AUGUST 2020 INNOVATION LANDSCAPE SERIES Maternity Care in Medi-Cal A lmost 500,000 babies are born every year in had no postpartum care relative to 6% of those privately California — about one-eighth of all babies born insured).2 They are also more than twice as likely (18% nationwide — and the state’s Medicaid program, compared to 8%) to report feeling that they never have Medi-Cal, plays an outsized role in covering those births. anyone to turn to for emotional or practical support.3 Although Medi-Cal covers one in three Californians, it pays for nearly one in two of the state’s births. This paper Pregnant people covered by Medi-Cal have worse examines the opportunities for technology-enabled inno- experiences and outcomes. Almost 10% of people cov- vations to improve the value and quality of the maternity ered by Medi-Cal also report feeling that their source care that Medi-Cal delivers. of insurance made them more vulnerable to unequal treatment during their hospital stay, compared to 1% of While most babies in the US are born healthy, and mater- privately insured pregnant people.4 In addition, pregnant nal mortality and morbidity are rare, adverse outcomes people covered by Medi-Cal are slightly more likely to are more common among people covered by Medi-Cal deliver via c-section, due almost entirely to higher c-sec- — especially those who are Black. Too often pregnant tion rates among Black pregnant people,5 who are also people covered by Medi-Cal receive care that is frag- the most likely to feel strongly that childbirth should not mented, insufficient, or discriminatory at worst. Outside be interfered with unless medically necessary.6 of the health care delivery system, they are also more likely to face barriers to accessing social needs, such as Those covered by Medi-Cal — and especially those who food and housing. Together, these factors result in higher are Black — are also more likely to deliver babies with health risks, poorer outcomes, poorer patient experi- higher needs or experience severe maternal morbidity ences, and avoidable costs for pregnant people. These or mortality. These disparities cannot be explained away disparities offer opportunity for improvement and, in by patient-level factors such as age, income, education turn, innovation for those entrepreneurs that can work level, insurance status, cesarean birth, or higher preva- within Medi-Cal’s unique approach to delivering and lence of comorbidities.7 Instead, the evidence points to reimbursing care. multiple factors at different levels, including health sys- tem quality 8 and the impact of racism and chronic stress,9 including that coming from the health system10 and the Opportunities for Innovation individual provider.11 Pregnant people covered by Medi-Cal bring greater complexity but receive less care. Pregnant people with Medi-Cal coverage are more likely to have or develop comorbidities that complicate pregnancy, such About the Author as elevated body mass index, diabetes, or preeclamp- Melora Simon, MPH, is an independent consultant who sia. Notably, they are almost twice as likely as privately provides strategic planning, project management, meet- insured pregnant people to experience prenatal depres- ing facilitation, and organizational support to health care organizations. She has previously held positions with the sion. However, compared to people covered by private Pacific Business Group on Health, Health Plan of San insurance, those covered by Medi-Cal are much less likely Mateo, Stanford Clinical Excellence Research Center, to receive early prenatal care (78% compared to 93%)1 and McKinsey & Company. or robust postpartum care (12% of Medi-Cal recipients INNOVATION IN ACTION These brief profiles focus on technology and workforce innovations piloted recently in Medi-Cal. While these examples are not exclusively mediated by managed care plans, it is important to note that many of them are, and that pregnant people covered by Medi-Cal fee-for-service are less likely to have access to these innovations. Navigating Pregnant People to Better Outcomes Engaging Members in Educational In 2017, patient engagement and navigation company Maternity Content Docent Health partnered with Dignity Health, a health In 2018, Wildflower, a maternity-focused digital health care delivery system now part of CommonSpirit Health, to company, partnered with two Medi-Cal plans, Blue Shield provide extra support to pregnant people, with the goal of Promise and Inland Empire Health Plan (IEHP), to fill a avoiding poor maternal outcomes. need for accessible, evidence-based educational informa- tion for pregnant members. Innovation. Following an interaction with the health sys- tem, Docent Health connects members with lay “docents” Innovation. Wildflower offered both plans a patient-facing or navigators that help triage members’ needs and con- educational app available in English and Spanish. IEHP nect them with appropriate services and information. chose to offer members a more tailored version, which customized the information displayed based on the mem- Scope. Over the course of the pilot, which started in 2017 ber’s population-specific risk factors and locally available and is now being rolled out across the CommonSpirit sys- resources. tem, more than 20,000 pregnant people and their families across three unique markets and all payer types used Do- Scope. Blue Shield Promise offered the app to members in cent’s services. Two-thirds of participants actively engaged San Diego County, while IEHP offered the app to all preg- with Docent’s offerings, most often to find relevant resourc- nant members in Riverside and San Bernardino Counties. es, prepare for their inpatient experience, or to follow up Over the course of a formal pilot, 47 Blue Shield mem- after returning home with key questions or concerns. bers used the app, representing about 1% of births at the participating clinics. IEHP continues to offer the app, and Impact. Patients with Medi-Cal coverage engaged by it has been downloaded by 1,864 members to date, repre- Docent had a statistically significant lower average length senting just under 10% of births in the same time period. of stay and NICU days, and had higher rates of full-term deliveries and healthy birthweight infants, relative to Impact. Across both plans, Wildflower found that less Medi-Cal patients not engaged by Docent. CommonSpirit than one-third of those who downloaded the app did so reported that Docent “provided additional touches with in their first trimester. For IEHP, 95% used the English ver- patients efficiently while optimizing tasks that were previ- sion (though Spanish was also available) and two-thirds of ously assigned to care teams.” members completed a risk factor survey, which enabled the plan to offer care management and/or behavioral Lessons learned. The accessibility of Docent’s navigators health resources. Using a case-control study, IEHP found created a new pathway for patients to have issues ad- that members who used the app had an increased likeli- dressed and escalated as appropriate. Digital communica- hood of completing a postpartum visit within eight weeks tion methods, like texting, proved critical for engaging of birth, but were no more likely to promptly connect to members. One challenge was evaluating the impact of Do- prenatal care. cent on measures related to patient satisfaction and return on investment. Impact related to clinical outcomes and Lessons learned. Relatively low uptake in both situations workflow were easier to discern. Even though Docent was reaffirmed the importance of dedicating resources to a new tech-enabled service, CommonSpirit staff reported promoting any new tool available for members and the that it reduced the workload of frontline team members challenges of plans as an engagement partner, as they rather than adding to it. Overall, the pilot affirmed for the often do not know about a pregnancy until the second tri- CommonSpirit team that a robust supporting platform is a mester. As a result, clinic partners, especially FQHCs, were vital piece of any effort to close disparities related to social critical to outreach — as was the use of digital communica- risk factors. tion methods, such as texting. One notable challenge was finding a balance between wanting to frequently update the app’s content and needing to have content approved by plans and regulators. Opportunities for future improve- ment identified including engaging members earlier in their pregnancies and more closely linking the app’s con- tent to clinical care. California Health Care Foundation www.chcf.org 2 Structure of Maternity Care $ Relatively low priority for plans. Delivery is a high-cost service, with median spending of about in Medi-Cal $7,000 per live birth, compared to about $2,100 in The structures and policies that determine where mater- average annual spending per year per beneficiary for nity care happens and what providers get paid for it drive children and $4,700 for childless adults. However, it access and outcomes. Understanding how those policies is significantly lower than the $19,600 average annual differ within the Medi-Cal system is the key to identifying spending per year per beneficiary for people with and operationalizing successful innovations. disabilities. An estimate using median spending per live birth and the number of live births covered by Medi-Cal suggests that pregnant people make up Payment 1.4% of Medi-Cal enrollees and account for 1.8% When it comes to maternity care, Medi-Cal’s approach to of spending. In other words, although Medi-Cal is a paying providers differs from other payers in key ways: very important player in maternity care in California, maternity care is a relatively small piece of all that $ The 40/60 split. Despite Medi-Cal largely shifting Medi-Cal covers. toward managed care overall, 40% of births paid for by Medi-Cal are still covered by the fee-for-service $ Fragmented risk. All Medi-Cal managed care plans (FFS) system. The rest are covered by managed are partially insulated from the risk of costly births care. The majority of FFS births are to two groups requiring the neonatal intensive care unit (NICU), of people that become newly eligible for Medi-Cal and some have almost no risk. In 37 of California’s on the basis of their pregnancy: those unable to 58 counties, Medi-Cal carves out the most intensive verify satisfactory immigration status and those with newborn care from managed care plans and cov- incomes 139% to 213% above the federal poverty ers it under the FFS system through the California line. These 40% of pregnant people covered by the Children’s Services (CCS) program.12 As of July 2019, FFS system do not benefit from the access, coordina- incentives are more aligned in the other 21 counties, tion, innovation, and quality-improvement activities where the Whole Child Model integrates coordina- typical of Medi-Cal managed care plans. tion and financing for all required newborn care and the care of children with special health care needs.13 $ Lower reimbursement. For nearly all maternity care However, even in these counties, plans receive an services, Medi-Cal reimbursement rates are signifi- enhanced capitation rate for children enrolled in cantly lower than commercial reimbursement rates. the CCS program. As a result of the payment poli- In Sacramento, for example, commercial rates can be cies — which were designed to improve access and 4 times as high for hospitals, and 10 times as high for coordination for this population — plans are not anesthesiologists, when compared to Medi-Cal FFS incentivized to invest in the prenatal care and wrap- rates. According to leaders interviewed for this paper, around services critical to prevent the kinds of poor managed care plans often pay more than Medi-Cal neonatal outcomes that require NICU care. FFS but still significantly less than commercial plans. These reimbursement disparities also exist in other types of care such as oncology and orthopedics, but maternity providers see a much larger portion of Medi-Cal patients than do providers in most other specialties. Maternity Care in Medi-Cal www.chcf.org 3 Provision $ Greater role for allied health professionals. Health Other differences in maternity care covered by Medi- education, nutritional support, and psychosocial Cal have to do with the people and places that deliver services are covered benefits in Medi-Cal through a this care. Appendix B details the different professions unique program called the Comprehensive Perinatal involved in maternity care and their reimbursement by Services Program (CPSP).24 These services, which are Medi-Cal. Importance differences here include: integrated into prenatal and postpartum care, can be delivered by licensed staff or by lay community $ Lack of continuity across the perinatal episode. health workers, and in multiple settings, including For privately insured patients, the same clinician individually or in groups, and in the home. In addi- (or at least a clinician from the same medical group), tion, doulas25 are slightly more likely to support typically provides prenatal and postpartum care and pregnant people covered by Medi-Cal than those is the birth attendant. This is less likely to be true for with commercial insurance, in spite of the fact that pregnant people covered by Medi-Cal. Only half of labor support provided by doulas is not a covered those who received prenatal care from a Federally benefit.26 This may be because some safety-net hos- Qualified Health Center (FQHC) or Look-Alike14 had pitals offer free hospital-based doula services. an FQHC provider as their birth attendant.15 Many FQHC providers do not serve as birth attendants due to the unique financing of FQHCs,16 resulting in a Implications for Innovators lack of continuity of care at a particularly vulnerable More than 7 of 10 of California’s pregnant people are time. Instead, deliveries are typically handled by an people of color. That number rises to more than 8 in on-call physician, contracted by the hospital, and 10 for those covered by Medi-Cal. Improving the out- often unknown to the pregnant person. Indeed, a comes and experiences of California’s pregnant people national survey reported that 25% of Black and 23% requires providing care that is culturally and linguistically of Latinx pregnant people had never met their birth concordant, that integrates medical and psychosocial attendant.17 needs, and that addresses potential sources of bias and discrimination within the health care system. Innovators $ Smaller role for midwives despite greater demand. alone cannot solve all these problems, but they do have Midwives attended just 6.8% of Medi-Cal births com- the power to help address them. pared to 16% of privately insured births in California in 2018.18 However, three times more people with Plans have limited business incentives to reduce the Medi-Cal coverage want a midwife than actually total cost of care, but are eager to improve perfor- use them.19 mance on measures of timely prenatal and postpartum care, including mental health. Though Medi-Cal pays $ Small role for freestanding birth centers despite for many births, maternity spending is not significant evidence of effectiveness. More than 99% of all relative to spending on other conditions. In addition, the births, including Medi-Cal births, currently take place carve-out of most NICU costs from Medicaid managed in hospitals, and hospitalization for pregnancy and care plans means that much of the potential cost sav- childbirth is the number one reason for hospitaliza- ings from investment in upstream interventions will not tion in California.20 Use of freestanding birth centers be recouped by the plans. When plans do realize sav- is a covered benefit and has been shown to have a ings, the heavy weighting given to historical costs in the positive impact on birth outcomes among people state’s rate-setting process27 can result in lower future covered by Medicaid.21 However, less than 4 in 1,000 rates, which discourages investments that reduce costs Medi-Cal births currently take place outside the hos- significantly.28 As a result, the business case for partner- pital22 despite 100 in every 1,000 pregnant people ing with health plans to improve outcomes and reduce with Medi-Cal coverage saying they would like to costly preterm births is not as strong in Medi-Cal as in give birth in a freestanding birth center.23 other markets. Plans are, however, motivated to improve California Health Care Foundation www.chcf.org 4 quality (i.e., HEDIS) scores around timely prenatal and postpartum care.29 They also articulated, in interviews for INNOVATION TO WATCH this paper, an interest in improving access and coordina- Improving Outcomes Through Community- tion for maternal mental health. Based Doulas Not all innovation is through technology. In the last Hospitals seek to reduce overall length of stay for few years, several Medi-Cal plans, including Anthem, Medi-Cal-covered pregnancies, but have limited busi- HealthNet, and IEHP, and a few counties and cities in California, have partnered with community-based ness incentives to reduce NICU use in particular. Given doulas, running pilots that pay for doula services for low rates of reimbursement under Medi-Cal, hospitals pregnant members to reduce maternal morbidity and generally lose money on Medi-Cal patients, and preg- maternal and infant mortality. Many of these pilots nant people are no exception. As a result, hospitals are have focused on Black pregnant people as disparities seeking solutions that reduce length of stay, ED visits, in outcomes are most pronounced for this population. and readmissions for pregnant people with Medi-Cal These pilots are too recent to show results, but impor- tant lessons have been learned about the need, when coverage. In addition, California hospitals are also under launching these programs, for strong partnership with pressure from purchasers and the press30 to reduce and leadership by the community the pilots are aiming low-risk c-section rates, even though in some cases, a to serve. While doula care is not a technology innova- c-section may be more profitable than a vaginal birth tion, it meets an important need expressed by patients for the institution. In contrast, they have limited busi- that is associated with improved outcomes. In addition, ness interest in reducing NICU admissions because NICU there are opportunities for technology to expand the reach of doulas. stays receive enhanced Medi-Cal reimbursement and are highly profitable for hospitals. The quality and financial incentives of FQHCs are based on the volume of encounters. As a result, they Solutions Landscape seek solutions that encourage robust engagement with Across our stakeholder interviews and market research, prenatal and postpartum care and that count toward their four categories of companies rose to the surface as being per-visit rate. Many enroll in CPSP, tapping into incre- most common and most capable of having an impact mental reimbursement for wraparound psychosocial, on maternity care outcomes for people covered by educational, and nutritional services. For the most part, Medi-Cal. See Figure 1 for examples of companies in FQHCs reported that they are seeking tech-enabled these categories: software platforms, rather than service solutions, as they A Behavioral health. Improving access to in-person prefer to hire their own staff. In interviews for this paper, or virtual behavioral health services tailored to the FQHCs articulated pain points around specialty access, unique needs of new and expecting parents care coordination for patients with complex needs, and re-engagement in postpartum care after delivery. A Inpatient birth. Supporting providers in improving the quality and/or efficiency of the birth episode A Outpatient care coordination. Addressing frag- mentation across the perinatal episode through a combination of education, screening, services and/or referrals $ Parent education and engagement. Delivering basic information about prenatal care and birth directly to consumers Maternity Care in Medi-Cal www.chcf.org 5 Among those categories, outpatient care coordina- solutions and demonstrated experience working in tion stood out as having the most potential to address Medi-Cal (see page 7). Appendix A follows with an addi- the unique challenges plaguing maternity care within tional list of maternity care start-ups working across all Medi-Cal — especially fragmentation. As a result, Table 1 four categories that are led by founders identifying as dives deeper into companies with both outpatient women and/or people of color. Figure 1. Maternity Care Company Landscape* OUTPATIENT CARE COORDINATION AND SERVICES INPATIENT BIRTH PARENT EDUCATION BEHAVIORAL HEALTH SOFTWARE AND SERVICES AND ENGAGEMENT *This landscape is not exhaustive and it is not an endorsement of the companies included in it. California Health Care Foundation www.chcf.org 6 Table 1. Outpatient Care Companies with Medicaid Experience TARGET CUSTOMERS / SERVICES OFFERED EXAMPLE CLIENTS IN CALIFORNIA SAFETY NET LANGUAGES BabyScripts App and platform for clinic staff aiming Integrated delivery systems, FQHCs English and to reduce need for in-person care; Spanish Borrego Health remote monitoring solutions for higher-risk pregnancies, including round-the-clock nurse triage line Docent Health Services of lay docents on a tech platform Health systems Staffing and to support patient experience, connection, scripting aligned CommonSpirit, Sutter Health and triage needs with local needs Mahmee Telehealth and care management platform Allied health professionals, delivery systems English and for allied health professionals Spanish CHLA/AltaMed, L.A. Dept. of Health Maven Clinic Patient-facing app and network of telehealth Employers / health plans English and providers to augment in-person care Spanish No current safety-net clients in California Ovia Health Patient-facing engagement app plus nurse Employers / health plans English and health coaches Spanish No current safety-net clients in California Wildflower Health Patient-facing engagement app with robust, Health plans, employers, delivery systems English and evidence-based content and ability to tailor Spanish Blue Shield Promise, CommonSpirit, IEHP Maternity Care in Medi-Cal www.chcf.org 7 Appendix A. Companies to Watch — Solutions with Founders Identifying as Women and/or People of Color The chart below identifies companies at all stages surfaced through our research and scanning that have founders identifying as women and/or people of color. It is not exhaustive, nor an endorsement. These companies are included because the CHCF Health Innovation Fund is committed to using its platforms to help draw attention and mobilize solu- tions to the disparities that exist in the entrepreneurial sector as a whole, and in the health tech space in particular, as relatively few ventures are led by women or people of color. IN THEIR OWN WORDS: WEBSITE DESCRIPTION FOUNDER(S) BabyLiveAdvice A virtual care team to support you from pregnancy to parenthood. Sigi Marmorstein Culture Care A telemedicine start-up for Black women. Connecting women to physicians, Monique Smith culturally and digitally. Joy Cooper Mahmee Mahmee is a HIPAA-secure care management platform that makes it easy for Melissa Hanna payers, providers, and patients to coordinate comprehensive prenatal and Linda Hanna postpartum health care from anywhere. Maven Clinic On-demand access to virtual care and services built specifically for you — Katherine Ryder all in one app. Momswell MomsWell supports the clinical decision-making providers need to identify, Maureen Fura educate and support patients with maternal mental health complications, Melissa Guevara like postpartum depression. Motherboard Birth [M]otherboard is where education meets collaboration and informed Amy Haderer decisionmaking. Our interactive software helps you create your personalized “[M]otherboard” (aka visual “birth plan”). Oula Health We’re a multidisciplinary team of obstetricians, midwives, and doulas powered Elaine Purcell by technology to deliver exceptional care that extends from our clinics into Adrianne Nickerson your home. Ovia Health Ovia Health’s comprehensive maternity and family benefits solution is Gina Nebesar transforming the way women and families are supported throughout the parenthood journey. Quilted Health Quilted Health is better maternity care: evidence-based, community centered, Christine Henningsgaard and designed for you. Radical Health Radical Health uses indigenous restorative circle practice to create space for Ivelyse Andino a new kind of dialogue between clinicians / health care providers, researchers, service providers, and community members. SoShe SoShe is the only birth class and customizable birth plan that is app-based, Shannon Field evidence-based, and expert-approved. Wildflower Health Wildflower is reinventing how women connect to care by integrating our personal- Leah Sparks ized digital solution with the provider, the payer, and best-in-class partners. Wolomi Wolomi is the only digital community that offers support to women of color to Layo George improve maternal health outcomes. California Health Care Foundation www.chcf.org 8 Appendix B. Maternity Workforce — Professions and Reimbursement by Medi-Cal DIRECT MEDI-CAL EDUCATION REQUIRED BILLING Support Providers Doula No special requirements; No Provide physical, emotional, and informational labor support to mother before, certification available during, and after birth. Lactation Consultant/Counselor Certification No International Board Certified Lactation Consultant, Certified Lactation Counselor Provide education and counseling to support breastfeeding. Medical Providers Labor and Delivery Nurse Associate’s, bachelor’s, or No, paid by Registered nurse providing direct patient care in obstetrics and labor, and/or master’s degree in nursing hospitals delivery and reproductive care. Midwife CNM: Master’s degree in Yes, but physician Certified Nurse-Midwife (CNM), Licensed or Certified Professional Midwife (LM) nursing supervision time Provide midwifery care, including perinatal, well-woman, and newborn care. is not reimbursed LM: Accredited midwifery May attend births in or outside of hospitals. CNMs require physician supervision. program certificate Physician M.D. or D.O. plus residency Yes Obstetrician/Gynecologist, Family Physician, OB/GYN Hospitalist Provide medical and surgical care to women, including providing pregnancy care. OB Hospitalist specializes in inpatient care, including obstetric emergencies. Behavioral Health Providers Clinical Psychologist Ph.D. or Psy.D. in psychology Yes Diagnose and treat a range of mental health disorders, and provide psychotherapy. Psychiatrist M.D. or D.O. plus residency Yes Provide psychiatric care to adults using medications and/or psychotherapy. Therapist Master’s degree Yes Licensed Marriage Family Therapist, Professional Clinical Counselor, Clinical Social Worker Provide counseling or therapy services to groups or individuals to address wellness, personal growth, and pathology. Notes: This list is based on CHCF correspondence with 2020 Mom, Maternal Mental Health NOW, and Emily C. Dossett, M.D. (Keck School of Medicine, LAC+USC), June 2016. It captures only the most common maternal mental health providers. Sources: Medical Board of California; California Board of Registered Nurses; DONA International; International Board of Lactation Consultant Examiners; The Academy of Lactation Policy and Practice. Maternity Care in Medi-Cal www.chcf.org 9 About the Foundation Endnotes The California Health Care Foundation is dedicated to 1.Natality public-use data 2016–2018 (expanded), CDC WONDER Database, September 2019. advancing meaningful, measurable improvements in the 2.Carol Sakala et al., Listening to Mothers in California: A way the health care delivery system provides care to the Population-Based Survey of Women’s Childbearing Experiences, people of California, particularly those with low incomes National Partnership for Women & Families, September 2018. and those whose needs are not well served by the status 3.Sakala et al., Listening to Mothers. quo. We work to ensure that people have access to the 4.Sakala et al., Listening to Mothers. care they need, when they need it, at a price they can 5.Natality public-use data 2016–2018 (expanded), CDC WONDER afford. Database, September 2019. 6.Sakala et al., Listening to Mothers. CHCF informs policymakers and industry leaders, invests 7.Elizabeth A. Howell, “Reducing Disparities in Severe Maternal in ideas and innovations, and connects with changemak- Morbidity and Mortality,” Clinical Obstetrics and Gynecology 61, ers to create a more responsive, patient-centered health no. 2 (June 2018): 387–99, doi:10.1097/GRF.0000000000000349. care system. 8.Elizabeth A. Howell et al., “Black-White Differences in Severe Maternal Morbidity and Site of Care,” American Journal of Obstetrics and Gynecology 214, no. 1 (Jan. 1, 2016): p122.e1–7, For more information, visit www.chcf.org. doi:10.1016/j.ajog.2015.08.019. 9.Stephanie A. Leonard et al., “Racial and Ethnic Disparities in Severe Maternal Morbidity Prevalence and Trends,” Annals of Epidemiology 33 (May 2019): 30–36, doi:10.1016/j. annepidem.2019.02.007. 10.Rachel R. Hardeman, Eduardo M. Medina, and Katy B. Kozhimannil, “Structural Racism and Supporting Black Lives — the Role of Health Professionals,” New England Journal of Medicine 375 (Dec. 1, 2016): 2113–15, doi:10.1056/NEJMp1609535. 11.Brian D. Smedley, Adrienne Y. Stith, and Alan R. Nelson, eds., Unequal Treatment: Confronting Racial and Ethnic Disparities in Health Care, National Academies Press (US), 2003, doi:10.17226/12875. 12.California Children’s Services (CCS) covers approximately 200,000 children annually, including 25,000 under age 1, according to the Stanford Center for Policy, Outcomes, and Prevention analysis of 2014 CCS claims data. It provides diagnostic and treatment services, including medical case management to children under 21 with CCS-eligible medical About the Innovation Landscape Series conditions as well as all neonates who require supplemental As part of its efforts to help promising products and oxygen, ventilator assistance, or a peripheral line, catheter, or services succeed and scale in California’s safety net, tube if they are receiving care in a CCS-eligible NICU. Examples the CHCF Health Innovation Fund conducts high-level of CCS-eligible conditions include chronic medical conditions landscape analyses of issue areas especially ripe for such as cystic fibrosis, hemophilia, cerebral palsy, heart disease, tech-enabled innovation. The Fund publicizes the cancer, traumatic injuries, and infectious diseases producing major findings of these landscape analyses to inform other sequelae, as well as others. funders and customers seeking scalable solutions to 13.The Whole Child Model grew out of a comprehensive challenges in the safety net. stakeholder process to redesign CCS initiated in late 2014. It was designed to meet six goals: implement patient- and Readers should note that these reports are not intend- family-centered approach, improve care coordination through ed to be exhaustive, nor are they endorsements of the an organized delivery system, maintain quality, streamline care companies included in them. Finally, because solutions delivery, build on lessons learned, be cost effective. landscapes can evolve quickly, these reports may not fully reflect the current market. www.chcf.org/innovationfund California Health Care Foundation www.chcf.org 10 14.An FQHC Look-Alike is a health center that meets all 26.Sakala et al., Listening to Mothers. requirements and is part of the Health Center Program but 27.Managed Medi-Cal plans’ capitation rates are set by the state does not receive federal award funding. Approximately one- Medicaid agency using a number of factors, the most important third of Medi-Cal deliveries in 2018 received prenatal care from of which is the “experience” over the last year — another way of an FQHC or FQHC Look-Alike, assuming all pregnant patients saying the amount and cost of services used. As a result, if the receiving prenatal care at FQHCs and FQHC Look-Alikes are plan uses fewer costly services, it results in lower payments from covered by Medi-Cal. the state in the future, a phenomenon known as “premium slide.” 15.Author analysis of Health Center Program Awardee Data 28. Intended Consequences: Modernizing Medi-Cal Rate Setting to from the Uniform Data System, California State Report, Table Improve Health and Manage Costs, CHCF, March 2018. 7, reporting from the Bureau of Primary Health Care, Healthcare Resources and Services Administration, 2018. 29.Managed Medi-Cal plans are held accountable for their performance on specific measures, including those related to 16.FQHCs are paid based on a system that was historically timely prenatal care. Plans performing below the threshold tied to their costs. As a result, each FQHC has its own per- set by the state are required to undertake performance visit rate that is significantly higher than the FFS fee schedule improvement projects. In addition, high-performing plans on reimbursement for many services. Medi-Cal managed care plans these accountability measures receive a greater share of so-called can set their own rates for FQHCs (and are required to pay them “auto-assignment” members that do not select a plan when they similarly to non-FQHC providers), and the Department of Health enroll in Medi-Cal. Care Services directly reimburses FQHCs for any difference between the managed care rate and their per-visit rate based on 30. April Dembosky, “‘Times Up’: Covered California Takes Aim at a “wraparound” payment. In an important exception to the rule Hospital C-Section Rates,” Kaiser Health News, May 24, 2018. that Medi-Cal pays less than commercial insurance, the average FQHC rate provides a higher level of reimbursement for prenatal and postpartum care than many commercial insurers. However, deliveries are reimbursed separately and are not subject to this per-visit rate. 17.Eugene Declerq et al., Listening to Mothers II (PDF), National Partnership for Women & Families, August 2008. 18.Author analysis of custom data request from the California Maternal Quality Care Collaborative, received December 17, 2019. 19.Sakala et al., Listening to Mothers. 20.Author analysis of Natality public-use data 2016–2018 (expanded), CDC WONDER Database, September 2019. 21.Lisa Dubay et al., “Improving Birth Outcomes and Lowering Costs for Women on Medicaid: Impacts of ‘Strong Start for Mothers and Newborns,’” Health Affairs 39, no. 6 (June 2020): 1042–50, doi:10.1377/hlthaff.2019.01042. 22.Author analysis of Natality public-use data 2016–2018 (expanded), CDC WONDER Database, September 2019. 23.Sakala et al., Listening to Mothers. 24.CPSP grew out of a perinatal demonstration project called the Obstetrical Access Project that operated from 1979–1982 in 13 California counties. Comprehensive services were shown to reduce the low-birthweight rate by one-third and to save approximately two dollars in short-term NICU costs for every dollar spent. CPSP services became a Medi-Cal benefit in 1987, and it covers up to 21.5 hours of individual support services and up to 27 hours of group classes. Additional services are available but require authorization from managed care plans or DHCS. 25.Doulas are nonmedical professionals who provide emotional, physical, and informational support and guidance in different aspects of reproductive health. Doulas are not covered by Medi-Cal in California, but are in some other states. More detail is available at healthlaw.org (PDF). Maternity Care in Medi-Cal www.chcf.org 11