Black, American Indian, and Alaska Native (AI/AN) women are two to three times more likely to die from pregnancy-related causes than white women, according to the Centers for Disease Control and Prevention. To address these disparities in Louisiana, Medicaid insurer AmeriHealth Caritas recently incorporated health equity incentives into its Perinatal Quality Enhancement Program.
In a recent interview with Healthcare Innovation, Rodney Wise, M.D., Louisiana market chief medical officer for AmeriHealth Caritas, described the scope of the problem and how the maternal health equity metrics were developed.
HCI: Can you talk about some of the historical issues with maternal health outcomes and disparities in Louisiana? Is the problem, which is bad nationally, worse in Louisiana than in most other states?
Wise: As you know, the pregnancy outcomes in the United States compare poorly with most other industrialized countries. And unfortunately, Louisiana compares poorly to almost all other states. We certainly have been in the bottom few of states when you look at pregnancy outcomes, whether that is infant mortality, preterm birth, and and also maternal mortality. These issues are longstanding in our state. They're very multifactorial, but we do know that health disparity plays a large role in the poor outcomes. And that's both in Louisiana and in in the U.S., The disparity between African-American moms and the non-Hispanic whites is fairly stark. Infant mortality is typically twice for the Black versus white and most of that is related to preterm births and low birth weights. Looking at maternal mortality, which is been worsening in this country, the disparity ratio between Black women and white women and that's looking at pregnancy-associated maternal mortality, that's defined as any death within a year of delivery, in our state it's usually two to four times as many Black moms are dying after birth than white moms.
HCI: Is one problem just a shortage of OB/GYNs in the state?
Wise: Well, certainly Louisiana is a state with a lot of health deserts as defined by March of Dimes. The problem with that is we have parishes or areas with very small populations. While there may be a community hospital there that can provide the service, it is just not large enough to support an OB provider. So yes, there is a shortage of providers. We have physicians, we have a few certified nurse practitioners, not a lot of certified midwives. We have doulas, but doulas don't provide care, they support the mom. Doulas are reimbursed in Medicaid through a value add by the companies, but their enrollment has not been great yet. We're looking forward to seeing if telehealth will make access better, especially to specialists like maternal and fetal medicine that currently is only in the major urban areas.
HCI: AmeriHealth Caritas recently incorporated health equity metrics into its Perinatal Quality Enhancement Program for maternal care providers in Louisiana. Under this program, all the Louisiana network providers who deliver a minimum number of babies each year can receive incentives above and beyond their standard reimbursement for meeting health equity and other benchmarks. Can you describe the health equity metrics AmeriHealth Caritas has put in place?
Wise: We've had our Perinatal Quality Enhancement Program for several years, and it focuses on providers who performed the best and the timeliness of prenatal care — for instance, performing certain STI screening, like chlamydia, gonorrhea and syphilis, because we know those infections contribute to preterm birth, and it also focuses on postpartum care. We reward providers who perform the best in each of these areas. We decided to look at providers who have the lowest disparity ratio. So instead of looking at the bad things that contribute to the disparity, whether it's substance use or SDIs, let's look at the providers who are performing the best. We ran the data on our providers who had the lowest disparity rate in each of the areas. From doing that, we identified a diverse group of providers and invited them into a roundtable discussion. We were pleased with the discussions that we had. There was a series of discussions with providers on what in their practice may have contributed to this low disparity and we focused on prenatal care, intrapartum or during labor and delivery, and also the postpartum care
HCI: Were there some common themes that emerged from those conversations that you could focus in on?
Wise: Yes, one primary one for me, and it's something I think we all know inherently, but it is taking the time to establish a relationship with the patient — making them feel like you have their best interest at heart and want them to have a good outcome. We also identified several areas of education for patients that the providers pointed out. For instance, we have medical transportation in Medicaid, but it appears that some patients — and it especially affects the rural areas — aren't really aware of that benefit or the degree of the benefit. There was patient education around diet, exercise, food, everything. We also found that the OB providers oftentimes weren't aware of their referral sources that were available — that may be a specialist that the patient would need, or it might be behavioral health counseling.
HCI: Does it seem to matter whether the providers are connected to a larger health system or not?
Wise: It really didn't. We certainly had a couple of providers from very large systems. But it seemed as though it was the provider and their office staff and the attention paid in their attitude toward delivering care more than the size of the system.
HCI: How did the health equity metrics change? You mentioned that you were already rewarding people who were doing well at this but was there a new phase to this where you're providing more of an incentive?
Wise: Yes, you know that this extra time it takes to establish a relationship is something that they're typically not compensated for. So the initiative we came up with is that we're incorporating a reduction in the disparity in the health equity incentives. So we'll look at a couple of measures around the timeliness of prenatal care and the postpartum care. And those are really related to that provider interaction with the patient. And those providers who are performing the best in those areas will receive additional compensation in the program.
HCI: How long after you've implemented these equity incentives before you could assess whether they're having an impact or not?
Wise: We just implemented it within the last year. I would hope within a year to two years that we can see differences, and we'll be sharing some of these best practices with other OB providers in the program so that they will know that the health equity component is there, and hopefully, implement things to improve outcomes and their practices.
HCI: Are there other conditions that AmeriHealth Caritas is working on providing similar types of equity incentives around — something like diabetes?
Wise: Yes, we do have other health equity initiatives. We actually do have a diabetes health equity initiative that we've been doing for a couple of years. We look at most of our HEDIS data, which is quality reporting, by race, ethnicity, and language. And as part of our health equity focus, we work with our health equity director, and we'll be looking at programming to focus on that.
HCI: You mentioned that STIs are an issue here. Is there a broader statewide effort from public health to address STIs and maternal health outcome issues in Louisiana?
Wise: The state’s public health maternity program has had a longstanding focus on SDIs, but within the last year, there has been increased focus on congenital syphilis as the congenital syphilis rates have been increasing in Louisiana and most other states. So that has been a focus. And part of the congenital syphilis issue is that providers are not repeating testing in the third trimester of pregnancy or at delivery. So actually, part of our quality program emphasizes third trimester syphilis testing and rewards providers who consistently and regularly test in the third trimester.
HCI: Is there anything else about the program that you want to mention?
Wise: As a company, we feel that closing these gaps, closing the disparities, is solvable. I don't anticipate that this one initiative will be the solution, but I certainly think that it will be a part of it.
