Preconception Health Policy and Finance

1. Preconception Health Policy and Finance Anne Rossier Markus, JD, PhD, MHS Associate Research Professor, Department of Health Policy The George Washington University 2007 CityMatCH Urban MCH Leadership Conference August 26-28, 2007 Denver, Colorado

2. Outline - Access to Quality Preconception Care • CDC Recommendation: • To Improve Health Insurance Coverage of Preconception Care • especially for low-income women who may be at • higher risk for adverse birth outcomes • CDC Select Panel’s Workgroup on Financing of Preconception Care • CDC Action Steps • Improving the Design of Medicaid Family Planning Waivers • Monitoring, and Tying Payment to, Quality of Preconception Care through the HEDIS Measurement System

3. CDC Select Panel’s Workgroup on Financing of Preconception Care:Findings and RecommendationsMarch 9, 2007

4. Workgroup Membership • Co-Chairs: • GWU SPHHS Department of Health Policy • Dartmouth-Hitchcock Medical Center Department of Pediatrics • CDC Workgroup Lead • Members: • JIWH; KFF • AGI; ACOG; MOD • NACCHO • ASTHO; NCSL • AMCHP; NACHC; National Healthy Start Association • CDC; HRSA-MCHB; CMS

5. Working Parameters 1. Vision for Preconception Care 2. Definition of Preconception Care 3. Standard of Preconception Care BUT 4. Mixed private and public financing system with lack of universal coverage of women of reproductive age

6. 1. Vision for Preconception Care • All women of childbearing age have health coverage • All women of childbearing age are screened prior to pregnancy for risks related to outcomes • Women with a prior adverse pregnancy outcome have access to intensive preconception care to reduce their risks

7. 2. Definition of Preconception Care A set of interventions that aim to identify and modify biomedical, behavioral, and social risks to a woman’s health or pregnancy outcome through prevention and management, emphasizing those factors which must be acted on before conception or early in pregnancy to have maximal impact.

8. Brief Interventions Immunization Smoking cessation Alcohol misuse Weight management Family planning Folic acid 3. Standard of Preconception Care & Core Components Assessment & Screening Medical & reproductive history; Genetic & family history; Environmental & occupational exposures; Family planning and pregnancy spacing; Nutrition, folic acid intake, and weight management; Medications; Substance use (alcohol, tobacco and illicit drugs); Infectious diseases; Psycho-social (e.g., depression, domestic violence, housing) Health Promotion & Counseling Healthy weight; Nutrition; Preventing STD & HIV infection; Family planning methods; Abstaining from tobacco, alcohol, and illicit drug use before and during pregnancy; Consuming folic acid; Controlling pre-existing medical conditions (e.g., diabetes); Risks from prescription drugs; Genetic conditions Source: Kay Johnson, March 2007

9. 4. Mixed Financing & Lack of Universal Coverage of Women of Reproductive Age Sources: US Current Population Survey, AGI, KFF.

10. March 9 Meeting Objectives • Discuss and reach consensus on key attributes of a high performing system of preconception care financing (public and private) • Discuss options for Medicaid coverage • Discuss the roles of public health programs (i.e., Health Centers, Title X Family Planning, Title V MCH Block Grant, Healthy Start) • Discuss next steps

11. Key Attributes of a High Performing System of Preconception Care Financing • Eligibility • Enrollment and Transition between Financing Arrangements • Benefits and Coverage Rules • Cost-Sharing • Access to Community Providers • Privacy, Confidentiality and Access to Health Information • Quality and Provider Compensation

12. Eligibility (consensus) • Cover all women during their reproductive life span (from menarche to menopause) • Cannot set arbitrary limits based on age • Cannot impose coverage limits or waiting periods based on pre-existing conditions • Cannot use an asset test • Must provide subsidies for women whose family incomes are considered low (e.g., < 200% FPL)

13. Enrollment & Transition • Public financing: • Enrollment at the point of care, through outstationing, and in other locations convenient to consumers • Continuous enrollment until circumstances change, requiring review (e.g., change in income) • Loss of private coverage should be an immediate qualifying event for public coverage • Private financing: • Portability of coverage

14. Benefits & Coverage Rules • Equivalent to the existing standard of preconception care • Screening/assessment • Counseling/health education and promotion • Interventions/treatment • No arbitrary limits or exclusions • Provided by any licensed HCW within scope of practice • Medical necessity standard promotes (i) attainment and maintenance of optimal health in reproductive years and (ii) correction and amelioration of physical or mental conditions that could adversely affect reproductive health

15. Cost-Sharing • No deductibles for services identified as primary preventive care • Use of co-payments and/or coinsurance only if affordable • Availability of direct subsidies for community-based providers that serve low-income women to help offset the cost of cost-sharing and to furnish enabling services

16. Access to Community Providers • Provider network in the community should be adequate to furnish covered services • Participation of community health providers should be allowed

17. Privacy, Confidentiality and Access to Health Information • Patients and health care providers should have full and ready access to health information necessary for treatment and payment, in a secure and interoperable environment • Systems should exchange essential information to measure population health with public health agencies

18. Quality & Provider Compensation • Appropriate compensation for providers up to their scope of practice • Compensation guided by principles of quality performance, with regular and systematic measurement of process and outcome of care • Existing measures (e.g., HEDIS postpartum care) • New measures (e.g., reproductive health plan, minimum number of visits, screening tools)

19. Options for Medicaid Coverage

20. Federal and State Levels • “Women” as a new optional eligibility category • State’s choice to (i) cover some or all women not currently covered and (ii) determine scope of benefits essential to wellness – e.g., • Full Medicaid benefits • Preventive preconception package • Family planning

21. Roles of Public Health Programs

22. Public Health Programs • Title X FP programs serve ~4.6 million women of childbearing age (FP education; contraceptives; pregnancy tests) • Title V MCH services block grant programs serve ~2.5 million pregnant women (prenatal,delivery, and postpartum care for low income, at-risk pregnant women) • Health centers serve ~4.5 million women of childbearing age and provide prenatal care to some 330,000 pregnant women

23. Other Programs (Cont.) • HRSA’s Healthy Start program serves high-risk pregnant women in 99 communities in 38 States, the District of Columbia, and Puerto Rico (interconception activities) • WIC serves ~8 million women during pregnancy and postpartum (nutrition screening and counseling; supplemental food; referrals to health services)

24. Federal and State Levels • Programs need augmented federal appropriation • Within existing funds, opportunities to embed preconception care into existing services • Need to monitor and disseminate promising practices at the state and local level

25. Next Steps

26. Products and Activities • Revise and distribute principles for financing preconception care • Develop prototype fact sheets for federal and state advocates • Prepare an update on preconception benefits within Medicaid family planning waivers • Publish a special issue of Women’s Health Issues • Work with selected state/local leaders on advocacy

27. Improving the Design of Medicaid Family Planning Waivers

28. US Women of Child-Bearing Age, 2006 • According to the US Census Bureau, there are nearly 62 million women age 15-44 • 34% are low-income (<200% of poverty) Source: http://www.census.gov/hhes/www/cpstc/cps_table_creator.html

29. Insurance Coverage of US Women of Child-Bearing Age, 2003 Sources: US Current Population Survey, AGI, KFF.

30. Uninsured Women by Age, 2004 Total: 19.5 million Source: Salganicoff, A., Ranji, U., and Wyn, R. Women and Health Care: A National Profile, Kaiser Family Foundation, Washington, DC, July 2005

31. Uninsured Women of Childbearing Age (15-44) by Educational Attainment, 2006 Total: 12.4 million Source: US Census Bureau, Current Population Survey, Annual Social and Economic Supplement, 2006 http://www.census.gov/hhes/www/cpstc/cps_table_creator.html

32. Uninsured Women of Childbearing Age (15-44) by Parental Status, 2006 Total: 12.4 million Parent is defined as having 1 or more related children under age 18 Source: US Census Bureau, Current Population Survey, Annual Social and Economic Supplement, 2006 http://www.census.gov/hhes/www/cpstc/cps_table_creator.html

33. Uninsured Women of Childbearing Age (15-44) by Income, 2006 Total: 12.4 million Source: US Census Bureau, Current Population Survey, Annual Social and Economic Supplement, 2006 http://www.census.gov/hhes/www/cpstc/cps_table_creator.html

34. Uninsured Women of Childbearing Age (15-44) by Employment, 2006 Total: 12.4 million Source: US Census Bureau, Current Population Survey, Annual Social and Economic Supplement, 2006 http://www.census.gov/hhes/www/cpstc/cps_table_creator.html

35. Children below federal minimum income levels Ages 1-6: 133% FPL Ages 6-19: 100% FPL Adults in families with children (Section 1931 and TMA) Pregnant women <133% FPL Disabled SSI beneficiaries Children above federal minimum income levels Children ages 19-21 Adults in families with children (above Section 1931 minimums) Pregnant women >133% FPL Disabled (above SSI levels) Disabled (under HCBS waiver) Medically needy Girls, Adolescent Girls, and Women’s Eligibility for Medicaid Mandatory Populations Optional Populations

36. Income Eligibility Levels for Medicaid for Pregnant Women, 2006 Source: Kaiser Family Foundation, 2006 http:www.statehealthfacts.org

37. Income Eligibility Levels for Medicaid for Women as Parents, 2006 Source: Kaiser Family Foundation, 2006 http:www.statehealthfacts.org

38. Medicaid Defined Benefits “Mandatory” Items and Services “Optional” Items and Services • Prescription drugs • Medical/remedial care furnished by licensed practitioners • Diagnostic, screening, preventive, and rehab services • Clinic services • Dental services, dentures • Physical therapy • Prosthetic devices, eyeglasses • TB-related services • Primary care case management • ICF/MR services • Inpatient/nursing facility services for individuals 65 and over in an institution for mental diseases (IMD) • Inpatient psychiatric hospital services for individuals under age 21 • Home health care services • Respiratory care services for ventilator-dependent individuals • Personal care services • Private duty nursing services • Hospice services • Physicians services • Laboratory and x-ray services • Inpatient hospital services • Outpatient hospital services • Early and periodic screening, diagnostic, and treatment (EPSDT) services for individuals under 21 • Family planning and supplies • Federally-qualified health center (FQHC) services • Rural health clinic services • Nurse midwife services • Certified nurse practitioner services • Nursing facility (NF) services for individuals 21 or over Source: KFF, 2005.

39. Purposes of Family Planning • Provide individuals with personal choice in determining the number and spacing of their children and in preventing unintended pregnancies • Ensure individuals’ reproductive health and well-being (through, e.g., prevention of STDs and HIV, routine cancer screenings)

40. Unintended pregnancy in the US • Unintended pregnancy includes “Mistimed” (wanted to become pregnant in the future, but not yet) and “Unwanted” (did not want to become pregnant now or in the future) • Associated with delayed PNC and substance abuse during pregnancy, which may lead to adverse birth outcomes

41. Unintended pregnancy in the US (Cont.) • Of the 6.4 million pregnancies in US in 2001, 49% were unintended; of the 4 million births, 1.4 million were from an unintended pregnancy • 40% of women who had an unplanned birth had used contraception during the month of conception • More prevalent in poor and low-income women

42. Rates of Unintended Pregnancy, by Race/Ethnicity and Income, 2001 Unintended Pregnancies per 1,000 Women Source: Finer & Henshaw, 2006 Perspectives on Sexual and Reproductive Health, 38(2)

43. Basics of Medicaid FP Waiver Programs • Under Section 1115 of SSA • Allows states to expand eligibility to women who otherwise do not qualify for Medicaid specifically for Medicaid FP services • Can be based on loss of eligibility of women postpartum or for any reason (e.g., starting a job) • Ineligibility due to income levels • First waiver approved by HHS in 1993 (SC)

44. 26 States Have Medicaid Family Planning Waivers • 5 states—for women who have lost Medicaid eligibility postpartum • 2 states—for women who have lost Medicaid eligibility for any reason • 19 states—based on income; ~200% FPL (2001: ~ 1.7 million clients served in 13 states) Source: Guttmacher Institute, 2007 SPIB: State Medicaid Family Planning Eligibility Expansions; Gold, 2003 “Medicaid Family Planning Extensions Hit Stride”

45. Services Provided Through Medicaid Family Planning Waiver Programs • Coverage of FP services and supplies available to Medicaid enrollees in the state • No cost-sharing • FP services and supplies reimbursed 90% by federal government; other services (e.g. STD testing) reimbursed at usual matching rate for the state Source: Frost et al., 2006 “Estimating the impact of expanding Medicaid eligibility for family planning services”

46. Evidence of Impact of FP Waivers on Program Costs and Unintended Pregnancies • Budget neutral but not always reduction in number of unintended pregnancies (Edwards, Bronstein & Adams, 2003) • CA program prevented 108,000 unintended pregnancies in 1997-98 (Foster et al., 2004) • Simulation of income-based expansions to 200% and 250% of FPL found it would be cost-effective if implemented nationally (Frost, Sonfield and Gold, 2006) • Income-based expansions are effective at reducing births; save money or are at least budget neutral for states; and are at least budget neutral nationally (Lindrooth and McClullough, 2007)

47. Strengthening the Design of Family Planning Waivers in Relation to Preconception Care

48. A. Coverage & Payment of Quality FP and Preconception Care • What are the guidelines for a quality FP and preconception care benefit (e.g., CMS, CDC, ACOG/AAP)? • What are the services covered and paid by States (e.g., survey of preconception benefits and CPT codes recognized by states for reimbursement within FP waivers)? • To what extent does state coverage and payment reflect the standard of care and are there opportunities for a core benefit to increase ability to ensure quality?

49. Federal Guidelines for FP Benefit-Exist but Could be More Specific to Preconception Care CDC Recommendations: Medical & reproductive history; Genetic & family history; Environmental & occupational exposures; Family planning and pregnancy spacing; Psycho-socialassessment Image reproduced from KFF, 2005 “Medicaid: A Critical Source of Support for Family Planning in the US”

50. Examples of CPT Codes • 99384/94 (12-17 yrs); 385/95 (18-39 yrs); 386/96 (40-64 yrs) -Preventive (no symptoms), new/established patient • 99420: Health risk assessment instrument for MH/SA services • 99501-Home visit for postnatal assessment and follow-up care • 96152- Health and behavior intervention