Federal Efforts to Improve Maternal and Infant Health Data Capacity and Health Outcomes

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1 Federal Efforts to Improve Maternal and Infant Health Data Capacity and Health Outcomes US Centers for Disease Control and Prevention (CDC) Centers for Medicare & Medicaid Services (CMS) Health Resources and Services Administration (HRSA)

2 Agenda Centers for Disease Control and Prevention (CDC) Wanda D. Barfield, MD, MPH, FAAP, Captain, USPHS, Director Division of Reproductive Health, National Center for Chronic Disease Prevention and Health Promotion, Centers for Disease Control and Prevention Centers for Medicare and Medicaid Services (CMS) Stephen Cha, MD, MHS, Chief Medical Officer, Center for Medicaid and CHIP Services (CMCS) Health Resources and Services Administration (HRSA) Michael C. Lu, MD, MS, MPH, Associate Administrator, Maternal and Child Health Bureau (MCHB) Michael D. Kogan, PhD, Director, Office of Epidemiology and Research, MCHB 2

3 Federal Efforts to Improve Maternal and Infant Health Data Capacity and Health Outcomes

4 CDC s Division of Reproductive Health (DRH) Priority Areas Strategic Partnerships: Infant Health Sudden Unexpected Infant Death (SUID) Prevention Preterm Birth Prevention Women s Health Family Planning Methods, Services & Utilization Chronic Disease Prevention in Women of Reproductive Age Pregnancy Health Maternal Mortality & Complications of Pregnancy Teen Pregnancy Prevention Partnerships strive to move science to practice Optimal Reproductive Health for a Healthy Future 4

5 DRH Strategic Areas of Focus Specific targets to measure the impact of our efforts: Chronic Disease Prevention & Health Promotion of Women of Reproductive Age: Advance integration of chronic disease prevention and health promotion within health care services in programs serving women of reproductive age Teen Pregnancy Prevention: Develop and promote evidence-based programs, policies, and practices for preventing unintended teen pregnancy Family Planning Methods, Services, and Utilization: Develop and promote the evidence base for quality family planning services and methods Maternal Mortality and Complications of Pregnancy: Identify and review maternal deaths and complications of pregnancy to inform prevention efforts Infant Morbidity and Mortality: Involves Preterm Birth and Unexpected Infant Death (SUID) Prevention, and investigates causes of death and consequences of morbidity during infancy Global Reproductive Health: Improve maternal and newborn health through training, surveillance, or monitoring, and measurement; and to build capacity in global maternal and child health epidemiology 5

6 CDC and Federal Partners on the Prevention of Teen/Unintended Pregnancy Three Ways We Are Working Together Family Planning Expansions Long Acting Reversible Contraception (LARC) Performance Measurement 6

7 Connection Between Family Planning (FP) and Medicaid Medicaid is the largest public payer of publicly funded FP services Covers 75% of costs Family planning covered at higher rate than other services The Federal program covering 90% of costs 30 states expanded Medicaid eligibility for family planning Most basing eligibility solely on income These expansions occur through two mechanisms: Waivers (n=19) State Plan Amendment (n=11) Family planning expansions are focus of a Healthy People (HP) 2020 objective: FP-14 Increase the number of States that set the income eligibility level for Medicaidcovered family planning services to at least the same level used to determine eligibility for Medicaid-covered, pregnancy-related care Increase the number of States that set the income eligibility level for Medicaid-covered family planning services to at least the same level used to determine eligibility for Medicaid-covered, pregnancy-related care 7

8 DRH Activities: Family Planning Expansions Reviewed existing evaluations of state family planning waiver programs Identified need for more uniformity of measures across states, especially for program participation and key outcomes Documented need for publicly funded planning in post- Affordable Care Act (ACA) period Analysis of Massachusetts data showed continued need for publicly funded family planning services (Morbidity and Mortality Weekly Report (MMWR) 2014;63:59 62) Modeling unmet need for family planning services nationwide, based on Massachusetts experience (in progress) Estimated the potential number of Medicaid preterm births averted by family planning, by year and state (in progress) Included adoption of a family planning expansion as sole indicator of progress in CDC s 2014 Prevention Status Report for teen pregnancy prevention 8

9 Example of DRH Collaboration: Long-Acting Reversible Contraception (LARC) Long-acting reversible contraception (LARC) includes intrauterine devices (IUDs) and contraceptive implants LARC can help reduce rates of teen/unintended pregnancy and save $$ Offering LARC in the immediate postpartum period, while the woman is still in the hospital after delivery: Is safe (CDC 2010, Grimes 2010) Removes barriers to access and the American College of Obstetricians and Gynecologists (ACOG) recommends it Is acceptable to many women (e.g., 50% of teens in Colorado were using a LARC 2-6 months after delivery; CDC 2013) High typical effectiveness Should be first-line recommendations for all adolescents (ACOG, 2012) 9

10 Postpartum Insertion of LARC (continued): Perceived barriers to immediate postpartum insertion of LARC included: Global hospitalization fee No inpatient code for LARC Perception CMS/Medicaid did not want to cover it CDC s role in helping to remove barriers Raise CMS headquarters (HQ) awareness of the issue Promote awareness of South Carolina s strategy for removing barriers Inform other states about the issue (via Have You Heard, Maternal and Child Health (MCH) epidemiologist assignees, Title X grantees, ACOG, etc.) Form a Community of Practice Support a Learning Collaborative to address implementation challenges Conduct an economic evaluation 10

11 Performance Measures: Contraceptive Services CMS/HQ recommends performance measures to states There are currently no measure of contraceptive services CDC validating 2 performance measures for contraceptive services % contraceptive clients using a most or moderately effective method of contraception % contraceptive clients using LARC CDC s MCH Epidemiologist assignee in Iowa piloting the measures using Medicaid claims data Goal: CMS/HQ recommends to state Medicaid programs that they use these performance measures 11

12 Performance Measures at the State Level through Pregnancy Risk Assessment Monitoring System (PRAMS) CDC s PRAMS Collects state-specific data, population-based data on maternal attitude and experiences before, during, and shortly after pregnancy New PRAMS questionnaire revision (2016): Address national initiatives such as Healthy People (HP) 2020, the Collaborative Improvement & Innovation Network (CoIIN) to Reduce Infant Mortality, Preconception Health, etc. Assess uptake of health insurance coverage and women s preventive health services in the ACA» Contraception methods and related counseling» Sexually Transmitted Infection (STI) counseling and HIV screening/counseling» Breastfeeding support, supplies, counseling» Domestic violence screening» Gestational diabetes screening Apply science to practice framework by collecting data that can inform implementation of clinical guidelines, program strategies, and policies 12

13 Data Linkage and Use Training Purpose Train states to obtain and link Medicaid and Vital Statistics data for surveillance, performance monitoring, quality improvement purposes Timeline Linked data will allow for measurement of various maternal and child health indicators, including the C-section and low birth weight rate measures in the CMS Core Set of Children s Health Care Quality Measures December 2013 September 2014 Project Components Web-trainings (every 4th Monday of the month at 12:30 p.m. ET) for all participants; in-person training for analysts; collaborative state project Participants Teams of state colleagues from relevant departments (e.g. public health, Medicaid) 13

14 Medicaid Moving Forward Stephen Cha, MD, MHS Chief Medical Officer, Center for Medicaid and CHIP Services Centers for Medicare & Medicaid Services

15 Medicaid/CHIP The Center for Medicaid and CHIP Services is the nation s largest insurer: almost 60 million rely on Medicaid and CHIP Joint state-federal program 48% of births One of every four children Largest payer of mental health services More low-income adults to come 15

16 Medicaid Moving Forward A few of the ways we re seeing a new Medicaid Program 16

17 Delivery and Payment Reform Seamless set of services across silos for: Better Care, Better Health, Lower Costs 17

18 Improving Data and Information on Medicaid & CHIP Birth Outcomes Core Set of Maternity Measures for Medicaid and CHIP Timeliness of Prenatal Care Frequency of Ongoing Prenatal Care Behavioral Health Risk Assessment (for Pregnant Women) Well-Child Visits in the first 15 months of life Postpartum Care Elective Delivery Antenatal Steroids Cesarean Rate (for 1 st pregnancy) Percentage of Live Births Weighing less than 2,500 grams Partnered with CDC to conduct training for states on data linkage and use of state Vital Records, Medicaid claims and Title V data to facilitate collection of relevant Medicaid quality measures Initial states for training: AZ, GA, KY, IN, MA, ME, MI, MS, NM, NV, OK, SD, WV and WY Conducted analysis of Medicaid and private insurance birth outcomes and hospital costs using the Healthcare Cost and Utilization Project (HCUP) Nationwide Inpatient Sample (NIS) data 18

19 Strong Start for Mothers and Newborns: Two Strategies to Improve Birth Outcomes The Strong Start initiative has two different but related strategies: 1. Reducing Early Elective Deliveries Testing a nationwide public-private partnership and awareness effort to spread the adoption of best practices that can reduce the rate of early elective deliveries before 39 weeks for all populations 2. Enhanced Prenatal Care Approaches Testing the effectiveness of specific enhanced prenatal care approaches to reduce preterm births for high-risk women enrolled in Medicaid and CHIP 19

20 Strategy 2: Enhanced Prenatal Care Approaches 1. Group Care Group prenatal care that incorporates peer-to-peer support in a facilitated setting for three components; health assessment, education and support 2. Birth Centers Comprehensive prenatal care facilitated by midwives and teams of health professionals including peer counselors and doulas. Focus includes building relationships with patients 3. Maternity Care Homes Enhanced prenatal care at traditional prenatal sites expanding access and continuity, care coordination, and content 4. Home Visiting - CMS is partnering with the Administration for Children and Families (ACF) and HRSA on a 4 th model - evaluating HRSA s Maternal, Infant, and Early Childhood Home Visiting Program (MIECHV) 20

21 Improving Birth Outcomes: Expert Panel Expert Panel on Improving Maternal and Infant Health Outcomes in Medicaid and CHIP Convened by CMCS contractor in June 2012 co-chaired by Mary Applegate, MD and James Martin, MD FACOG Met for one year to identify strategies to improve birth outcomes 21

22 Improving Birth Outcomes: Summary of Expert Panel Strategies Data Measurement and Reporting Enhanced Maternal Care Management Effective Reproductive Enablers Perinatal Payment Strategies Improve measurement of the timing and content of postpartum care Assure use of progesterone treatment for women at high risk for preterm birth through improved screening, tracking and policies Implement reimbursement and new policies to promote LARC Unbundle global based obstetric fee schedules Adopt contraception and family planning measures Coverage for continuous doula support during labor Improve rates and content of adolescent well-care visits through measurement, data infrastructure & incentives Adopt blended payment for Cesarean and vaginal deliveries Coverage for comprehensive prenatal care (i.e., including physical, mental, social services) for women with chronic medical conditions through 90 days postpartum Provide coverage and provider incentives to increase rates of wellwoman visits Include obstetric services in valuebased payment incorporating maternal and neonatal regionalization where appropriate Payment, program and policy actions to support breastfeeding Reimbursement and service delivery policies that engage adolescents, their parents and physicians to promote mental, physical & reproductive care Develop mechanism for designating high risk pregnancies & risk adjusted payments Education & other supports for identification and treatment of maternal mental health conditions Reimburse qualified educators for childbirth education Programs and policies for screening, referral and treatment of women with substance abuse disorders 22

23 Next Steps Launch a Maternal and Infant Health Initiative, building on Expert Panel Strategies Define strategic goals Engage states, providers and beneficiaries Leverage federal partnerships Technical Assistance Quality Measurement 23

24 For more information visit Medicaid.gov: Maternal and Infant Health Care Quality Topics/Quality-of-Care/Maternal-and-Infant-Health-Care-Quality.html 24

25 Transforming the State System Development Initiative (SSDI) Grant Program and the Title V Performance Measure System Michael D. Kogan, PhD Michael C. Lu, MD, MS, MPH US Department of Health and Human Services (HHS) Health Resources And Services Administration (HRSA) Maternal And Child Health (MCH) Bureau

26 SSDI and the Block Grant Examples of current state accomplishments using SSDI funding: Real time data: Provisional rates of infant mortality in Florida and Ohio Geographic Information Software (GIS): Teen pregnancy in California & Rhode Island KIDSNET databook Data Linkage: Linked birth/death records, Medicaid, WIC, and Newborn Screening in Alaska, Louisiana, New York, and West Virginia 26

27 First Steps Identify what s working well with the SSDI program and where are the gaps Working well: Provides basic infrastructure for MCH Epidemiologist Funds needed staff, e.g., program analyst or epidemiologist Helps support data linkages and emphasis on informatics Gaps: Unevenness in capacity Lack of standardization 27

28 Standardized MCH dataset Purpose: To develop a consensus-based, common set of state MCH reporting measures, definitions, and data elements Importance: 1) Provide data comparability across state & local areas 2) Promote the sharing of data/analytic tools 3) Improve consistency of health data reporting 4) Support evidence-based policy development 5) Inform development of National Performance Measures 28

29 MCH Dataset Subgroup Methodology Objective Scoring Criteria 1. Data availability: i.e., about how many public health agencies in the 50 states and DC would have access to data for this indicator 2. Data Quality: i.e., the quality of the data that is available to measure this indicator 3. Simplicity: i.e., degree to which an indicator is simple to calculate and explain to professionals and the public 4. Public Health Impact: i.e., the potential public health impact of intervening on this indicator 5. Prediction i.e., the potential to predict an individual s health and wellness and/or that of their offspring 6. Connection to Wellness i.e., the degree to which this indicator has a connection to health and wellness based on current science 29

30 Expected Outcomes Greater collaboration across states vis-à-vis data analysis and what works programmatically Greater focus on developing infrastructure, quality improvement, and program effectiveness States will have a corpus of standardized data elements/indicators which are important for the work of any MCH department The corpus can be dynamic, i.e., new indicators can be incorporated using the same methodology, e.g., add life course indicators 30

31 Performance Measures for the Revision of the Title V Block Grant

32 Challenges A comprehensive examination of the Block Grant performance measures had not been done since 1995 There was not reliable data for some measures It was difficult to tie the national Title V measures to the State Title V programs Comparability across States was impossible for many measures because of different data sources 32

33 Goals of the Workgroup Design a transformed performance measurement system that could show the contributions of Title V programs more directly while still maintaining flexibility for the States and reducing their reporting burden 33

34 Proposed Solutions for Measurement Framework for a three tier structure for measures introduced: 1. National Outcome Measures 2. National Performance Measures 3. State-Initiated Structure / Process Measures National Outcome Measures and Performance Measures would be drawn from national data sources and prepopulated for States to analyze State-initiated Performance Structure/Process Measures would be developed by the States to measure strategies and activities of the Title V program toward the national measure 34

35 National Performance Outcome Measure: Health Domains Maternal/Women s Health: low-risk cesarean, preconception care Perinatal/Infant Health: perinatal regionalization, safe sleep, breastfeeding Child Health: developmental screening, early intervention, school readiness Adolescent/Young Adult Health: adolescent well visit, transition, bullying Life Course: insurance adequacy, medical home, immunization, nutrition and physical activities, oral health, smoking 35

36 Framework Measure Example National Outcome Measure: Infant Mortality and Sudden Unexpected Infant Deaths (SUID) National Performance Measure: Percent of infants placed to sleep on their backs; Percent of infants placed to sleep without soft bedding; Percent of infants placed to sleep alone without bed-sharing (Healthy People 2020 indicator) Possible State-Initiated Structure/Process Measures: 1) Percent of birthing hospitals that have adopted a safe sleep policy 2) Percent of birthing hospitals that have received formal training from the MCH Department 3) Implementation of public service announcements (PSA) to raise awareness of safe sleep broadly and/or through partner organizations 4) Use of data from Fetal and Infant Mortality Review (FIMR) or Child Death Review to inform programming efforts and preventive information 36

37 Collaborative Improvement & Innovation Network (CoIIN) to Reduce Infant Mortality Partnership among HRSA, Association of State and Territorial Health Officials (ASTHO), Association of Maternal and Child Health Programs (AMCHP), CDC, CityMatCH, CMS, March of Dimes, National Governors Association (NGA), National Institutes of Health (NIH) and the States Began in the 13 Southern States in January 2012, launching now in Region V, with national expansion by the end of 2014 States share best practices and receive technical assistance to make progress toward shared goals in common priority areas Keys to Success Collaborative learning Rapid cycle improvement Measurement system with real-time data Partnership and leadership 37

38 Regions IV & VI Infant Mortality CoIIN Strategy Team Aims and Data Sources By December 2013: Reduce non-medically indicated early elective delivery (< 39 weeks) by 33% (Birth Certificate, BC) Reduce smoking rate among pregnant women by 3% (BC) Increase to 90%, or 20% above baseline, mothers delivering Very Low Birth Weight (VLBW) infants at the appropriate level of care (BC) Increase safe sleep practices by 5% (Pregnancy Risk Assessment Monitoring System, PRAMS) Change Medicaid policy to increase number of women who receive interconception care (ICC) in 5-8 states (Medicaid-linked data) Title V SSDI supplement, and key federal partners CDC and CMS, are helping to improve data timeliness and quality 38

39 Accomplishments Early Elective Delivery: Overall 25% decline in early elective deliveries since 2011 baseline Smoking Cessation: Overall 8% decline in smoking during pregnancy since 2011 baseline Interconception Care: 7 out of 8 states documented Medicaid policy or procedure change to improve ICC access or content Perinatal Regionalization: significant engagement of partners and mobilization of teams in the states to address levels of care designations in context of 2012 American Academy of Pediatrics (AAP) guidelines Safe Sleep: collaborative learning sessions to share best practices and innovations are being conducted monthly 39

40 Thank You! 40

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