May 31, 2020
Nina Brown-Ashford, DrPH, MPH
Acting Director, Office of Minority Health
Centers for Medicare & Medicaid Services
7500 Security Blvd.
Baltimore, MD 21244
Dear Dr. Brown-Ashford;
Thank you for the opportunity to respond to the Maternal and Infant Health Care in Rural Communities Request for Information. The National Committee for Quality Assurance (NCQA) strongly supports the Center for Medicare & Medicaid Services’ focus on maternal health inequities and social determinants of health in rural communities.
The barriers in rural communities to improving access, quality and outcomes in prenatal, obstetrical, and postpartum care include a dearth of providers, inadequate insurance coverage and underlying social determinants. These factors interact to exacerbate the problem. There are several important steps you can take to help address these factors:
- Extending post-partum coverage in Medicaid;
- Incorporating more maternal and infant health quality measures into the Medicaid core sets;
- Improving data flow to support better care coordination;
- Implementing a Health Equity Summary Score to help clinicians identify and target risk factors;
- Encouraging states to require performance-based accreditation that rates Medicaid health plans on their maternal and infant health quality metrics; and
- Supporting state initiatives to promote Patient-Centered Medical Homes and Patient-Centered Specialty Practices that have multiple provisions to help clinicians address social determinants and improve quality.
Extending Coverage: You can help to improve maternal and infant health care access, quality and outcomes by extending Medicaid coverage. You can do this in the short term by encouraging states to seek 1115 waivers to do so. In the longer term, you can work with Congress to ensure a minimum of 12 months enrollment for new mothers and other Medicaid enrollees. Broader insurance coverage would mean more mothers in rural areas could afford the care they and their newborns need. It would provide additional time for the first postpartum visit and helps to prevent complications that can affect the health of both mother and baby after pregnancy.
Better coverage also, in turn, could encourage more clinicians to practice in rural areas, which would further improve access. More continuous enrollment also supports robust measurement of maternal and infant health metrics, many of which require longer lookback periods. Several of NCQA’s HEDIS® measures are already in the Medicaid core sets, such as for Well-Child Visits, Prenatal and Postpartum Care and Breast Cancer Screening.
Quality Measures: You could further help to improve rural maternal and infant health by incorporating additional HEDIS® quality measures into the Medicaid core sets, such as:
- Prenatal Immunization Status
- Perinatal Depression Screening and Follow-Up
- Postpartum Depression Screening and Follow-Up
Two of these measures address maternal depression, a high-priority, undertreated condition for which screening is less common in rural areas. The other addresses immunization, for which rates are lower in rural areas. All three have electronic specifications and thus support the move to digital quality measures (dQM) that reduce reporting burden, improve accuracy of results and allow us to measure more of what matters with the rich clinical data in electronic health records, registries, health information exchanges and other electronic sources.
Importantly, the Medicaid Core Set Workgroup recently recommended adding two of these measures, the Prenatal Immunization Status and the Postpartum Depression Screening and Follow-up, to the Core Set.
Improving Data Flow: You also could encourage data connections so that services that occur in different settings, for example in primary care, obstetrics, and pediatric settings, can be shared with all of a mother and infant’s relevant providers. Making sure that all members of mothers and infants’ care teams have all pertinent information can help to improve care coordination, patient experience and outcomes alike.
Another approach would be to support creation of an HL7® Fast Health Interoperability Resource (FHIR®) Implementation Guide based on the defined use cases and associated data sets related to issues contributing to poor rural maternal and infant health. Interoperability is key to improving collecting data and providing meaningful coordination across the care continuum, which can be especially difficult in underserved rural communities.
Health Equity Summary Score: As measure developers, NCQA is working to understand methods that will capture member risk factors in a standardized way across the entire population. We are involved in a coding collaborative for food insecurity, transportation insecurity and housing insecurity which will:
- Develop use cases to support documentation of specific social domains across enrollment, screening, diagnosis, treatment, and population health management activities within EHR and related systems;
- Identify common data elements and their associated value sets to support the uses cases;
- Develop a consensus-based set of recommendations on how best to capture and group these data elements for interoperable electronic exchange and aggregation; an
- Adjusting payment and data policies to better support maternal and infant care delivery and coordination.
NCQA research contributed to a paper published in the Journal of General Internal Medicine. Developed, as a proof-of-concept, a Health Equity Summary Score (HESS) is a succinct, easy-to-understand score could be used to promote high quality care to those with social risk factors. The paper demonstrates the feasibility of developing and estimating a HESS intended to promote and incentivize excellent care for racial-and-ethnic minorities and dually eligible Medicare Advantage enrollees. Implementing a Health Equity Summary Score would help clinicians identify and target risk factors that contribute to poor rural maternal and infant health.
Performance-based Health Plan Accreditation: Many states use NCQA’s performance-based Health Plan Accreditation, often in tandem with pay-for-performance programs, to drive improvement on these and other quality measures. Twenty-six states require NCQA Accreditation for health plans serving their Medicaid population and five others accept NCQA Accreditation. (Please see a map and list of state HPA requirements here.) Our program standards evaluate plans on:
- Quality Management and Improvement.
- Population Health Management.
- Network Management.
- Utilization Management.
- Credentialing and Recredentialing.
- Members’ Rights and Responsibilities.
- Member Experience.
- Medicaid Benefits and Services.
The Population Health standards are especially relevant to improving rural maternal and infant health because we evaluate how well health plans:
- Implementing effective population health strategies;
- Assessing and stratifying Patients by Risk;
- Identifying Resources like food banks and patient supports;
- Sharing Patient Data with all care team members who need it;
- Supporting patients in Self-Management;
- Delivering wellness and prevention services;
- Managing complex chronic conditions; and
- Identifying and acting on opportunities for improvement.
CMS could improve maternal and infant rural health by supporting state efforts to mandate performance-based accreditation and working with Congress to require it for all Medicaid health plans.
Patient-Centered Medical Homes and Specialty Practices: NCQA Patient-Centered Medical Home (PCMH) program is a proven tool for improving many aspects of quality. The program includes 101 distinct criteria across six concepts:
- Knowing & Managing Your Patients
- Patient-Centered Access & Continuity
- Care Management & Support
- Performance Measurement & Quality Improvement
- Care Coordination & Care Transitions
- Team-Based Care & Practice Organization
Our Patient-Centered Specialty Practice (PCSP) program builds on the medical home to establish “medical neighborhoods.” The program recognizes obstetric and gynecological practices that provide ongoing, coordinated patient-centered care to patients. Clinics operated by Certified Nurse Midwives also are eligible for the PCSP program.
The PCMH and PCSP programs both address screening for post-partum depression in their standards.
Promoting PCMH and PCSP recognition in rural communities and encouraging pregnant women and new mothers to seek care in them would improve rural maternal and infant health by expanding access, improving care coordination, addressing disparities, and reducing hospital and emergency department visit.
Payment Policy: Finally, you could improve maternal and infant rural health by designing payment policies to meet women where they are, for example paying for maternal depression screening that occurs in pediatricians’ offices during well-baby visits. This could help address a recent Centers for Disease Control & Prevention recently finding that, while 13% of new mothers reported depressive symptoms during the postpartum period, one in eight new mothers were not asked about depression by their clinicians postpartum.
Thank you again for the opportunity to comment on the draft. If you have any questions, please contact NCQA Director of Federal Affairs, Paul Cotton, at (202) 955-5162 or firstname.lastname@example.org.
Margaret E. O’Kane
 HEDIS, the Healthcare Effectiveness Data & Information Set, is a registered trademark of NCQA.
Rural-Urban Comparisons of Child and Maternal Mental Health Barriers, American Academy of Pediatrics.