# Presentation: 849096

## The Role of Medicaid in Improving Birth Outcomes          

- Christopher Botsko and Judith Gallagher, Health Systems Research
- Support From:  The March of Dimes and
- The Kaiser Family Foundation

## Objectives

- Describe Medicaid policies and coverage that are designed to improve birth outcomes.
- Discuss the challenges of maintaining such coverage in the current political and economic environment.

## Sources of Data for Presentation

- Survey of Medicaid coverage of perinatal services conducted for the Kaiser Family Foundation, 1999-2000.
- Case studies of comprehensive approaches to promoting positive birth outcomes conducted for the March of Dimes.

## What Services Do State Medicaid Programs Cover? (as of 3/00)

- Case management (covered in 42 states)
- Nutrition counseling (34 states)
- Psychosocial counseling (37 states)
- Smoking cessation (18 states)
- Transportation (38 states)
- Home visits (37 states)
- Substance abuse treatment (22 states)

**Notes:**
One issue is what exactly is covered by State Medicaid programs.  In late 1999 through early 2000 HSR conducted a survey for the Henry J. Kaiser foundation on Medicaid coverage of perinatal services.  

As you can see most States provide coverage for case management and care coordination for pregnant women.  Somewhat fewer coverage transportation to doctors visits, home visits, and psychosocial counseling.  Nutrition counseling is covered by 34 States.  You get a real fall off when you reach substance abuse treatment and smoking cessation.  Here are two areas where there are clear links to improving birth outcomes, but most States are not covering the services.

Caution:  Even when there is coverage there still may b e issues of quality and access.  Idaho example 

- Case Studies of Comprehensive Approaches to Promoting Positive Pregnancy Outcomes

**Notes:**
I’m going to turn from the coverage of specific services to an examination of some comprehensive approaches to promoting positive pregnancy outcomes.  While doing the literature review we identified a number of efforts that looked promising.  After discussing them with Lisa we jointly developed a list of programs for further study.  We conducted telephone interviews with program administrators and reviewed information about the programs.

## Colorado Prenatal Plus Program

- Provides care coordination, nutrition, and mental health services for high-risk pregnant women
- Set reimbursement fee for full package (10 visits) of services
- Challenges
-  Reimbursement does not cover costs
-  Decline in number of providers

**Notes:**
The Colorado prenatal plus program has 27 different providers who are heavily concentrated in the urban areas of the State. It is designed for high-risk pregnant Medicaid recipients.  Most are county health departments or community health centers with a few other private non-profit agencies. Could be statewide but it is challenging to recruit providers.  There is a multidisciplinary team led by a care coordinator who works with a nutritionist and mental health specialist when warranted.  
In return for these services a provider is paid $540 for 10 visits (only one of which can not be in person) and $280 if the women only receives partial services.  This in now way covers costs and as a result of this and tough economic times, which have caused a reduction in other funding sources that might make up costs, the number of providers has dropped 34 in 2001 to 27 currently.

## Montana MIAMI Program

- Care coordination and referrals for high-risk pregnant women (i.e., targeted case management)
- Home visits from nurse, social worker, and nutritionist
- Challenges
-  Implementation required changes in definition of targeted case management, services, and rates

**Notes:**
The Montana Initiative for the Abatement of the Mortality of Infants or MIAMI program also involves care coordination and referrals for high-risk women.  This program operates in 22 county health departments serving 33 counties and 6 Indian Reservations.  A State program that uses Medicaid dollars for what is known as “targeted case management.”  In order to implement the program they had to work with Medicaid to change definitions and develop services and rates.  The program involves home visits which is an important strategy in a place like Montana where people are spread out and not easy to get to central sites.  Despite some evidence of positive results this program came close to being eliminated this past year because of budget problems.

## Delaware MOMS Program

- Hospital-based case management program
- Coordinates with Medicaid to prevent duplication.  Generally “takes a backseat” for Medicaid clients.
- Challenges
-  Provide a support services program that does not duplicate existing efforts

**Notes:**
The Delaware MOMs program is based at Christiana Hospital.
They do risk screening, phone case management, and referrals for pregnant women who are signed up to deliver there.
Unlike the other programs it is not targeted at low-income women or Medicaid recipients.  It is entirely underwritten by the hospital.  It takes a back seat for Medicaid client because the Medicaid managed care plan has its own case management program and no one wants to duplicate that. However if they have a Medicaid client who is not using Medicaid case management services they may provide services.  This type of program recognizes that these are issues not confined to a single population.  The program administrators see real benefits to doing it within the hospital system, as all the info on risks etc (like domestic violence, smoking, etc as well as medical risks) are on their computer system and are available to doctors and nurses at delivery. Which is not always the case if you a separate program handling these issues.

## California Black Infant Health Program

- Provides outreach and social support
- Works to ensure prompt enrollment in Medicaid and supplements services for a high-risk group
- Works to ensure cultural competency
- Challenges
-  Importance of providing access to services
- Need to target groups with higher risk of            prematurity and other poor birth outcomes

**Notes:**
The Black Infant Health Program grew out of demonstration program trying to address the issue that African American infants were dying at about twice the rate of other infants.  The program now operates in 17 counties and 3 additional cities or towns.  These are the counties with the largest African American populations.  State-funded program that seeks to get pregnant women enrolled in a timely fashion.  No matter how good Medicaid coverage is it is going to be more useful if you get women enrolled early in her pregnancy.
In addition to direct service the program has also examined information and services provided in other programs.  They have examined the state approach to SIDs and domestic violent prevention to see if these efforts are culturally competent or whether they were inadvertently taking approaches which alienated the African American population.
This type of program recognizes that poor birth outcomes are not evenly distributed throughout the population and if you may need to target groups with higher rates of prematurity and other poor birth outcomes.
That gives you an overview of the programs we examined Judy will talk about some of the implications of what we learned.

## Strengthening or Maintaining Medicaid Perinatal Services in Challenging Times

- Data
- Partnerships
- Constituency