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Pennsylvania Releases HealthChoices Physical Health RFA

This week, our In Focus section reviews the Pennsylvania HealthChoices Physical Health Medicaid managed care request for applications (RFA), issued by the Pennsylvania Department of Human Services on October 15, 2019. Medicaid managed care organizations (MCOs) will serve the five HealthChoices zones covering all 67 counties: Southeast, Southwest, Lehigh-Capital, Northwest, and Northeast. Contracts are worth nearly $13 billion.

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Utah Releases Medicaid Expansion Fall Back Plan Waiver Amendment

This week, our In Focus section reviews the Utah Medicaid Section 1115 Demonstration Waiver amendment Fallback Plan, released for public comment on September 27, 2019. The Fallback Plan would raise Utah’s Medicaid expansion income limit to 138 percent of the federal poverty level (FPL)[1]. Voters in the state passed full Medicaid expansion through a ballot initiative in 2018, however, the state only enacted partial expansion through a waiver. The Fallback Plan looks to fully expand Medicaid, while also implementing certain provisions, including work requirements and premiums.

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Medicaid Managed Care Enrollment Update – Q2 2019

This week, our In Focus section reviews recent Medicaid enrollment trends in capitated, risk-based managed care in 29 states.[1] Many state Medicaid agencies post monthly enrollment figures by health plan for their Medicaid managed care population to their websites. This data allows for the timeliest analysis of enrollment trends across states and managed care organizations. All 29 states highlighted in this review have released monthly Medicaid managed care enrollment data into the second quarter (Q2) of 2019. This report reflects the most recent data posted. HMA has made the following observations related to the enrollment data shown on Table 1 (below):

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Preliminary Insights on 2020 Medicare Advantage and Part D Plan Offerings

This week, our In Focus section reviews the Medicare Advantage (MA) and Part D landscape files for the 2020 plan year released by the Centers for Medicare & Medicaid Services (CMS) on September 24, 2019. These files include information on MA and Part D offerings, including premiums and benefit design. This year’s release signals continued growth for the MA program in 2020. Nationwide, the number of MA plans continues to increase, with 3,144 offerings, up from 2,741 in 2019.  Among these plans, 2,832 will offer Part D coverage. CMS states that the average monthly plan premium is expected to decrease 14 percent to $23.00 in 2020 down from $26.87 in 2019. According to CMS, this is the lowest average monthly premium since 2007.

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The Future of the ACA: Implications of 5th Circuit Decision in Texas v. United States

This week, our In Focus section reviews Texas v. United States., the most recent legal challenge to the Affordable Care Act (ACA). In July 2019, the United States Court of Appeals for the 5th Circuit heard oral arguments in the case and is reviewing the decision of United States District Court for the Northern District of Texas (District Court). The District Court ruled that the “individual mandate” provision of the ACA is unconstitutional as a result of the 2017 Tax Cuts and Jobs Act (TCJA) zeroing out of the tax penalty for not having health insurance and, consequently, that the entire ACA should be struck down as a result. As the nation awaits the 5th Circuit panel’s decision, this article discusses background, next steps in the court process, and the potential far-reaching implications of this case.

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Highlights from this Week’s HMA Conference on The Next Wave of Medicaid Growth and Opportunity

This week, our In Focus section provides a recap of the fourth annual HMA Conference, The Next Wave of Medicaid Growth and Opportunity: How Payers, Providers, and States are Positioning Themselves for Success, held this Monday, September 9, and Tuesday, September 10, in Chicago, Illinois. Nearly 500 leading executives representing managed care organizations, providers, state and federal government, community-based organizations, and other stakeholders in the health care field gathered to address the challenges and opportunities for organizations serving Medicaid and other vulnerable populations. Conference participants heard from keynote speakers, engaged in panel discussions, and connected during informal networking opportunities. Below is a summary of highlights from this year’s conference.

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Hawaii Releases Quest Integration Medicaid Managed Care RFP

This week, our In Focus section reviews the Hawaii QUEST Integration (QI) Medicaid Managed Care request for proposals (RFP), issued by the Hawaii Department of Human Services (DHS) on August 26, 2019. DHS intends to contract with four health plans. All four will serve Medicaid and Children’s Health Insurance Program (CHIP) members in Oahu, while two will also operate statewide. The two plans with the highest scoring technical proposals will serve beneficiaries statewide. The Quest Integration program is worth $2.2 billion annually.

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Strategies to Support Postpartum Visits for Women in Medicaid

This week, our In Focus section comes from HMA Community Strategies (HMACS) Senior Associate Diana Rodin and HMA Managing Principal Sharon Silow-Carroll who authored a recent article in the Journal of Women’s Health drawing on data from the recently completed five-year evaluation of the Strong Start for Mothers and Newborns II Initiative to identify promising approaches to support women in Medicaid to attend postpartum visits. Nationally, less than 60 percent of women enrolled in Medicaid or the State Children’s Health Insurance Program attend a scheduled postpartum medical visit, and some states have much lower rates.[1],[2]

Growing Attention to Postpartum Care

Postpartum care, the care provided to women in the months immediately after they give birth, is important for promoting maternal and infant health and well-being. A majority of women report at least one health issue within the year after birth,[3] and postpartum care may be particularly essential when complications such as depression, obesity, hypertension, diabetes, and substance use disorders are present during pregnancy.[4],[5],[6],[7] High-quality postpartum care can aid in detection of cardiac or hypertensive complications or suicidal ideation that can lead to maternal mortality, which is particularly high in the United States.[8],[9] Postpartum visits also offer opportunities for treating ongoing or chronic conditions, addressing complications related to pregnancy or birth, facilitating healthy pregnancy spacing,[10] addressing breastfeeding concerns,[11] and answering health and parenting questions. Timely postpartum care can reduce emergency department visits and hospitalizations.[12]

Strong Start Examined Enhanced Models of Prenatal Care and Identified Promising Postpartum Strategies

Strong Start provided enhanced prenatal care with the goals of reducing rates of preterm birth and low birthweight among Medicaid-enrolled women. It tested three different models of care: Group Prenatal Care (GPC: almost always CenteringPregnancy [Centering] or a close variant);[13] Maternity Care Homes (MCH), similar to a medical home; and Birth Centers, following the midwifery model of care[14] supplemented by support from peer counselors. All models typically focused on relationship-based care and psychosocial support along with referrals and health education. Strong Start offered patient services from 2013 to 2017, with 27 federal grant awardees operating more than 200 sites in 32 states, the District of Columbia, and Puerto Rico. Awardees included health systems, national organizations, community clinics, and private medical practices. As of the end of Strong Start in early 2017, 45,599 women had participated in the program.[15]

Findings: Increasing Care Continuity and Tailoring Strategies to Needs Can Increase Postpartum Visits

Recognizing the importance of providing support after birth, Strong Start awardees emphasized making resources and referrals available postpartum, sharing information about the importance of postpartum care, promoting awareness of and screening for common postpartum issues, and continuing contact with participants after birth—which was often a challenge when Medicaid ended for women after 60 days postpartum. Provider sites generally struggled with postpartum attendance prior to Strong Start, and attendance remained a challenge despite some reported improvements. Both awardees and program participants described a variety of barriers to postpartum visit attendance, but also identified aspects of Strong Start enhancements and other strategies that they perceived to increase access to postpartum care. These barriers and strategies are summarized in Table 1 below:

Table 1: Postpartum Visit Barriers and Strategies

Barriers Strategies
Care Continuity
  • Lack of provider continuity over the course of prenatal care
  • Discontinuity with delivery and postpartum care providers
  • Increase provider continuity across prenatal, delivery, and postpartum visits; build relationships and trust (e.g., Birth Centers typically provide opportunity to form relationships with all midwives; group prenatal care has facilitator continuity; maternity care homes may assign a consistent care coordinator)

Postpartum Information and Linkages

  • Insufficient patient information on coverage duration and availability of postpartum services/programs
  • Inadequate referrals and enrollment assistance for post-Strong Start programs and services
  • Inadequate community-based services to meet population needs
  • Address information gaps through care coordinators
  • Strengthen referral relationships with community-based organizations
  • Improve referral processes to identify and link women to appropriate resources and provide enrollment assistance/navigation
  • Enhance services to meet needs (e.g., screening and treatment for depression, postpartum classes and support groups)
Participant-Level/Logistical
  • Lack of transportation and child care
  • Out-of-date patient contact information for postpartum visit scheduling and reminders
  • Lack of effective processes for ensuring postpartum visits are scheduled

 

  • Assist with transportation scheduling, address challenges with Medicaid transportation vendors or provide vouchers
  • Offer postpartum home visits
  • Welcome newborns and other children at postpartum visits or offer childcare
  • Address communication barriers (e.g., use texting and social media, proactively update contact information)
  • Enhance outreach (e.g., schedule postpartum visit while woman is still at birth facility, use postpartum check-in calls and visit reminders)
Provider, Payer, and Patient Incentives
  • Lack of incentives for payers, providers, and women to prioritize postpartum visits

 

  • Offer postpartum “baby shower,” baby gifts or coupons, or other activities that encourage women to return
  • For State Medicaid: use Value-Based Payment, quality measures to encourage health plans and providers to increase postpartum visit rates

Continuity of care was the most common factor identified as affecting postpartum visit attendance. Having separate clinicians for prenatal, delivery, and postpartum care services, as well as lack of insurance coverage soon after delivery and lack of transportation were barriers to returning for postpartum care. However, Strong Start programs’ increased emphasis on postpartum visits often prodded awardees to examine how they could improve access. Awardees found success with strategies that were tailored to the causes of attrition in the postpartum period, such as prenatal emphasis on the importance of postpartum visits, scheduling the postpartum visit before a woman left her birth facility, conducting home visits, and linking women to ongoing health care programs or services. Awardees also found success when they were able to target their efforts to meet women’s specific needs (e.g., support for postpartum depression, substance use disorder treatment, or access to desired family planning options), and when they were able to provide a visit with a familiar provider, group of peers, or care coordinator. These findings add to other evidence supporting the effectiveness of continuity of care through consistent providers, care coordinators, home visits, group-based prenatal care, and enhanced education and support. The results of Strong Start identify many strategies that appear effective and are immediately replicable.

For more information, please contact Diana Rodin at drodin@healthmanagement.com or Sharon Silow-Carroll at ssilowcarroll@healthmanagement.com. This study was supported by a team from the Center for Medicare and Medicaid Innovation at CMS and the Urban Institute.

 

 

[1] Measure Applications Partnership. Strengthening the Core Set of Healthcare Quality Measures for Children Enrolled in Medicaid and CHIP. National Quality Forum, 2017.

[2] de Bocanegra HT, Braughton M, Howell M, Logan J, Schwarz EB. Racial and ethnic disparities in postpartum care and contraception in California’s Medicaid program. Am J Obstet Gynecol 2017;217(1):47.e1-47.e7.

[3] Haran C, van Driel M, Mitchell BL, Brodribb WE. Clinical guidelines for postpartum women and infants in primary care–a systematic review. BMC Pregnancy and Childbirth 2014;14(1):51.

[4] American College of Obstetricians and Gynecologists. Optimizing postpartum care. Obstet Gynecol 2018;131(5):e140-e150.

[5] Accortt EE, Cheadle AC, Schetter CD. Prenatal depression and adverse birth outcomes: an updated systematic review. Matern Child Health J 2015;19(6):1306.1337.

[6] Yonemoto N, Dowswell T, Nagai S, Mori R. Schedules for home visits in the early postpartum period. Cochrane Database of Systemic Reviews, 2013.

[7] Rosenbloom JI, Blanchard MH. Compliance with Postpartum diabetes screening recommendations for patients with gestational diabetes. J Womens Health 2018;27(4), 498-502.

[8] Bodnar-Deren S, Klipstein K, Fersh M, Shemesh E, Howel EA. Suicidal ideation during the postpartum period. J Womens Health 2016;25(12):1219-1224.

[9] Division of Reproductive Health, National Center for Chronic Disease Prevention and Health Promotion. Pregnancy Mortality Surveillance System. Centers for Disease Control and Prevention 2018.

[10] Cross-Barnet C, Courtot B, Hill I, Benatar S, Cheeks M, Markell J. facilitators and barriers to healthy pregnancy spacing among Medicaid beneficiaries: findings from the national Strong Start Initiative. Women’s Health Issues 2018;28(2):152-157.

[11] Wilcox A, Levi EE, Garrett JM. Predictors of non-attendance to the postpartum follow-up visit. Matern Child Health J 2016;20(1):22-27.

[12] Brousseau EC, Danilack V, Cai F, Matteson KA. Emergency department visits for postpartum complications. J Womens Health 2018;27(3):253-257.

[13] Strong Start awardees implementing Group Prenatal Care predominantly used the CenteringPregnancy approach, an evidence-based model of Group Prenatal Care formalized in 1998 through the Centering Healthcare Institute (CHI), a 501(c) 3 nonprofit organization that assists health care providers in making the changes needed to implement Group Prenatal Care. For more information about CHI or CenteringPregnancy, see https://www.centeringhealthcare.org.

[14] The Midwives Model of Care. Midwives Alliance North America, n.d.

[15] Hill I, Benatar S, Courtot B, et al. Strong Start for Mothers and Newborns evaluation: Year 4 annual report, 2 vols. Centers for Medicare & Medicaid Services 2018;1-110.

HMA Colleagues Author Journal Article on Strategies to Support Postpartum Visits for Women in Medicaid

HMA Community Strategies (HMACS) Senior Associate Diana Rodin and HMA Managing Principal Sharon Silow-Carroll have authored an article drawing on data from the recently completed five-year evaluation of the Strong Start for Mothers and Newborns II Initiative to identify promising approaches to support women in Medicaid to attend postpartum visits.

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