Doula Services Improve Maternal and Child Health Outcomes

Medicaid Programs Increasingly Reimbursing for Doula Services

Doulas are professionals who provides physical, emotional, and informational support to a woman throughout pregnancy, childbirth, and postpartum. Doula’s act as a facilitator between the laboring women and her physician by ensuring that mom and dad get the information they need in a way that they understand so they can make informed decisions. 

Evidence suggests that support from doulas is linked to lower c-section rates and fewer complications. Medicaid finances more than half of all births each year in 25 states, indicating that Medicaid reimbursement policy can be a particularly effective lever to improve maternal health outcomes. Two states have enacted legislation to provide reimbursement for care by doulas as a way to improve maternal health outcomes and address existing maternal mortality disparities.

Currently, Minnesota and Oregon take advantage of the fact that doulas can reduce healthcare costs while improving outcomes in their state Medicaid programs. In the 2018 budget, Minnesota increased the reimbursement rates for doulas.  The new law also requires Oregon’s coordinated care organizations (which deliver Medicaid services) to provide information about how to access doula services online and through any printed explanations of benefits. The law tasked Oregon Medicaid with facilitating direct payments to doulas, which was addressed through rulemaking.  

New Jersey recently enacted legislation to improve maternal health among disproportionately affected groups of women by permitting the state to seek a state plan amendment or waiver that establishes Medicaid reimbursement for doula services. The legislation follows a recently piloted state doula program aimed at reducing health disparities in communities with high infant mortality rates.

Indiana also enacted legislation ensuring that pregnancy services covered by Medicaid also include reimbursement for doulas. The law incorporates doula services into the state’s obstetrician navigator program through the department of health, as well as the family and social services administration, allowing Medicaid reimbursement for services provided by doulas. Like in New Jersey, this legislation allows the state to apply for a state plan amendment or waiver necessary to implement doula reimbursement in Medicaid.

There’s growing momentum to conduct comprehensive reviews of maternal mortality data, which could help better understand the underlying causes of health disparities. Using a health equity lens to develop policy and design clinical interventions could also prove valuable by ensuring that services are culturally competent, affordable, and accessible by populations who need them most. 

Twenty-nine states (including Arizona) have committees that review maternal deaths and make public policy recommendations.  Arizona took a big step forward this last legislative session with the passage of SB 1040 Maternal Mortality Report which establishes a Maternal Fatalities and Morbidity Advisory Committee to explore public health policy interventions to improve maternal outcomes.

Perhaps the Advisory Committee, which meets on Friday August 30 from 9:30am to 12:30 pm at the Arizona State Laboratory, will explore the role that Doulas can play in improving birth outcomes and make some evidence based recommendations to better use their services in Arizona’s care network (our Board President Mary Ellen Cunningham will be representing AzPHA on the committee).

Addressing Postpartum Depression with Public Health Policy

As Arizona embarks on an in-depth look at maternal mortality in the coming months no doubt that postpartum depression will be part of the discussion.  

Moms with postpartum depression can have feelings of sadness, anxiety, and exhaustion that may make it difficult to care for themselves and their kids.  Data from the CDC’s Pregnancy Risk Assessment Monitoring System (PRAMS) show that one in nine U.S. women experience symptoms of postpartum depression.

While there’s not a single cause of postpartum depression—it likely results from a combination of physical and emotional factors—women are at greater risk for developing postpartum depression if they have one or more of the following risk factors:

  • Symptoms of depression during or after a pregnancy.

  • Previous experience with depression or bipolar disorder.

  • A family member who has been diagnosed with depression or other mental illness.

  • A stressful life event during pregnancy or shortly after giving birth.

  • Medical complications during childbirth.

  • Mixed feelings about pregnancy.

  • Lack of strong emotional support from a partner, family, or friends.

  • Alcohol or other drug use problems.

Legislative approaches to address maternal mental health conditions and postpartum depression include increasing awareness of risk factors for and effects of postpartum depression, increasing access to prenatal and postpartum screening for these risk factors, and increasing access to treatment and support services for women at high risk for postpartum depression.

Below is an overview of state legislative activity in 2019 to address the screening and treatment for maternal mental health conditions and postpartum depression.

Texas passed 2 bills addressing postpartum depression. One (HB 253) requires their health and human services commission to develop and implement a five-year strategic plan to improve access to postpartum depression screening, referral, treatment, and support services.  The other bill (SB 750) instructs the commission to develop and implement a postpartum depression treatment network for women enrolled in the state’s medical assistance program.

In Oklahoma, SB 419, directs the state licensing boards to work with hospitals and healthcare professionals to develop policies and materials addressing education about and assessment of perinatal mental health disorders in pregnant and postpartum women.

Illinois passed HB 2438 which requires that mental health conditions occurring during pregnancy or postpartum be covered by insurers.  HB 3511 (the Illinois Maternal Mental Health Conditions, Education, Early Diagnosis, and Treatment Act) requires their department of human services to develop educational materials for health care professionals and patients about maternal mental health conditions and requiring birthing hospitals to supplement the materials with relevant resources to the region or community in which they are located.

Virginia passed HB 2613, which adds information about perinatal anxiety to the types of information licensed providers providing maternity care must provide to each patient (including postpartum blues and perinatal depression).

Arizona will be exploring strategies to improve maternal health outcomes as part of the implementation of SB 1040 Maternal Mortality Report – which established a Maternal Fatalities and Morbidity Advisory Committee to explore public health policy interventions to improve maternal outcomes.

Perhaps the Advisory Committee, which meets on Friday August 30 from 9:30am to 12:30 pm at the Arizona State Laboratory, will explore the role public policy can play in reducing the public health impact of post-partum depression. Our Board President Mary Ellen Cunningham will be representing AzPHA on the committee.

AHCCCS Accepting Public Comments on their Oral Health Policy Manual

These Polices are Important in Reducing Health Disparities

AHCCCS is in the process of accepting comments on their oral health policy manual for their EPSDT program- so this is your opportunity to do some administrative advocacy and provide them with your insight and comments.

Here’s a link to the Manual and comment page: AMPM 431 – Oral Health Care for Early and Periodic Screening, Diagnosis and Treatment Aged Members

A Stakeholder group organized by First Things First staff (and AzPHA members) Kavita Bernstein and Vince Torres met last week and developed some priority recommendations that would improve children’s oral health.  Those recommendations are listed below.

You can use This Link to get to their comment page. Below are some of the recommendations for you to consider submitting.  Please use your own voice and incorporate your own perspective.  Personalized comments have more impact than block-copy-paste ones.

The sample comments below state the page number in the Manual that the comment goes with. Please ensure to include the Policy Page Number relating to each comment.

Remember that our collective voice is stronger than one…  so please take some time to submit your comments in the next couple of weeks.  The comment period ends right after Labor Day.

Page 2

Recommendation for AHCCCS to expand provider types who can provide oral health screenings within pediatric settings to include RN, RDH and APDH. This would allow for co-location models, as well as, more flexibility for pediatric clinics in service delivery.

Page 3

Recommendation for AHCCCS to consider the use of the definitions for ‘urgent’ and ‘routine’ from the Association of State and Territorial Dental Directors (ASTDD). This would allow for a consistent approach to screening and referral across health plans and providers.

Recommendation that AHCCCS consider a tighter timeline for urgent referrals given that three business days could span over a weekend and may be too long for a child exhibiting signs of pain, infection and swelling.

Recommendation for AHCCCS to expand provider types that can apply fluoride varnish within a pediatric setting, to include MAs.

Page 4

Recommendation for AHCCCS to consider allowing reimbursement for nutrition counseling by a dental home to align with the requirement to provide this specific service.

Page 5

Recommendation for AHCCCS to consider stronger, clarifying language that defines ‘medical necessity’.

Recommendation for AHCCCS to consider language that permits and reimburses for sealants on primary teeth as evidenced by positive outcomes seen by IHS and would be in alignment with the AAPD Dental Sealant Policy and Recommendation.

Recommendation for clarity on the definition of a dental provider – in addition, there is no definition in AMPM 100 to which health plans and providers can align.

Page 7

Recommendation for AHCCCS to consider the impact of a two tiered consent process on dental mobile clinics

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Recommendation for AHCCCS to clarify who ‘all providers’ are in new bullet point #7. In addition, recommendation for AHCCCS to assess the feasibility of pediatric clinics (and families) scheduling a child to come into the clinic solely for a dental screening. Recommendation for AHCCCS to consider language that indicates that providers should schedule the dental screening within the next EPSDT visit (if at a primary care clinic) or at the next dental visit (if at a dental home)

Homeland Security Establishes Final “Public Charge” Rules

Here’s my Best Shot at Explaining What the New Rules Will Do

I’m sure you’ve the flurry of reports about the Department of Homeland Security (DHS) “public charge” final rule. There will be lawsuit(s) challenging the new rules, but for now the new regulations are scheduled to kick in October 15, 2019.

The bottom line is that the new regulations will change the criteria the federal government uses to make decisions about legal permanent resident applications. The final rules will block legal immigrants from extending their temporary visas or gaining permanent residency if the government decides the applicant is likely to rely on public benefits in the future.

The Feds already consider whether applicants for legal permanent residency receive Temporary Assistance for Needy Families or Supplemental Security Income (SSI) when they evaluate applications for permanent resident status.

When the new Rules take effect on October 15 they’ll also consider whether applicants receive Medicaid (AHCCCS), the Supplemental Nutrition Assistance Program (food stamps), or Section 8 Housing assistance. 

The definition of a “public charge” in the final Rule is: “an individual who receives one or more designated public benefits for more than 12 months in the aggregate within any 36-month period”.

The draft rules released last year had included criteria that would have applied these standards to kids and adults. The final Rule won’t consider whether benefits were used by an applicant’s children. Likewise, if lawfully present kids receive benefits (e.g. Medicaid) that fact won’t be considered against them if the child later applies for legal permanent residency (a “green card”).

Here are some things to remember about this new Rule

  • This is an issue of legal immigration- unauthorized migrants are largely ineligible for public assistance;

  • This doesn’t directly impact current legal permanent residents (current green card holders). The public charge test won’t be applied to legal current residents (green card holders) applying for citizenship;

  • The new rule isn’t retroactive – meaning public benefits received before 10/15/19 won’t be counted as a public charge; and

  • The new rules don’t apply to refugees. Existing statute prevents DHS from using these criteria for refugees.

Even though the final Rule excludes benefits received by children, this policy will still have a significant impact on children’s health as well as the health of their families and our communities.

Public health note:  We know from both national reports and from assistors and community organizations working in Arizona, that families are afraid and withdrawing from or reluctant to participate in benefits for which they or their children are legally eligible. Nationally, nearly one in four children have an immigrant parent, and almost 90% of them are US citizens.  Missing out on safety net programs for which folks are entitled can result in bad health outcomes because of social determinants that won’t be addressed and missed doctor’s appointments which could result in missed developmental screenings and interventions.

The US government has made their decision – and the new policy will be implemented unless overturned by the courts. There’s nothing short suing that will undo this decision for now.

What we can do is to get the word out to families in this category that signing up their kids for safety net benefits to which they’re entitled won’t count against them when they apply for legal permanent status- nor will it count against their kids if they eventually apply for a green card. We can minimize the public health impact of this decision if the public health system is effective in ensuring that families know this important information! 

Immigration Status, Public Benefits & Access to Care

Medicaid generally limits eligibility (for immigrants) to qualified legal immigrants with refugee status, veterans, and people lawfully present in the US for 5 years or more. State Medicaid programs can elect to provide coverage to legally present immigrants before the 5-year waiting period ends (Arizona does not).

States get matching funds from CMS when they choose to provide Medicaid coverage to legally present immigrants who are children or pregnant before the end of the 5-year waiting period.  33 states have elected to cover lawfully residing immigrant children and 25 states cover legally present pregnant women (Arizona does not).

The Affordable Care Act made it possible for the legally present immigrants who are ineligible for Medicaid (due to being in the five-year waiting period) to qualify for commercial coverage and subsidies on the Federal health insurance marketplace.

Immigrants eligible for Medicaid or employer-sponsored insurance face several coverage and service barriers.  As I mentioned above, immigration officials consider the likelihood of individuals and families becoming a “public charge,” which can result in denied admission to the US or status as a lawful permanent resident. 

The criteria that will be considered beginning 10/15/19 will include whether applicants receive Medicaid (AHCCCS), the Medicare Part D Low Income Subsidy, the Supplemental Nutrition Assistance Program (food stamps), and Section 8 Housing program. The existing Rule only considered participation in Temporary Assistance for Needy Families.

Fear that using safety net services will mean that they’ll be considered a public charge contributes to some families of mixed immigration status avoiding use of services like TANF, Medicaid, SNAP etc.  Some eligible immigrants avoid services because they think family members will become involved in immigration enforcement actions.

Research findings by the Kaiser Family Foundation found that changes in healthcare use and decreased participation in Medicaid and the Children’s Health Insurance Program because of this immigration policy.

Anyway, it’s a complicated system but I hope this makes it a little clearer.

History of Considering Public Benefits

The term “public charge” as it relates to admitting immigrants has a long history in immigration law, appearing at least as far back as the Immigration Act of 1882.  In the 1800s and early 1900s “public charge: was the most common ground for refusing admission at U.S. 

Those immigration laws have evolved over the history of the country, with the most recent overhaul being the Personal Responsibility and Work Opportunity Reconciliation Act of 1996 (often referred to as PRWORA or welfare reform).  That’s the law that created Medicaid’s “qualified immigrant” standard.

In 1999, the Immigration and Naturalization Service (DHS didn’t exist yet) issued Rules to “address the public’s concerns about immigrant fears of accepting public benefits for which they remained eligible, specifically medical care, children’s immunizations, basic nutrition and treatment of medical conditions that may jeopardize public health.”

Here’s that final Rule from 1999, which didn’t include Medicaid our housing benefits in the public charge definition. The new DHS Rules will consider whether adult applicants receive Medicaid (AHCCCS), the Medicare Part D Low Income Subsidy, the Supplemental Nutrition Assistance Program (food stamps), or Section 8 Housing assistance.  

The final Rule won’t consider whether benefits were used by an applicant’s children. Likewise, if lawfully present kids receive benefits (e.g. Medicaid) that fact won’t be considered against them if the child later applies for legal permanent residency (a “green card”).

FDA Finally Proposes Updated Cigarette Warning Labels

In 2009 the Congress directed the FDA to create more graphic warning labels and mandate them on packs of cigarettes. In 2012, the FDA proposed 9 new more graphic labels. The tobacco industry sued the FDA arguing that the proposed new warning labels violated their 1st Amendment rights to free speech. Astonishingly, a 3 judge panel agreed because the propoised labels were crafted to evoke a strong emotional response rather than to educate consumers.

So it was back to the drawing board. Over the next few years the FDA didn’t propose new labels, so some health groups sued the FDA in 2016 because they still hadn’t complied with the 2009 law (now 10 years old). The health groups won, and the court ordered the FDA to come out with new draft warning labels by August with final ones in March of 2020.

You can read more about the new labels and look at them on the FDA website. Perhaps the new labels will be finally on packs of cigarettes next spring- more than 10 years after the law was passed and signed.

National Family Planning Program in for a Major Shake-Up

Title X is a super important public health program that provides folks with comprehensive family planning and related preventive health services. It’s designed to prioritize the needs of low-income families or uninsured people. The overall purpose is to promote positive birth outcomes and healthy families by allowing individuals to decide the number and spacing of children.

The services provided by Title X grantees (the funding comes from the federal government) include family planning and contraception, education and counseling, breast and pelvic exams, breast and cervical cancer screening, screenings and treatment for sexually transmitted infections and HIV.  It also focuses on counseling, referrals to other health care resources, pregnancy diagnosis, and pregnancy counseling. Title X funding does not pay for abortions.

Back in March of this year, the US Department of Health & Human Services published in the Federal Register a final rule making changes to the federal regulations governing the Title X national family planning program. The final rules dramatically change the existing Title X family planning program nationally and in AZ.  The changes include:

  • Eliminating Title X’s long-standing legal and ethical requirement for non-directive pregnancy options counseling; and

  • Requiring a “bright line” of physical and financial separation between the provision of family planning and abortion services.

Numerous provider groups, state attorneys general and non-profit organizations sought an injunction after the new Rules were announced (seeking an injunction to stop the rule from taking effect while the courts decide the legality of the rule). 

Legal History of the Case

Multiple federal district court judges blocked the new restrictive rules from going into effect. On June 20, 2019, a three-judge panel of the 9th Circuit Court of Appeals granted the Administration’s request to lift the preliminary injunctions, allowing the new Title X rules to be enforced. In early July, the 9th Circuit court ordered the cases be reheard en banc (meaning by all the judges on the 9th circuit versus a three-judge panel).

On July 11, the en banc court refused to block the new Title X rules from taking effect.

So, what’s the bottom line then?  For now- the new April Title X Rules that eliminate Title X’s long-standing model of offering non-directive pregnancy options counseling, and requiring a “bright line” of physical and financial separation between the provision of family planning and abortion services stand. 

Title X grantees including the Arizona Family Health partnership received notice from HHS that they must certify that they comply with the new regulations by September 18.  The plans for how they intend to comply were due Friday August 18.

What remains to be seen is what happens to the family planning network after September 18.  If Planned Parenthood decides to no longer provide Title X because of the new Rules, there would be a big gap in the network and folks that usually get their family planning services via Title X would need to find other places to go for these services. Since other providers are likely booked up- that means there cojld be some pretty significant delays in getting appointments for family planning services.

A Primer: How Arizona’s Ambulance Licensing System Works

The Basics

Arizona uses a Certificate of Necessity (CON) system to regulate ground ambulance service.  The overall idea is to have a regulatory system that optimally allocates resources, makes sure every place in the State has adequate emergency medical services, and that reduces rates to the extent possible.  

Any entity that wants to run an ambulance service needs to get a CON from the ADHS. It’s basically a license to run an ambulance service. The CON describes the geographic service area, level of service (advanced life support or basic life support), hours of operation, response times, effective date, expiration date for emergency medical services in the specific geographic area.  

An ambulance service that gets a CON is supposed to stick with the criteria on their certificate and operate in accordance to the statutes and rules by which it’s governed. 

A common misconception is that Arizona’s CON system is designed to limit the number of ambulance services in Arizona. That’s not the case.  Parts of the State (especially areas with high populations lots of transports) have multiple providers and overlapping service areas where more than one ambulance company can provide services. 

The Statutes and Rules require that people who want to start an ambulance service have to demonstrate that there’s “a public necessity” for the proposed service. There are detailed statutes that define what the words “public necessity” mean for the purposes of providing direction to the ADHS Director when she or he decides whether to approve a CON application.  There’s also a guidance document that outlines what the words “other things as determined by the Director” means.

How it Works

When someone wants to get a CON they apply to the ADHS. There are usually competitors that don’t want the applicant to get it (because the new applicant will be taking some of their cheese).  When someone challenges an application (called an intervenor) a hearing is scheduled with the Office of Administrative Hearings (in the ADOA).

A new statute limits that hearing to 10 days of testimony (a big improvement because these hearings used to go on for weeks or even months). The Hearing Officer listens to the testimony and documents and issues an “Order” with their opinion whether the Director should issue the CON. 

The ADHS can take or not take the Hearing Officer’s opinion. She or he can approve the CON, deny it, or approve it with some modifications.  There’s a lot of interest among the parties when these CON applications are being considered – mostly because there’s a bunch of money at stake. CON applications are quite litigious.

Here’s a couple of recent cases that illustrate recent urban and rural CON applications. 

The Case of Community Ambulance (Urban)

An outfit called Community Ambulance applied for a CON to be able to do inter-facility transports (no 911 service) in Maricopa County. The goal was to have a CON that would provide inter-facility service between the Dignity Health facilities in Central AZ.  Dignity Health was supportive of the application because they believe contracting with Community Ambulance would help them more efficiently transport their patients between facilities- improving patient care and reducing costs. 

While the current providers (AMR and a couple others) can and do provide inter-facility transports in Maricopa County, the applicant and their supporters believe that a specific service dedicated strictly to interfacility would improve efficiency (Dignity would have contracted with Community Ambulance for this specific service). 

After reviewing the application and documents, a Hearing Officer at the Office of Administrative Hearings recommended that the ADHS deny the application. Here’s that Opinion. Upon review of the Hearing Officer’s opinion, the ADHS Director agreed with the hearing officer opinion and denied the CON. 

There’s an opportunity to appeal, and Community Ambulance filed a Motion for Review with the Director. The ADHS Director can review the case and change her mind or stay with the initial decision. If the CON remains denied, Community Ambulance can appeal to Maricopa County Superior Court.

The Case of Timber Mesa (Rural)

Back in 2017, an outfit called the Timber Mesa Fire District applied to extend the boundaries of their CON to include the city of Show Low.  An existing CON was in place in Show Low (Show Low EMS- now called Arrowhead Mobile Healthcare).

After hearing the evidence- the Hearing Officer recommended that the ADHS deny the CON application because: 1) Timber Mesa didn’t show that more resources were needed in the service area; 2) the reduction in call volume for Show Low EMS would make Show Low EMS unable to meet their current obligations; and 3) Timber Mesa didn’t prove that Show Low EMS has engaged in substandard performance in either 911 or interfacility service.

The ADHS Director didn’t agree with the Hearing Officer’s recommendation and approved Timber Mesa’s CON boundary expansion into Show Low. 

Show Low EMS (now Arrowhead Mobile Healthcare) appealed the ADHS Director’s decision in Superior Court.  Last week, the Superior Court judge in the case agreed with Arrowhead that “the Director exceeded her statutory authority when she “sua sponte” amended CON 111 to include the Expanded Service Area”.  It’s now the ADHS’ job to read the Judge’s decision and figure out what to do next.

Editorial Note: When I was in the Director position, I was reluctant to issue additional CONs in rural areas because adding too many providers in rural areas can jeopardize overall service and increase costs. That’s because when transports are spread “too thin”, one or both ambulance service providers may not be able cover their expenses – which can cause them to ask for rate increases or neglect underpopulated areas which jeopardizes response times.  

In urban and suburban urban areas, I was more inclined to approve CONs that met the basic statutory requirements because there are usually plenty of transports around to ensure that ambulance providers can meet their expenses…  and increasing the number of providers can safely increase competition. In urban and suburban areas there’s a lot less risk that adding additional resources will cause rate increases or result in providers neglecting the less populated parts of the service area.

This primer is just a short summary of the CON system and how it works in Arizona. One can spend an entire career on this subject and still learn something every day- so take this for what it’s intended- a small window into the complicated world of Ambulance service Certificates of Necessity in Arizona.