Medicaid Prenatal Care: States Improve Access and Enhance Services, but
Face New Challenges (Briefing Report, 05/10/94, GAO/HEHS-94-152BR).

About 37,000 infants die in the United States each year, many
unnecessarily. Low birth weight is a major contributor to infant death
and is associated with higher initial medical costs for infants and
long-term medical and special education costs for those who survive.
Public funds pay for many of these expenses.  This briefing report
discusses (1) whether states are using Medicaid to improve access to
prenatal care services and enhance services to poor women and what
reported effect that may have on birth weight and infant mortality and
(2) whether lessons have been learned about providing care for
underserved populations that Congress should consider as it debates
health care reform. GAO concludes that states have improved access to
and beefed up the prenatal care provided to poor women by Medicaid.
Although early indicators suggest a reduction in infant mortality and
low birth weight rates, some health care proposals could undermine these
efforts.

--------------------------- Indexing Terms -----------------------------

 REPORTNUM:  HEHS-94-152BR
     TITLE:  Medicaid Prenatal Care: States Improve Access and Enhance 
             Services, but Face New Challenges
      DATE:  05/10/94
   SUBJECT:  Health care programs
             Medicaid programs
             Disadvantaged persons
             Community health services
             State-administered programs
             Children
             Women
             Public assistance programs
             Health care services
IDENTIFIER:  AFDC
             Health Security Act
             Special Supplemental Food Program for Women, Infants, and 
             Children
             Early and Periodic Screening, Diagnosis, and Treatment 
             Program
             HHS Maternal and Child Health Program
             Indiana
             Massachusetts
             North Carolina
             Washington
             Healthy Start Program
             Maternal and Child Health Block Grant
             Illinois Healthy Moms, Healthy Kids Program
             WIC
             
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Cover
================================================================ COVER


Briefing Report to the Chairman, Committee on Labor and Human
Resources, U.S.  Senate

May 1994

MEDICAID PRENATAL CARE - STATES
IMPROVE ACCESS AND ENHANCE
SERVICES, BUT FACE NEW CHALLENGES

GAO/HEHS-94-152BR

Medicaid Prenatal Care


Abbreviations
=============================================================== ABBREV

  ACOG - American College of Obstetricians and Gynecologists
  AFDC - Aid to Families With Dependent Children
  EPSDT - Early and Periodic Screening, Diagnostic, and Treatment
     program
  HCFA - Health Care Financing Administration
  HHS - Department of Health and Human Services
  HMO - health maintenance organization
  MCH - Maternal and Child Health
  PHS - United States Public Health Service
  SSI - Supplemental Security Income
  WIC - Special Supplemental Food Program for Women, Infants, and
     Children

Letter
=============================================================== LETTER


B-256211

May 10, 1994

The Honorable Edward M.  Kennedy
Chairman, Committee on Labor and Human Resources
United States Senate

Dear Mr.  Chairman: 

About 37,000 infants die in the United States each year, many
unnecessarily.  Although the nation's infant mortality rate continues
to decline, the most recent data available ranks the United States
22nd among nations in infant mortality and 21st in low birth weight. 
Low birth weight is a major contributor to infant death and is
associated with increased initial medical costs for infants and
long-term medical and special education costs for those who survive. 
Public funds pay for many of these expenses. 

In response to concerns about infant mortality, beginning in 1986 the
Congress expanded Medicaid eligibility for prenatal care.  In
addition, the Congress allowed states to use Medicaid to reimburse
for services that enhance prenatal care, such as health education and
nutrition counseling.  Moreover, many states are now moving their
Medicaid population into managed care\1 to improve access and control
costs.  Given these changes to Medicaid, you asked us to determine

  whether states are using Medicaid to improve access to prenatal
     care services and enhance services to low-income women and what
     reported effect that may have had on birth weight and infant
     mortality and

  whether lessons have been learned about providing care for
     underserved populations that the Congress should consider as it
     weighs health care reform. 

As agreed with your staff, we interviewed state and local officials
in four states--Indiana, Massachusetts, North Carolina, and
Washington--and reviewed state and local documents to determine state
changes to Medicaid and to prenatal care services and any evaluation
of their effects.  We included states from different geographic
regions, and sought states that had evaluated aspects of their
prenatal care efforts, and provided Medicaid reimbursement for
enhanced services.  We also interviewed federal officials and public
health experts to determine what services they believed were needed
to improve birth outcomes and how other federal programs, such as
Title V, the Maternal and Child Health Block Grant, assisted states
in serving low-income pregnant women.  In addition, we reviewed
national surveys of state prenatal care conducted by the National
Governors' Association and the Alan Guttmacher Institute and analyzed
the literature on comprehensive prenatal care, managed prenatal care,
and health outcomes.  We did our work between June 1993 and March
1994 in accordance with generally accepted government auditing
standards.  We briefed your committee on the results of this work
and, as agreed with your office, are providing you with our final
results in this report. 

In summary, we found that since 1986, many states have used Medicaid
to improve access and enhance prenatal care services for women, but
states' efforts to improve outcomes will face challenges in the new
health care environment.  The states we visited varied in their
efforts to improve access and in how many women they reached with
enhanced prenatal care services.  While it may be premature to
definitively judge outcomes, those states serving a majority of
Medicaid women with enhanced services had done evaluations that
suggested these services improve birth outcomes. 

The health care system is in a state of change, with increased use of
managed care for the Medicaid population and both state and national
efforts at health care reform.  Both trends may open access for
low-income families but could also undermine efforts to enhance
prenatal care and improve birth outcomes for low-income women. 
Medicaid managed care has had quality and access problems in the
past--if states want to improve infant health, they must focus on
making managed care plans accountable for improving the health of the
enrolled population.  And health care reform may bring changes in
financing that may limit states' abilities to maintain enhanced
services. 


--------------------
\1 Managed care refers to a health care delivery system with a single
point of entry.  A primary care physician participating in the health
plan provides basic care and decides when a referral to a specialist
or admission to a hospital is necessary. 


   STATES IMPROVED ACCESS TO
   PRENATAL CARE AND ENHANCED
   SERVICES
------------------------------------------------------------ Letter :1

Today, Medicaid pays for almost one-third of all U.S.  births--about
1.2 million per year.  In addition to Medicaid, other federal
programs, including the Special Supplemental Food Program for Women,
Infants, and Children (WIC), the Title V Maternal and Child Health
(MCH) program, and the Healthy Start Initiative also fund aspects of
prenatal care. 

Most states have used Medicaid to improve access to prenatal care
services, and many have also enhanced the prenatal care services
reimbursable through Medicaid.  Thirty-four states have increased
Medicaid eligibility levels beyond the federally mandated level to
help low-income women get prenatal care.  Almost all states made
administrative and policy changes to ease pregnant women's entry onto
Medicaid, such as expediting their Medicaid eligibility
determinations or allowing them to mail in their Medicaid
applications.  Forty-four states have also begun to reimburse for
more enhanced prenatal services, such as care coordination,\2 to
improve state birth outcomes. 

The states we visited implemented a number of strategies to get women
onto Medicaid and into prenatal care: 

  Three states allow pregnant women to apply for Medicaid eligibility
     by mail, rather than in person, and North Carolina plans to
     implement it in the future. 

  Two states implemented expedited eligibility while one recommends
     expedited eligibility but does not require it. 

  North Carolina disregards parental income for pregnant teens
     because state officials found that teens were moving out of
     their parents' homes to qualify for Medicaid-financed prenatal
     care at a time when they needed the support of their families
     most. 

  Washington expanded eligibility for family planning from 60 days
     postpartum to 1 year postpartum with their own state funding to
     delay repeat pregnancies. 

In addition, each state had specific outreach strategies to bring
women into care. 

The states we visited all reimbursed for some enhanced services,
although women's access to enhanced services varied greatly by state. 
States such as North Carolina and Washington developed statewide
programs through which almost 60 percent of their Medicaid-enrolled
pregnant woman could get Medicaid-financed care coordination and
health and nutrition education services.  On the other hand, Indiana
chose to provide Medicaid-financed care coordination services only to
high-risk women, and only 3 percent are served. 

It may be too soon to definitively judge whether these efforts will
improve low birth weight and prenatal care utilization rates, since
many factors, such as overall economic conditions, can affect such
rates and the enhanced services are relatively recent.  However,
evaluation evidence from the two states with the most extensive
enhanced services suggests that such services have positive effects
at reducing low birth weight.  In North Carolina, Medicaid women who
did not receive care coordination had low birth weight rates 21
percent higher than women who did, and their infants' average
Medicaid charges for the first 60 days postpartum were $277 higher. 
In Washington, the low birth weight rate for all low-income births
declined from 6.2 percent before its program started to 5.5 percent
in 1991. 


--------------------
\2 Care coordination includes performing a risk assessment,
developing a plan of care, coordinating referrals to appropriate
service providers, and follow-up to ensure clients receive needed
services. 


   LESSONS FOR HEALTH CARE REFORM
------------------------------------------------------------ Letter :2

Health care delivery for low-income women and children is changing. 
States are increasingly enrolling their low-income pregnant women and
children into managed medical care and, at the same time, state and
national health care reform may be imminent.  While both trends may
increase access to medical care, they could also undermine state
efforts to enhance prenatal care. 

Enrolling women in managed care plans does not ensure that women are
entering care, getting the services they need, nor having healthy
births.\3 Past evaluations have shown that making managed medical
prenatal care available to low-income women has generally not
improved their likelihood of actually getting adequate medical
prenatal care nor their birth outcomes.  If states want to improve
infant health, they must focus on making managed care plans
accountable for improving the health of their enrolled population. 
Two mechanisms exist to do so.  One is using the quality assurance
process to monitor health outcomes and take corrective action when
health outcomes are poor.  A second is to put performance
expectations into managed care contracts to ensure that Medicaid
women actually receive the care for which the government has already
paid. 

Content of care and access to services are also important to
improving outcomes.  While the Administration's Health Security Act
covers pregnancy-related services, it is not specific on what
services would be covered for pregnant women and how comprehensive or
enhanced the services would be.  Both the American College of
Obstetricians and Gynecologists (ACOG) and the Public Health Service
(PHS) recommend (1) initial and continuing risk assessment, (2) the
development of a care plan and referral to other educational and
social services as needed, (3) health and nutritional education
promoting positive health behaviors, and (4) extra services for women
assessed at high risk.  PHS includes more intensive care
coordination, mental health services, substance abuse services,
social services, and home visiting as services for women at higher
risk. 

Health care reform may remove Medicaid as a financing mechanism for
more enhanced services to many currently eligible pregnant women. 
The Health Security Act would continue Medicaid financing for some
groups of recipients for services not included in the comprehensive
benefit package, but perhaps almost half of currently eligible
pregnant women might no longer be eligible for these additional
services.  Some other health reform proposals would abolish Medicaid
altogether.  Other sources of financing have been proposed.  The
Health Security Act would establish a grant fund to allow health
providers to fund services to enable low-income people to access the
health care system.  And the Chafee-Thomas bill would establish a new
Maternal and Infant Care Coordination program that would give grants
to states to help states develop coordinated, multidisciplinary, and
comprehensive primary health care and social services and health and
nutrition education programs, targeted to women of childbearing age,
particularly to women at risk of having a low birth weight infant. 
Such sources might help states maintain the prenatal improvement
efforts they have begun. 

We discussed a draft of this briefing report with responsible Health
and Human Services (HHS) officials in the Health Resources and
Services Administration, Bureau of Maternal and Child Health and in
the Health Care Financing Administration, who generally agreed with
our findings, and have included their comments where appropriate. 

As arranged with your staff, unless you publicly announce its
contents earlier, we plan no further distribution of this briefing
report until 7 days from the date of this letter.  At that time, we
will send copies to the Secretary of Health and Human Services and
other interested parties. 

Please contact me on (202) 512-7119 if you or your staff have any
questions.  Major contributors to this briefing report are listed in
appendix II. 

Sincerely yours,

Mark V.  Nadel
Associate Director, National
 and Public Health Issues


--------------------
\3 Usually, managed care plans receive a set monthly fee to provide
care and are then put at financial risk.  If the cost of care exceeds
the fee payments, the health plan loses money.  This can provide an
incentive to limit medical services. 


BACKGROUND
============================================================ Chapter 1

While rates of infant mortality have been declining in the United
States for many years, rates of low birth weight have been relatively
stable.  If low birth weight rates could be reduced, infant mortality
rates should decline further.  Public health experts have stated that
at least some low birth weight births are preventable.  Since low
birth weight is associated with smoking, drinking alcohol, using
illicit drugs, and having poor nutrition during pregnancy, low birth
weight rates could be improved if mothers would improve their health
habits.  Women who receive late or no prenatal care, uninsured women,
teenagers, older women, poor women, and African American women have
higher rates of low birth weight. 

Public health experts agree that access to medical prenatal care is a
basic service needed to help prevent infant mortality, but that
high-risk women may need more than just medical prenatal care.  The
Institute of Medicine concluded in 1985 that providing comprehensive
prenatal care that included medical prenatal care, health education,
psychosocial and nutritional services, and screening for risk, could
reduce low birth weight.  Since their review, additional research on
programs that provided more comprehensive prenatal care, or that
provided elements of more comprehensive care, such as nutrition
education or smoking cessation support, found positive and
statistically significant effects on birth outcomes.  In 1987, GAO
found that low-income women faced barriers to receiving early and
adequate prenatal care, with lack of money the major stumbling block. 
Low-income women also reported problems with lack of transportation
and child care and with not knowing they were pregnant and problems
getting appointments.  Many women faced multiple barriers. 

Starting in 1986, the federal government, through a series of
Medicaid law changes, encouraged states to reduce barriers and
improve perinatal services by liberalizing Medicaid eligibility rules
and allowable services for low-income pregnant women and children. 
The Congress mandated that pregnant women with income at or below 133
percent of the federal poverty level would be eligible for Medicaid
coverage during pregnancy by 1990.\1 The Congress also required
states to provide adequate Medicaid payment to obstetric and
pediatric providers sufficient to enlist enough providers so that
care and services are available to Medicaid recipients at least to
the extent that such care and services are available to the general
population in the geographic area. 

Medicaid pays for almost one-third of all U.S.  births--about 1.2
million per year.  The federal government also funds the Maternal and
Child Health Program as part of the Title V Block Grant, which
provides funds to states--$687 million in fiscal year 1994, of which
almost $575 million is distributed to states--to provide services for
pregnant women and children.  The federal government funds the
Healthy Start initiative--$97.5 million in fiscal year 1994--which
provides grant funds to selected communities with extremely high
rates of infant mortality.  The federal government also funds the
Special Supplemental Food Program for Women, Infants, and Children,
which provides supplemental food and nutrition education to
low-income pregnant, breastfeeding, and postpartum women, infants,
and children up to age 5 who are found to be at nutritional
risk--$3.2 billion in fiscal year 1994. 


--------------------
\1 The Omnibus Budget Reconciliation Act of 1989, Public Law 101-239. 


STATES USED MEDICAID TO IMPROVE
ACCESS AND SERVICES
============================================================ Chapter 2

   Figure 2.1

   (See figure in printed
   edition.)


   STATES IMPROVED ACCESS TO
   PRENATAL CARE AND ENHANCED
   PRENATAL CARE SERVICES
---------------------------------------------------------- Chapter 2:1

Most states instituted a broad set of strategies to improve women's
access to medical prenatal care and enhance prenatal care services. 
States made program and policy changes designed to increase the
number of women eligible for care, ease entry into care, increase
reimbursement to obstetric providers, and provide enhanced services
such as care coordination/case management. 

Many states have taken advantage of the Medicaid expansions of
eligibility to increase the number of low-income women receiving
Medicaid-financed prenatal care and improve access to care.  By
January 1994, 34 states had increased eligibility by providing
Medicaid coverage to pregnant women with incomes above 133 percent of
the federal poverty level, and 45 states eliminated their assets
tests.  Many states also improved access to Medicaid by making
administrative and policy changes, such as simplifying the
application form.  Fifty of the 51 states (including the District of
Columbia) have implemented at least one strategy to streamline
Medicaid eligibility.  (See table 2.1.)



                          Table 2.1
           
               Many States Adopt Strategies to
                    Streamline Eligibility

                                                      Number
                                                          of
Strategies to streamline eligibility                  states
--------------------------------------------------  --------
Dropped assets test                                       45
Adopted presumptive eligibility                           30
Shortened Medicaid application                            42
Expedited pregnant women's eligibility                    25
 determinations
Allowed mail-in of eligibility forms                      20
------------------------------------------------------------
Source:  National Governors' Association, 1994. 

A survey by the Alan Guttmacher Institute\1 found that almost all
states increased Medicaid reimbursement for obstetric services
between 1986 and 1991.  The Institute estimated that the Medicaid
global obstetric fee for an uncomplicated delivery increased 15
percent in constant 1986 dollars during this period. 

In addition, states tried to provide more enhanced prenatal care
services by allowing Medicaid reimbursement for such services.  Among
these are care coordination, risk assessment, nutritional counseling,
health education, psychosocial counseling, and home visiting.  (See
table 2.2.)



                          Table 2.2
           
           Many States Allow Medicaid Reimbursement
            for Some Enhanced Services to Pregnant
                            Women

Medicaid-reimbursable enhanced prenatal care       Number of
services                                              states
--------------------------------------------  --------------
Care coordination/case management                         42
Risk assessment                                           43
Nutritional counseling                                    36
Health education                                          37
Psychosocial counseling                                   33
Home visiting                                             37
------------------------------------------------------------
Source:  National Governors' Association, 1993. 


--------------------
\1 State Implementation of the Medicaid Eligibility Expansions for
Pregnant Women, Alan Guttmacher Institute, New York:  1993. 


THE STATES VISITED VARIED IN THEIR
IMPLEMENTATION OF MEDICAID
EXPANSIONS
============================================================ Chapter 3

The four states we visited had similarities as well as significant
differences in their efforts to improve access to care and enhance
prenatal services to low-income women.  North Carolina and Washington
provided the most extensive enhanced services, and both had
evaluation evidence to suggest that their strategies had positive
effects on birth outcomes.  Despite varying efforts to establish such
services, state officials in all the states agreed that enhanced
services are necessary for comprehensive prenatal care for women. 
States that are moving their Medicaid population into managed care
are taking steps to continue providing enhanced services as medical
care financing changes.  However, despite efforts to increase
prenatal care, state and local officials report that barriers to care
and service gaps remain. 

The four states we visited differed somewhat in the number of
Medicaid-financed births, their infant mortality rate and percentage
of low birth weight births, and other indicators of access to
prenatal care, such as early or late entry into care.  (See table
3.1.) Indiana has had the greatest increase in percentage of births
paid for by Medicaid.  Massachusetts and Washington have lower infant
mortality rates than the national average, while Indiana's and North
Carolina's rates are higher.  Massachusetts is the only state of the
four that has both decreased in the percentage of women receiving
late or no prenatal care and increased in the percentage of women
receiving care in the first trimester.  Starting in 1985, before the
Medicaid expansions, Massachusetts used state money to finance
perinatal care coverage for uninsured pregnant women with incomes
below 185 percent of the federal poverty level through its Healthy
Start Program.  Massachusetts is also the only state visited that has
expanded coverage of pregnant women to 200 percent through its own
state program. 



                                    Table 3.1
                     
                     States Differ in Infant Mortality Rates
                       and Reliance on Medicaid to Finance
                                   State Births

                                    Ind.     Mass.      N.C.     Wash.      U.S.
------------------------------  --------  --------  --------  --------  --------
Total number of births
--------------------------------------------------------------------------------
1991                              85,707    88,205   102,362    79,711  4,110,90
                                                                               7

Estimated percentage of Medicaid births
--------------------------------------------------------------------------------
1991                                  39        23        39        36        32
1985                                   5        16        11        18        15

Infant mortality rate
--------------------------------------------------------------------------------
1991                                 9.1       6.6      10.8       7.5       8.9
1986                                11.3       8.5      11.5       9.8      10.4

Percentage of low birth weight births
--------------------------------------------------------------------------------
1991                                 6.7       5.9       8.4       5.1       7.1
1986                                 6.4       5.8       7.9       5.2       6.8

Percentage of women obtaining first trimester prenatal care
--------------------------------------------------------------------------------
1991                                76.7      85.5      76.3      75.1      74.6
1986                                74.3      82.0      77.6      75.3      74.3

Percentage of women obtaining late or no prenatal care
--------------------------------------------------------------------------------
1991                                 5.6       2.4       5.2       4.1       5.6
1986                                 5.1       2.8       4.6       4.8       5.9
--------------------------------------------------------------------------------
Sources:  Estimated percentage of Medicaid births, 1985 and 1991 (for
the U.S.) from Frost et al.  State Implementation of the Medicaid
Eligibility Expansions for Pregnant Women, Alan Guttmacher Institute,
New York, 1993.  U.S.  estimate is based on responding states only. 
All other data from the National Center for Health Statistics. 

   Figure 3.1

   (See figure in printed
   edition.)


   STATE IMPLEMENTATION OF
   INCREASED AND STREAMLINED
   ELIGIBILITY DIFFERED
---------------------------------------------------------- Chapter 3:1

Although all four states increased their Medicaid eligibility for
pregnant women beyond the federally mandated level by 1991, they
expanded eligibility at different times and to different degrees. 
Massachusetts, North Carolina, and Washington began expanding
eligibility before Indiana.  By 1991, Indiana had expanded its
eligibility level to 150 percent of the federal poverty level, and
the other states had expanded to 185 percent of the federal poverty
level.  Massachusetts and North Carolina eliminated their assets
tests in 1987, Indiana did so in 1988, and Washington did so in 1989. 

The states also differed in how quickly they acted to streamline
eligibility and in the actions that they took.  Massachusetts and
North Carolina adopted presumptive eligibility in 1987.  Indiana
adopted presumptive eligibility in 1988 but abolished it in 1991. 
Only North Carolina placed Medicaid eligibility workers in health
care settings (outstationing) early, in 1987.  The other states began
to do so only after the federal government required some
outstationing in 1991.  Massachusetts, North Carolina, and Washington
all shortened their Medicaid application forms, but that did not take
effect until 1990 or later. 

In addition, the states used several other approaches to ease entry
into care: 

  Three states (Indiana, Massachusetts, and Washington) allow
     pregnant women to apply for Medicaid eligibility by mail, rather
     than in person, and North Carolina plans to implement it in the
     future. 

  Two states (Massachusetts and Washington) implemented expedited
     eligibility while North Carolina recommends expedited
     eligibility but does not require it. 

  North Carolina disregards parental income for pregnant teens
     because state officials found that teens were moving out of
     their parents' homes to qualify for Medicaid-financed prenatal
     care at a time when they needed the support of their families
     most. 

  Washington expanded eligibility for family planning from 60 days
     postpartum to 1 year postpartum with its own state funding to
     delay repeat pregnancies. 

Several states increased provider reimbursement.  According to
information from the Alan Guttmacher Institute, Washington, North
Carolina, and Massachusetts increased their Medicaid obstetrical
reimbursement rates for uncomplicated deliveries from 20 to 85
percent in constant 1986 dollars between fiscal year 1986 and fiscal
year 1991.  Indiana's reimbursement rate remained essentially the
same in constant dollars during this period. 

   Figure 3.2

   (See figure in printed
   edition.)


   ENHANCED SERVICES STRUCTURE
   DIFFERED IN THE STATES VISITED
---------------------------------------------------------- Chapter 3:2

All four states we visited allowed Medicaid reimbursement for
enhanced services:  risk assessment, care coordination/case
management,\1 and home visiting (See table 3.2).  Massachusetts,
North Carolina, and Washington also allow Medicaid reimbursement for
health education, nutritional education, and psychosocial
counseling.\2 However, the states differed in what services they
reimbursed for, who was eligible, how services were structured, how
many women received services, and whether these services were
available statewide.  These differences could affect the likelihood
that women receive the services. 



                          Table 3.2
           
            Visited States Reimbursed for Enhanced
                           Services

                                            Mass        Wash
Medicaid reimbursed enhanced service  Ind.  .     N.C.  .
------------------------------------  ----  ----  ----  ----
Care coordination/case                X     X     X     X
management

Risk assessment                       X     X     X     X

Home visiting                         X     X     X     X

Nutritional counseling                      X     X     X

Health education                            X     X     X

Psychosocial counseling                     X     X     X
------------------------------------------------------------
North Carolina and Washington both had statewide programs of enhanced
services for which any Medicaid-eligible pregnant woman was eligible. 
They both served about 58 percent of their Medicaid pregnant women in
1992.  Massachusetts either provided larger reimbursements to medical
care providers who agreed to provide enhanced services or required
health maintenance organizations (HMOs) to provide them.  However,
Massachusetts did not know how many pregnant women received enhanced
services and did not monitor whether medical care providers were
actually providing the services.  Indiana limited care coordination
to high-risk women, and only 3 percent of Medicaid pregnant women
received services.  In addition to Medicaid efforts, in every state
we visited, state Maternal and Child Health (MCH) agencies were
involved in activities to improve services for pregnant women and
enroll them in care.  The collaboration was closest in North Carolina
and Washington, where the state MCH and Medicaid agencies jointly
developed identifiable programs and shared program administration. 
For more information, see appendix I. 

   Figure 3.3

   (See figure in printed
   edition.)


--------------------
\1 Care coordination includes performing a risk assessment,
developing a plan of care, coordinating referrals to appropriate
service providers, and follow-up to ensure clients receive needed
services. 

\2 Health education includes information on healthful behavior during
pregnancy, among other topics.  Nutrition education includes
information on the relationship between proper nutrition and good
health during pregnancy and infant feeding.  Psychosocial counseling
involves helping women with problems that can affect health status,
such as physical abuse during pregnancy. 


   MCH PLAYS KEY PARTNERSHIP ROLE
   IN DEVELOPING SERVICES
---------------------------------------------------------- Chapter 3:3

Both North Carolina and Washington chose to deliver enhanced services
through a statewide program developed, implemented, and monitored
collaboratively by their MCH and Medicaid agencies.  These programs
included outreach, have name recognition with local providers,
planned data collection at the beginning of their programs to allow
for evaluation, do not limit enhanced services to high risk women,
and are actually serving a large number of Medicaid women. 

Both programs share administration between MCH and Medicaid staff. 
The Baby Love Program was jointly developed and is jointly
administered by the state MCH bureau, the state Medicaid bureau, and
the North Carolina Office of Rural Health and Resource Development. 
State officials told us that these three agencies developed a
partnership that broke down traditional turf barriers and worked
together to focus on infant mortality. 

Washington's First Steps project is administered by Medicaid and the
state's MCH bureau.  The project, enacted in 1989, currently has a
central clearinghouse coordinator to provide consistency statewide
and to link communities, clients, and providers.  Interagency working
groups provide project direction and monitoring for First Steps'
services.  The Medicaid agency administers the maternity case
management services, while the MCH administers the maternity support
services. 

   Figure 3.4

   (See figure in printed
   edition.)


   EVALUATION EVIDENCE MIXED BUT
   SUGGESTS BENEFITS FROM ENHANCED
   SERVICES
---------------------------------------------------------- Chapter 3:4

Researchers are beginning to examine the Medicaid expansions to
determine whether the strategies used will improve birth outcomes,
but it may be too soon for definitive answers.  Nationally, infant
mortality declined at a slightly faster rate between 1989 and 1991
than it did between 1981 and 1986.  However, the low birth weight
rate was essentially stable through the 1980s and other measures of
access, such as starting prenatal care during the last 3 months of
pregnancy, did not improve. 

Using national or state data for all women to evaluate the expansion
overlooks (1) other trends that influence national and state figures,
(2) the extent to which efforts focused only on low-income women can
influence whole population figures, and (3) time lags in
implementation and data collection. 


      OTHER TRENDS
-------------------------------------------------------- Chapter 3:4.1

Between 1986 and 1991, the United States experienced a recession, and
at least one study has correlated increased rates of late or no
prenatal care and low birth weight among low-income women to times of
economic stress.\3 In addition, during this time crack cocaine use
became more common among child-bearing women.\4 ,\5 Both of these
trends could adversely affect birth outcomes indicators.  On the
other hand, technological advances have improved neonatal hospital
care and should be improving birth outcomes.  Given such influences
on overall state birth outcome rates, it is difficult to isolate the
effect of state Medicaid expansions from other trends over time. 


--------------------
\3 Elliot S.  Fisher, James P.  LoGerfo, and Janet R.  Daling,
"Prenatal Care and Pregnancy Outcomes during the Recession:  The
Washington State Experience," American Journal of Public Health, Vol. 
75, No.  8 (1985), pp.  866-869. 

\4 Drug Exposed Infants:  A Generation At Risk (GAO/HRD-90-138, June
28, 1990). 

\5 Drug Abuse:  The Crack Cocaine Epidemic:  Health Consequences and
Treatment (GAO/HRD-91-55FS, Jan.  30, 1991). 


      LOW-INCOME FOCUS
-------------------------------------------------------- Chapter 3:4.2

In addition, state efforts for low-income women affect only that
segment of the population, and changes in outcomes among low-income
women might be masked by changes among more affluent women. 


      TIME LAGS FOR DATA AND
      IMPLEMENTATION
-------------------------------------------------------- Chapter 3:4.3

Finally, states were still implementing aspects of their expansions
in 1991.  But 1991 infant mortality rates, the most recent national
results available, represent the results of 1990 and 1991
pregnancies.  Therefore, it is probably premature to judge the
effects of the expansions by looking at statewide rates for all
women. 


   EXPANDING ELIGIBILITY ALONE MAY
   NOT IMPROVE OUTCOMES
---------------------------------------------------------- Chapter 3:5

Several evaluations of expanding financial eligibility for prenatal
care suggest that expanding access alone may not be enough to improve
outcomes.  Two evaluations of expanded Medicaid eligibility in
Tennessee showed no overall improvements in birth outcomes following
expansions in Medicaid eligibility, although after Tennessee
increased eligibility levels to 100 percent of the federal poverty
level, late or no prenatal care decreased.\6 An evaluation of the
Massachusetts Healthy Start program (which expanded financial
eligibility for perinatal care before the Medicaid expansions)
compared prenatal care and birth outcomes in 1984 and 1987 between
(1) uninsured women and women with private insurance and (2)
uninsured women and women with Medicaid coverage.  This evaluation
found no statistically significant changes in birth outcomes or
satisfactory prenatal care for uninsured women compared to either
control group.  This evaluation also examined the difference in
prenatal care and birth outcomes among uninsured women in 1987 by
comparing those in Healthy Start with those who remained uninsured. 
The results showed that women who enrolled in Healthy Start were
significantly more likely to receive satisfactory prenatal care and
less likely to have a poor birth outcome.  However, the evaluators
were unsure whether this was due to the program or to selection
bias.\7


--------------------
\6 Joyce M.  Piper, Wayne A.  Ray, Marie R.  Griffin, "Effects of
Medicaid Eligibility Expansion on Prenatal Care and Pregnancy Outcome
in Tennessee," JAMA, Vol.  264, No.  17 (1990), pp.  2219-2223.

Joyce M.  Piper, Edward F.  Mitchel, Jr., Wayne A.  Ray, "Expanded
Medicaid Coverage for Pregnant Women to 100 Percent of the Federal
Poverty Level," American Journal of Preventive Medicine, Vol.  10,
No.  2 (1994), pp.  97-102. 

\7 Jennifer S.  Haas et al., "The Effect of Providing Health Coverage
to Poor Uninsured Pregnant Women in Massachusetts," JAMA, Vol.  269,
No.  1 (1993), pp.  87-91. 


      OUTCOMES IMPROVED WITH
      ENHANCED SERVICES
-------------------------------------------------------- Chapter 3:5.1

However, two evaluations showed positive outcomes among low-income
women in states where many Medicaid pregnant women received enhanced
prenatal services.\8 North Carolina compared outcomes among Medicaid
pregnant women who had received care coordination, health education,
and psychosocial support to those who did not and found improved
birth outcomes among women who had received these enhanced
services.\9

Washington has evaluated its First Steps project and found that low
birth weight has declined in its low-income population since the
program's implementation.\10 Both these evaluations suggest that
providing enhanced services is beneficial.  In addition, a recent
evaluation of a randomized trial of comprehensive prenatal care in
Tennessee found an increase in birth weight among first-time mothers
who received comprehensive prenatal care.\11

In North Carolina, Medicaid women who received Baby Love Maternity
Care Coordination were compared to Medicaid women who did not.  The
researchers found the following: 

  Among Medicaid women who did not receive care coordination, the low
     birth weight rate was 21 percent higher, the very low birth
     weight rate was 62 percent higher, and the infant mortality rate
     was 23 percent higher. 

For each $1.00 spent on maternity care coordination, Medicaid saved
an estimated $2.02 in medical costs for newborns up to 60 days of
age. 

  Comparing only women with term births, women who received care
     coordination for 3 or more months had lower rates of low and
     very low birth weight than those who received it for less than 3
     months.  In addition, their average Medicaid newborn costs were
     $396 lower than Medicaid women who had received care
     coordination for less than 3 months. 

In Washington, an evaluation of the Washington First Steps project
found that, in comparing rates in 1988 before the First Steps project
and in 1991: 

  The proportion of women with no prenatal care declined 52 percent,
     and the proportion of women with care beginning after the second
     trimester declined 22 percent. 

  Declines in the proportion of women receiving delayed, later, or no
     prenatal care have been greatest among women in demographic
     groups with historically poorest access to prenatal care--that
     is, low-income women, racial minorities, teens, and unmarried
     women. 

An evaluation comparing birth outcomes from January to June 1988 and
from July to December 1991 found the following: 

  The low birth weight rate for all low-income births declined from
     6.2 percent to 5.5 percent.  Among non-low-income births, the
     low birth weight rate declined from 3.4 to 3.1 percent. 

The very low birth weight rate also declined and declined more for
low-income births than for non-low-income births. 


--------------------
\8 Neither Massachusetts nor Indiana has conducted a statewide
evaluation of its Medicaid expansions. 

\9 P.A.  Buescher, et al., "An Evaluation of the Impact of Maternity
Care Coordination on Medicaid Birth Outcomes in North Carolina,"
AJPH, Vol.  81, No.  12 (1991), pp.  1625-1629. 

\10 Frederick A.  Connell, et al., First Steps Evaluation Report
(Seattle:  1993), p.  38. 

\11 F.  Joseph McLaughlin et al., "Randomized Trial of Comprehensive
Prenatal Care for Low-Income Women:  Effect on Infant Birth Weight,"
Pediatrics, Vol.  89, No.  1 (1992), pp.  128-132. 


LESSONS FOR HEALTH CARE REFORM
============================================================ Chapter 4

No matter what happens with health care reform, states are
increasingly using managed care to provide for low-income pregnant
women's health care.  Medicaid managed care has had access and
quality problems in the past.  But enhanced prenatal care services
can be continued under managed care.  And states can use other
mechanisms, such as quality assurance programs, coupled with state
monitoring and oversight, to improve health outcomes.  In addition,
putting performance or service expectations into managed care
contracts may achieve expected service or performance levels. 

Current health care reform proposals, if enacted, would change
funding and services for low-income women.  What services would be
included for pregnant women is a significant issue that has not yet
been fully addressed.  Changing funding streams may complicate state
efforts to provide enhanced services. 

   Figure 4.1

   (See figure in printed
   edition.)


   STATES ARE MOVING THEIR
   MEDICAID POPULATION INTO
   MANAGED CARE, BUT MEDICAID
   MANAGED CARE HAS HAD PROBLEMS
   IN THE PAST
---------------------------------------------------------- Chapter 4:1

States are rapidly developing or expanding their Medicaid managed
care programs, most often for low-income women and children on
Medicaid, to increase access to care and control costs.  Currently,
49 states have a managed care program in place or planned, and
Medicaid enrollment in managed care doubled between 1987 and 1992. 

Several models of Medicaid managed care exist.  They range from
prepaid or capitated models where organizations are paid a per capita
amount each month to provide or arrange for all covered services, to
primary care case management models, which are similar to traditional
fee-for-service arrangements except that providers receive a per
capita management fee to coordinate a patient's care in addition to
reimbursement for services provided.  Common to all managed care
models is the use of a primary care physician to control access and
coordinate delivery of health services. 

Managed care is seen as a way to improve Medicaid recipients' access
to medical services by ensuring that Medicaid patients have a primary
care provider, but Medicaid managed care has had quality and access
problems in the past.  In the past we found managed care plans for
Medicaid recipients that

  used incentive payments to physicians that rewarded them for
     limiting services to Medicaid program beneficiaries;\1

  lacked adequate quality assurance programs;

  did not gather and analyze utilization data to detect potential
     underserving of program beneficiaries;

  did not follow up and correct care quality problems;\2

  did not provide timely and federally mandated Early Periodic
     Screening, Diagnostic, and Treatment (EPSDT) services for
     children;\3 and

  contracted with physicians whose performance was substandard or
     unprofessional.\4

Moving to a managed care model creates new challenges for state
oversight.  Paying for Medicaid services on a capitated basis gives
providers incentives to stint on services.  In addition, putting
providers at financial risk can put them at risk of insolvency, which
can leave beneficiaries unprotected.  For some states, managed care
programs are new, and states need to take the time to adequately plan
and develop the organizational structure to administer and monitor
managed care programs.  However, states have been working to improve
their monitoring and quality assurance for these programs. 

   Figure 4.2

   (See figure in printed
   edition.)


--------------------
\1 See Medicaid Managed Care:  Healthy Moms, Healthy Kids--A New
Program for Chicago (GAO/HRD-93-121, Sept.  7, 1993) and Medicaid: 
HealthPASS--An Evaluation of a Managed Care Program for Certain
Philadelphia Recipients (GAO/HRD-93-67, May 7, 1993). 

\2 For the above problems, see GAO/HRD-93-121. 

\3 See GAO/HRD-93-67 and Medicaid:  Oregon's Managed Care Program and
Implications for Expansions (GAO/HRD-92-89, June 19, 1992). 

\4 See GAO/HRD-93-67. 


      MEDICAID MANAGED CARE HAS
      HAD MIXED RESULTS AT
      IMPROVING BIRTH OUTCOMES
-------------------------------------------------------- Chapter 4:1.1

Managed medical care has not always improved adequacy of prenatal
care and birth outcomes for Medicaid women.  Four evaluations
compared the level of prenatal care and birth outcomes among Medicaid
women in six managed care arrangements with those of similar Medicaid
women in fee-for-service care.  Enrollment in managed medical care
did not significantly improve adequacy of prenatal care or birth
outcomes of Medicaid women in four of six managed care plans
reviewed.\5 In two plans, managed care enrollees had better birth
outcomes.\6

   Figure 4.3

   (See figure in printed
   edition.)


--------------------
\5 Timothy Carey, Kathi Weis, and Charles Homer, "Prepaid versus
Traditional Medicaid Plans:  Lack of Effect on Pregnancy Outcomes and
Prenatal Care," Health Services Research, Vol.  26, No.  2 (1991),
pp.  165-181.

Neil Goldfarb et al., "Impact of a Mandatory Medicaid Case Management
Program on Prenatal Care and Birth Outcomes," Medical Care, Vol.  29,
No.  1 (1991),
pp.  64-71.

Medicaid:  HealthPASS:  An Evaluation of a Managed Care Program for
Certain Philadelphia Recipients (GAO/HRD-93-67, May 17, 1993).

James Krieger, Frederick Connell, and James LoGerfo, "Medicaid
Prenatal Care:  A Comparison of Use and Outcomes in Fee-for-Service
and Managed Care," American Journal of Public Health, Vol.  82, No. 
2 (1992), pp.  185-190. 

\6 See Carey, Weis, and Homer and Krieger et al. 


      STATES WE VISITED PLAN TO
      CONTINUE ENHANCED SERVICES
      UNDER MEDICAID MANAGED CARE
-------------------------------------------------------- Chapter 4:1.2

In all four states we visited, some or all of their Medicaid-eligible
pregnant women are in managed medical care systems.  However,
officials from all four states we visited believe enhanced services
such as care coordination/case management and social services are
necessary to have positive birth outcomes.  Therefore, these states
have preserved a Medicaid reimbursement mechanism for their enhanced
services under managed care to ensure that these services will
continue. 

  Indiana is planning to bring its Medicaid Aid to Families with
     Dependent Children (AFDC) and AFDC-related population into
     managed care in the next 3 years.  It plans to use managed care
     providers as gatekeepers for care coordination and reimburse
     enhanced services such as care coordination separately. 

  All Massachusetts women and children enrolled in Medicaid are in
     managed care arrangements.  Enhanced services are reimbursed
     through the enhanced global fee for those providers who choose
     to offer enhanced services and through a capitated rate for
     HMOs. 

  A relatively small proportion of North Carolina Medicaid enrollees
     are in managed care.  Pregnant managed care enrollees can
     receive Baby Love services, which are reimbursed separately. 

  Washington is currently moving most of its Medicaid population into
     managed care.  However, it is maintaining maternity support and
     maternity case management services as additional fee-for-service
     reimbursed services to encourage their use.  The state has tried
     to either link new managed care providers with maternity support
     and maternity case management service providers or have managed
     care providers become maternity support or maternity case
     management service providers. 


   BETTER OUTCOMES REQUIRE
   PROVIDER ACCOUNTABILITY,
   APPROPRIATE SERVICES, AND
   ACCESS
---------------------------------------------------------- Chapter 4:2

   Figure 4.4

   (See figure in printed
   edition.)


      BETTER OUTCOMES REQUIRE
      PROVIDER ACCOUNTABILITY
-------------------------------------------------------- Chapter 4:2.1

While there are no clear and simple answers, improving low-income
women's birth outcomes in a managed care environment may require
managed care plans to become accountable for improving their
patients' outcomes.  The means for achieving this may be through
quality improvement efforts\7 coupled with changes in practice if
health outcomes are poor or through putting performance or service
expectations into managed care contracts. 

The quality assurance process provides one mechanism to work on
improving health outcomes under managed care.  Federal law requires
that all managed care organizations contracting with state Medicaid
programs under capitation or other risk payment arrangements have an
internal program of quality assurance as part of their contract. 
Internal quality assurance programs consist of systematic activities
by the managed care organization to monitor and evaluate the care
delivered to its enrollees according to predetermined objective
standards and to effect improvements in care as needed.  States are
responsible for monitoring each managed care organization to assess
the extent to which its quality assurance program meets
state-specified standards and the quality of health care delivered by
the managed care organization. 

In 1991, the Medicaid bureau began the Quality Assurance Reform
Initiative to develop a Health Care Quality Improvement System for
Medicaid managed care programs.  As part of this effort, the Health
Care Financing Administration (HCFA) has developed A Health Care
Quality Improvement System for Medicaid Managed Care:  A Guide for
States.  This document outlines (1) a framework for a health care
quality improvement system for Medicaid managed care; (2) recommended
standards for internal quality assurance programs of managed care
organizations; (3) recommendations on priority clinical areas of
concern, use of clinical indicators, and practice guidelines; and (4)
a recommended scope of work for conducting external quality reviews. 

HCFA recommends that state Medicaid agencies require managed care
contractors to continuously monitor and evaluate the quality of care
they provide for pregnant women.  Care for pregnant women and
childhood immunizations are considered the two top-priority
categories for monitoring quality of care.  HCFA recommends using
date of entry into prenatal care, number of visits, whether the woman
has a live birth or fetal loss, when the woman joined the managed
care organization, and birth weight to monitor quality of care. 
Through this monitoring, states can identify managed care plans that
are not improving health outcomes for Medicaid pregnant women and
help the plans take corrective action. 

Quality assurance programs can only work if the federal and state
governments diligently monitor quality of care.  States and
participating plans have not always complied with quality assurance
systems and procedures in the past nor taken corrective action
quickly.  In our prior work, we documented some of the potential
problems that arise when safeguards and oversight systems do not
function properly--such as plans' not adequately documenting services
provided in medical records, not systematically collecting
utilization data, and not following up on reported problems to ensure
corrective action was taken. 

A second approach to improving outcomes under managed care is to put
measurable performance expectations into managed care contracts. 
Washington has put the expectation into its contracts that managed
care providers will provide EPSDT services to 40 percent of its
enrolled children in 1993, 50 percent in 1994, and 80 percent by
1995.  A HCFA managed care official did not know of any other states
trying to put measurable performance expectations into managed care
contracts.  But performance expectations could be used for prenatal
care--for example, the percentage of enrolled women who entered
prenatal care in the first trimester.  If performance expectations
lead to improved EPSDT enrollment among children in managed care in
Washington, other states may try similar strategies. 

   Figure 4.5

   (See figure in printed
   edition.)


--------------------
\7 The National Academy of Sciences defines quality of health care as
"the degree to which health services for individuals and populations
increase the likelihood of desired health outcomes and are consistent
with current professional knowledge."


      BETTER OUTCOMES REQUIRE
      IMPROVED ACCESS
-------------------------------------------------------- Chapter 4:2.2

Currently health care reform is high on the Congress's and the
administration's agenda.  A number of competing proposals for change
have been introduced in the Congress.  If health care reform
legislation is passed, it will change prenatal and well child care
for low-income families.  While it may give access to some kinds of
care for some families, it may also close access for some kinds of
care. 

Services that Medicaid recipients can now receive may not be provided
if they are not part of the comprehensive benefit package.  For
example, in the Administration's bill, the Medicaid program will no
longer cover services provided as part of a comprehensive benefit
package.  Medicaid will be limited to long-term care services and
Medicare cost-sharing.  However, Medicaid coverage for items and
services not covered under the comprehensive benefit package will
continue to be covered for Medicare, AFDC, and Supplemental Security
Income (SSI) recipients and for children under age 18 (or up to age
22 at state option.) However, this coverage would not extend to
non-AFDC low-income pregnant women currently being covered under the
Medicaid expansions. 

Many low-income pregnant women now covered in state programs for
enhanced services are not AFDC or SSI recipients.  They would not
have Medicaid coverage for these services if enhanced services are
not included in the comprehensive benefit package.  This change in
coverage may impact states' abilities to continue to provide such
services.  In Washington, for example, in the first 6 months of 1991,
only 52 percent of the pregnant women receiving First Step services
were recipients of AFDC or certain other state income support
programs. 

The Administration's bill addresses the needs of medically
underserved populations or locations for special services to enable
people to gain access to the health care system and to promote their
health.  The bill establishes grant funds to provide health services
for medically underserved populations.  It provides extra funding to
Community and Migrant Health Centers and to develop qualified
community health plans and practice networks, with the proviso that
these practice networks serve medically underserved populations or in
health professional shortage areas.  In addition, the bill
establishes grant funding for enabling services, including
transportation, outreach, education, translation, and other services. 
The bill authorizes $1.2 billion for enabling services for fiscal
years 1996 through 2000. 

A different health care reform bill, S.1770/H.R.3704 (Chafee- Thomas)
would authorize a new "Maternal and Infant Care Coordination" program
to provide grants to states for the coordination of Medicaid, WIC,
family planning, MCH-Title V, community health centers, and substance
abuse programs.  These grants are to help states develop and
implement coordinated, multidisciplinary, and comprehensive primary
health care and social services, and health and nutrition education
programs designed to improve maternal and child health, targeted to
women of childbearing age, particularly women at risk of having a low
birth weight birth. 

   Figure 4.6

   (See figure in printed
   edition.)


      BETTER OUTCOMES REQUIRE
      APPROPRIATE CARE CONTENT
-------------------------------------------------------- Chapter 4:2.3

While the Health Security Act covers pregnancy-related services, it
is not specific on what services would be covered for pregnant women
and how comprehensive the services would be.  The American College of
Obstetricians and Gynecologists and the Public Health Service have
developed standards of practice and recommended content of care and
service packages.\8 These reports approach prenatal care in slightly
different ways and stress necessary content of care to different
degrees, but generally, as a part of or in addition to medical
prenatal care, they recommend

  initial and continuing risk assessment, coupled with the
     development of a care plan and referral to other educational and
     social services as needed;

  health and nutritional education promoting positive health
     behaviors and reducing negative behaviors, including emphasis on
     avoiding smoking, alcohol, and drug use, particularly illicit
     drugs;

  extra services for women assessed at high risk, including more
     intensive case management or care coordination, mental health
     services, substance abuse services, social services, and home
     visiting. 


--------------------
\8 American College of Obstetricians and Gynecologists, Standards for
Obstetric-Gynecologic Services, Seventh Edition (Washington, D.C.: 
1989).

American Academy of Pediatrics, American College of Obstetricians and
Gynecologists, Guidelines for Perinatal Care, Third Edition (Elk
Grove Village, IL and Washington, D.C.:  1992).

Caring for Our Future:  The Content of Prenatal Care, U.S.  Public
Health Service, Expert panel on the content of prenatal care
(Washington, D.C.:  1989).

National Perinatal Information Center, Perinatal Health Strategies
for the 21st Century, (Providence, R.I.:  1992). 


VISITED STATES STRUCTURED ENHANCED
SERVICES TO PREGNANT WOMEN
DIFFERENTLY
=========================================================== Appendix I

   Figure I.1

   (See figure in printed
   edition.)


         INDIANA
----------------------------------------------------- Appendix I:0.0.1

In Indiana, Medicaid reimburses for care coordination on a
fee-for-service basis to an individual practitioner who is not
required to join a sponsoring organization or provider practice. 
This approach will change in July 1994, when the state places its
Medicaid-eligible pregnant women into managed care systems.  At that
time, prenatal care providers will become the gatekeepers for care
coordination.  While all Medicaid-eligible pregnant women can be
assessed for risk, only those considered high risk are eligible for
Medicaid-reimbursed care coordination, which includes additional
services.  Medicaid officials told us that approximately 3 percent of
its pregnant Medicaid population receives care coordination. 

Indiana MCH also has a prenatal care coordination program that
incorporates the Medicaid care coordination reimbursement when
appropriate and provides additional MCH block grant, and sometimes
county, money to place prenatal care coordinators across the state. 
The primary purpose of this program is to get women into prenatal
care as early as possible, then provide them whatever services they
need to have a healthy birth outcome.  While Indiana Medicaid
reimburses for care coordination services for at-risk women only,
this program serves all low-income pregnant women.  Currently 66 of
Indiana's 92 counties have at least one prenatal care coordinator. 
Few Indiana low-income pregnant women receive these MCH-funded
services.  Approximately 6 percent of the Medicaid population
receives prenatal care through MCH services.  MCH officials estimated
that in 1992, of those women receiving prenatal care through MCH, 6
percent received care coordination services. 


         MASSACHUSETTS
----------------------------------------------------- Appendix I:0.0.2

Medicaid reimburses for coordinated medical management, health care
counseling, and obstetrical risk assessment and monitoring through
its enhanced global fee.  However, while all Medicaid pregnant women
are eligible for these services, not all providers elect to offer
them and receive the increased fee.  For Medicaid-eligible pregnant
women receiving care through a health maintenance organization, the
HMO contract requires the HMO to provide these enhanced services. 
The HMO is reimbursed through its capitated rate.  While Medicaid
officials could not tell us how many women receive enhanced services,
they believe most of these women receive them because most providers
bill for the enhanced global fee, and HMOs are required to provide
them.  However, the state Medicaid agency does not monitor providers
to ensure that those billing the enhanced global fee are actually
providing these services.  At one site we visited that provided some
enhanced services, staff did not realize that the fee the health
center received for pregnant women required them to provide enhanced
prenatal services in addition to medical prenatal care. 

Low-income women in Massachusetts can also access some services
through the Healthy Start program administered by the Department of
Public Health's MCH bureau.  The Healthy Start program, established
in 1985, primarily addresses the financial barriers to comprehensive
obstetrical care; however, through its statewide system, it also
provides telephone referral to link pregnant women to other vital
services such as the Special Supplemental Food Program for Women,
Infants, and Children and the Parenting and Pregnancy Support
Programs.  The Parenting and Pregnancy Support Programs, located at
22 sites across the state, are geared toward women, infants, and
their families at risk due to social and environmental factors.  The
programs' services include home visiting, service coordination and
advocacy, health education and promotion, health assessment and
monitoring, parenting education and support, and infant developmental
monitoring.  While both Healthy Start and the Parenting and Pregnancy
Support Programs are administered by the Department of Public
Health's MCH bureau, Medicaid helps fund these two programs. 


         NORTH CAROLINA
----------------------------------------------------- Appendix I:0.0.3

In 1987, North Carolina introduced its Baby Love Program which, in
addition to offering outreach and advocacy, established a statewide
system of maternity care coordination.  North Carolina provides care
coordination to all Medicaid recipients who wish to enroll in the
Baby Love Program.  This statewide program's care coordination
services include risk assessment, nutritional counseling,
psychological/social services, home visits, and postpartum maternal
and newborn home assessment.  Baby Love staff provide technical
assistance to local providers and each year run a Baby Love
conference, where providers come together to share ideas and receive
training.  These enhanced services are available in all 100 North
Carolina counties, and approximately 58 percent of the pregnant
Medicaid participants who gave birth from July 1991 to June 1992
received them. 

North Carolina is also experimenting with lay Maternal Outreach
Workers to supplement the work of care coordinators by serving as
outreach workers and to provide more intensive services to some
women.  The Maternal Outreach Workers, chosen from women in the
community with natural leadership skills, provide some of their
services through home visiting.  This project is funded jointly
through Medicaid and a foundation grant and is being evaluated. 


         WASHINGTON
----------------------------------------------------- Appendix I:0.0.4

Washington's enhanced prenatal services are provided primarily by two
components of the First Steps project.  Medicaid reimburses these
services on a fee-for-service basis.  The two components of First
Steps that involve delivery of enhanced services are "maternity
support services" and "maternity case management": 

  All Medicaid-eligible women can receive maternity support services,
     which are preventive health services, including assessment,
     education, intervention, and counseling.  These are provided by
     an interdisciplinary team of community health nurses,
     nutritionists, and psychosocial workers.  In 1992, about 58
     percent of Medicaid-eligible women delivering babies in the
     state obtained maternity support services.  Medicaid reimburses
     maternity support service providers for as many as 10 visits per
     client, including home visits.  If the provider identifies the
     client as high risk, Medicaid reimburses for as many as 20
     visits.  Providers also refer these high-risk clients to
     maternity case management. 

  Maternity case management services are provided to high-risk
     pregnant women--predominantly substance abusers or pregnant
     teens.  In 1992, case management was received by more than 20
     percent of Medicaid-eligible women delivering babies in the
     state.  Medicaid reimburses case management providers on a
     monthly basis through the babies' first year of life.  Providers
     must meet face-to-face monthly with each client to review the
     required written service plan. 


MAJOR CONTRIBUTORS TO THIS
BRIEFING REPORT
========================================================== Appendix II

Rose M.  Martinez, Assistant Director, (202) 512-7103
Denise D.  Hunter, Evaluator-in-Charge
Sheila K.  Avruch
Betty S.  Clark

RELATED GAO REPORTS

Infants and Toddlers:  Dramatic Increases in Numbers Living in
Poverty (GAO/HEHS-94-74, Apr.  7, 1994). 

Medicaid Managed Care:  Healthy Moms, Healthy Kids--A New Program for
Chicago (GAO/HRD-93-121, Sept.  7, 1993). 

Medicaid:  HealthPASS--An Evaluation of a Managed Care Program for
Certain Philadelphia Recipients (GAO/HRD-93-67, May 7, 1993). 

Medicaid:  States Turn to Managed Care to Improve Access and Control
Costs (GAO/HRD-93-46, Mar.  17, 1993). 

Integrating Human Services:  Linking At-Risk Families With Services
More Successful Than System Reform Efforts (GAO/HRD-92-108, Sept. 
24, 1992). 

Federally Funded Health Services:  Information on Seven Programs
Serving Low-Income Women and Children (GAO/HRD-92-73FS, May 28,
1992). 

Early Intervention:  Federal Investments Like WIC Can Produce Savings
(GAO/HRD-92-18, Apr.  7, 1992). 

ADMS Block Grants:  Women's Set-Aside Does Not Assure Drug Treatment
for Pregnant Women (GAO/HRD-91-80, May 6, 1991). 

Prenatal Care:  Early Success Enrolling Women Made Eligible by
Medicaid Expansions (GAO/PEMD-91-10, Feb.  11, 1991). 

Home Visiting:  A Promising Early Intervention Strategy for At-Risk
Families (GAO/HRD-90-83, July 11, 1990). 

Drug-Exposed Infants:  A Generation at Risk (GAO/HRD-90-138, June 28,
1990). 

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