FALLING THROUGH THE CRACKS: Discussion

Comprehensive, perinatal care coordination—including risk assessment and appropriate follow-up interventions—results in improved pregnancy outcomes and enhanced infant health. Toward this end, the Public Health Service Expert Panel recommended that early and ongoing risk assessment, health promotion, and medical and psychosocial interventions be adopted as routine elements of prenatal care for all women (US Public Health Service Expert Panel on the Content of Prenatal Care, 1989). With a focus on the low-income population, this survey-based systems analysis describes the capacity of health care systems in Hennepin and Ramsey counties to provide this type of care coordination during pregnancy.

Community Update

Since Spring, 1999, when this survey was undertaken, significant changes have occurred in health care, as well as public health itself. These transitions have had an impact on system capacity beyond the survey results reported in this document. Agency mergers and closures, in addition to reorganization and reallocation of funds, have altered the health care delivery system in the metropolitan area, as well as statewide. In addition, consumers of health care services have changed markedly, as individuals and families of many different racial/ethnic groups have taken up residence in the state of Minnesota. The following examples of a shifting health care landscape should be taken into account when reading this report and considering the issues presented here.

Mergers and Closures
North End Medical Center, serving the east side of St. Paul, merged with Model Cities Health Center in October, 2001. North End no longer had sufficient resources to serve its community as a freestanding facility. Although located in a medically underserved area, North End did not enjoy the status and benefits of a federally-funded health clinic. In contrast,Model Cities is federally-qualified and thereby eligible for funds to support its infrastructure. More mergers of this type are expected to occur as centers seek to create efficiency in their systems so they may continue to provide care for underserved communities.

Representing a different decision-making process, the Hennepin County Community Health Department closed its Women’s and Children’s Health Clinics in Fall of 2000. These clinics, located in St. Louis Park and Brooklyn Center,were the only facilities using a public health model to serve the low-income population of suburban Hennepin County. By utilizing public health nursing, together with a variety of community-based agencies, the centers provided comprehensive, prevention-focused services to an “at-risk” population of women and children. These closures leave a service void in suburban Hennepin County.

A Changing Populace
Early results from the 2000 U.S. Census confirm that minority populations have grown substantially in the past decade in Minnesota, with particularly high numbers in the Twin Cities metro area. This increase includes significant changes in existing African, Asian, Hispanic, and African-American populations, as well as new immigrants and refugees from all parts of the world. Due to such diverse population growth, health care agencies are experiencing increased pressure to provide competent medical interpreters, as required by Title VI of the U.S. Civil Rights Act. Failure to provide qualified interpretation during health care effectively denies the patient access to care, which constitutes a civil rights violation. While acknowledging its importance, survey respondents discussed this mandate largely in terms of the costs involved: additional time to recruit and arrange for interpreters, provision of care with interpreters present, and payment of interpreters. For a full discussion of this issue see: Bridging the Language Gap: How to Meet the Need for Interpreters in Minnesota (November, 1998) [6].

Likewise, families living at or below the poverty threshold also appear to be increasing, especially in urban areas [7]. One program which addresses the needs of this population is Temporary Assistance for Needy Families (TANF), the federal government’s welfare-to-work program designed to move families with children off welfare and into the work force within five years. In 2000, the Minnesota legislature provided additional TANF funds to all Minnesota counties, designating that the money be used for public health nurse supervised home-visiting. In Hennepin County, approximately 75 percent of these funds were allocated for visits to pregnant and parenting teens. In Ramsey County, these funds are also being used for home visits to low-income adolescent parents and to young women who began childbearing as teens. This funding may result in capacity building and improved operation of the public health nursing agencies described in this report. It is critical that this home visiting program become integrated with existing systems of perinatal care, rather than contribute to further fragmentation and confusion for families.

 
It is critical that this home visiting program (TANF) become integrated with existing systems of perinatal care, rather than contribute to further fragmentation and confusion for families.
 

Twin Cities Healthy Start
The Twin Cities Healthy Start (TCHS) program was implemented with federal funds from the Maternal and Child Health Bureau of the Department of Health and Human Services. In a highly competitive process, approximately $1,000,000 per year for fiscal years 2000 and 2001 was awarded to Minneapolis and St. Paul, largely due to data demonstrating severe racial and ethnic disparities in infant mortality within the two cities. The program’s purpose is to provide outreach, case management, and health education to American Indian and African American families under the direction of a community consortium. As staff of this new program attempted to navigate the perinatal system, they discovered that the existing structure contained many administrative barriers and was often characterized by fragmentation and poor communication [8]. Thus, the Healthy Start Collaborative was formed to address barriers faced by pregnant women—even those who have an outreach worker and a nurse case manager provided by TCHS. This Collaborative includes representatives from MDH and DHS, as well as the Minnesota Council of Health Plans. It is intended that the Collaborative will be an ongoing problem-solving group committed to assuring the success of TCHS in improving pregnancy/ infancy outcomes. With the second award of federal funding for FY 2002-2005,TCHS is developing service networks among the contracting community partners to improve integration of care.

In its interpretation of federal Medicaid enhancements, Minnesota implemented a policy design that relies heavily on the traditional medical model. Policy choices—such as allowing physicians to be reimbursed for prenatal care coordination—do not mirror the direction chosen by many other states.  

Minnesota Medicaid Reform

Having considered the most recent community changes, it is also advisable to reflect on earlier history. The federal Consolidated Omnibus Budget Reconciliation Act (COBRA) of 1985 enabled state Medicaid programs to develop enhanced benefits for prenatal clients. These services were intended to expand access to a broad variety of nonmedical supports, especially by exercising the option of care coordination benefits.

One of the specific, stated intentions of COBRA enhancements was to spur states to refine and reform the content, quality, and organization of perinatal services offered through public programs. It was anticipated that this would be accomplished by means of close collaborative relationships between state Medicaid programs and the Maternal and Child Health (MCH) programs of state departments of health. As described by the National Governor’s Association Report (1989) on Medicaid Prenatal Care Coordination, the COBRA enhancements were envisioned as supplying the “glue” to hold together delivery systems that are often highly fragmented, thereby providing care that is both comprehensive and continuous.

The Medicaid program is a critical component of any state’s infant mortality reduction strategy partly because a large percentage of high risk pregnancies are covered by Medicaid. Medicaid expansion, backed by financial incentives, made it possible for states to improve care during pregnancy by providing enhanced services including care coordination (Hill & Breyel, 1989). In its interpretation of federal Medicaid enhancements, Minnesota implemented a policy design that relies heavily on the traditional medical model. Policy choices—such as allowing physicians to be reimbursed for prenatal care coordination—do not mirror the direction chosen by many other states. Other states have elected not to reimburse physicians for care coordination but to use public health nurses, social workers, and/or community health workers as care coordinators. (See Appendix 6, Examples of Effective Care Coordination, for descriptions of programs in North Carolina, Rhode Island, and Washington. Also, the National Governors’ Report describes programs in Virginia, New Jersey, Alabama, Arkansas,Ohio, and Tennessee.) In some states this new funding allowed reinvestment in public health systems that had been struggling for resources (Gold, Singh, & Frost, 1993).

Minnesota Pregnancy Assessment Form: Origin and Use
The need to administer Medicaid’s “enhanced services” for “at-risk” pregnancies for both fee-for-service and PMAP patients prompted some providers to request one form to document pregnancy risks. A standardized risk assessment tool, the Minnesota Pregnancy Assessment Form (MPAF), was developed to meet this need. DHS and the health plans adopted the MPAF as the form they would accept from providers. Providers use the MPAF to identify risks and document contracted obligations to provide enhanced services to “at-risk”women. The MPAF identifies medical, social, and behavioral risk factors, but does not prompt or facilitate interventions and referrals to deal with them.

The DHS manual which defines “at-risk” pregnancies and enhanced services to address identified risks does not exclude public health nurses from providing home visits during pregnancy. But the manual also allows medical providers to do care coordination, one of the Enhanced Services [9]. Data provided by the community health centers indicate that often their providers are poorly connected to public health nurses and rarely refer to them, choosing instead to do their own care coordination and other enhanced services internally. There appears to be no incentive to do otherwise either for the surveyed community health center providers or for other providers of medical care to the PMAP population. In this scenario, public health nurses are not utilized and community health center providers are both overworked and poorly reimbursed.   In this scenario, public health nurses are not utilized and community health center providers are both overworked and poorly reimbursed.


Public Health Nursing and Other Care Coordination Models

Several recent publications report the value of public health nurse home visiting in improving long- term outcomes for infants and children, as well as cost savings for society (Kitzman et al, 2000; Randolph & Sherman, 1993; Wilkinson, Korenbrot,& Greene, 1998). There are also many references to other types of case management and care coordination programs which demonstrate improved birth outcomes, including increased birth weight and reduced health care costs. Although the Survey Framework described in this report suggests that home visiting will be a component of care coordination during pregnancy and infancy, the Survey Team is aware that home visiting may not always be practical or desired by clients. Other effective models of perinatal care coordination and case management take place in agencies and clinics. Some models use social workers, nurses, or other well-trained case managers familiar with the population they serve as well as with community resources, referrals, and various assistance programs. All provide assessment, care plan development, and referrals to community or government resources through face-to-face encounters with their clients (See Appendix 6). “Telephonic case management,” as described by the health plans surveyed in this study, is not included among these models. Whether it is effective in improving outcomes has not been demonstrated by health plans nor has evidence of effectiveness been found in the research literature.

   
 
The findings of this survey imply that public health nursing has lost many of its community connections because of financial and capacity strains affecting their agencies.
 


Safety Net Capacity

The findings of this survey imply that public health nursing has lost many of its community connections because of financial and capacity strains affecting their agencies. Currently, care coordination/case management by public health nurses during pregnancy rarely happens in Hennepin and Ramsey counties. As the survey data indicate, most public health nurse visits are to post partum mothers and newborns. When public health nursing services are initiated during pregnancy, it is usually to address an identifiable medical problem. Opportunities to provide prenatal education and support to other at-risk women during pregnancy are missed. From the survey conducted in this study, it is clear that public health nursing agencies are aware of the increased complexity of issues families face,many of which impact pregnancy outcomes. From their comments (see Appendix 5), it is also clear that these agencies would do additional preventive activities during pregnancy if more resources, including staff, were available.

Community health center capacity is also a significant issue. The centers described their struggle to provide interpreters, retain qualified providers and other staff, continue to offer quality “wrap-around” services, and keep their doors open to meet the needs of increasing numbers of high risk and underserved families in the two metropolitan counties. Since the survey, the only community health clinic serving suburban Hennepin County has closed leaving a service gap in the safety net capacity (see earlier “Community Update” section).

The community health centers described their struggle to provide interpreters, retain qualified providers and other staff, continue to offer quality “wrap-around” services, and keep their doors open to meet the needs of increasing numbers of high risk and underserved families in the two metropolitan counties.
 

Department of Human Services’ Policies

The Minnesota Department of Human Services (DHS) is the state agency responsible for administering federal Title XIX funds to provide health care to low-income Minnesotans. Related to perinatal care,DHS administers fee-for-service Medical Assistance, and it contracts with health plans for the Prepaid Medical Assistance Program (PMAP), a state program instituted in the early 1990s. As DHS proceeded with Minnesota’s Medicaid reform, they increased the number of low-income women eligible for insurance during pregnancy and also expanded health care options by including private obstetrical providers. The threshold of insurance eligibility for pregnant women was raised to 275 percent of the federal poverty level and the field of potential providers was greatly expanded, thereby improving access to prenatal care for many women.

While PMAP ensured prenatal care for a larger number of low-income women, it did not assure that a pregnant woman with psychosocial risk factors would receive the coordinated
services that address those risk factors.
  While PMAP ensured prenatal care for a larger number of low-income women, it did not assure that a pregnant woman with psychosocial risk factors would receive the coordinated services that address those risk factors. In effect, the creation of PMAP moved the public health system a step away from the Medical Assistance funding source, shifting primary provision of care to the health plans. Public health agencies then had to negotiate with managed care organizations in order to serve their customary clients. Survey responses from public health nursing and community health centers indicate that this shift has led to major barriers in providing needed services to their clients.

Additionally,many low-income women do not receive care for chronic conditions, preventive health care, family planning services, preconception care, or dental care because insurance is not activated until pregnancy is documented. Furthermore, sixty days after giving birth,women’s eligibility for Medical Assistance drops back to 67 percent of the federal poverty level, resulting in abrupt termination of services for many women. Unfortunately, low-income women’s interconceptional health care needs are not well served by these aspects of DHS policy.

Perinatal Care Coordination and Managed Care Organizations

It is unreasonable to expect managed care to be an omnipotent resource for all health care challenges. In the case of comprehensive perinatal services, it is unlikely that a managed care organization would encompass enough of the internal system components needed to provide the type of complex, integrated service described in the Survey Framework of this study. For the larger health plans, the PMAP population represents only a small percentage of their total population served. In contrast, the smaller health plans serving only or primarily PMAP clients tend to have the most comprehensive systems in place. However, even they may not be able to provide optimum service integration.

In 1999, the most recent year for which data are available, the net income from Minnesota’s Prepaid Medical Assistance Programs (PMAP) was $57 million. PMAP has been a profitable product for managed care since 1995, producing over $20 million per year for the plans [10]. According to an article in the Minneapolis Star Tribune, the health plans view this profit as offsetting their losses from other government programs (Howatt, 2000). However, this argument is overstated. When looking at all state public programs combined (PMAP, prepaid GAMC, and MN Care), managed care plans still earned $30 million in 1999 and also showed profits between $3 million and $27 million each year since 1995 [11].

This report views those profits in light of the apparent unmet needs of pregnant women on PMAP to receive care coordination services. It is hoped that federal Medicaid enhancements distributed to the health plans in Minnesota would support provision of enhanced services to pregnant women, not to potentially offset losses in other areas. While public health and community health centers are competing for scarce resources to serve this high-risk population, health plans, by comparison, have surpluses of Title XIX (Medicaid) dollars through their PMAP contracts. This report suggests that DHS not necessarily renegotiate a lesser contract for PMAP, as was mentioned in the Star Tribune article previously referenced, but that DHS redirect these funds for services more in line with the Theory and Framework described in this report—either through health plans or other providers.

Community Perspectives

Families are aware that the issues they face and the types of services available to them have an impact on their pregnancies. In a recent study of American Indian perspectives on pregnancy and infant care in the Twin Cities,American Indian women were asked about the factors contributing to infant mortality in their community. Their responses included “a range of institutional and behavioral factors…from alcohol, substance abuse, and lack of education and information, to lack of health care, insurance and discrimination of health care providers” [12].

In a similar discussion with African-American women, solutions were proposed. As an example, “respondents [who were] in relationships with community-based providers were more likely to follow-through in arranging timely prenatal care” [13]. Research literature reinforces and supports the finding that women who are connected to a provider or who have a “medical home” before pregnancy are more likely to begin prenatal care early (Gazmararian, Arrington, Bailey, Schwarz, & Koplan, 1999).

With funding from the Federal Centers for Disease Control and Prevention (CDC) the MDH conducted the REACH (Racial and Ethnic Approaches to Community Health) planning process in 1999-2000. The purpose of the project was to engage in a dialogue with communities suffering from infant mortality disparities that would, in part, provide direction and insights to government and private health systems.

Key messages from the REACH African American Work Group related to this report include:

  • Provide consistent, affordable, quality insurance coverage for everyone regardless of socioeconomic status (a single-payor system).
  • Insurance programs must cover preconception care, preventive health care, and wellness programs.
  • Include fathers in insurance coverage to promote healthier babies and families [14].

Advice from the REACH American Indian Work Group includes:

  • Implement a revised continuity-of-care system in the American Indian community beginning with prevention/health promotion and prenatal care, and continuing through extended pediatric care.
  • Offer preconception care to provide family planning, diet and nutrition, and overall health care before pregnancy.
  • Consider the importance of continuity of care in order to build trust between the mother and the health care provider [15].

FOOTNOTES

6. This report addresses the question of how to ensure access to public services—beginning with health care—for Minnesotans who speak little or no English. It was prepared and published by the “Working Group” of the Minnesota Interpreter Standards Advisory Committee. It may be downloaded from: www.healthadvocates.org [Attn: Non-MDH Link] or contact Jeanne Watson at 612-676-5530 or by email: jeanne.watson@health.state.mn.us
7. Minnesota State Demographer, Preliminary Data from the 2000 Census.
8. Personal communication with Coral Garner,Director of Twin Cities Healthy Start.
9. Minnesota Health Care Programs Provider Manual, June, 2000. Available from the Minnesota Department of Human Services.
10. Minnesota Department of Health, Health Economics Program. The Minnesota HMO Profile – Part II: Enrollment and Financial Performance. May, 2001.
11. Minnesota Department of Health, Health Economics Program. Unpublished data. August, 2001.
12. American Indian Perspectives on Pregnancy and Infant Care. American Indian Policy Center, September, 2000.
13. Twin Cities Healthy Start Project African American Prenatal Care Survey. Rainbow Research, Inc.,November 30, 2000.
14. Reach Project: A Report of Findings of the African American Work Group. April, 2000. Available from the Minnesota Department of Health, Maternal and Child Health.
15. REACH Project: A Report of Findings of the American Indian Work Group. April, 2000. Available from the Minnesota Department of Health, Maternal and Child Health.

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