2.2 Group Prenatal Care

Covering doula services as a preventive service is a medium-term investment. It requires NC Medicaid to submit a State Plan Amendment (SPA) to CMS and receive federal approval. New Jersey, Oregon, and Virginia were approved for their doula-related SPAs, while other states are currently in the SPA submission process. Medicaid reimbursement of doula services may require additional funds from the NC General Assembly to initiate this new benefit; however, doula services can be cost-saving in the long run. Relying upon Medicaid data from multiple states, a team of researchers modeled the cost effectiveness of doula care and estimated an average saving of $986 per birth due to reductions in preterm births and C-sections.377

Encouraging the NC General Assembly to appropriate funds for doula training grant programs may be more difficult given state budget restraints. Yet, given these grant programs would be a minor appropriation amount it may be more feasible. A bill introduced in the NC General Assembly would establish awarding up to five doula training grants ranging from $10,000 to $50,000 annually.378 Alternatively, NC Medicaid could encourage PHPs to privately fund community-based doula programs, similarly to BlueCross NC’s current grant program.

NC Medicaid should require PHPs to cover group prenatal care.

Implementation: • NC Medicaid should add group prenatal care in PHP contracts.

• NC Medicaid should work with stakeholders to develop an adequate incentive payment rate for group prenatal care.

Background

Group prenatal care differs from traditional childbirth education classes in several ways. In traditional classes, the program is not clinicallybased and provides information on subjects such as newborn care, breastfeeding, and the labor and delivery process. In contrast, in group prenatal care, women with similar due dates meet with a health care provider in a group setting, where group discussions are facilitated by the clinical staff. Women participate in collecting health metrics, such as taking blood pressure and charting, and have the opportunity to meet one-on-one with the medical specialists.379 CenteringPregnancy is a specific evidence-based group prenatal care that has been implemented across the country. As discussed in the background section, Black women experience much higher rates of poor maternal outcomes. Specifically—as it relates to group prenatal care—Black women experience higher rates of depression during the pregnancy and postpartum period.380 Black women also are at higher risk for giving birth to a preterm and/or low-weight baby, which, in addition to causing worse outcomes for the infant, can be associated with increased rate of maternal depression and other maternal health conditions.381 Black women generally experience higher levels of stress in their daily life, which in turn can negatively impact their pregnancy health and outcomes.382

Black women with Medicaid expressed higher levels of dissatisfaction and lower levels of medical support during pregnancy care than white women with Medicaid.383 Low levels of medical support are also associated with pregnant women underutilizing low-cost pregnancy care options (e.g., office visits) and overutilizing high-cost care. In a study in North Carolina, pregnant women with Medicaid were three times more likely to visit the emergency department for nonurgent reasons than pregnant women with private insurance. The researchers point to “uncertainty regarding symptoms, a lack of consistent medical care, or psychosocial issues” as the primary reasons for the overutilization of emergency services.384

North Carolina Context

In North Carolina, group prenatal care models are not covered by Medicaid. However, NC Medicaid has previously considered covering group prenatal care, specifically through CenteringPregnancy. A 2019 report commissioned for the NC Office of State Budget and Management concluded CenteringPregnancy’s benefits would outweigh its costs for the pregnant person and baby, as well as for taxpayers and other indirect entities.385 Additionally, UnitedHealthcare is currently providing grants for North Carolina OB-GYN practices to create and run CenteringPregnancy programs.386

Evidence

Group prenatal care can help reduce incidences of maternal and infant morbidity for Medicaid enrollees, specifically for Black pregnant women. A systematic literature review of group prenatal care studies found high-quality evidence, across multiple studies, that group prenatal care is especially beneficial to Black pregnant women.387 Specifically, low-income Black women that receive group prenatal care have a reduced risk of delivering before term or at term to a low birthweight baby, a reduced risk of receiving a C-section, and an increased rate of breastfeeding initiation.388 Additionally, Black women report being more satisfied with their pregnancy-related care.389 Researchers posit that “one potential explanation for improved outcomes in African American women is the provision of social support, coping strategies and stress reduction through group prenatal care.”390 Group prenatal care may also reduce overutilization of high-cost care (e.g., visiting the emergency department for a nonurgent reason).391

CenteringPregnancy, a specific group prenatal care method, has showed positive results among Medicaid populations. In Georgia, multiple studies throughout the state confirm the positive effects of the program specifically on Black Medicaid enrollees.392 Of note, one of the Georgia studies was run through telehealth and still found positive effects.393 In South Carolina, Medicaid enrollees were more likely to attend their postpartum visit and less likely to have a preterm birth if they went through the group prenatal care program.394

Nine states, including Louisiana, Michigan, South Carolina, and Texas, currently reimburse providers for group prenatal care at a higher rate than traditional prenatal care.395 These enhanced reimbursement rates vary from $40 per patient per visit for group prenatal care to a rate that only is enhanced if the provider serves large groups. This would be difficult to implement in North Carolina, where PHPs are reimbursed via bundled package payment models instead of a fee-for-service schedule.396 However, NC Medicaid could use incentive payments, which is a similar tool to higher reimbursement rates but fits within NC Medicaid’s pregnancy medical home bundle. NC Medicaid already provides two incentive payments: $52.50 for every pregnant patient receiving care in a PMH who received standardized risk screening and $157.50 for every patient receiving a comprehensive postpartum visit 14-60 days after giving birth.397