4. Quality Measures

NC Medicaid should encourage PHPs to decrease disparities in maternal health outcomes.

Implementation:

• NC Medicaid should tie quality metrics in PHP contracts to tobacco cessation, perinatal depression, substance use disorder, and hypertension among pregnant and postpartum women.

North Carolina Context

NC Medicaid requires PHPs to report two Health Effectiveness Data and Information Set (HEDIS) measures, timeliness of prenatal care and postpartum care, as well as contraceptive care. It requires PHPs to report non-HEDIS measure indicating the percentage of women who had a live birth and were provided a most effective/ moderately effective contraceptive method or long-acting reversible method of contraception within 60 days of delivery.424

During the first two contract years, NC Medicaid will not tie these maternal health quality metrics to provider payment rates. Starting in the third contract year (2023-2024), NC DHHS will withhold payments for certain services that do not meet quality metrics. NC Medicaid will consider overall performance improvement for each plan’s enrolled population relative to other PHPs, as well as the relative improvement in the performance for a group with disparate outcomes when it determines rewards for quality metrics.425

Several North Carolina stakeholders reported that tying quality metrics to payments might exacerbate health inequities. If providers are concerned that their Medicaid payments might decrease, they could be selective in the patients they see; specifically, they might not see patients who are historically associated with poor maternal outcomes.

However, because these payments are tied to PHPs instead of providers, there is a lower risk of adverse selection. According to stakeholder interviews, these incentives may encourage PHPs to ensure enrollees receive adequate treatment for their conditions and specifically support women of color in receiving treatment to reduce racial disparities in care. For example, even when a provider conducts a perinatal depression screening (see Screening of Perinatal Mental Health Conditions recommendation above) and a woman tests positive, there is no accountability to ensure the pregnant or postpartum woman receives adequate treatment. Thus, a large portion of people do not end up receiving treatment. Black women, specifically, are much less likely to be properly screened for depression and receive mental health treatment.426

Evidence

Quality measures present opportunities to improve maternal health among Medicaid enrollees. The Centers of Medicaid and CHIP Services published a set of recommendations on three focus areas to improve maternal and infant health: i) cesarean section births among women at low-risk for complications, ii) improved postpartum care, and iii) improved well-child visits.427 All the recommended strategies are accompanied by quality measures that can be incorporated into quality improvement systems.

NC Medicaid should consider other perinatal data as additional quality metrics to withhold payments. Other perinatal data could include perinatal depression screening and followups, which PHPs are already required to report. Additionally, PHPs are required to report hypertension, tobacco cessation, and substance use screening and intervention. These outcomes—all of which contribute to maternal mortality and morbidity—should be broken down by pregnancy and postpartum status and considered as quality measures.428

When determining the withhold percent, NC Medicaid has several payment specificities to consider. Some states have robust methods to these calculations with respect to quality measures. For example:

• Louisiana withholds one percent of each MCO monthly capitated payment, which can be earned back if the MCO meets the state-established measure or improves two percentage points from the prior year.429

• Missouri and Ohio withhold three percent of each MCO annual capitated payment, which can be earned back if the MCO meets certain standards on HEDIS measures. High-performing MCOs in Ohio are eligible for an annual bonus, which is funded by an unreturned withheld dollars.430

Additional Considerations

NC Medicaid’s plan to consider overall and relative performance improvements in disparate outcomes when it determines rewards for quality metrics is promising. Disaggregating the quality measures (hypertension, tobacco cessation, perinatal depression screening and follow-up, and substance use screening and intervention) specifically for pregnant and postpartum women as separate measures to withhold PHP capitation payments would incentivize PHPs to improve maternal health outcomes but requires a medium-term investment from NC Medicaid. NC Medicaid cannot withhold payments until 2023. Additionally, NC Medicaid would need to analyze the disaggregated data submitted by PHPs in order to confirm that there have been recent and consistent racial and ethnic disparities among these quality metrics.

5. Administrative Burden

NC Medicaid should reduce administrative burdens that keep pregnant and postpartum enrollees from enrolling in Medicaid.

Implementation:

• NC Medicaid should create a shortened Medicaid enrollment form specifically for pregnancy Medicaid.

• NC Medicaid should pursue a State Plan Amendment to exempt under 21 pregnant people from income determination for pregnancy Medicaid.

NC Medicaid should improve enrollees access to translation services during perinatal appointments.

Implementation:

• NC Medicaid should incentivize PHPs to reduce wait times for translation services during perinatal appointments and increase access to translation services through telehealth.

North Carolina Context

Much of the administrative side of NC Medicaid happens at county health departments, making for unique management challenges in easing administrative burdens for Medicaid enrollees. North Carolinians may apply to Medicaid by phone, paper application, in-person, or online. A simplified web application is available across the state in English and Spanish through ePass offered by NC Medicaid.

Administrative burdens present a barrier for potential enrollees to access benefits and care. Data from NC DHHS suggests that some pregnancy Medicaid enrollees do not enroll until relatively late in their pregnancy. In 2019,

56 percent of pregnancy Medicaid enrollees received care during their first trimester, with significant disparities between racial and ethnic groups: when disaggregated by race, 65 percent of non-Hispanic white enrollees received first trimester care, while the rate of first trimester care was 58 percent and 52 percent for nonHispanic Black enrollees and Hispanic enrollees, respectively.431

Looking at the state overall, there is a disconnect between Medicaid enrollees and poverty rates (see Figures 12 and 13). Despite the higher poverty rates in the eastern region of the state, pregnancy Medicaid enrollment is lower than in the west. These data suggest there may be Medicaid-eligible pregnant women in the eastern part of the state that never enroll in coverage.

NC Medicaid has made progress on easing administrative burden by starting to reimburse for translation services used by enrollees during appointments. However, language inaccessibility was identified in our stakeholder interviews as a barrier to maternal care. A 2021 study of Spanish-speaking pregnant women in North Carolina found that patients who do not speak English have longer appointment wait times due to the time needed to find a translator.432 In a focus group conducted as part of this study, women reported that care centers did not provide sufficient interpreters and sometimes relied on the enrollee’s family members to interpret during appointments.433

Evidence

Easing administrative burden offers a chance to reduce disparities and increase Medicaid enrollment for eligible pregnant people. The White House identified administrative burden as a key priority in increasing equitable outcomes through social safety net programs. Their 2021 report offers an application design framework, which NC Medicaid should consider in streamlining pregnancy Medicaid applications (see Table 3).

By using plain language and clear step-bystep instructions, NC Medicaid can increase pregnancy Medicaid enrollment and reduce geographic, racial, and ethnic disparities. The most recent available data on pregnancy Medicaid enrollment processes shows 25 states use shortened Medicaid enrollment forms.434

Exempting people under 21 from pregnancy Medicaid income determination will further reduce hurdles for accessing coverage. California and New York have enacted this policy in their Medicaid programs through State Plan Amendments.435 Given there are racial age disparities for when pregnant Medicaid enrollees give birth in North Carolina, pursuing this recommendation could reduce racial and ethnic disparities by making it easier for younger enrollees to access pregnancy Medicaid coverage. In 2019, Medicaid enrollees under 18 had 1,484 births, about 2.3 percent of all births covered by Medicaid. For all Black non-Hispanic Medicaid enrollee births, 2.5 percent were to those under 18 and for all Hispanic enrollee births, 3.3 percent were to those under 18.436

Table 3. White House Application Design Framework to Ease Administrative Burdens

Opportunity Area to Improve Equity

Reducing form complexity and improving comprehensibility

Known Burden Drivers Potential Solutions

• Lengthy forms and instructions driven by legal design requirements.

• Questions that cannot be answered based purely on an applicant’s own memory or knowledge about themselves.

• Multiple or supplemental forms during a single application experience.

• Eligibility requirements that are overly complex and not well known.

• Ensure that all instructions and notices are written in plain language and translated into multiple languages.

• Adopt principles of human-centered design (e.g., early and routine user interviews and A/B testing to continually refine design and language).

• Provide step-by-step examples of process involved in claiming benefits, accessing protections, or navigating a service.

Additional Considerations

Pursuing a State Plan Amendment requires legislative action, and therefore it is a mediumterm solution to reduce administrative burden for under 21 enrollees. In comparison, creating a shortened application form and improving translation services act are short-term solutions because both can be implemented without legislative action.

To ensure that enrollees have access to timely translation services, NC Medicaid should provide financial rewards to PHPs that achieve shorter wait times for enrollees, though all translation services to continue to be reimbursed at a base level regardless of wait times. NC Medicaid should also work with PHPs to expand access to translation services provided through telehealth during enrollee appointments, particularly in areas with translator shortages or for enrollees who speak less commonly spoken languages. These are relatively short-term solutions, as these changes can be made by altering PHP contracts.

Conclusion

North Carolina Medicaid is a leader in innovative approaches to health care delivery and addressing non-medical drivers of health. The ongoing transition to Medicaid Managed Care represents an opportunity for the state to bring comprehensive, quality health care to enrollees who face barriers to care because of social determinants of health such as race, ethnicity, primary language, and rural residence.

This report specifically addresses the challenges of enrollees with SCD and who are pregnant or postpartum. These ubiquitous challenges relate to churn, provider supply, care management, transportation, and data gaps. For SCD enrollees, challenges relate to continuity of care during the pediatric to adult transition and lack of universal screenings. Pregnant and postpartum enrollees face challenges related to continuity of care across the peripartum period and lack of clinical and non-clinical support.

The recommendations in this report were determined after four months of research, including 22 interviews with North Carolina stakeholders and a review of academic literature and evaluations of other states’ policies. We hope this report helps NC Medicaid succeed in fulfilling the promise of managed care, especially with respect to addressing the inequities in SCD and maternal health outcomes.