Medicaid Strategies to Promote Full-Term Births
Posted May 03, 2016 by Tamara Kramer
NASHP, in Partnership with NICHQ, Releases Issue Brief on Increasing Access and Use of Progesterone
Reducing the rate of pre-term birth is a major priority for state health agencies and a growing concern for state Medicaid programs. Medicaid agencies provide coverage for over half of the nation’s births each year and pay for a higher rate of premature or low-birth weight babies than the private insurance market (10.4 percent versus 9.1 percent).
Pre-term birth, a birth that occurs prior to 37 weeks of gestation, is the leading cause of infant mortality in the United States. Early delivery is associated with a host of long-term health issues for the infant, including sight and hearing loss, cerebral palsy and developmental and intellectual disabilities.i In addition to the severe adverse health risks, premature births result in staggering costs for the U.S. health system. Pre-term births account for approximately 50 percent of all pregnancy-related spending, with the cost of a premature infant birth being nine times higher than the spending on healthy deliveries ($13,729 versus $1,498).
A number of states have implemented initiatives to promote full-term births and their results are showing that reducing the rate of pre-term delivery is achievable. Curbing pre-term birth is also a major focus of the Collaborative Improvement and Innovation Network to Reduce Infant Mortality (IM CoIIN
) convened and funded by the Maternal and Child Health Bureau, Health Resources and Services Administration, and led by NICHQ.
One promising treatment option that can reduce the risk of recurrent premature birth is the use of progesterone, a naturally occurring hormone. Studies show that the use of progesterone can decrease the likelihood of early delivery by almost 50 percent in women who previously experienced a preterm birth. The American College of Obstetricians and Gynecologists
(ACOG) and the Society for Maternal and Fetal Medicine
have recommended use of a progesterone-based drug as a strategy to reduce pre-term births since 2008.
Despite these recent findings, low-income, at-risk women in many states still do not have access to progesterone. This is often the result of drug reimbursement policies that fail to cover progesterone or the challenges related to administration of progesterone drugs, which in some forms requires weekly injections that many states require be performed in a medical office. To support increased utilization, a growing number of Medicaid agencies are implementing new policies related to progesterone access, administration and reimbursement.
Some examples include:
- In Louisiana, the state Medicaid program has established the nation’s first statewide pay-for-performance program for 17P (a version of the progesterone drug). Managed care organizations that serve Medicaid patients in the state are ineligible for full state payment for billed expenses unless they meet a progesterone-specific managed care measure. The measure requires managed care organizations to increase the 17P usage rate from 5 percent to 20 percent in its eligible pregnancy population.
- North Carolina has a quality improvement initiative focused on 17P utilization, which is a part of its Pregnancy Medical Home program. The program, launched in 2011, includes over half of the maternity care providers in the state, with over 350 practices and 1,600 individual providers participating. To take part in the Pregnancy Medical Home model, providers must agree to offer and provide 17P to all eligible patients.
- Iowa convened an Obstetrical Care Statewide Task Force with Medicaid serving as one of the primary members. The task force has developed an Obstetrical Care Statewide Strategic Plan that includes the goal of eliminating the patient barrier to appropriate progesterone use and the creation of a protocol recommendation for home health nurse administration of progesterone (to overcome issues of the weekly medical visit) by 2018.
Research and early outcomes from leader states demonstrate that efforts to increase progesterone access can lead to healthier babies and avert high health care costs. Continued focus on increasing progesterone coverage and removing barriers to its use will be important for states seeking to reduce the rates of premature birth and infant mortality.
Tamara Kramer, JD, is a Policy Associate on the Child and Family Health Team at the National Academy for State Health Policy.
[i] Medicaid Health Plans of America: Center for Best Practices, “Preterm Birth Prevention: Evidence-Based Use of Progesterone Treatment, Issue Brief and Action Steps for Medicaid Health Plans”, November 2014. Available at: http://www.mhpa.org/_upload/PTBIssueBrief111714MHPA.pdf.