NYC’s Healthfirst Works to Reduce Postpartum Outcome Disparities
In New York City, complications of childbirth and pregnancy kill Black women at a rate up to 12 times that of White women. Healthfirst, one of the nation’s largest nonprofit health insurers, and Mount Sinai Health System partnered on an educational intervention and payment redesign program, which was shown to improve timely access to healthcare services and community resources for low-income, high-risk mothers.
Healthfirst was established in 1993 by 15 New York hospitals. It serves 1.5 million members in New York City and on Long Island, as well as in Westchester, Orange, and Sullivan counties. Over 1 million members are in the Medicaid program.
Many low-income women fail to get appropriate medical follow-up after delivery, putting their long-term health at risk. In a recent interview, Healthfirst executives described both the scope of the problem and their evidence-based intervention.
“We know from the public health literature that the issue around maternal morbidity and mortality is quite significant, with Black women in particular, dying at a rate three times higher than White women, Latino women as well, about 1.8 times and this extends to pretty much all populations of color,” said Susan Beane, M.D., Healthfirst’s executive medical director. “The scope of the problem has been apparent for a long time. But it's not always that easy to detect a disparity like that — you have to look for it. From the Healthfirst point of view as a managed care company, it's not always immediately evident to us that our members may have gaps in medical outcomes.” But in 2015, Mount Sinai and Healthfirst took a deeper dive into the data on women in East Harlem and launched into this work.
Women’s health coach and nutritionist Gessie Thompson said women who come to her for coaching and consultation are realizing that they have to push back if their symptoms are being ignored or downplayed. “There is a baseline difference that we see in terms of how Black women are attended to when they are navigating a pregnancy. They have to fight for and advocate for themselves at a time when they're very vulnerable,” she said. “They've just had a baby, they've come through so much, and yet they have to be the chief advocate for themselves.”
Thompson has been partnering with Healthfirst on community engagement and educating and empowering women to take control of their own nutrition and mental wellness, as well as how to navigate and advocate for themselves in the healthcare system.
Beane noted that there is a stress that women of color carry with them throughout life that's not always tangible when they walk into the doctor's office. “Maybe a woman was exposed to violence in their community; maybe a woman is exposed to racism in the system,” she said. That can translate physiologically to the poor cardiovascular and other types of outcomes that Black women have.
Errol Pierre, Healthfirst’s senior vice president for state programs, noted that millions of babies are born through the Medicaid program each year. “There are barriers to accessing care through Medicaid, so for Healthfirst, we realized it's so much more important than just giving someone an insurance card and saying good luck. Because if you do that, you end up getting the disparities that coach Gessie just talked about. Those disparities extend past the insurance card to social determinants of health. That speaks to income, that speaks to education, that speaks to transportation, that speaks to finding a doctor who looks like you, so that when you say your pain is eight on a scale from one to 10, it's not minimized.”
What Healthfirst tries to do, Pierre added, is wrap other services around the insurance card to help get the best health outcome possible. New mothers may have to choose between using their disposable income to get to the doctor's office with an Uber or pay for childcare. Those are the tough decisions Healthfirst tries to help with, he said. “The other thing we do is on payment. Dr. Beane has done extensive work with our quality program, rewarding doctors for doing the right thing. And so when we take away race and ethnicity and just say every woman over 40 must get a mammogram or every woman needs her two OB-GYN visits per year, we're mitigating systemic racism, we're mitigating disparities, because the doctor is now encouraged financially, to treat everybody equitably.”
Beane said the wrap-around services that Pierre described acts as sort of an in-kind payment to the providers. “In addition to the incentive, which could be dollars, we surrounded that practice with this cushion of helping women that they probably were not able to help on their own,” she said.
She also one aspect of a research study that was published in the AJPH in 2020 was to identify care gaps between women in East Harlem and the other women covered by Healthfirst. “We found a 12 percent gap, so we were actually measuring against a known disparity,” she said. The intervention was evidence-based. The women received outreach from community health workers who offered to help them get back into care. “We found overwhelmingly that women did want that help. Remember that we in the delivery system have a lot of rules. We wanted women to get back at three weeks. Maybe that's hard for women for all the reasons that Errol said, and so through this intervention, by holding their hand, by giving them guidance, they could get as many follow-up calls as they wanted. They also had help with social determinants of health.” Through the intervention, they were able to eliminate the disparity between those women, who were mainly women of color, and their overall population.
She said that the study proved these kinds of interventions work. Now the health system has to align around making it happen on a larger scale. “We have to have the right kind of concordant coaches, a delivery system that is willing, a payer that is willing. We have to figure out how all of those pieces work together and align those pieces,” Beane said. “And we believe that it can actually move forward, not only for us, but there are others within New York State interested in attempting to do the same.”
New York State’s Department of Health created a task force around maternal mortality, especially in Black women, and there's a postpartum taskforce doing similar work. “I applaud New York State for really taking this excess mortality seriously,” Beane said.
There are changes happening at the national level, too. The American Rescue Plan allows states to extend Medicaid coverage for postpartum care from 60 days to a full year.
There is also legislation being introduced called the Black Maternal Health Momnibus Act of 2021, a combination of 12 different bills that have been brought together. They range from critical investments in social determinants of health as well as advocacy — having someone advocate for you in the room when you can't advocate for yourself, Pierre said. “It also involves funding for community-based organizations like the Brooklyn Prenatal Network, which is a community-based organization we work very closely with in Brooklyn.”
The legislation also focuses on some new models of payment, Pierre said. “We have to get our data collection better and the right quality measures,” he added. “Not every state is collecting data like New York State is. We have to have better data and more transparency, so we can actually see the outcomes and how disparate they are.”
