By Amanda Jezek, March of Dimes

Health reform has the potential to provide tremendous opportunities to expand health insurance coverage, but what many people do not realize is that the new law also makes significant investments designed to improve the quality of health care — particularly in Medicaid.  These provisions are critical in making sure that care provided to Medicaid beneficiaries meets the highest standards of evidence and follows clinical care guidelines.  

Quality measurement and reporting can provide a comprehensive snapshot of how well Medicaid is serving the women, children, families and others who rely upon the program, and identify areas where improvements can be made.  These efforts hold great promise for the millions of people who will enter Medicaid in 2014, and also for the millions more who currently depend upon the program — including a huge number of pregnant women.

HHS posted for comment in the Federal Register a proposed initial core set of adult quality measures for use in Medicaid.  The Affordable Care Act calling for this action mirrored language in the Children’s Health Insurance Program Reauthorization (CHIPRA) which established the precedent by initiating the selection and dissemination of a core set of pediatric quality measures.  Health reform presents an important opportunity to build upon CHIPRA’s efforts, particularly with regard to maternity care. 

Given that Medicaid finances more than 41 percent of births nationwide, maternity care is a common sense area of focus.  In fact, the proposed core set of adult measures includes the following four of great importance to pregnant women.  These measures are well established and have been recommended for use by  several national organizations that specialize in  measure development and use:

1.  Elective deliveries between 37 and 39 weeks gestation:  A January 2009 study published in the New England Journal of Medicine, found that elective Cesarean sections and inductions before 39 weeks pose significant risks to infants’ health, including respiratory problems, feeding difficulties, infections, and higher rate of neonatal intensive care unit (NICU) admissions.i  These increased health problems led to higher rates of utilization of health care services and ultimately higher health care costs. The final weeks of pregnancy are a very important period of fetal lung development and brain growth and the health consequences for children born 37-39 weeks gestation with no medical indication can be significant and require costly care.
2. Pregnant women at risk of preterm delivery at 24-32 weeks gestation receiving antenatal corticosteroids prior to delivery:  Antenatal corticosteroids are typically recommended for women at risk, or experiencing preterm labor, to help the fetus’s lungs mature so that he or she can breathe more easily after birth. Corticosteroids reduce breathing problems in newborns and help prevent a serious lung condition called respiratory distress syndrome. Corticosteroids also help prevent bleeding in the newborn’s brain and a serious bowel disease called necrotizing enterocolitis. 
3. Medical assistance with smoking and tobacco use cessation:  This is critically important for pregnant women and particularly timely given that states are now required to cover tobacco cessation counseling for pregnant women in Medicaid.  Inclusion of this measure can help ensure that states are in compliance with the new federal law and help improve the quality of cessation services.  Women who smoke during pregnancy are more likely than nonsmokers to have a low birthweight or preterm baby.  According to the American College of Obstetricians and Gynecologists (ACOG), it is estimated that eliminating smoking during pregnancy would reduce infant deaths by 5 percent and reduce the incidence of singleton low birth weight infants by 10.4 percent.  Pregnant women enrolled in  Medicaid are 2.5-times more likely to smoke than other pregnant women according to data collected by the Centers for Disease Control and Prevention (CDC).
4. Postpartum care:  This measure captures the percentage of women who had a postpartum visit 21-56 days after delivery.  Postpartum care has been shown to help women improve appropriate spacing for subsequent pregnancies, reducing the risk of preterm birth which can be devastating for families as well as extremely costly.  In fact, a recent Institute of Medicine report estimates that the societal economic cost of preterm birth totaled at least $26.2 billion in 2005, the latest year for which data is available.  The medical component of that total was $18.8 billion – 85 percent of which was health services provided to infants.  The IOM Committee estimates that more than half of these medical costs are borne by Medicaid and other public programs. 

The proposed adult core measure set has been released for public comment, and its final composition may change as a result of those comments.  Stakeholders who care about the quality of maternity care in the Medicaid program should encourage HHS to include the above quality measures in the final version of the  initial core set. 

State reporting on quality measures in the core set is voluntary, so it is also important  that states be strongly encouraged to adopt and report on these measures.  Some states are already doing so, and  others can begin right away. 

The data obtained through quality measurement and reporting provides an enormously useful body of information for  to federal and state policy makers, consumers, health providers, payers and advocates that can be used to improve the care provided to pregnant women in Medicaid.  Improved care can ultimately result in better health outcomes for mothers and their children.  Healthier families — for which health  coverage is only one factor –should ultimately be the true goal of health reform.