case management? How much is this going to cost? And they've been able to put together some evidence that it's a fairly successful program and results in better outcomes. They, too ‑‑ despite this, they were faced with a situation where the program was going to be cut and maybe eliminated all together in recent years.
They were able to mobilize enough people and mobilize enough of a constituency that they essentially stopped that. The program was able to survive what was ‑‑ it was essentially on the chopping block. It was being written out by the legislature. They got together and were able to prevent that.
The Delaware Moms Program is a different sort of program. It's a hospital‑based case management program. It coordinates with Medicaid to prevent duplication. And what I mean by that is, technically, these services are supposed to be covered for Medicaid folks by the Medicaid managed care agency. The reality is that the way the Medicaid managed care agencies interpret their contract, they don't necessarily provide the same level of services. They read it differently than the state reads it in a lot of ways. Some of them just, you know, they figure these services aren't really something that they have to do, it's something that people may ask for.
So what happens in some cases is that, you know, if the folks at the hospital where this program is run out of find Medicaid clients who have not received this package of services or need further assistance, they'll kind of step in and do the services. And we run across other private hospitals that do this stuff for their non‑Medicaid population, and it can be very useful.
What they essentially provide is they do risk screening, they do phone case management and referrals for pregnant women who are signed up to deliver there. So if someone signs up to deliver, they'll essentially call and see what are the issues. They want to know ahead of time what's happening. They want to be prepared at the hospital level to deal with any kind of complications and risks.
And, I mean, it's no small part self interest. I mean, these cases can be very expensive if there's something you could have prevented and suddenly you have complications on your hands. And it's something I think ‑‑ you would think especially ‑‑ we were doing some rural work recently, and it's something, you know, hospitals have a real interest in doing if they think about it, because in a lot of cases women were delivering at hospitals who were too high risk for the level of hospital, and they should have been ‑‑ someone should have called them up, found that out, and suggested that ‑‑ arranged to have them deliver elsewhere. But the hospital didn't do it, and pediatricians don't always do it. I mean OB/GYNs don't always do it.
So what this service ‑‑ so it provides the telephone case management. Services like this I think can be very useful, and I think one thing that sometimes is forgotten from the public sector is that it's very useful to work with these kind of programs because, in a sense, there are too many parents who will tell you that they were in the hospital, their child had some ‑‑ they had some risk issues, they had some concerns, and no one at the hospital ‑‑ I mean, they may have gotten a number for the early intervention program in their state, but no one at the hospital really explained what it does, no one at the hospital really ‑‑ they may have not known what it does or they may have just thought the number was enough and the parent actually understood it.
But if you don't have that level, it may be a long time before the parent actually gets to that point. Nobody else may be there. Lots of parents leave hospitals, especially parents who may have only a tangential connection to the system, lots of parents leave hospitals, and their next contact isn't for a while. They don't see a pediatrician. They may see a pediatrician who knows about as much about the early intervention program as the hospital or makes the same kind of referral ‑‑ here's a number you can call ‑‑ and that doesn't really cut it for a lot of parents. It just doesn't. They don't ‑‑ unless you explain, you know, here is a number you should call, here's why you might want to call them, here's some sense of what will happen once you get there.
The California Black Infant Health Program provides outreach and social support. And this is actually one of the only programs ‑‑ this is the only program I'm talking about that focuses on enrollment issues. They work to ensure prompt enrollment in Medicaid and supplement services for a high risk group. So the idea here is that lots of ‑‑ lots of black women were not being enrolled ‑‑ who were high risk were not being enrolled in a timely fashion, and the Black Infant Health Program made a specific effort to find out why and to go and do outreach for folks.
They worked to ensure cultural competency. So one of their roles is essentially to look at forms, to look at material, to look at program material and say is there anything about this material that just isn't going to reach black women? Is there anything about this material that isn't going to reach high risk women? And it's a very important function. I mean, it's a very important function that I think often gets dropped. And I think of it in terms of focus groups, in terms of parents' reaction to Medicaid material if they get it in the mail.
If you talk to, for instance, Hispanic families, oftentimes they get disenrolled, and when you ask about it, the reason they seem to get disenrolled is they take the form and they throw it out. And they take the form and throw it out because they don't know it's important and because it costs a lot of money to get the forms translated, if it's not translated, or the Spanish is so unclear that they just can't figure it out. So they throw it out. And later on they go to the doctor or the hospital and they find out that they haven't been in Medicaid for some time.
I think the same thing is true of some of the issues with paying fees, that it's not always an issue of the fact that the family didn't have the money, it's a fact that the family didn't really understand what they were being asked to do. Too often ‑‑ I mean, I look in Medicaid forms all the time, and there are too often times when I look at them and say, you know, I know this stuff, I do this stuff for a living, and I have no idea what they want me to do with this. And I think it's very important to kind of take forms like that and to go to a Medicaid office and sit down with a group of people and ask them what does this mean? What are we asking you to do with this form?
And I think ‑‑ so cultural competency isn't just about race and ethnicity, but it's also about the fact that people who don't work in the healthcare field might not understand what we're saying. I don't always understand the forms I get from my insurance company, and we oftentimes expect people to understand things that are simply not part of their world.
So I think that the ‑‑ the challenges this program addressed is important to providing access to service. It also addresses the issue that prematurity and bad birth outcomes are oftentimes a bigger issue in certain populations and that it makes sense to target populations with particular approaches and you can begin to address things.
CHRISTOPHER BOTSKO: Strengthening or maintaining Medicaid perinatal services in challenging times.
And I think data is certainly one issue that you can show that you have some effect. And, I mean, I think people oftentimes say, well, this costs a lot of money or we have to do this exactly right. I think academics sometimes come in and provide consulting where they say, well, you have to do it this way, and this is going to cost a lot of effort and time. And, you know, I think there's ‑‑ you have to have data that has some integrity, but it doesn't necessarily mean that you have to have a Cadillac model of data. You have to figure out a way to collect data. You have to work with your Medicaid office so that they're willing to share data and that they're willing to understand what you're trying to pull out of their system. But it doesn't necessarily have to be a high‑expense, high‑demand kind of thing. But if you could show data, it's very helpful.
Partnerships I think is another issue that, in many respects, to make these programs work their best, you have to have links between different part of them and difference between different parts of the system. Far too many pediatricians simply don't know how the public system works. They don't know about the early intervention program. There might be home visiting programs out there that are not income based, parents as teachers programs, and they might run across somebody who is simply not doing well. They're seeing a family who, for one reason or another, the woman may have just gotten a divorce, we saw families whose husbands were deployed in Iraq, and there may be stuff out there that can kind of say, well, you know, we can kind of work together and keep an eye on you, and if we ‑‑ if you need help, we want to be able to have you be able to access that help quickly.
And far too often parts of the system simply ‑‑ I mean, you don't know about it. Providers either don't know about it, they don't understand it, they don't have a number to call, which is another thing. I mean, providers go crazy because they have a case, all they want to do is find one person they can call who might be able to offer some information. And there's stuff out there sometimes, and they have no idea how to access it because they don't have a single number to call.
And, finally, constituency. I think the Montana program and the other programs show that you really kind of have to work on having a constituency out there, and it should be a varied constituency. It can't just be providers. The providers stand in front of legislators. People might say they have a self interest.
Family advocates are great, but they're still working for somebody. If you have parent who can come in and say, you know, things were really going poorly and this program kind of helped pull me up, it can be very effective, and it can also ‑‑ if you promote a constituency, people are willing to come out and talk about these things.
So I will finish up now and turn to Tom.