Hello, everyone, and welcome to today’s webinar on Policy Options to Advanced Maternal Mental Health During Pregnancy. I am Sarah Dash, president and CEO of The Alliance for Health Policy, and for those who are not familiar with us, welcome. We are a non partisan organization dedicated to advancing knowledge, and understanding of health policy issues for the health policy community. Today’s briefing is brought to you in partnership with Health Affairs and generously supported by the California Healthcare Foundation, The Perigee Fund and The WK Kellogg Foundation. I’d like to remind everyone that you can join today’s conversation on Twitter, at the hashtag. I’ll help live and join our community at all health policy, as well as on Facebook, and LinkedIn, we want you to be active participants. So, please, do get your questions ready. You’ll have a little icon with a speech bubble.
You can use that to ask your questions at any time during the broadcast, as well as any tech questions that you may have, and we will try to get it to as many of your policy questions as we can during this webinar.
Please be sure to check out our website, allhealthpolicy.org.
You’ll get background materials, speaker bios, a resource list, and an expert list, as well as, a recording of today’s briefing, which will be made available following the session.
Policymakers have turned increased attention in recent years to maternal health, as well as to mental health, and more recently, the topic of mental health before, during and after pregnancy is gaining increased bipartisan attention. So, before we turn to our expert panel, it is my pleasure that, at two bipartisan legislators from the House in the Senate have offered brief record remarks to open our conversation.
First, I’ll introduce remarks from Congresswoman, Lisa, Blunt, Rochester of Delaware, and we’ll roll the video.
Good afternoon, everyone. I’m Congresswoman, Lisa Blunt, Rochester from Delaware. And it’s my honor to address you today at the start of the Alliance for Health Policies Perinatal Mental Health Briefing.
To President and CEO, Sarah Dash, the Board of Directors, the staff, thank you for all that you do each day to advance equitable health policy in our country And for your tireless efforts to improve our country’s health care system and help Americans better understand health policy.
I’d also like to recognize today’s speakers. I’m sure all of you will get a lot of knowledge and resources, and so thank you for sharing that information. And a special thanks to all of you, the attendees, for taking the time to join.
You will hear from a diverse group of experts about an issue of utmost importance, perinatal health and its relationship with perinatal mental health.
And importantly, you’ll also hear about how we can all work together to implement policy to prevent mental health issues during pregnancy, especially in the face of the covert 19 pandemic.
The pandemic has only exacerbated issues that were already present in our health care system, including the rise of black maternal mortality rates and the need for better mental health resources for mothers.
We know that mental health is critically important for the health and well-being of expected berthing people and their children.
Unfortunately, health disparities exist for black mothers and other mothers of color.
As a member of the Black Maternal Health Caucus, I introduced a bill called the Moms Matter Act, which would make critical investments in community based programs that provide mental health and behavioral health treatments and support to moms with maternal mental health conditions, or substance use disorders.
I’m proud to say that this Bill, which is the only mental health title of the broader Black Maternal Health Malm nimbus Act, was included in the Build Back Better Act, which I voted to pass in my committee last month.
The Act would make historic investments in the women of our nation.
It was saved moms’ lives and in racial and ethnic maternal health disparities and advance birth equity across the United States.
Specifically, the Build Back Better Act would provide $100 million for maternal, mental health equity grant programs. It would also provide $175 million in funding for local entities to address social determinants, maternal health, like housing, nutrition, and environmental conditions.
Ultimately, we will save lives and improve the quality of life for our families. I look forward to working with my colleagues, and each of you to promote solutions to protect Moms’. I hope you find today’s briefing, informative and inspiring.
Stay safe. and be well.
Thank you so much, Congresswoman, Blunt Rochester, and next, I’m pleased to introduce our Honorary Co-chair for the Alliance, Senator, and doctor Bell Cassidy of Louisiana for his opening remarks.
United States, Senator, and doctor Bill Cassidy, glad to be with you today, even if it’s virtual, as a doctor as senator, improving health outcomes for moms and newborns top priority, and as a husband and a father, it’s personal, Louisiana has one of the highest rates of maternal mortality in the country.
And it’s not just physical health implications that come with that, but mental health implications as well.
I worked in the Louisiana Charity Hospital for over 25 years.
I know the need to improve mental and physical health outcomes for all mothers.
Earlier this year, I introduced the bipartisan Maternal Health Quality Improvement Act.
Authorizing new Federal grant programs aimed at reducing maternal mortality, Fewer Moms’ Die, particularly in those communities at highest risk, those which are medically underserved.
That bill supports training, resources, and doctors and nurses to better care for new moms and their babies.
I also worked with Democrats to write the Connected Mom Act, which makes indicators of potential pregnancy complications by blood pressure, blood glucose, and pulse available on the expectant moms cell phone.
On top of this, I remain focused on improving access to mental health services for mothers and expectant mothers.
To the doctors in the room, physician advocacy, especially in regards to health care policy, like maternal, Mental Health, critical.
As we continue to respond to the pandemic, we need the medical community to tell the medical community how the panel impact how maternal health.
We need your help, Your insight, your knowledge from the front lines of maternal care. The best ideas come from experience. Doctors know where the system works and where it does not engage with policymakers at the local, state, and federal levels with solutions to these issues.
Thanks for your advocacy, for your service to our patients, to the profession of medicine to our country.
I look forward to working with you to advance women’s health care.
Sorry, Sarah, you’re on mute.
I double click that, I apologize, folks. All right, we’re back. So, thank you, again, to Senator Cassidy and Congressman Blunt Rochester, for your remarks, and for your bipartisan interest in advancing maternal and perinatal mental health. Before we move forward, I want to address briefly the terminology that you’ll hear in this program and set our intention. Today you’re going to hear a blend of terms like perinatal, maternal, and birthing person, as well as women, parents, partners, moms. Our focus for this, again, is on mental health before, during and after pregnancy.
And we want to recognize that not all families look the same. And that pregnancy birth and post-partum experiences are extremely varied. It is our intention to be as inclusive as possible with this briefing, and so we again, look forward to hearing from our diverse set of perspectives on the panel and to hearing your questions.
And we’re really glad to be bringing this programming to you today to share the latest evidence, understand the real life impact of perinatal mental health challenges and outline emergency and excuse me, emerging and maybe emergency policy considerations. As this, this really is a more nascent area of both research and policy action. To learn more, I would encourage you to check out the Health Affairs October issue, which is dedicated to this topic, as well as the Health Affairs Podcast, and the event that they held earlier this month in October, in order to really delve into the research and the evidence. And now, joining me today is a panel of wonderful and noteworthy experts. I’m joined by Ms. Joy Burkhard, who is Founder and Executive Director of 2020 Mom, a non-profit, social change organization, working to close gaps in maternal mental health care.
She has an extensive background working in quality improvement and legislative compliance for a Fortune 50 health insurer, and has a passion for improving access, quality and innovation in healthcare delivery system. Next, I’m pleased to introduce doctor Veronica Gillispie-Bell who is a Board Certified Obstetrician and gynecologist and Associate Professor at Ochsner Health in New Orleans, Louisiana.
She serves as the senior site lead and section head of obstetrics and gynecology at Oxford Center. And is the director of Quality for Women’s Services for the Ochsner Health System. We are joined today also by Ms. Carrie Hanlon, whose project director at the National Association of excuse me, National Academy for State Health Policy, where she analyzes state policies designed to improve population health and advance health and racial equity, particularly for pregnant or parenting, individuals’ and young children. She leads research and provides technical assistance to States with a focus on Medicaid payment care delivery and performance measurement strategies.
And I’m so pleased to welcome Ms. Kay Matthews, who is the founder of the Shades of Blue Project.
Ms. Matthews graduated with a two year degree in early childhood development from North Harris College in Houston, Texas, and furthered her education in the Mental Health field by becoming a licensed community health worker.
She has received numerous awards from both her community and her peers sits on the board and is partners with several national organizations.
Ms. Matthews has published best-selling self help journals 365 days to recovery, finding your way out of the Darkness and the Recovery State of Mind Daily Journal. She teaches her community, how to advocate for themselves before, during and after childbirth.
So welcome all, and let me ask Joy Burckhardt to start us off if you want to turn on your camera.
Right, thank you for joining us, Joyce. So I am going to turn it over to you to share your experience and characterize the current state of perinatal mental health here in the United States.
Great. Thank you so much, Sarah. And I first want to thank on behalf of all the speakers, the Alliance Health Affairs, the funders of all of this important work, and, of course, the members of Congress who’ve taken leadership positions on maternal mental health, recognizing that this is a bipartisan issue that we should all care about. I wanted to start by sharing that though we’re here to talk about a daunting problem that has largely been unaddressed. It’s a very exciting moment for the fields of maternal mental health.
Thousands of cross sector researchers, clinicians, and advocates have been working for years to get this point to get to this point, which is a tipping point in both awareness and identification of true and tangible policy solutions. As mentioned, my name is Joye Burkhardt and I serve as executive director of a non-profit organization called 2020 Mom or a 10 year old organization that has been studying the barriers to screening, diagnosis and treatment of these disorders and identifying solutions that can be implemented at scale.
I wish to acknowledge, and perhaps it should go without, saying, that all women and families should have access to health care coverage, Paid leave, especially after birth, and have their basic needs met.
And this infrastructure should of course be available without unfair racial or even gender identification bias.
My comments today there will focus on opportunities to improve the detection and access to care of maternal mental health disorders within the healthcare system.
Because the US largely operates in a privatized health system, we all know that it can be very difficult to implement standards of care and track national trends.
Several years ago, because of the great work of reporters, our national maternal mortality crisis was exposed.
These reporters highlighted the critical role of the CDC and its partners who were trying their best to support states in tracking these deaths with little funding and support.
This reporting helped lead to the introduction and the passage of the Preventing Maternal Deaths Act signed into law in 20 18.
It created a framework for the CDC to support states and investigating causes of maternal deaths, setting in place a strong movement, which so many of us are thrilled to be a part of towards improving maternal health and maternal health care delivery.
That work didn’t initially include, and has only just begun to scratch the surface and maternal deaths by suicide, or even overdose.
It’s in part because we’re talking about two systems of care. Not just the medical care system, but also the mental health care system, and this is why the policy implications for maternal mental health care must be addressed both within the context of maternal health and on its own and in the context of mental health.
So I wanted to start with more basics. You might be asking exactly what do you mean by maternal or perinatal mental health disorders? What are they? And most of us, I think all of us have heard about post-partum depression, which is where research first centered, right?
And which for 10 plus years, post-partum depression has been declared the most common complication of pregnancy. But there are many more disorders and symptoms that are equally as important to identify and treat with accuracy.
Like maternal, OCD, and intrusive and unwanted thoughts, like mania and psychosis, Birth trauma and PTSD and anxiety, which we now know is more common than even depression during the perinatal period and we define the perinatal period currently as pregnancy through one year post-partum.
So there’s a range of disorders and a range of onset.
And so we know about post-partum depression and now the other disorders.
And we’re also grateful that society has started to talk about and begin to understand the negative impact of these untreated disorders, not only on the mother but on the infant and early childhood brain and central nervous system development.
But what about pregnancy? Again?
Not just the post-partum.
Research is clear that new onset of depression and anxiety is nearly as common in pregnancy as in the post-partum period.
And when untreated and pregnancy, these disorders can impact the baby in utero and lead to pre-term birth.
We also know that even prior to the pandemic tween and teen girls and young women in the U S were suffering from their own mental health epidemic.
And many of these young women are now having babies with preexisting and often untreated mental health disorders.
Perhaps they were stable on medication and were being treated.
But directed to go off medications by obstetrician’s who include OB GYN midwives, or even family practice providers who treat during pregnancy and deliver babies. But without either of the provider, or the patient fully understanding the pros and cons of going off medication.
As a nation, we’re now also tuned into the growing mental health problem in our country.
Which has now become, because of …
19, become so pervasive, not just in young girls, but in all of the population, that one in four Americans are suffering from mental illnesses right now, and mothers certainly have not been immune.
So, with all this in mind, you might be asking, OK, I get it.
What did doctors think about maternal mental health disorders and what their role should be in solving this crisis and what do professional trade associations like the American College of Obstetrics and Gynecology and the American Psychological and Psychiatric Associations have to say?
Well, they all agree that screening and identification should be a top priority for health care providers.
The American Academy of Pediatrics should be applauded as they were the first trade association to recommend screening recognizing the critical impact on infants, not just mothers.
It wasn’t until 20 15 when the American College of Obstetrics and Gynecology first recommended screening that things really began to change for the field.
Their recommendation triggered a chain reaction, and most notably, the US.
Preventive Services Task Force, convened by the bi arc federal agency recommended screening in early 2016, because of their recommendations, carrying a requirement that insurers cover such services.
There was excitement, and there was also misunderstanding that suddenly screening would just happen now that the US Preventive Services Task Force has said, it should be so.
The core problem, though, is not insurance, denials of screenings.
Screening was really already largely being covered by most insurers.
Rather, it was, was and remains that substantial barriers for both providers and patients exist in referrals and access to mental health care.
But why is it so much harder to access mental health care over medical care in the US, while we believe that there are three main reasons, which I like to refer to as the three P’s. And I’ll go over those very briefly.
First is payment, In the US, we have a separate payment system for mental health care, as I’ve addressed, a separate delivery system, and this exists for both privately insured and publicly insured patients.
It’s what we call, and you’ve heard, be called carve outs, mental health carve outs and, and tell carve outs are addressed. We, in the maternal mental health field will hobble along.
trying our best to adequately detect and treat maternal mental health disorders and other mental health disorders and tell mental health payment is reformed and carved into the medical care system.
Providers, I mean, education of providers, shortages of providers, capacity of providers, including care co-ordination, access to expert consultation around mental health and incentives and payment, and with providers and this P, we can start by supporting reimbursement of obstetric providers for screening and initial treatment plan development.
We can also provide grants to states and public health hospitals to develop inpatient and outpatient treatment programs, and look to SAMHSA, so there’s a continuum of care. SAMHSA has developed residential treatment programs for substance use disorders, which we think can be replicated for mental health disorders. And, again, there’s an opportunity to create a continuum of care for maternal mental health disorders, not just an hour of talk therapy with the behavioral health professional or the ER, which is essentially what exists right now.
We also must quickly address mental health provider shortages.
And one way we think we can do this quickly is to proliferate the use of state certified peer support specialists, which can be referred to as a form of community health workers that treat mental health disorders or support mental health disorders. Every state now has a state sanctioned certification process in place for peers.
These peers can not only provide mental health support, but can be trained to screen, and also provide clinical and social support care co-ordination.
And finally the three P, the third P, Performance Measurement In a fragmented privatized health system, a framework for Quality Measurement is absolutely critical, and help helps to implement a standard of care and hold payers and other players accountable.
We don’t yet have a measure in place for screening rates of maternal mental health disorders, or for measuring outcomes. When patients are screened. Are they getting well. Those measures don’t yet exist, and are critical to solving this problem.
These three P’s payment, providers, and performance measurement offer immediate, and Tangible next steps for policy in health care systems change. And I can’t wait to unpack these with the others on the panel. And I now turn it back to my colleague, Sarah Dash and K Matthews from the Shades of Blue Project.
Great! Thank you so much, Joy! I mean you covered a really extraordinary range of issues from as you said the three P’s payment, provider, performance measurement, and the history of screenings. I don’t think I had realized it was quite so recent within just the last 10 years. So with that. and just in the interest of time, I’m going to go ahead and turn this right over to doctor Veronica Gillespie Bell who can tell us more from that provider perspective. What what She is seeing on the on the provider level and Doctor … thank you for joining us today and on call on top of it.
Of course my pleasure. Thank you so much, Sarah, for the introduction, and thank you all for allowing me to be here with you today. Thank you to the Alliance for giving us a platform to be able to convey our experiences and our, our suggestions and opinions, and thank you all to the members that are here to hear what we, what we have to say about mental health disorders.
Today, I will give you my perspective as an obstetrician and gynecologist practicing here in Louisiana. But I will also give you my perspective as the medical director of the Louisiana Perinatal Quality Collaborative and the Pregnancy Associated Mortality Review.
As a Medical Director of the Pregnancy Associated Mortality Review, I lead the committee that reviews all maternal deaths in Louisiana, regardless of cause.
We define a death as the death of an individual during pregnancy, up till or up to one year at the end of pregnancy, regardless of the cause.
We just released our 2018 Pregnancy Associated Mortality Review report, and then that report revealed that the leading cause of maternal death in Louisiana in 20 18, with substance use disorder.
And we know that a lot of individuals that are using substances are using them to self medicate for mental health disorders. And so we know that we have to address mental health disorders if we’re going to improve substance use disorders and thusly improve our maternal morbidity and maternal mortality.
The other thing that we noted in doing this review is that looking at the timeframe from when the majority of those deaths occur, 83% were after 42 days. And I say that to say, that we traditionally think about pregnancy and pregnancy care as pregnancy and then six weeks after.
And so as we think about policy changes and the things that we will need to address so that we can improve mental health disorders, it will be also addressing how we think about the post-partum period.
That is not just a six week timeframe. We have to think about de stigmatizing mental health. And so the discussions that we’re having today are opening up further discussions around the our communities in our country so that we can de stigmatize mental health in certain communities, Communities, especially communities of color, and especially because of historically, particularly black women, how we have been portrayed and conveyed in social situations. And having to be portrayed as such strong black women that are just continue on. It is stigmatized to sometimes mentioned or say that that you need help.
And so we have to de stigmatize mental health by continuing to talk about it and to normalize the fact that that mental health and peri perinatal mood disorders do happen.
As my colleague mentioned just a second ago, as I mentioned, when we look at these maternal deaths, 83% of those pregnant the associated but not related to a condition of the pregnancy occur after 42 days.
So that means that we need to make sure that our pregnant birthing persons have access to care. That means extend expanding Medicaid beyond six weeks up to one year post-partum. And I know that Medicaid is a State decision as far as expansion is concerned, but I do think that there’s congressional things that can that can be done to help encourage State and incentivize State even more to expand Medicaid. Having access to care is something that helps to improve these maternal outcomes, as we know.
We also have to think about the social determinants of health, as was mentioned previously. We know that those social determinants of health, transportation, housing, all those things, are barriers to care.
Because of those social determinants of health, we have to think about different ways of delivering care. I commonly have said, we have built a healthcare system around the health care system, and not a health care system, around our patient.
We make it very difficult for patients to see us.
And in 20 21, we have to think about using things like telehealth as a way to deliver care in a different way. As Senator Kathy mentioned, he introduced the connected mom at, and part of that was work that, that was done with, with myself and partners here at …. We have a connected mom program where we are able to offer telehealth for our patients to be able to setup virtual visits. Actually have a few view coming up this afternoon, And so it allows patients to be in their environment, be in their community, and still be able to connect with the doctor. In addition to Telehealth, we have to not not that is the end all, be all. We have to also improve the infrastructure to be able to have Telehealth.
We know that in rural areas of the country and in urban areas, broadband is not what it needs to be in order to achieve some of these means of telehealth that we, that we want to use to help connect with our patients better.
So, in addition to the, the, the, the, having telehealth as a in our electronic medical record and in our health care systems, we have to build up our infrastructure so that our patients can access the Telehealth.
And, again, thinking about different ways of delivering care.
Community health workers, they are so important to improving maternal morbidity and mortality from a lot of different causes, but especially when we talk about mental health and perinatal mood disorders. It’s so important to be able to go and visit a patient in their home and understand what their environment is like, what their social determinant of health looks like. To better be able to treat them. And through the use of Nurse home visiting programs, through our community partners, through Doulas, Super Perinatal Health Workers. We have the opportunity to expand our obstetric workforce and actually bring here to the patients and visit those patients in their home.
Also, we’re thinking about legislative policy and things that can help improve our outcomes from mental health disorders, our state perinatal quality collaboratives. As I’ve mentioned, I am the medical director of our Louisiana Perinatal Quality Collaborative. And I am here to tell you that Quality collaboratives can lead to change. The change that we have seen in Louisiana is not unique, but just to mention how we have the ability to change our initial our initiative. Our initial initiative was reducing maternal morbidity from hemorrhage and hypertension and by working with our birthing facilities to use improvement science to help put those best practices into place. In birthing facilities, we were able to reduce severe maternal morbidity from hemorrhage by 35% and by 49% for black women and then reduce severe maternal morbidity from hypertension by 12%.
So, we we know that our state perinatal quality collaboratives have that ability to change. And now one we need to make sure that they are they are quality collaborative in every state that they have funding to exist. And then those quality collaboratives need to lead those initiatives.
To help with screening and treatment for. For substance use disorder and perinatal mood disorders. As it was already mentioned, we don’t have have accountability around screening. It is the recommendation that we screen at different intervals. or for post-partum depression, which is only one mood disorder, that recommendation is in there. And so that is the best practice.
But when we have best practices, and you don’t use improvement science to put those practices into place, it can take 17 years.
And so it’s not that we don’t always know what to do, we don’t know how to do it as providers and as health care system. And perinatal quality collaboratives are really good with the How do you do this?
And so again, we need to use our state perinatal Quality Collaboratives to make sure that every birthing facility, every provider’s office is doing what we call SBIRT, Screening, Brief intervention, and Referral to Treatment.
And as we think about referral to treatment, that means we also have to expand our obstetric workforce and not in the way that we may think of obstetricians and and doers and midwives, although we do need to expand in that way. But we need psychiatrists and we need to have access to psychiatrists.
We do a social determinants of health dashboard here in Louisiana, as we review on maternal death.
And if you look at our dashboard, we have more mental health providers in Louisiana than in, but per capita than most of the United States.
However, that does not always equal access. Many of those providers do not accept insurance, and they definitely do not accept Medicaid insurance. And so we need to think about ways to incentivize in improving and increasing the number of, of psychiatrists that will be specifically dedicated to perinatal mood disorders, but also that will then accept Medicaid and help the underserved and the under underserved. We have many policies and many, many different programs to improve the number of primary care physicians in rural areas, air air in rural areas, which is great. And psychiatrists are typically not seen as a primary care physician, but I believe that they are primarily, and they have a huge important role to play in, making sure that we are improving our maternal outcome. And for being able to screen and treat.
for mental, For …, perinatal mood disorders, as well as substance use disorders. As it was already already mentioned, one of the barriers to screening is the inability to then refer patients, and where do you send them, and how do you get help?
And I saw this firsthand, I’ve seen it many times firsthand in my practice, but I think the time that stands out the most for me, is a patient that I was taking care of. Taking care of her for her whole pregnancy. From the time, she was about 12 weeks.
Was very excited about the pregnancy had good family support because I took care of her family members as well and everything had been going great.
And then at 32 weeks, as she came in and she said, I need it to stop moving and She met her baby And she very well knew. it was not a it she she knew the gender of the baby.
And she said, I just need it to start moving. I keep hitting my belly, because I need it to stop movie. I am hearing Lions, and seeing and snakes and bears.
And, you know, we talked we talked through that and immediately, I said, well, we need to get you into the emergency room.
Because you are having, you seem to be having some homicidal or suicidal ideation as well as psychosis, get her to go to the emergency room.
And because she did not say the right word, then she could not be what we call … where she is made to stay in the hospital.
First, suicide precaution, so she was discharged home.
And so I worked with her to try to find a psychiatrist that could treat her and and khatri, what was what was starting to become psychoses.
And she didn’t have Medicaid as insurance in, by the time I quit, when I could find a provider, the earliest that they were able to see you see her was three months, and though I am not not, not a psychiatrist. I am trained as part of our training as obstetrician’s, to at least begin that, that screening, brief intervention for treating a range of perinatal mood disorders, and so I was able to start treatment and she was able to get stabilized. And was eventually able to see a psychiatrist.
But it was just a lesson to me, and I’m just one provider.
And this was just one patient of how difficult it is to access mental health services.
Even when you have insurance, it’s still under insurance, and it makes it very difficult.
I’m thankful that I, that the patient felt comfortable to talk to me, and that I ask the right questions, and we were able to start treatment. Because I am fearful to think of what that outcome would have been had we not been able to partner in her treatment.
And so I have plenty more to say, but I will not want to, Do, not want to monopolize all of the time, so I’ll Stop right there and turn it back over to Sarah, so we can hear from our other panelists.
Thank You. Thank you so much for, I guess what?
I want to dramatic story and just illustrates, I mean, if it’s that hard to find care for somebody in dire distress, and really life threatening distress, the so many women and, and, and berthing persons who who, who are experiencing perhaps less acute. But also, you know, that depression, anxiety, You know, things that really interfere with their functioning and how hard it is to then, you know, find care for that. So, you know, I know we’ll get into some more of those workforce and access issues, but I think that certainly certainly illustrates some of the challenges. So thank you. And so, so next, I’d like to turn, turn it over to Carrie from an …. Go ahead and share what is happening at the State level, and then we’ll hear, and then we’ll hear from Tom Matthews, who is going to share our community perspective. So Terri Handlin, go ahead. And by the way, just for those who are used to a one hour webinar at the Alliance, this does go to 115, So I just want to point out to you all 115 Eastern time. So, please go ahead and also submit your questions while while you’re thinking of them, Alright, Carry over to you.
Great. Thank you so much, Sarah and the Alliance for providing the opportunity for my organization and me. I’m with the National Academy for State Health Policy To participate, I learn something new every time. I attend one of the webinars and hear from these panelists. That’s great rich information. As I mentioned, my focus is on state policy and particularly Medicaid policy. That is what the organization I work with Mashpee focuses on.
So I wanted to highlight some of the trends that we’re seeing in terms of how states are working to promote access to high quality perinatal mental health care within Medicaid programs. Specifically.
And so, touching on some things that have already been mentioned, but maybe adding a little bit more detail, So, um, I’ll mention coverage, so, of course, are perinatal mental health services offered in a state Medicaid benefit package. How long are those services covered for?
And then also look at some ways that have already been mentioned, that other providers and practice settings can be included and are being included in efforts to help identify mental health needs. And then, finally, again, piggybacking on some of what’s been mentioned. Talk about some of state efforts to measure and reward efforts to identify and improve identification of perinatal mental health needs. So I just want to start by looking at coverage. So Federal law requires pregnancy related Medicaid coverage to last 360 days post-partum, but states we see are increasingly looking to extend that coverage to for all of the reasons that have been mentioned to ensure that post-partum health and mental health needs are met to promote continuity of care and to reduce maternal mortality and morbidity. And I just wanted to highlight some recent examples.
So Georgia provides post-partum coverage for six months, Missouri, received approval to provide substance use disorder and mental health services for those individuals diagnosed with a substance use disorder for up to 12 months post-partum. And then just yesterday, New Jersey received approval to extend post-partum coverage to 12 months.
And so the program is a partnership between the State and the Federal Government but just wanted to note that there, that is definitely a trend and that there is growing interest in that, in terms of who provides care and can help with mental health needs during pregnancy or post-partum. Again, there’s growing interest in exploring opportunities to invest in non traditional providers, including, for example, doulas, to support pregnant and parenting people. And there are at least three states that are authorized to offer a doula benefit in their Medicaid programs, and several more that are in various stages of implementing that coverage. Because current evidence suggests that pregnant people who received ula care are more likely to have a healthy birthing outcome, which can lead to cost savings for State Medicaid programs. And improve overall health.
And I think, as Ben mentioned before, Doulas provide continuous, physical, emotional, and informational support before, during, and after birth, and promote health equity, and can help address some of the social determinants of health that have been mentioned. And I wanted to note that there’s a particular focus in states on community based doulas, who are trusted members of the community, who collaborate closely with community stakeholders and institutions. And so that’s definitely an area that, that states are focusing on within their Medicaid programs. And then, as has been mentioned, another provider who can help identify particularly post-partum mental health needs. Are pediatricians or family docs who provide the well baby or are, well Child Check Up says, I think Joy mentioned.
And it’s something that states overwhelmingly have policies about. So most 43 states have a policy around reimbursing it and covering post-partum depression screening during a well visit for the reasons that have been mentioned. Just the understanding that maternal or primary caregiver health is intrinsically linked to young children’s development.
And I just wanted to kind of try to pull it all together a little bit by noting that Medicaid agencies also promote access or into promote access to high quality perinatal mental health care by requiring providers or the managed care organizations if they have that type of system. The organizations that they contract with to deliver services to measure and improve performance in areas of care, like screening for substance use or depression among pregnant people, or by offering providers or contractors rewards for meeting quality goals in those areas. And this is something that Nashville has looked at across the country. So one example is quality measures, which have been discussed that there are some gaps in terms of availability there. But this is an area where state Medicaid agencies can require providers or managed care organizations to report. Or these are things that managed Care organizations may track voluntarily.
The state can also require managed care organizations to undertake projects to improve aspects of care. That topic can be picked, either state or by the contractor.
And here, again, is an area where there has been emphasis on things like improving linkage to addiction services during pregnancy and other aspects of perinatal mental health. And then the payment is, is always so important, and looking at how to reward improvements in an access to care, and how to reward delivery of care, in innovative ways, is something that there’s a lot of state activity. And I just wanted to mention, one that I think is an example of pulling together the quality measurement, but also the care delivery who’s delivering the care.
So Pennsylvania is an example, just one of many states that has a particular payment initiative around maternity care where providers can earn incentive payments for meeting goals and measures around social determinants as well as prenatal and post-partum depression screening and the follow up. And then initiation of substance misuse or dependence treatment. And a key part of the initiative is maternity care team that includes both licensed and non licensed staff and the unlicensed staff can include community health workers or do lists.
So just a few options, an examples of ways that state Medicaid agencies are working to promote access to high quality perinatal mental health care.
And just want to underscore what has mentioned before just the importance of partnership between Medicaid and other improvement collaboratives, other agencies in the state, to make sure that, for example, Medicaid related recommendations or suggestions have, you know, are implemented and can be put forward to to help improve outcomes in states.
So, thank you, and I’m looking forward to further discussion.
Great. Thank you so much, Carrie. And this is great. And so, is now my pleasure to introduce K Matthews. And we’ve heard so much about the importance of community organizations and community providers. And so, I can’t wait to hear your story. And you’re also an author in the Health affairs issue. So, welcome. Welcome to the panel, and turn it over to you.
And thank you for having, myself and it says of the project, as a part of this panel, I’ll jump right into how important it is to have community component in all that is being done. What you’ve heard from my colleagues is about the current policy policy that have been at the state to state How each state is certainly different. I’m in Texas. We somewhat always pick up our own rules here, so we know how that works. But the community piece becomes very important.
In many ways, In thinking about how community level peer can be a tad bit different from the medical care system, there’s a level of trust that is built in those of us that are working in the community.
But how we play a part in the healthcare system is we merge our ability to be able to serve the community in a way that we can then carry that over to where our clients, who would be the healthcare patients, we can work collaboratively and collectively together.
one of the things Joyce touched on was the peer support model that’s very, very effective.
We are, we, so often in mental health, just as a whole, we specifically are talking about maternal health. We want, we want to notice someone is feeling like us, like we’re not by ourselves. We’re not alone. Others, know that we exist, and that they may be experiencing the same thing.
And, that’s really have the wheels and starts to turn, getting help, is someone who can have a conversation with you, just like, y’all can identify together, and they go from there, and then the care co-ordination starts to happen there. So, the peer support model is very, very important in all of these.
And how the peer support model can continue to grow, is definitely, through policy, policy, has the, back this model wholly across the board. And we’re starting to see that, of course, in the Moms Matter Act, and in several ways. But the value has to be there, The value, to know that we can work with doctors and nurses, hospitals, clinics, and hat, and bridge that gap that currently exist. When we’re thinking from a population.
Standpoint of African American, women are less likely to receive any type of assistance when it comes to maternal mental health, whether that’s a diagnosis, or an acknowledgement that something is actually happening.
That’s where our numbers are, one in four versus one and seven will experience a perinatal or maternal, mental health mood disorder. So those numbers are disparaging alone, right, so we know what solutions can actually work. And to be honest with you, this is a collaborative effort.
We’ve all got to come together in this way. Policy is one piece like Policy is the overarching piece that tells us that, Hey, this is how things are supposed to go. And then everything up under that policy starts to come in fall into place.
And this is how we’re going to reduce these numbers across the board. Reduced numbers on the mortality and morbidity, sat reduced numbers. In mental health. All of these things fall under. I always say that tunnel, the mental health component is also at the top and everything that happens under it was so often mental health.
Is that at the first and foremost of our minds, We’re trying to adjust all of the other things, but not. So, in other words, we are, we typically are right now, just see what has been done or what what adverse outcome has happened to the woman or the pertinent person, versus how this person feels about what is happening to them. And so when we merge those two things together, that’s our power right there. That’s how we decrease stigma. This is how we decrease our numbers.
You turn this whole thing around. And then also, when policy back sounds like what is out there, what is happening right now, and policy, which is great. Because I know some folks that have been working in this field for 20 plus years, and now they’re starting to see how it’s our turn it around, and it’s getting better. But we still have so much further to go. one of the things also is what policies do it and bringing them is peer support model is. Being able to acknowledge that all birthing experiences are encompassed in that we have to acknowledge that. A birthing experience and the outcome is not the same, so we have to acknowledge that as well. But pulling in the community. That’s going to be the key component to this. You cannot do any of this without the input from the folks that we are actually out here fighting for with the policy. We’re making policy for people. Now we need to involve the people in the implementation of the policy.
I’m actually looking for some more of the Q and A piece, because the conversation is what we need to have at this point as those that are all here right now. How can we take what we’ve learned today for myself and others that are on the premises and thoughts are implemented like right now, right? And then we’ll policy kids.
Then we’re ready to wrap it up in goal because just the action that certainly has to happen.
Thank you so so much, kay, Kay Matthews and I’d like to invite everybody to join us and while while they’re doing that, you know, you said something that I thought was so powerful.
You said, it’s not just what happened clinically or with outcomes but maybe on a piece of paper is how the, how the birthing person felt about the experience and how they’re feeling.
And I the question I want to start off and ask, ask each of you is, are we asking the right questions? And are we asking the right people, and communities, and if we’re not, what do we need to do about that? And how do we need to? How does policy and how to policymakers need to support that? And I suspect that has something to do with the quality metrics and performance measurement. But let me start with you, case.
And since, since you kind of ran it.
I mean, are you seeing that the right questions and the right people are being asked now about, you know, these perinatal mental health challenges or how far do you think we have to go?
We have a long way to go. It’s about responsibility. Someone has to be you have to be committed to doing is when we talk about screening, it’s great to screen. And then what you have to screen and refer and not blindly refer. So see there are many steps in doing this the right way, so that folks are receiving the care that they need. You screen, right, Mom tells you all of the I’ve had my clients come in, is very well, I actually circle this on the PHQ. nine ought to Edinburgh and nobody said anything to me, they just took the paper and added it to my backup file. So see that that’s not the way to screen. When we have a responsibility to screen we then don’t blindly refer, so we refer also have to make sure we’re referring clients or patients to someone who wants to help them is no need to take them from 1. 1. 1 place to the NAICS, and they may feel like you know what this is just not working. I will just figure it out in so many people.
have the mindset. I will just figure it out, because the system is not working for them. And so we have a long way to go in our accountability of one who should actually be doing the screening, and then when you are doing the screening, your referral process, and then the follow through, It takes absolutely nothing to follow up and say, hey, I refer to parts of patient over to you two weeks ago. How’s everything going, you know? So referring, following up, is very imperative to make sure that folks are really getting the care and the help that they need.
Thank you. And Veronica, you pointed out, you didn’t really sound like the systems are in place clinically, or there may be starting to be put in place. I’m curious, You. know, because I have heard something in the affairs podcast that, you know, as Jennifer more pointed out, who was the issue advisor, for that, that, a lot of these screening tools.
We’re actually developed on, you know, white women with commercial insurance, predominantly. So do you have thoughts on that, like, how could the actual quality of the screening tools themselves be improved?
Yeah. I think that’s a really good point. I think part of it, and I’m gonna say this as a, as a provider, the screening tool is just that. It’s a screening tool, is not a diagnostic tool, and it is the, it is the place to open the conversation. So Joseph … was mentioning, if we’re gonna give patients a piece of paper, or send out something through the electronic health record, or have them do it when they come to the office, where they fill it out, and then it goes into their file? And nobody ever looks at it than that.
Not helpful at all.
It is meant to be a way, to say, I’m looking at this and and and I am one providers, what I do in my practice, But I look at the score and say, you know, looking at this, and I ask every single patient, no matter what their score is. I looked at your scale and your edinburg placental depression scale.
Your score is this, this indicate this, do you agree with that? Is that how you are feeling? And it’s, again, is just so important to start having that conversation.
I’ve talked to patients where they are depressed, they need medication. They need to be in need to be in therapy, because we know the outcomes are better if you can get into psychotherapy and pharmacotherapy. I’ve talked to patients where it’s not about needing medication. It’s about the adjustment of being a new mom and my, I can’t really prescribe this, my prescription is you need some help. You need some family help. This is how you can.
These are some resources to get to get somebody to help with food, to help with a night, to help with a nanny, to help get your childcare for your other children, to overcome some of those other, those other life stressors that are held, that are making it harder to adjust. And so, again, the the tool is meant to start the conversation, not to be the, the diagnostic tool.
Thank you so much. And I want to ask and, Joy, if you have thoughts on that and I love that if if you could just write, you know, your prescription is you need some help, like what the system to actually address that. And then carry, I want to ask you specifically in the Medicaid. You know, and, and, and get more specific on how Medicaid and states can address some of these things. So, Sir Joy, any thoughts to add on this?
Yeah, a couple of thoughts come to mind. And I love that first comments that, you know, just prescribing, you, know, get outside, get some sunshine. Take your vitamin D and your omega threes which are evidence based here to matter. And those are simple action steps all providers can take.
Where I really put here is that until we integrate payment systems, and Reimburse, OB GYN is upset other abstract.
Obstetric providers like midwives, and even family. practice providers in rural settings. And these things are hard to do and not all. Providers have received some of the baseline training that we heard about in mental health. Many obstetricians, especially those who’ve been schooled long ago, still haven’t had baseline training in mental health. And so how do we look at solving those gaps? Those are things I think we should look at critically. But, in terms of who we’re screening and how we’re screening, there’s definitely some opportunities there. I always love case remarks about, I’m not leaving people out and doing this in a culturally responsive way and, of course, addressing the, then what not putting the screener in in a tool.
And we really went back to the role of obstetric providers and then one there should be no wrong for but obstetricians. You can develop the treatment plan. I love the SBIRT model to doctor … Lipsey Bell and mentioning that model as a framework for mental health.
Great. Yeah, and on the note of not leaving anybody out, you know, we have an audience question about making sure that, you know, the Hispanic population is also not left out that PPD is higher and wanting to know if anyone here is is addressing that.
And I might ask, I might give carry the very difficult task and saying, you know, as as you’re looking at, you know, Starting from this point of, are we asking the right people, the right questions at the right time? You know, and, and then what can State Medicaid agencies in particular, and then other aspects of State policy do about this?
Do we even have the right tools to figure out, you know, who the populations are, we’re trying to reach, and And how, and then, how do we, how do we bring some of these best practices forward at the state level?
Yeah, all great questions, I mean, I think, as far as, do states have the information they need, I think, it’s better, I feel like the states we work with, they always want it to be even more better. I mean, certainly, limitations in terms of missing race, ethnicity, language data is a challenge, you know, referenced earlier, too siloed systems. If, and, you know, kind of facilitating this no wrong door approach, if a potential need is identified in, you know, one care setting.
How does another, a provider in a different setting find out about it, and, you know, some of what Kay mentioned before, about what happens to a referral, how to make sure that every provider involved in a person’s care has the information they need. I mean, these are huge and expensive, The questions that, you know, I think do kind of go back to, You know, the core question, Sarah, though, are, the, are the right questions? Being asked, is who needs to give input being considered?
And I think that, no, in terms of how to make sure the information sharing gets done, in a way, that is meaningful and most know, helpful to patients, is, you know, I think that’s, that’s the ultimate challenge, is how to make sure that that feedback is first solicited and then directly applied to policy.
And, I think, that is, you know, it’s baby steps and, kind of ongoing challenge.
But I think that is, States are looking to do, how can we have consumer advisory panels, but, again, it’s this balance, and making sure that community members are being over tasks, are being compensated for their time, and that feel like they are being meaningfully engaged.
Millimeter hmm. Thank you. And it’s like you’re reading the minds of our audience, because we got a really good question from someone who’s who’s as a philanthropic organization. They’re looking to build a better system to support maternal mental health and well-being. And as they engage partners, who really should, I, should they insurers at the table? And they mentioned, you know, women and birthing people, OB GYN, mental health, home visit. You know, who are we missing? And I’m sure would be happy to follow up, you know, here at the alliance with a conversation about that.
And it just it does point to like, you know, and let’s all remember that new parents are also a little busy and it’s it’s hard enough to participate. So like is there a constituency around?
And these issues, right. Because once you sort of are no longer in that chair with a newborn baby or you’re busy with preschool and you’re busy with everything else. And, you know, and that might be kind of an interesting, I can join. Maybe that’s some of what you’re trying to work on and K at community levels. Building that constituency.
Yeah, it’s hard to believe.
We only have 10 minutes left, so I wanna, I wanna, I want to kind of keep, keep moving here with, with the conversation. I want to again just to focus on policy. And by the way, for those who are interested in the post-partum coverage provision amur option the Kaiser Family Foundation has a great state tracking tool and we’ll we’ll make sure that’s in the resource list for you all. But that Terry let me let me keep you on the spot for for just a minute here.
I mean, you mentioned that, three states, I believe, have expanded coverage for Doulas services, and then I wasn’t quite sure how many states had also expanded, sort of, requirements for, for Medicaid Managed Care as far as, you know, other things that they could do.
Can you have more specific, like, how do you specifically expect that these policies would affect perinatal mental health, improve perinatal mental health, like, what outcomes would you be looking for?
Yeah. That’s a good question.
I mean, and I think it goes back to that idea of having good quality measures, and I think that’s why state policymakers and providers and community members are all feeling a little stuck, I mean, as far as, um.
So, let me take a step back. So, in turn, your question is: For states that have added a doula benefit, what would we expect to see as the outcome from that?
Yeah, let’s start with that. That’s a good specific question. Yeah.
Sure, so, I mean, I think one, and I would definitely defer to co panelists as well.
I mean, I think it would be some of the qualitative things like feeling listened to heard, represented, you know, the importance of culturally congruent care.
But I think also because of the benefits of culturally congruent care that things like no post-partum visit, timeliness, follow-up for screenings. I mean, I think it gets to more the quality measures. We do have seeing an increase in those.
And there are states that do a lot of hot spotting and analysis of social determinants and other information across the state to see improvements in the areas where there is most need.
Great. There was a question. Thank you. There’s a question that came in around privacy rules, and I’ll ask you, doctor Female, around you, do do you think privacy rules get in the way of understanding a pregnant person’s mental health history? How important is that in your, in clinical care?
Do you think, like, what could what can be done on that sort of information front, or these things, that just kind of a rise in pregnancy, like you pointed out?
You know, in my opinion, privacy is not the issue. We, our system is broken, that that data, as Kay mentioned, our system is broken. When I think about the maternal deaths that we review and we look for areas of prevention, I cannot tell you how many times patients were seen in the Emergency Room, seen an urgent care for substance use disorder for IPV four mental health disorders. And a referral was made, but nothing that was it.
The referral was made, There’s nobody there to link the, the, the pieces to close the gap. To if I have a patient that is in, For example, the home visiting program and and the home visitors see something or tells them that. There’s no way for that connection to take place as Kay mentioned. And I mentioned as well. We’ve got to expand obstetric workforce And so we do need to use perinatal community work. Workers may lead to Youth doulas, but we’ve gotta connect those systems so that we’re not working in these silos.
I think privacy is very small, and we and we have ways of, with HIPAA and those things that we can get around any privacy issues. It’s just that we don’t have anything, any body to connect.
Yeah, thank you so much, Ann.
We did get a question about whether any of these policies address mental health needs of people who have lost a pregnancy, and birth via a miscarriage stillbirth.
And while I I I’m going to say I think the answer is no, but I want to ask you, is the clinician And also like, do you have, is our special care that’s needed in those circumstances?
I would say in general, in general, we don’t have policies that specifically address the mental health need for patients that have experience loss.
I think we as clinicians, do screen differently for those individuals and screen more intently for those individuals that have experienced a loss from a policy standpoint.
Not exactly completely addressing the mental health disorders, but we did in Louisiana, and alas, lead us 20 21 Legislative Session, a bill was passed that give income tax credit for any individual that experience as a stillbirth. The Way that the laws are different from state to state. But because there are burial expenses that are associated with that time period, between 20 weeks and 24 weeks, where 24 weeks is really the customer viability. And if you deliver that that pregnancy than it has to be buried and then there’s the in addition to the the the the mental anguish that goes along with that then there’s a financial component to and so that bill did pass at least addressed that part of it. And so, at least, I think that is highlighting and putting an emphasis in our state on some of the specific challenges that that individual that deliver, a baby that they don’t go home with, That they that they experience.
Thank you so much.
And, obviously, a very complex and challenging set of circumstances, but since that is often kind of stigmatized, or swept under the rug, I thought that was important from our audience. So, um, we are sadly, at the almost at the end of our webinar for today, and there’s so much more to talk about. So I thank you all for joining us.
I want to ask each of you, if you’ve heard just to give sort of, if you had your magic wand, if you could wave your magic wand and make one change today, what would that be?
And let me start K. If I may begin with you. If you could wave your magic wand, what what change would you ask for?
Actually, be follow-up. So what doctor Bill just discussed is that we don’t look at it, the mouse as something separate from the maternal health experience. It is a birthing experience and so we think about mental health, we must think about our outcomes So this bargain experiences and outcomes, which all have this way of, including maternal mental health. So that’s my magic wand, is that we stop separating birthing outcomes and we look at whole learning experiences.
Thank you, Joye, what would you do?
Quickly, I’m gonna bring it back to policy and say that we need to, if I were to wave my magic wand, we need to pass the Moms matter Act. And also look at the triumph fact Moms Matter.
Act addresses gaps in care by black and brown women.
And we know that those gaps this in extraordinary ways and they have to be solved for.
And the triumph fact calls for a task force, a Federal agency task force, to look at the roles of various federal agencies in solving this problem of maternal mental health, and also issued a report back to Congress and to state governors and legislatures on the role that states can play. I would wave my magic wand and make those two bills pass and get signed into law.
Thank you. Carrie, your thoughts?
And mine is probably a little geeky, but it goes back to the information sharing and connecting the dots.
I think everyone mentioned that just kind of like flipping a switch so that everyone has all different providers have access to information from you know different parts of the system and also that people themselves have inferred that information and can inform it and correct it where needed.
All right. And finally, doctor Gillespie value you get the last word since you’re on call. For me and I do think this could be addressed the policy I would have for every individual that interest pregnancy would inter pregnancy with a perinatal nurse navigator to help connect the dots. To help follow through To help connect the obstetrician to the psychiatrist, to the cardiologist, to be that medical home. That one person that in that patient’s medical home, to connect the dots, it is very difficult as a lay person to navigate the health system, in general. And then we have all of, it was we mention all these gaps. So every individual, when pregnancy has started through your, your, your insurance provider, MCO, the Medicaid …, you would be assigned a perinatal health health person to help connect it up.
Well, that sounds amazing. And I think there’s a lot more people that are going to want you to be there, doctor Patrick. So, well, thank you all so so much, for joining us, today, and I want to thank Health Affairs again, and I want to thank the California Health Care Foundation … and WK Kellogg Foundation.
As well as I’m effort for a very valuable insights and also to Alan Wail of Health Affairs and Jennifer more into the entire Alliance team. Thank you so much for joining us and we will be sending a brief evaluation survey And you can please make suggestions for future briefings on this or other topics that we will take a close look at. Please join us on November ninth for a briefing on Advancing patient centered Cancer Care as well as on November 17th for a briefing on improving healthcare for people experiencing homelessness. And again I want to thank Kate Matthews, Veronica Gillespie, Bell Terri Handlin enjoyed Burkhart for your time and energy and all of your work on these really important topics. Thanks again.