3.2 Screening of Perinatal Mental Health Conditions

NC Medicaid should incentivize PHPs to conduct perinatal mental health screenings.

Implementation:

• NC Medicaid should explicitly include mental health screenings in all three obstetrics bundles.

• NC Medicaid should require well-child care providers to conduct postpartum mental health screenings during the infant’s medical visits for the first year postpartum when the birth mother is present.

North Carolina Context

More than one in ten women suffer from postpartum depression, and seven in 100 experience depression and/or anxiety during their pregnancy.413 Women with severe forms of depression may commit suicide—a leading cause of maternal mortality.414 Maternal depression is also associated with other risk factors for maternal mortality and morbidity.415 Women of color have a much higher rate of perinatal depression than white women (38 percent v. 13-19 percent).416 Conversely, Black women receive lower levels of treatment for their perinatal mental health condition.

Currently, mental health screenings are not included in the obstetrics service packages. The antepartum service package bundle includes antepartum visits, services, counseling, fetal surveillance testing, and genetic testing case management. The postpartum service package bundle includes exams, contraceptive counseling and contraceptives, and vaccinations.417 The global obstetrics package includes the services in the antepartum and postpartum packages, as well as labor and delivery. Starting in 2018, NC Medicaid allowed obstetrics providers to be reimbursed for three emotional/behavioral assessments in the postpartum period, but these assessments are not required.418 Additionally, NC Medicaid does not currently allow providers to conduct postpartum mental health screenings for mothers at their infant’s well-child visits.419

Evidence

NC Medicaid requires PHPs to report both the percentage of deliveries in which members were screened for clinical depression while pregnant and, if positive, received follow-up care.420 While data collection is an important first step, there is more NC Medicaid can do to ensure all Medicaid enrollees, particularly Black mothers, are screened for peripartum mental health conditions and referred to timely and adequate mental health care.

NC Medicaid should include in all three obstetrics bundles a requirement for providers to conduct depression screenings. Screening is the first step in detecting and treating perinatal mental health conditions. After speaking with North Carolina stakeholders, we recommend not tying performance measures to incentive payments because there is a risk providers might select against taking on patients who are more likely to bring their quality metrics down. Therefore, this policy might have the opposite of its intended effect of delivering equitable perinatal care. Performance measures directed at PHPs, however, should be considered. PHPs cannot discriminate against seeing patients in the same way providers can, so tying quality metrics to PHP payments would not result in serious adverse selection issues.

Additionally, NC Medicaid should allow providers to conduct postpartum mental health screenings at the infant’s well-child visits. Based on interviews with stakeholders and a review of research, women with Medicaid are more likely to attend well-child visits than to attend their own postpartum visit. CMS allows states to include maternal depression screenings during a well-child visit as part of the Early and Periodic Screening, Diagnostic, and Treatment (EPSDT) benefit.421 EPSDT benefits are not subject to cost-sharing and, if the member requests it, come with scheduling and transportation assistance.422 Many states require providers to conduct maternal depression screenings as part of the EPSDT well-child visit and reimburse accordingly. North Carolina should adjust their PHP contracts to require—rather than just recommend—coverage of four maternal depression screenings per child under the age of one.423 One drawback of this approach is that children and parents with NC Health Choice are excluded because NC Health Choice does not require EPSDT.

Additional Considerations

These two recommendations—including mental health screenings in all three obstetrics bundles and requiring maternal mental health screenings during well-child visits—would require a medium-term investment from NC Medicaid. The Medicaid agency would need to update PHP contracts, which according to DHHS employees will happen twice a year starting in 2022.