Medicaid expansion poses new challenges for health plans

While expansion means better health, it is creating logistical and operational concerns that health plans must rapidly address.

Despite much effort and good intentions, U.S. infant mortality rates remain high compared to other wealthy nations, especially in low-income populations. According to the Centers for Disease Control and Prevention (CDC), of the 27 wealthiest countries, the U.S. has the highest infant mortality rate. 

Clearly, there is room for improvement.

Over the past decade, health plans and external health services companies have developed programs to meet the needs of expectant mothers, but they face big challenges. Not only must they address the needs of a diverse population with a range of healthcare and psychosocial needs; they must also deal with new state and federal policies, regulations and reporting requirements.  

The Affordable Care Act (ACA) expansion of Medicaid coverage in 2014 to individuals who fall at or below 138% of the federal poverty line is perhaps the most dramatic challenge of all. Many health plans in the states that have expanded their Medicaid coverage may not have the resources to adequately manage the complexity and magnitude of coordinating the care and costs of this population.

The question is whether to build more expertise internally, or to look to external partners, specifically those with strong nurse case management approaches.  It’s a question every health plan serving a Medicaid population must explore and strategically address.

Challenges of today

In 2014, 15 million uninsured Americans, including 7 million women, became newly eligible for Medicaid coverage. More than 30% of these women are of childbearing age. That's 4.6 million women, 3.4 million of whom have incomes below the FPL.

Already, costs for pregnancy, delivery and newborn infants make up a significant percentage of total Medicaid spend. A noteworthy percentage of this cost is related to adverse outcomes of pregnancy that lead to a neonatal intensive care (NICU) admission.  Medicaid mothers experience a higher percentage of adverse newborn outcomes than mothers in the commercial population. They are more likely to have a preterm or low birth weight infant, and their pregnancies are more likely to result in an admission to the neonatal intensive care unit (NICU).

While expansion means better health, it is creating logistical and operational concerns that health plans must rapidly address. Demand for services is increasing, yet many health plans are running on lean staffing models. Plus, despite our best efforts, emergency room utilization by Medicaid members is increasing in some expansion states. What’s more, there is a growing shortage of physicians,  especially in lower income communities, and many physicians do not accept Medicaid. In short, there is much to accomplish, but scant resources.

Next: More Care for More Women



More care for more women

ACA regulations in combination with Medicaid guidelines and policies also present challenges for Medicaid plans, especially those in states that have participated in the expansion.

Under the ACA, health plans are required to provide perinatal and postpartum maternity care, as well as care during pregnancy and childbirth services. Additionally, all health insurance marketplace plans offered under the ACA and Medicaid plans now cover pregnancy and childbirth for women who become pregnant before their coverage takes effect. Medicaid and the Children’s Health Insurance Program (CHIP) provide coverage whenever the patient enrolls, which means pregnant women may enroll outside open enrollment.

The ACA also provides $1.5 billion for a new home visiting program that pairs new and expectant families with trained professionals who provide parenting information, resources and support during pregnancy and through the child’s first three years.  A preference for visitation is given to at-risk families. 

Additionally, the ACA requires that preventive service be covered by all new insurance plans without copays, deductibles or other added costs for women.  Some of these benefits include: coverage of breast-feeding counseling and equipment, folic acid supplementation, and screening for gestational diabetes.

CMS has an initiative to increase the number of states consistently collecting and uniformly reporting voluntary core quality measures that assess the results of care, including measures related to maternity care, such as:

  • Timeliness of prenatal care;

  • Frequency of ongoing prenatal care;

  • Post-partum care rate;

  • Behavioral health risk assessment for pregnant women;

  • Cesarean rate (reduce rate);

  • Low birth weight rate* (improve percentage newborns weighing less than 2,500 grams); and

  • Well-child visits in the first 15 months of life.

The CMS is seeking to improve the quality and quantity of the data collected in order to measure and improve the quality of health care for children and adults enrolled in Medicaid and CHIP.  This is where some health plans may really need assistance from partners who have the resources to improve both quality care and quality reporting.

Next: Need for Expertise



Need for expertise

External partners can help address the challenges of adapting to policy changes and increased demand. One important resource to explore is that of nurse case managers trained and experienced in maternal health services.

These nurse case managers can become an important bridge between the patient and physician, addressing the needs of high-risk patients by providing education, therapy and medications to help ensure that pregnancies are carried to term.

In established maternal health programs, nurse case managers visit patients in their home, at work or even at shelters for the homeless; they go where the patients need them. They help assess psychosocial needs, check vital signs, encourage patients to keep up with routine check-ups and other appointments and administer medication to prevent nausea and pre-term labor if needed.

These nurses also provide important care coordination and an extra layer of guidance while helping to answer basic questions about nutrition, medications, vitamins, when to go to a doctor and other questions important to expectant mothers. It’s a service that lends itself to a diverse population that may often face challenges getting to routine appointments, or who may lack access and/or funds for reliable transportation.

Plus this ability for patients to interact with a trusted caregiver in a convenient environment ensures higher adherence to recommended care guidelines and can help reduce the care load for busy physicians.

Programs are now in place addressing the needs of the maternal health populations providing guidance for other such initiatives. A program from a leading health management company decreased the risk of spontaneous preterm birth up to 50% in a population of nearly 14,000 patients receiving a drug therapy to prevent preterm birth,  and reduced the average length of stay in the NICU for Medicaid preterm babies by 8-9%.

Next: Steps to Take



Steps to take

For all these reasons, seeking help in support of maternal health efforts is important and a step that warrants serious consideration. Look for partners that offer:

  • A team of experienced physicians and skilled high-risk nurse case managers;

  • Clinicians with a wide range of expertise, experience and knowledge to supplement and support the health plan's internal physician/provider resources;

  • An organization that will work with you to develop programs tailored to your needs;

  • An organization with a good  reputation and current clients that speak well of the programs and the results they have achieved;
  • The ability to identify women at risk for preterm births or adverse birth outcomes;

  • Strong education and support programs to identify and prevent complications;
  • OB case management for women with complicated pregnancies;

  • Homecare services from an OB nurse, including monitoring and administration of physician-prescribed drug therapies to prolong pregnancies;

  • A strong track record of  coordination with physicians and other caregivers;

  • Unlimited telephonic nurse availability and support throughout pregnancy;

  • Post-partum depression screening; and

  • First-year-of life programs.

Also look for programs that will help identify populations at risk. This can be surprisingly challenging for health plans. It begins with identifying the women in their populations who are eligible for maternal health programs: Who are they and where are they?

Low birth weight and the Cesarean delivery are used in vital records and can help with identification; however, administrative data is usually needed to identify women covered by Medicaid. Not all states have a system to link these records. Health plans' contractors that have their own technology resources and contacts can help in the important identification phase.

Jill Abramson, RN, is senior director of product management for maternity services for Alere Health, an Optum company. She is responsible for the life cycle of Alere Health’s Maternal-Newborn Solutions suite of products and services, with a focus on supporting the unique needs of the Medicaid population. Prior to joining Alere Health, Jill held a variety of nursing positions in Massachusetts, California and Georgia including critical care, management, clinical quality and community health.