Access to obstetric care in rural communities is in decline. Healthcare organizations have responded to a Centers for Medicare & Medicaid Services (CMS) request for information (RFI) on maternal and infant health care in rural communities with several suggestions, including extending coverage for women with a Medicaid-covered birth beyond the statutorily-mandated 60 days postpartum and expanding telehealth coverage.
The American College of Obstetricians and Gynecologists (ACOG), representing more than 60,000 physicians and partners, prefaced its recommendations by noting that between 2004 and 2014, approximately 179 rural counties lost hospital-based obstetric services, resulting in a 9 percent increase from 45 percent to 54 percent of rural counties without hospital-based obstetric services. Additionally, more than half of rural women live more than a 30-minute drive to the nearest hospital offering perinatal services.
The United States is the only well-resourced nation with a maternal mortality rate that is on the rise, ACOG noted. The stark racial and ethnic disparities in maternal mortality are also significant and concerning: Black women are three to four times and American Indian and Alaska Native women are two to three times more likely to die due to pregnancy-related causes than their non-Hispanic white counterparts. Besides extending Medicaid payment and telehealth coverage, ACOG made several other recommendations, including:
• Expand Durable Medical Equipment, Prosthetics, Orthotics, and Supplies (DMEPOS) benefits to include blood-pressure monitoring, glucose monitoring, weight monitoring, and pulse oximetry as determined medically necessary and prescribed for pregnant and postpartum women to participate in comprehensive maternal monitoring through telehealth.
• Pilot a value-based purchasing program in which the agency rewards hospitals that appropriately transfer care during labor and delivery or other inpatient admissions related to pregnancy.
• Develop a comprehensive strategy to address issues related to prior authorization, including a reduction in the volume across the health care system, elimination of low-value prior authorization, and standardization of prior authorization requirements.
Portland, Ore.-based OCHIN, a nonprofit community-based health information technology collaborative, supports more than 500 health centers, many of them FQHCs. Many of its members have seen an increase in the demand for prenatal care in recent years.
In a written response to the RFI, Jennifer Stoll, OCHIN’s executive vice president for government relations and public affairs noted that the greatest barrier its members encounter is the lack of proper tools to deliver care to the increased number of prenatal patients who are seeking care in their clinics. “These patients experience higher complications and present with complex conditions requiring a multi-layer system to deliver the care necessary to improve outcomes for mother and child. As rural hospitals are closing at high rates, increasing the distance between operating hospitals and patients, pressure is being placed directly upon FQHCs and RHCs. Lacking the necessary funding, these health centers need the tools to move from ambulatory care to quasi-inpatient care to properly care for these patients, as patients want to deliver where they are,” she wrote.
OCHIN also is seeing disparate health outcomes as a result of unequal broadband access. “A reliable broadband connection is critical for providers as well as patients. When providers lack a reliable connection, they cannot operate with the necessary level of interoperability to ensure patients receive the highest level of care, and cannot easily access specialty consultations when a complicated patient presents in their health center. When patients cannot access broadband from within their home, they have no choice but to travel to their provider, at times putting themselves in a high-risk situation to seek care when it could be delivered virtually.”
Expanding access to virtual prenatal care for rural communities would have an enormous impact for many patients who have difficulty traveling great distances, missing work, or acquiring short-term childcare, OCHIN said.
OCHIN made the following recommendations to CMS and HHS:
• CMS should allow states flexibility to innovate and apply for waivers to allow redesign for rural communities wishing to innovate on rural health care centers of the future.
• HHS can support provider technical assistance programs such as the health center- controlled network (HCCN) program or the regional extension centers, to ensure rural health centers receive support needed for broadband, technology and data.
• Support holistic, cross-sector models that support early childhood development through a combination of programs such as head-start, pre-conception education, and lay-health worker or home nurse reimbursement during pregnancy and post-partum periods.
In its letter to CMS, the Association of American Medical Colleges called the substandard maternal and infant health that exists in many parts of this country, including rural areas, unacceptable. The AAMC encouraged CMS to partner with community-based stakeholders to co-develop programs and policies that address systemic issues such as racism, discrimination, sexism, classism, which have an adverse effect on maternal health outcomes.
The issue of rural hospital closures are further compounded by a shortage of physicians, which is projected to reach between 46,900 and 121,900 primary care and specialty physicians by 2032. To address the physician shortage, the AAMC recommends easing the outdated restrictions on Medicare support for physician training. The additional primary care and specialist physicians trained by lifting the cap on Medicare-supported GME positions would allow the U.S. to more robustly respond to the needs of communities and patients across the country both in the near term and into the future.
The AAMC echoed other respondents in recommending that CMS support an expansion of telehealth models and work with other agencies and the private sector to improve broadband access and that it should extend Medicaid coverage beyond 60 days after delivery to optimize outcomes for women after birth.
The AAMC also encouraged CMS to explore further the work of the California Maternal Quality Care Collaborative (CMQCC) founded by Stanford University School of Medicine and the State of California. It uses research and evidence-based quality improvement toolkits to improve the health of mothers across the state. Through their efforts, California's maternal mortality rate decreased by 55 percent, but pregnancy-related disparities among racial and ethnic minority women remained. The AAMC also recommends further investigation and evaluation of other alternative care models (e.g., midwives, doulas, community health workers), which have the potential to expand healthcare access for women residing in rural communities.
