3. Provider Bias Training

Maternal Health-Specific Transportation NC Medicaid should require PHPs to provide NEMT tailored specifically to pregnant and postpartum women. Specifically, NC DHHS should require PHPs and NEMT brokers to allow enrollees to bring their children, and possibly an adult attendant if needed, to their appointments in all cases. This policy should be clearly communicated to enrollees. For an approach even more tailored to pregnant and postpartum women, NC Medicaid could require or incentivize PHPs and their NEMT brokers to provide a dedicated vehicle to transport groups of pregnant and postpartum women directly to their appointments without waiting for other enrollees to complete their appointments. This is a relatively short-term solution which can be implemented by updating PHP contracts.

3. Provider Bias

Training

NC DHHS should expand and improve its implicit bias training requirements to include perinatal and SCD providers.

Implementation: • NC DHHS should convene a working group to recommend an approach for expanding and improving implicit bias training.

North Carolina Context

Implicit bias in the health care system is a serious barrier for patients of color receiving the care they need. Although the state already requires PHP staff to undergo equity and implicit bias training, stakeholder interviews revealed that implicit bias training is a critical need for North Carolina.122

The North Carolina Institute of Medicine’s 2020 “Healthy Moms, Healthy Babies” report, which proposed recommendations to reduce infant and maternal mortality and morbidity in the state and address racial disparities, discussed implicit bias as a key factor that contributes to health disparities. Similarly, a needs assessment survey of ED providers in North Carolina on barriers to care for people with SCD revealed that nearly 40 percent of ED providers identified implicit bias as a barrier.123

Evidence

Research has shown that Black patients have lower levels of trust in the health care system due to experiences with biased providers and historical racist practices.124 Distrust in health care is associated with lower rates of recommended disease prevention and treatment of acute and chronic illness, as well as worse health status.125 It is crucial that providers

understand this context and develop strategies for building trust and communicating across lines of difference.

Implicit Bias in Sickle Cell Care In SCD care, implicit racial bias leads to negative interactions with providers, longer ED wait times during pain crises, and restricted access to adequate pain management.126 Racial bias also prevents patients with SCD from accessing opioids essential for pain management.127 Providers are more likely to suspect that Black patients and patients with SCD are addicted to opioids and engage in drug-seeking behavior than white patients and patients with non-SCD chronic conditions, even though rates of opioid use among patients with SCD did not rise while opioid use was accelerating in the general population.128 Patients with SCD report that opioid stigma has made providers more likely to underestimate and undertreat their pain.129

Implicit Bias in Maternal Health Care

Implicit racial bias can lead to negative maternal and child health outcomes for Black women, as they are less likely to receive prenatal education resources.130 Bias can contribute to Black mothers’ risk of serious pregnancyrelated conditions like postpartum hemorrhage and preeclampsia, as their concerns are often overlooked and ignored by health care providers.131 Several states including California, Illinois, Maryland, Michigan, and New Jersey require some form of bias training for health care providers by law.132 California specifically requires hospitals that provide pregnancyrelated care, alternative birth centers, and certain primary care clinics to establish an “evidence-based implicit bias program” that covers unconscious biases, strategies to communicate across different identities, and maternal health inequities, among other topics.133

It is difficult to estimate the impact of bias training programs because outcomes are hard to quantify.134 However, researchers have developed a series of best practices based on provider feedback. Providers reported that shorter trainings would be most effective, and that modules should be easy to divide into multiple sessions to fit into physicians’ busy schedules. Training courses should be available for free or at a low cost to low-resource hospitals.135 Ideally, Medicaid enrollee advisory boards or patient focus groups should inform the creation of training materials.

Additional Considerations

NC DHHS should establish a working group to investigate best practices to improve implicit bias training. The working group could consider recommending or requiring provider participation in the Carolina Global Breastfeeding Institute’s ENRICH program, which offers maternal healthfocused provider bias training, or the perinatal provider-focused, evidence-based training model developed by Diversity Science.136 Although SCD-focused bias training has yet to be implemented, NC DHHS can look to states like Michigan, which requires bias training for health care providers writ large for initial licensure or registration and renewal under the Michigan Public Health Code, for examples of bias training content and implementation strategy.137 These are relatively medium-term reforms. because NC DHHS already requires PHP staff to engage in some degree of bias training. The best practices the working group formulates for providers can be implemented quickly.