1. Improving Maternal and Perinatal Outcomes in North Carolina Patti Forest, MD Medical Director Division of Medical Assistance

2. North Carolina Statistics Infant mortality has declined 56% in the state since 1975 Infant mortality has declined 56% in the state since 1975 NC ranked 45 th among other states for infant mortality in 2004- 2005 NC ranked 45 th among other states for infant mortality in 2004- 2005 NC 2006 infant mortality rate was the lowest in state history at 8.1 deaths per 1,000 live births NC 2006 infant mortality rate was the lowest in state history at 8.1 deaths per 1,000 live births Medicaid paid for 48% of the 58,756 births in NC in 2005 Medicaid paid for 48% of the 58,756 births in NC in 2005 –10.9% of Medicaid births were classified as low birth weight but accounted for 42% of Medicaid infant payments

3. Our Challenges…. Racial Disparity

4. Our Challenges…. Regional Disparity

5. Our Successes…. And Continued Opportunities Teen pregnancy rate decreased from 71.7 per 1,000 pregnancies in 1990 to 35.9 per 1,000 in 2005 Teen pregnancy rate decreased from 71.7 per 1,000 pregnancies in 1990 to 35.9 per 1,000 in 2005 Percentage of live births that the mother smoked during pregnancy decreased from 20.6% in 1990 to 12.1% in 2005 Percentage of live births that the mother smoked during pregnancy decreased from 20.6% in 1990 to 12.1% in 2005 –Of pregnant women covered by Medicaid, approximately 20% smoke during pregnancy Percentage of live births that prenatal care began after 1 st trimester (or no care) declined from 24.5% to 16.4% Percentage of live births that prenatal care began after 1 st trimester (or no care) declined from 24.5% to 16.4%

6. Vision for Improving Care to Pregnant Women Optimize health of woman prior to, during, and after pregnancy Optimize health of woman prior to, during, and after pregnancy Optimize pregnancy intendedness and spacing Optimize pregnancy intendedness and spacing Identify and educate women at risk for preterm delivery prior to subsequent pregnancy Identify and educate women at risk for preterm delivery prior to subsequent pregnancy

7. Preconception Initiatives… Family Planning Waiver Waiver Year One 26, 039 female enrollees; 5,560 male enrollees 26, 039 female enrollees; 5,560 male enrollees 189 tubal ligations and 27 vasectomies performed 189 tubal ligations and 27 vasectomies performed During Waiver Year One 4,507 women used continuous “highly effective” birth control methods During Waiver Year One 4,507 women used continuous “highly effective” birth control methods 876 unintended pregnancies were averted due to the program 876 unintended pregnancies were averted due to the program Medicaid saved $9,505,557 during the first Waiver Year Medicaid saved $9,505,557 during the first Waiver Year Waiver Year Two Preliminary Figures Waiver Year Two Preliminary Figures 41,520 female enrollees; 41,520 female enrollees; 7,873 male enrollees 260 tubal ligations and 54 vasectomies performed 260 tubal ligations and 54 vasectomies performed Between 1435-1652 unintended pregnancies were averted due to the program Between 1435-1652 unintended pregnancies were averted due to the program Medicaid saved between $14,285,125-$17,073,493 during the second Waiver Year Medicaid saved between $14,285,125-$17,073,493 during the second Waiver Year

8. Medicaid for Pregnant Women (MPW) Medicaid coverage for women up to 185% of FPL during pregnancy and 60 days post-partum. Medicaid coverage for women up to 185% of FPL during pregnancy and 60 days post-partum. Limited to services related to the pregnancy or for treatment of illness or injury trauma that in the physician’s judgment may complicate the pregnancy. This includes: Limited to services related to the pregnancy or for treatment of illness or injury trauma that in the physician’s judgment may complicate the pregnancy. This includes: – Conditions related to the pregnancy, – Pre-existing conditions, and/or – New pathological conditions that may adversely affect the best possible outcome from the pregnancy

9. North Carolina Baby Love Program Program services include: Program services include: –Maternity Care Coordination –Childbirth Education –Maternal Care Skilled Nurse Home Visits –Maternal Outreach Worker Services –Health and Behavior Intervention –Home Visit for Postnatal Assessment and Follow- up Care –Home Visit for Newborn Care and Assessment

10. Maternity Care Coordination Staffed by nurses, social workers, and paraprofessionals Staffed by nurses, social workers, and paraprofessionals Provides formal case management services to eligible women during and after pregnancy and intervention as early in pregnancy as possible to promote a healthy pregnancy and positive birth outcomes Provides formal case management services to eligible women during and after pregnancy and intervention as early in pregnancy as possible to promote a healthy pregnancy and positive birth outcomes Referrals to community resources (housing, transportation, child care, etc.) Referrals to community resources (housing, transportation, child care, etc.)

11. Transitions to Interconception Care Refer to DSS to determine eligibility for transition from MPW to FPW Refer to DSS to determine eligibility for transition from MPW to FPW Education about folic acid, smoking, and risks for preterm birth, 17P for future pregnancies for qualified women Education about folic acid, smoking, and risks for preterm birth, 17P for future pregnancies for qualified women –Particularly important opportunity for women who had preterm delivery during current or previous pregnancies Refer patient to safety net providers Refer patient to safety net providers http://www.ncdhhs.gov/dma/MFPW/SafetyNetProvi ders.pdf

12. 17P (17 Hydroxyprogesterone Caproate) In 2006, NC General Assembly appropriated $150,000 to make 17P available for uninsured women (funded for a 2 nd year in 2007 session). In 2006, NC General Assembly appropriated $150,000 to make 17P available for uninsured women (funded for a 2 nd year in 2007 session). Medicaid began coverage of 17P in April 2007. Medicaid began coverage of 17P in April 2007. Challenges and barriers to access still exist due to status as a non-rebateable drug. Challenges and barriers to access still exist due to status as a non-rebateable drug.

13. How Does North Carolina Medicaid Cover 17P? Covered by NC Medicaid Physicians Drug Program for recipients who meet clinical criteria Covered by NC Medicaid Physicians Drug Program for recipients who meet clinical criteria Since it is not commercially available, it must be compounded by a pharmacy provider Since it is not commercially available, it must be compounded by a pharmacy provider Billed with HCPCS procedure code J3490 (unclassified drugs) and a copy of the invoice Billed with HCPCS procedure code J3490 (unclassified drugs) and a copy of the invoice

14. 17P Providers are reimbursed for the medication ($20/dose) as well as the injection Providers are reimbursed for the medication ($20/dose) as well as the injection The Physician Drug Program requires that the drug be administered in a physician’s office; therefore, recipients must make weekly visits to office rather than self-injecting The Physician Drug Program requires that the drug be administered in a physician’s office; therefore, recipients must make weekly visits to office rather than self-injecting

15. 17P The physician can write a prescription for the recipient to have filled at the pharmacy for home administration The physician can write a prescription for the recipient to have filled at the pharmacy for home administration However However –Pharmacists can only bill for the ingredient in a compound with a rebateable NDC (for 17P, that is just a few cents per dose) plus a dispensing fee of about $5 –Only one rebateable vendor for 17P

16. DMA Updates CMS is considering limiting services provided by states for targeted case management CMS is considering limiting services provided by states for targeted case management –Could impact Maternity Care Coordination resources –Potential impact on services provided by POETs/NOETs http://www.cms.hhs.gov/MedicaidGenInfo/Downloa ds/CMS2237IFC.pdf http://www.cms.hhs.gov/MedicaidGenInfo/Downloa ds/CMS2237IFC.pdf http://www.cms.hhs.gov/MedicaidGenInfo/Downloa ds/ http://www.cms.hhs.gov/MedicaidGenInfo/Downloa ds/

17. Essure System modifications are currently being programmed System modifications are currently being programmed Expected implementation date 3/28/08 Expected implementation date 3/28/08 Providers will be notified in Medicaid Bulletin Providers will be notified in Medicaid Bulletin

18. Websites http://www.dhhs.state.nc.us/dma/ http://www.dhhs.state.nc.us/dma/ http://www.dhhs.state.nc.us/dma/ http://www.dhhs.state.nc.us/dma/mp/mpindex.htm http://www.dhhs.state.nc.us/dma/mp/mpindex.htm http://www.dhhs.state.nc.us/dma/mp/mpindex.htm http://www.dhhs.state.nc.us/dma/babylove.html http://www.dhhs.state.nc.us/dma/babylove.html www.mombaby.org www.mombaby.org www.mombaby.org http://www.ncdhhs.gov/dma/MFPW/SafetyNetProvi ders.pdf http://www.ncdhhs.gov/dma/MFPW/SafetyNetProvi ders.pdf

19. Questions