Improving Maternal and Improving Maternal and Perinatal Outcomes in Perinatal Outcomes in North CarolinaNorth Carolina

Patti Forest, MDPatti Forest, MDMedical DirectorMedical DirectorDivision of Medical AssistanceDivision of Medical Assistance

North Carolina North Carolina StatisticsStatistics Infant mortality has declined 56% in the state Infant mortality has declined 56% in the state

since 1975since 1975 NC ranked 45NC ranked 45thth among other states for infant among other states for infant

mortality in 2004- 2005mortality in 2004- 2005 NC 2006 infant mortality rate was the lowest NC 2006 infant mortality rate was the lowest

in state history at 8.1 deaths per 1,000 live in state history at 8.1 deaths per 1,000 live birthsbirths

Medicaid paid for 48% of the 58,756 Medicaid paid for 48% of the 58,756 births in NC in 2005births in NC in 2005– 10.9% of Medicaid births were classified as 10.9% of Medicaid births were classified as

low birth weight but accounted for 42% of low birth weight but accounted for 42% of Medicaid infant paymentsMedicaid infant payments

Our Challenges….Our Challenges…. Racial Disparity Racial Disparity

NC Resident Infant Mortality Rates, 1977-2006

0.0

5.0

10.0

15.0

20.0

25.0

30.0

Rat

e per

1,0

00 L

ive

Bir

ths

Total

White

Minority

Total 15.8 16.6 15.2 14.4 13.2 13.7 13.2 12.5 12.0 11.6 12.1 12.6 11.5 10.6 10.9 9.9 10.6 10.0 9.2 9.2 9.2 9.3 9.1 8.6 8.5 8.2 8.2 8.8 8.8 8.1

White 12.2 13.1 11.2 12.1 10.7 10.9 10.5 10.0 9.5 9.3 9.6 9.6 8.7 8.2 8.0 7.2 7.9 7.5 6.8 7.1 6.9 6.4 6.8 6.3 6.1 5.9 5.9 6.2 6.4 6.0

Minority 23.3 23.9 23.3 19.4 18.3 19.6 19.1 18.2 17.5 16.6 17.6 18.7 17.0 15.9 16.9 15.7 16.4 15.6 15.0 14.3 14.8 16.3 14.8 14.4 14.8 14.2 14.0 15.6 14.9 13.6

1977 1978 1979 1980 1981 1982 1983 1984 1985 1986 1987 1988 1989 1990 1991 1992 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006

Our Challenges….Our Challenges….Regional DisparityRegional Disparity

Our Successes….Our Successes….And Continued And Continued OpportunitiesOpportunities Teen pregnancy rate decreased from Teen pregnancy rate decreased from

71.7 per 1,000 pregnancies in 1990 to 71.7 per 1,000 pregnancies in 1990 to 35.9 per 1,000 in 200535.9 per 1,000 in 2005

Percentage of live births that the mother Percentage of live births that the mother smoked during pregnancy decreased smoked during pregnancy decreased from 20.6% in 1990 to 12.1% in 2005from 20.6% in 1990 to 12.1% in 2005– Of pregnant women covered by Medicaid, Of pregnant women covered by Medicaid,

approximately 20% smoke during pregnancyapproximately 20% smoke during pregnancy Percentage of live births that prenatal Percentage of live births that prenatal

care began after 1care began after 1stst trimester (or no care) trimester (or no care) declined from 24.5% to 16.4%declined from 24.5% to 16.4%

Vision for Improving Vision for Improving Care to Pregnant Care to Pregnant WomenWomen Optimize health of woman prior Optimize health of woman prior

to, during, and after pregnancyto, during, and after pregnancy Optimize pregnancy intendedness Optimize pregnancy intendedness

and spacingand spacing Identify and educate women at Identify and educate women at

risk for preterm delivery prior to risk for preterm delivery prior to subsequent pregnancysubsequent pregnancy

Preconception Preconception Initiatives…Initiatives…Family Planning WaiverFamily Planning Waiver

Waiver Year OneWaiver Year One

26, 039 female enrollees; 26, 039 female enrollees; 5,560 male enrollees5,560 male enrollees

189 tubal ligations and 27 189 tubal ligations and 27 vasectomies performedvasectomies performed

During Waiver Year One During Waiver Year One 4,507 women used 4,507 women used continuous “highly continuous “highly effective” birth control effective” birth control methods methods

876 unintended 876 unintended pregnancies were pregnancies were averted due to the averted due to the programprogram

Medicaid saved $9,505,557 Medicaid saved $9,505,557 during the first Waiver Yearduring the first Waiver Year

Waiver Year Two Waiver Year Two Preliminary FiguresPreliminary Figures

41,520 female enrollees; 41,520 female enrollees; 7,873 male enrollees7,873 male enrollees

260 tubal ligations and 54 260 tubal ligations and 54 vasectomies performedvasectomies performed

Between 1435-1652 Between 1435-1652 unintended pregnancies unintended pregnancies were averted due to the were averted due to the programprogram

Medicaid saved between Medicaid saved between $14,285,125-$17,073,493 $14,285,125-$17,073,493 during the second Waiver during the second Waiver YearYear

Medicaid for Pregnant Medicaid for Pregnant WomenWomen(MPW)(MPW) Medicaid coverage for women up to 185% of Medicaid coverage for women up to 185% of

FPL during pregnancy and 60 days post-FPL during pregnancy and 60 days post-partum.partum.

Limited to services related to the pregnancy Limited to services related to the pregnancy or for treatment of illness or injury trauma or for treatment of illness or injury trauma that in the physician’s judgment may that in the physician’s judgment may complicate the pregnancy. This includes:complicate the pregnancy. This includes:– Conditions related to the pregnancy,Conditions related to the pregnancy,– Pre-existing conditions, and/orPre-existing conditions, and/or– New pathological conditions that may New pathological conditions that may

adversely affect the best possible outcome adversely affect the best possible outcome from the pregnancyfrom the pregnancy

North Carolina Baby North Carolina Baby Love ProgramLove Program Program services include:Program services include:

– Maternity Care Coordination Maternity Care Coordination – Childbirth Education Childbirth Education – Maternal Care Skilled Nurse Home Visits Maternal Care Skilled Nurse Home Visits – Maternal Outreach Worker Services Maternal Outreach Worker Services – Health and Behavior Intervention Health and Behavior Intervention – Home Visit for Postnatal Assessment and Home Visit for Postnatal Assessment and

Follow-up Care Follow-up Care – Home Visit for Newborn Care and Home Visit for Newborn Care and

Assessment Assessment

Maternity Care Maternity Care CoordinationCoordination Staffed by nurses, social workers, and Staffed by nurses, social workers, and

paraprofessionalsparaprofessionals Provides formal case management Provides formal case management

services to eligible women during and services to eligible women during and after pregnancy and intervention as after pregnancy and intervention as early in pregnancy as possible to early in pregnancy as possible to promote a healthy pregnancy and promote a healthy pregnancy and positive birth outcomespositive birth outcomes

Referrals to community resources Referrals to community resources (housing, transportation, child care, etc.)(housing, transportation, child care, etc.)

Transitions to Transitions to Interconception CareInterconception Care Refer to DSS to determine eligibility for Refer to DSS to determine eligibility for

transition from MPW to FPWtransition from MPW to FPW Education about folic acid, smoking, Education about folic acid, smoking,

and risks for preterm birth, 17P for and risks for preterm birth, 17P for future pregnancies for qualified womenfuture pregnancies for qualified women– Particularly important opportunity for Particularly important opportunity for

women who had preterm delivery during women who had preterm delivery during current or previous pregnancies current or previous pregnancies

Refer patient to safety net providers Refer patient to safety net providers http://www.ncdhhs.gov/dma/MFPW/http://www.ncdhhs.gov/dma/MFPW/SafetyNetProviders.pdfSafetyNetProviders.pdf

17P17P(17 Hydroxyprogesterone (17 Hydroxyprogesterone Caproate)Caproate)

In 2006, NC General Assembly In 2006, NC General Assembly appropriated $150,000 to make 17P appropriated $150,000 to make 17P available for uninsured women available for uninsured women (funded for a 2(funded for a 2ndnd year in 2007 year in 2007 session).session).

Medicaid began coverage of 17P in Medicaid began coverage of 17P in April 2007. April 2007.

Challenges and barriers to access still Challenges and barriers to access still exist due to status as a non-exist due to status as a non-rebateable drug.rebateable drug.

How Does North How Does North Carolina Carolina Medicaid Cover 17P?Medicaid Cover 17P? Covered by NC Medicaid Physicians Covered by NC Medicaid Physicians

Drug Program for recipients who Drug Program for recipients who meet clinical criteriameet clinical criteria

Since it is not commercially Since it is not commercially available, it must be compounded available, it must be compounded by a pharmacy providerby a pharmacy provider

Billed with HCPCS procedure code Billed with HCPCS procedure code J3490 (J3490 (unclassified drugs) unclassified drugs) and a and a copy of the invoicecopy of the invoice

17P17P

Providers are reimbursed for the Providers are reimbursed for the medication ($20/dose) as well as the medication ($20/dose) as well as the injectioninjection

The Physician Drug Program The Physician Drug Program requires that the drug be requires that the drug be administered in a physician’s office; administered in a physician’s office; therefore, recipients must make therefore, recipients must make weekly visits to office rather than weekly visits to office rather than self-injectingself-injecting

17P17P

The physician can write a prescription The physician can write a prescription for the recipient to have filled at the for the recipient to have filled at the pharmacy for home administrationpharmacy for home administration

HoweverHowever– Pharmacists can only bill for the Pharmacists can only bill for the

ingredient in a compound with a ingredient in a compound with a rebateable NDC (for 17P, that is just a rebateable NDC (for 17P, that is just a few cents per dose) plus a dispensing fee few cents per dose) plus a dispensing fee of about $5of about $5

– Only one rebateable vendor for 17P Only one rebateable vendor for 17P

DMA UpdatesDMA Updates

CMS is considering limiting CMS is considering limiting services provided by states for services provided by states for targeted case managementtargeted case management– Could impact Maternity Care Could impact Maternity Care

Coordination resourcesCoordination resources– Potential impact on services Potential impact on services

provided by POETs/NOETsprovided by POETs/NOETs http://www.cms.hhs.gov/MedicaidGenInfo/Dohttp://www.cms.hhs.gov/MedicaidGenInfo/Do

wnloads/wnloads/CMS2237IFC.pdfCMS2237IFC.pdf

EssureEssure

System modifications are System modifications are currently being programmedcurrently being programmed

Expected implementation date Expected implementation date 3/28/083/28/08

Providers will be notified in Providers will be notified in Medicaid BulletinMedicaid Bulletin

WebsitesWebsites

http://www.dhhs.state.nc.us/dma/http://www.dhhs.state.nc.us/dma/ http://www.dhhs.state.nc.us/dma/mp/mpindehttp://www.dhhs.state.nc.us/dma/mp/mpinde

x.htmx.htm http://www.dhhs.state.nc.us/dma/http://www.dhhs.state.nc.us/dma/

babylove.htmlbabylove.html www.mombaby.orgwww.mombaby.org http://www.ncdhhs.gov/dma/MFPW/http://www.ncdhhs.gov/dma/MFPW/

SafetyNetProviders.pdfSafetyNetProviders.pdf

QuestionsQuestions