A Labor of Love: State Policies and Partnerships to Lower Infant Mortality
State agencies across the country, from Medicaid to public health, to social services and corrections, are deeply engaged in multi-sector initiatives to reduce infant mortality. And for good reason — the United States ranks 25th among industrialized countries in infant mortality with a disproportionate number of being African Americans.
Despite the gravity of the problem, infant mortality is responsive to policy and prevention strategies. There are recognized risks including smoking, limited pre/interconception care, unsafe sleep practices, and pre-term birth as well as evidence-based interventions that require a multi-sector approach.
NASHP’s 29th Annual State Health Policy Conference a session on infant mortality featured a snapshot of three state approaches: Colorado, Indiana, and South Carolina. Each of these states has developed a public/private partnership committed to comprehensive strategies that address both medical and social factors related to infant mortality. Each has participated in HRSA’s Collaborative Improvement and Innovation Network to Reduce Infant Mortality (IM CoIIN), identified state policy levers, and documented success stories.
Colorado’s Nurse-Family Partnership (NFP) has produced many positive outcomes. In fact, cumulative data as of December 31, 2015 shows that in 61 of the 64 counties served by the program, 90 percent of babies were born at a healthy weight and 91 percent of babies were born at full term . Because the NFP serves only first-time mothers, Health First Colorado, the state’s Medicaid program, offers Prenatal Plus to provide case management, nutrition counseling, and psychosocial services to all pregnant women at risk for negative maternal and infant health outcomes. These negative outcomes may be due to numerous lifestyle, behavioral, and non-medical factors that could affect pregnancy including a lost job or excessive debt, partner in jail, or prior low birth rate infant.
Health First Colorado has also devised strategies to ensure the accessibility of Long-Acting Reversible Contraception (LARC). The program pays full purchase price for LARC and a fee schedule rate for insertion at a physician’s office. Federally Qualified Health Centers (FQHC) are reimbursed through a Prospective Payment System (PPS) encounter rate based on full-costs for LARC devices and insertion. Health First Colorado received approval from CMS to pay free standing Rural Health Clinics (RHC) a separate payment for LARC devices because their PPS is not based on full cost methodology. The insertion of LARCs at an RHC is still paid at their PPS encounter rate. The state is also working with providers to reduce the rate of C-sections in low-risk, first time moms, and is considering options to provide physicians with information on their own C-section rates to encourage quality improvement.
Indiana’s Perinatal Quality Improvement Collaborative recognizes the value of multi-sector partnerships and data-driven evidence-based strategies. Through a public/private partnership, the state Medicaid agency was able to establish a policy for nonpayment for early elective delivery. A Management and Performance Hub collects information from a variety of state data sources, including Medicaid, the Department of Corrections, and multiple State Department of Health sources including HIV/STD and Maternal and Child Health. This collection of data sources has assisted the state in identifying three distinct high-risk subpopulations that account for only 1.6 percent of the sample population but nearly 50 percent of infant deaths. This information has enabled the state to target interventions. These high-risk subpopulations include low birthweight, preterm birth, and limited access to prenatal care, the most significant factor identified.
As a demonstration of state commitment, the Safety PIN (Protecting Indiana’s Newborns) grant program enacted by the Indiana Legislature in 2015 appropriates $13.5 million to reduce infant mortality: $2.5 million will support development of a two-way app for pregnant women to encourage better prenatal care and $11 million will be distributed through a competitive grant program to nonprofit organizations, local health departments, and health care entities for innovative approaches to address infant mortality.
South Carolina’s Birth Outcomes Initiative is a public/private partnership of payers, providers, and other partners. Among its achievements are a dramatic reduction in early elective deliveries partly as a result of Medicaid nonpayment policies. Additionally through the initiative the state saw a 110 percent increase in LARC insertions in the past two years, and a decrease in infant mortality of 23 percent among non-white populations, and a 9 percent decrease overall.
South Carolina is the first state to initiate a pay for success model for birth outcomes, developed through a 1915(b) waiver in partnership with its NFP and the Children’s Trust. The program will enroll approximately 4,000 additional mothers in NFP evidence-based home visiting services over a four-year period. The waiver allows for “non-statewideness,” enabling the program to focus on communities most at risk. Through a combination of philanthropic support and Medicaid funding, the program provides upfront capital to expand services. Full success payments begin only if an independent randomized controlled trial finds that the NFP can meet the outcome targets: a reduction in preterm births by 15 percent, reduction in child injuries by 26 percent, and an increase in birth spacing by 20 percent. Other success payments will be made only if at least 65 percent of those enrolled reside within a set of targeted rural and underserved communities.
These states provide a snapshot of policy and financing levers that, as part of a comprehensive strategy, can make an impact on infant mortality. Questions remain about how best to capitalize on the momentum and develop complementary policy and programmatic approaches. For instance, what approaches can reduce the significant disparities as evidenced by an African American infant mortality rate that is two to three times higher than for the white population in each of the three states profiled? What are the most effective strategies for engaging African American communities in efforts to develop patient- and community-centered approaches? Some communities may be distrustful of LARC interventions unless they know the state policies for removal of the devices. In two of the three states profiled, Medicaid policies place limits on when removal is covered. In South Carolina they are covered when medically indicated and in Colorado coverage is provided when the medical provider and client are currently enrolled in the Medicaid program at the time of the LARC removal. What interventions are most effective in addressing social factors that contribute to infant mortality? Lessons will continue to emerge as all states continue to innovate and wrestle with these questions.