Ep 2 Publish Final File.mp3
2:06AM Oct 21, 2019
Dr. Valerie Good
Sen. Thomas Kean, Jr.
Welcome to emerging state policy, an open source podcast with me Your host Spencer Cahoon. Today we're going to be addressing prenatal care policy. And specifically, we're going to be looking at the Centering Pregnancy model for group prenatal care, which has the power to reduce preterm birth rates, reduce or eliminate racial disparities in those rates, reduce medical costs, eliminate time spent waiting at the doctor's office and increase patient satisfaction. The Centering Pregnancy model of group prenatal care has eight to 10 expecting mothers all meeting with their doctors for one and a half to two hour visits. It includes the standard wellness checks, but creates robust question and answer time and provides education on varying pregnancy and infant care topics throughout the prenatal visits. Joining us today will be Dr. Valerie good. A doctor specializing in family medicine with experience with both preterm births and centering. Angie Truesdale, CEO of the centering healthcare Institute, which provides training implementation support and advocacy for the Centering Pregnancy model, New Jersey State Senator Thomas Kean, who sponsored legislation in his states provide funding for Centering Pregnancy group prenatal care services through Medicare. In addition to working with New Jersey private insurance companies to ensure their support, we're going to be contrasting the current model of individual prenatal care with the group prenatal care model, examining the penetration of the Centering Pregnancy model in the States, the political approaches to implementation that have been tried by various states, the research on centering and the position of some of the key organizations in the area. Finally, we're going to be summarizing the benefits and the cost implement group prenatal care more broadly, we're going to be looking at the cost savings, which is over $2 for every single dollar spent. We're going to be looking at how it addresses the problem of preterm birth, which have been costing our state's a combined $26.1 billion annually, and the potential for reduction in that preterm birth rate as well as other rates.
And finally, we're going to be looking at the real human impact of changes in the prenatal care model, so stay tuned to learn more about the potential impact of broader support for Centering Pregnancy in your state on this episode of emerging state policy,
Let's take just a moment to explain the importance of this topic. So what is a preterm birth? A full term birth is a birth where the baby has been gestating for 39 to 40 weeks, and anything under 37 weeks is considered preterm birth. And to give you a feel for what the impact of this topic is, I'd like to share a couple stories. One cold winter night, I was rushing into the operating room due to fetal distress with my hubby and daddy to be sobbing outside alone. I had our micro miracle Jeremy holler Edwards the second on December ninth 2012 at 27 weeks, weighing two pounds, six ounces. I stayed by his side for 68 days praying for
Him, reading to him and holding him when allowed. He was fragile and kept in a dark incubator for many days. Some days he would quit breathing and his heart would stop. But this was quote normal in the nick you. We spent his first Christmas and then FQ and I cried holding him in his Christmas outfit, which was way too big for him. I can still smell the sanitizer and hear all of the beeps that became our world. I remember our calls throughout the night to quote tuck him in. As my husband and I stared in an empty crib. We made many Nikki friends as if we'd served in a silent war and finally came home. Victor's Jeremy is now 11 months old and the happiest baby I've ever seen. Thank God for Nick you staff, less our Miracle on premier day and every day.
And one other story, and this is from Grahams Foundation.
Jennifer and I always thought that when we were ready to start our family it would come easily. Unfortunately, it didn't happen that way for us. After six years of hope and frustration, the typical infertility procedures had still proven unsuccessful, still determined, we met a caring and compassionate doctor, Dr. Arthur Wescott and our first round of IVF, we learned we were finally pregnant. After the first ultrasound, the doctor was confident that we had one baby, but he thought there might be another. The next ultrasound confirmed it. We were expecting twins. Everything was progressing nicely until about 22 weeks when Jen developed preeclampsia. Jen was put on immediate bed rest. Jen did everything she could but unfortunately with her escalating blood pressure, the neonatologist said we needed to deliver immediately. Our daughter and son recent Graham were delivered on Thanksgiving Day, November 23 2006. By emergency c section at 25 weeks and three days gestational age. After Jen's discharged from the hospital, she remained on bedroom
For six weeks, I spent day and night at the Nick you and took Jen back and forth, as she was only allowed to be there for brief periods. Graham had an incredibly difficult journey. Our intuition knew that his time with us during his lifetime would be brief. Graham was with us for only 45 days. And we are grateful for every moment. When we look back, Graham had only one truly good day.
It was the one and only day that Jen was able to hold him. He was still on a ventilator at the time. Jen and I remember our nurse telling us at least three times that day, Graham definitely knows that his mom held him today. He definitely knows. It turned out to be just days before we had to say goodbye.
Family and friends from around the country joined us to celebrate Graham's life. There were at least a dozen Nick you staff and attendance as well. Having them there with us meant the world. We released 45 blue and white balloons at the surface to remember Graham
While Graham isn't with us today and body, he will be with us forever and spirit.
This is the reason we are dealing with policy addressing preterm birth rates to help other babies avoid these types of situations. With that, we're going to move into our interview with Dr. Valerie good. A licensed physician working in family medicine. Welcome to emerging state policy.
Thank you. Great to be with you.
Now, as our listeners today might not be familiar with what a physician working in family medicine does. Could you tell us a little bit more about what that entails?
Absolutely. My practice is pretty wide. So full spectrum family medicine, everything from working in the office without patients to running on my own patients in the hospital, working with residents, which means teaching younger doctors and then I also practice prenatal care with a focus in pregnancy and substance use disorder.
Gotcha. Well that sounds like plenty to keep you busy. So in your practice working with pregnant women and delivery, you've seen women who've been delivering preterm. What kinds of issues and impacts does that create for the mother and for the child?
Yeah, we absolutely see a lot of preterm delivery. When it comes to a mom who's delivering a baby preterm. The biggest risks are really if for some reason her water has broken early, she's at risk of infection. And then anytime there's a complication in the delivery such as the baby coming preterm, there's a higher chance that she could have any other complication and pregnancy like something like trouble with her blood pressure, preeclampsia for the babies, depends on how far along in the pregnancy they are. Babies are at risk for anything from trouble with their lungs that aren't developed, their brains that aren't developed, they can have problems with themselves, they can have problem. Simply feeding growing, getting bigger, maintaining their temperature, all those types of things, so they may end up with the DQ. As long as they're far enough along to survive. Hopefully they can get the right care and come along pretty normally, but some of these kiddos have trouble Throughout their lifespan with developmental delays or chronic lung disease, chronic growing issues, product issues with their bellies, it really depends case by case.
Not everyone listening to this necessarily has been engaged that much with family medical practices. Could you just tell our listeners very briefly what a NICU is and what the purpose of an NICU is?
Yeah, so a NICU is a neonatal intensive care unit. The idea of the NICU is the same thing as an ICU or critical care unit for adults, but it's for babies who have just been born. So generally, it's a place babies go if they're having some trouble right after a delivery, but it's also a place that babies can go. Usually within about four weeks. If the baby needs some extra support. They're often an adult hospital, but they are also at children's hospitals.
Gotcha. Forgive me if this seems like a very obvious question. But if it's the neonatal equivalent of an ICU for an adult, I assume that care is probably quite expensive.
Yeah, one of the things we know about centering is that it reaches healthcare costs. It actually does that primarily through creasing NICU admissions, which is sort of a roundabout way of also saying that moms who do centering have a lower rate of preterm delivery. So you know, we know the farther along you get in pregnancy, the more likely you are to not need to your child to go to the queue. We know that moms who do centering are more likely to make it to full term deliveries. And we know that if a baby needs to go to the NICU It's way more expensive to care for them there. Than in the well baby nursery. So it saves thousands of dollars per day, that they're not needing to be in the NICU.
I can certainly believe it.
And then for every one day longer than a baby is able to stay inside mom. They save about three days in a NICU.
Each day that a baby stays in utero, it's pretty impactful.
Gocha, I didn't realize the effect was so large.
Yeah, it's a really, really big deal. There's just something really amazing about women's bodies that we can't replicate in our medical science.
It's true. With all of our advancement. You mentioned that if a child is sufficiently preterm or has some of these early developmental delays they might have to spend some time in the NICU. What kind of impact Have you seen on families where they have a child who does have to spend some amount of time in the NICU?
It could be really significant ramifications for families, particularly unique challenges if those families already have children in the family and their parents are torn between home life and hospital life so kids can stay in the queue anywhere from a day to months and months on end, depending on what kind of support they need. Challenges specifically for moms and babies is trouble with the relationship between a mom and a baby when the mom would like to breastfeed the infant. So makes it particularly challenging if you are a mom trying to breastfeed your baby but they're in an incubator or they're on some kind of breathing support. And so, oftentimes, these moms are less pumping and having a lot of pressure to make enough milk for this little tiny baby that really gets a lot of benefit from it. Apart from the time constraints and the stress on the family of having children in multiple places, and especially one who's tiny, and this is just a chronic stress of trying to navigate, how to raise that child and care for another child, all those things together can really put a lot of pressure on a family
I would imagine. And with that, you also mentioned some of these children with developmental issues, end up with chronic lifetime issues. So presumably, these are children who would end up coming back to the doctor's office on a regular basis for these various chronic issues.
A lot of times they do, you know, it really depends on the child, how long that goes on, some of them who are not extremely premature, end up kind of on a regular schedule. For example, I have a niece who was born seven weeks premature around 33 weeks. She needed a little time in the queue, but she's actually the same age as my son and they meet milestones at the same time, and it's really amazing to see how she's overcome. Some kids are like that other kids aren't quite as fortunate and end up on oxygen therapy throughout their lifetime or feeding tube. their lifetime. So it really depends what differences that child has, how much they're going to need moving forward. Most of them end up with some early intervention therapies in the home and definitely have more visits to the doctor than the average.
Gotcha. You're a doctor who's also been involved in using the centering model in your practice.
Yeah, I love centering.
I'm glad to hear it. How have you seen mothers responding to that type of approach.
Moms love centering. And it's not a model that's for everyone. But you get out what you put into centering. And the relationships that I built are really beautiful. For instance, we had a group maybe as women, each person is welcome to bring a support person with them. And there was only one girl in the group who brought us port percent turbo. And when it came time for delivery for all these women, that month, every single delivery, she was there for every single one of those girls. And that's the kind of thing you're not going to get in traditional care. And I think that's part of what makes centering such a powerful thing. centering itself, meet basically all The maternal and infant mortality standards we're trying to reach like a magic elixir. And I think a lot of what that differences is just that community being surrounded by other women and by other moms to really understand what you're going through and provide a lot of support for you. Because when we look at the data about centering versus traditional care, moms with similar demographic have better outcomes and centering. So it's pretty neat.
That sounds very neat. And before we wrap up, are there any specific stories of clients you've worked with who come to mind for people who've really been impacted by preterm birth?
Yeah, as far as preterm birth, one of my great friends had a baby at 24 weeks, and then acute care that he got in Columbus, Ohio really saved his life great. She was there every day for months and months and really got carry that had she had her baby in another place. He may not have survived because he was right on the edge of could he survive or not? And he's a really healthy, funky, wild, very smart, little four year old now. So keys are definitely a place that we're glad to have. And it's a place you never want to need in your life or surely you hope you don't need the next you but when you do need the NICU, Wow, they really do good work.
Well, Dr. Good, thank you for joining us today on emerging state policy.
Thank you so much for getting the word out on this topic. It's a big passion for me.
Well, Dr. Good was able to share with us the impact of preterm birth and her experience and using centering in her practice. Let's take a look at the scope of the problem from the 50,000 foot view. Currently, the Center for Disease Control reports that the 2017 preterm birth rate in the US was approximately one in 10 infants born were born preterm, a 10% rate. They also noted that there was a very strong racial divide. One in 11 infants born to white mothers was preterm 9% were one in seven infants born to black mothers was preterm 14%. That's a 50 50% higher rate for black mothers. Now, obviously that is a very strong difference for black mothers compared to white mothers. Now let's dive down a little bit looking at the single state level. Looking at the March of Dimes, Paris stats and they're born to soon report, I picked a state at random in this case, Oklahoma, Oklahoma overall in 2017, had an 11.1% preterm birth rate. So a little bit above the national average. And that meant that approximately one out of nine children born in that state are born preterm. Now for comparison, that means that if you are a child and infants being born in Oklahoma, you are better off in Armenia, to Zika Stan, Ethiopia, Iraq, or Vietnam, not countries particularly well known for their excellent health care, but all countries that have a lower preterm birth rate than the state of Oklahoma. Now if you are a black woman in Oklahoma, Black women in Oklahoma have a 13.8% preterm birth rate, which is a little lower than the national average, but still notably higher than the white population. That means roughly one out of seven children born to black mothers is born preterm. And in addition to the countries I just listed countries that are doing better, RU ganda, Iran and Mongolia. So again, with this list, you can see that we are not doing particularly well with prenatal care compared to our neighbors, even our neighbors who we assume if you hadn't looked at the numbers that you probably would be doing better than Now, before we look at the state by state implementation, which we are going to in just a moment, it's important to understand the difference between our predominant system of individual prenatal care and group prenatal care through a Centering Pregnancy model. To lay out this background. Let's take a moment to speak with Angie Truesdell, CEO of the centering healthcare Institute. Welcome to emerging state policy.
Thank you. It's a pleasure to be with you.
Now as our listeners might not be familiar with you or the centering healthcare Institute, could you tell us a little bit about yourself and your organization?
Sure, the centering healthcare Institute created and now is the quality organization responsible for the centering model. We do the implementation support for clinical practices that want to implement the models and support them. also collect the data and assure model fidelity. The centering model includes during pregnancy, prenatal care, centering parenting, pediatric care for early childhood zero to two and centering healthcare, which is group care for a variety of chronic diseases and other patient populations.
Now, let me set up the background for a minute before centering came onto the scene. What was the model for women who are receiving prenatal care?
You know, there's still a lot of traditional prenatal care going on. I want to be clear about That?
Traditional prenatal care aligns with the schedule that set out by the American College of Obstetrics and Gynecology, and as a centering, and it's a schedule that has women coming in, starting around 12 weeks to meet with their doctor for what's largely quick belly checks. So a woman may wait for an hour in the waiting room for what is on average and eight to 13 minutes clinical visit, and the doctor asked a lot of a lot of questions, take some measurements, then ask usually, hopefully, if the women has any questions, and that's it. And like I said, those are usually eight to 13 minutes visits and it's pretty transactional.
So very brief visit overall conventionally. How does Centering Pregnancy change that prenatal care model?
Centering pregnancy changes it completely. Centering pregnancy is group prenatal care around that 12 week visit, those women are informed that they're going to be part of a closed cohort of women that have a similar due date. And they'll be experiencing their prenatal care together to 90 minute to two hour visit with the clinical provider, and it also has a co facilitator. That can really be anyone that is appropriate for that community. It could be a doula, it could be a social worker, it could be a medical assistant, and it can be a tribal elder community health worker, you can really put any trained centering facilitator in that second chair supporting the group. And the support part is important. The goal of centering is to not only just get those traditional baby check metrics and measurement taken, but really to have time for discussion. community that's built in the cohort to discuss what's going on in their pregnancy and overall life that's contributing their health and from common discomfort of pregnancy. What support systems you have when you're going through your pregnancy, your plans for safe sleeping plan for feeding, busting some, some myths about breastfeeding, then it goes a little bit deeper and talks about your plans for birth control so that you can make sure not to get pregnant too rapidly for the next pregnancy to be healthy, giving them time to heal between pregnancies and talking about inner relationship violence and our partner violence and addressing that and really creating a safe space for the group to connect and dive into these critically important topics that are incredibly stressful and if not address can lead to poor birth outcomes.
Sure, well, that sounds like a great collection of topics to be covering. And it sounds like that's only just the tip of the iceberg.
It really has the visit gives a format that clinics really adapt to their community's needs. And that extended time with the patient is really an opportunity for the women and the providers to really connect to support the pregnancy. But the biggest, probably most important thing is that the hierarchical structures between the patient and the provider are broken down through this we trained facilitators, clinical or otherwise, to be facilitated leaders. It's their job to keep the conversations factual, particularly on the medical side. They also are trained to really elevate lived experience, and also to stay quiet so that the group, the group can explore these topics of it. And that's really important. It's really important for women to have trust in their group and then their providers and expect a different experience from the healthcare system at this critical time.
Now, centering pregnancies been around since the 90s. But it's still only a limited use. So what have been some of the difficulties implementing it more broadly?
That's a great question. You know, we're in about 600 clinical sites right now in 47 states. And I think we have maybe 1% of the birth nationally. There's still a lot of work to be done.
Some of the barriers are purely structural. You know, the healthcare system is not set up yet to incentivize Value Based Payment. The reimbursements don't yet align with that, until providers are paid by outcome, rather than by volume. It's a little bit of a round hole in a square.
The clinical practices they have to invest in implementing the model and getting training and finding a space and outfitting it. Insurance companies, the payers, Medicaid system. All of those stakeholders are the ones that actually reap the benefit financially, on better outcome. Any avoidance of a nick you today is a huge thing for a pair. And so there's a misalignment in terms of who has to make the investment to reap the reward. Our medical schools don't train this way. Hmm. That's an issue, believe it or not space as hard to come by, again, because the incentives are based on volume and rapid transactional patient care. You'll have 12 patient rooms that are tiny little box, but no group space beyond the waiting room which has to be large because so many people are waiting in it.
You know, I'd never actually thought about that, that group space element, but as a normal human being has been to the doctor's office before. Those rooms are always very small. And you definitely could not fit 12 people in one of those rooms.
Yeah, now you really can't. So then there's some of the barriers, we're making progress on all of them. The space is probably the one that we can't influence the most. What we see on the space side is that size might start small because they're limited by space. And then after a year or two, and they feel more confident and seeing the outcomes. They start fighting for space and figuring it out. But it can be a barrier. The other one says systemic issues, more making some progress on from a policy perspective.
Yeah, and I guess looking at that progress and the state approaches, some states seem to be taking a grant based approach to implementing Centering Pregnancy, while others are focusing more on that systemic changing reimbursements in their Medicaid programs and private insurance providers to try to capture that value based medicine up front. So the providers are actually seeing that. Now, if you were speaking with a state legislator who's interested in implementing Centering Pregnancy, what would you tell them about the value of those various approaches?
I would say they're both incredibly valuable. My first ask of any state policy maker is to turn on a group care code in their state. If we can have clinical practices be able to notate centering in the claim tied to the outcome, then they get a data set that will make the case. And so just by doing that, or 10 steps ahead of where we start in anything. And then the first thing you mentioned were the grants. And I think the grants that we're seeing states do and we actually do some ourselves as an organization, and work with funders to create grants programs, offset those initial startup investments. And so because it's kind of accepting the system as it is and saying, All right, we can't have these providers having to foot the bill for these. So we'll offer grants to offset that. So it's a bit of a band aid, but it's how most sites get started with entering the payment incentives are the more meaningful opportunities for policy change. And what that says, hey, as payers, we are willing to share this saving and reward you for your efforts and your great outcomes that are generating savings. And so what those look like are enhanced reimbursement levels for patients who are seen in centering. And some of the states that have done it have really identified that it must be centering because we do have a commitment to quality and ensure the model fidelity that produces the outcomes we all want and the evidence base and so those payment instead can look like anything from $30 more per patient per visit. For the 10 visits, some tears outside of Medicaid system, some individual Medicaid managed care organizations are actually incentivizing at the hundred dollar level per patient per visit. That's a pretty wide range, but we're seeing most of them hover around that $30 level. We've also seen plan really focused on tying some of the birth outcomes to the heated measures that they've identified as part of their Value Based Payment incentive.
Thank you. Well, finally, where do you see Centering Pregnancy implementation now? And where do you see it going in the next five years?
In terms of our implementations support, we're only getting better will continue to get better. We began a multi year scaling initiative about 18 months ago with the assistance of private philanthropy dollars. And that effort should wrap up around 2324 should get us to about 1500 sites nationally, well, at least, and also help us where possible, grow that percentage of patients being seen and centering and all of those practices. And so what we're focused on is putting more centering staff on the ground to interact with stakeholders such as legislators, and policy audiences as well as the local medical society. So building out that regional and state infrastructure, it's going to be really important for us to be able to navigate who makes decisions on Medicaid in a meaningful way and support our site.
And we'll be speaking with Angie Truesdell a bit more later in the show.
Let's take a look at where the states are on implementation. of Centering Pregnancy and group prenatal care generally, looking at the states, it seems there are basically three stages they fall into their states where they're independent sites that don't have any specific state support. There are states where there is grant based support or temporary reimbursement based support. And there are states where there is reimbursement based support. And that can be with or without additional grant based support. So looking at those by category, North Carolina is an example of a state where there are independent centering sites, but there is no overarching state policy regarding centering. There's about two dozen sites that have been started with startup funds from the March of Dimes, and they've had some great impact so far. The 2017 2018 stats were that there was a 26% decrease in preterm birth in areas where centering was being used. And that's a comparison between women who are receiving group based prenatal care with the Centering Pregnancy model compared to women who are receiving traditional individual prenatal Care. The source for those stats are centering counts and the March of Dimes pair of stats. Now looking at our second category, and these are the states who have actually started engaging in some sort of policy support for group prenatal care. New York is a state that has reimbursement assistance only. And that's for targeted areas. And it's essentially a temporary pilot program. in 2017, New York started its first thousand days initiative. And there were a number of priorities in that first thousand days. One of those was to reduce preterm birth rates through enhanced use of centering. Now that project as part of the first thousand days initiative was funded starting in fiscal year 2019. And it's a pilot program that has enhanced reimbursements at that $30 per visit amounts like Angie Tuesday was talking about, and that's a two year period that the program is running for areas that have particularly high rates of preterm birth. So this is not a state that's implementing it broadly for anyone who's interested. But this is a state that's using it for a targeted intervention to try to improve preterm birth rate numbers in the worst hit areas. Now, on the other side of that, you have Ohio, which has a grant based support only currently temporary. And when I say has perhaps I'm overselling that a bit. There's a bill pending that has passed the House House Bill 11. In Ohio, that is pending in the senate at the moment. It's worth noting, this is a bill that has had bipartisan support. Everyone has voted in favor, there have been no votes against in the house level. And that would put $6 million aside over a two year period for grants in the 20 2021 calendar years. And those grants would be to providers who are looking to start centering practices. And that would help them with the scale up costs, getting additional space going through their certification, those upfront costs that might otherwise be a disincentive for providers. But after that is done, those grants don't cover anything else. So it gets it started. But once it started, it doesn't provide ongoing support. And again, that's a temporary program the way Ohio is looking at it. Now, there are other states that look at this a bit differently or have taken a different approach. Georgia has both changing their reimbursement and targeted grants. And it's worth mentioning before I dig into this a bit, that this is something that for Georgia has developed over time. Because from back in 2008 2009, that's when you had the first people coming out starting centering practices with March of Dimes funding, all the way to 2013. Where there was a telemedicine centering practice to help take the centering approach to rural areas that didn't have access to good prenatal care. And the impacts that Georgia has had from that have been significant and this is still during their grant period. They have taken areas where the preterm birth rate was as high as 18.2% in the African American population. With centering, they have brought that down to 8.1%. So 18.2 to 8.1%. That's more than cutting it in half. That is a dramatic impact. Now, using the same approach and another community that's primarily Hispanic, literally 100%. Hispanic population served, brought the preterm birth rate down from 12.1% to 6.7%. Again, almost cutting that preterm birth rate in half. So really dramatic impact on infants being born in those areas. After that received some acclaim, they moved to the point where in 2018, the state put aside some grant funding for centering, and they have enacted enhanced Medicaid payments. That's that reimbursement piece. So now George is at a place where they have grant funding to help center and practices on the front end, and they have the enhanced reimbursement to keep it going and provide that extra incentive to get providers to start using this model to start helping women And clearly based on their data, it has been helping women in that state. South Carolina similarly started in 2008 in the Greenville health system using the centering model, and they've been expanding ever since. And recently in 2017, their Department of Health and Human Services updated coverage in their Medicaid program for Centering Pregnancy. So they have that expanded reimbursement as well, though at the beginning back in 2008, when it started, it was targeted grants, it was philanthropic dollars, getting these programs started. Now they've seen the impact and they've moved to a more comprehensive state based approach. Montana has enhanced Medicaid payments for group prenatal care, Louisiana and 2015 approved enhanced Medicaid payments for group prenatal care. Virginia is on the same boat, New Jersey just recently in 2019. Passed Assembly Bill 5021 with both Republican and Democratic sponsors, it had unanimous votes in committee in both the Senate and the assembly.
With that, we're going to take a minute to speak with New Jersey State Senator Thomas key who serves as the Republican leader in the Senate. Welcome to emerging state policy.
It's great to be with you.
For anyone who might not be familiar with you. Could you tell us a bit about yourself and your district?
I'm the Senate Republican leader in New Jersey, I represent 210,000 people across three counties in New Jersey 16 communities, serving the state legislature for about 18 years.
Well, New Jersey is the first day to have passed legislation Assembly Bill 5021 to ensure that Medicaid covers group prenatal care with the Centering Pregnancy model. What originally brought this to your attention?
Local constituents. In fact, we meet with constituents all the time, my legislative office about issues on old range runs and local constituency came in as part of our conversations. We're starting to talk about the health and prenatal and birth disparities, that exists in New Jersey and nationwide. So once we realized the vast health outcomes disparities that existed, we started to work on a bipartisan basis with Republican democratic senators Joe Vitale, Ron rice, Bob Seger, and I sent letters to every insurance company that covered New Jersey. And we wanted to see what were the best practices in health from around the country. And so we started to find some best practices, look down south carolina model. And we started to understand that the better care inputs throughout all aspects of pregnancy, the better it is the outcome overall.
Now, there are studies showing that Medicaid accounts are about 40% of prenatal care spending. The other portion of that is private health insurance and individual payments, like you were just talking about. It sounds like you guys took a really comprehensive approach by making sure that private insurance was in the conversation with you about what best practices would be.
Oh, absolutely. We Want to make sure that we understood the issue that we were able to get in front of the issue that we were able to have access to information that we would not necessarily have outright? Certainly. And we want to come in and say, what's the best way to make sure more people can go through the privacy that we do some of these health disparities and get information out to mothers at all ends of the brain to spectrum?
That sounds fantastic. So let me ask you based on that, what sort of impact Are you hoping that this legislation will have on your constituents and your state as a whole?
Well, the more people who have healthy babies were brought the term, the more that we can make sure that the disparities in health are reduced in every way that we can. Back to them 18 people found that giving birth the United States women three times likely died and mother in Britain or Canada, and for the every one of those initiatives are stem, the near death experiences that are underreported, and so making sure that people who are going through the prenatal process are educated that their health is looked at, you can have these some of these group settings where people can have some broader conversations and understand by going through this process. At the time when other individuals are the exact same partner pregnancy, you can make sure that the health outcomes from the beginning to post birth are better than they currently are. Gotcha.
Now, as you earlier noted, you took this on in a bipartisan sort of way. In the news, we're always hearing claims that the parties can't work across the aisle. But it seems like that's exactly what you've done here. So Senator keen, what makes this issue a bipartisan one?
We all care about the healthy population. Sure, we all want to have the best possible information in this instance, but in many other cities, and I've always found that the best piece of legislation with those that can pass any legislative chamber on a unanimous basis, and by making sure that we have The best possible information with people who have the goal of reducing disparities and health and in other aspects of people's lives, we can usually find strong bipartisan agreement that is in the best interest in the short term and the long term of not only the 210,000 people I represent, but the millions of people were proud to call New Jersey home. And then my hope is that because we were so early in the process that others can look to buy new jersey is done and said, that makes sense. They can make sure more and more people are born healthy. They have fewer risks throughout the pregnancy, prenatal and afterwards for the mother. And we can do find common ground across the country.
Building on that, what advice would you give to other state legislators across the country who are considering proposing or voting for a similar group prenatal care legislation?
I think people have seen that this type of model works I think that anytime you can get more supportive environments, that you can make sure that you have a best possible outcome. And it can make people in every zip code across this country healthier.
And do you see this as the type of legislation that can ultimately be scaled up to possibly even at the national level?
I think it makes a lot of sense of scale. Yeah, this is an issue that this disparities you've seen impacts the entirety of the country. And so we can handle it one state time, as well as on national focus that you've seen in New Jersey. This is not only a focus of legislative efforts, but first lady Tammy Murphy is also taken us on has been going around date focusing on this issue as well. So this is an issue that is truly bipartisan, and people who are engaged in also understand the importance of making sure that group p prenatal care services are funded.
Well, Senator Keane, congratulations again on passing this first of its kind bill, and working to improve infant and child health and New Jersey. And thank you for joining us today. Today on emerging state policy,
Thank you very much for reaching out.
Now that we're all up to date about what the states are doing on this policy, and what some of the different approaches are, let's turn our attention to the research behind these policies. And I'm grouped into two broad categories. There's research about the impact that centering policies have. And then there is research about the cost savings related to that. Now, obviously, those two things are related. However, in terms of the arguments one might be making in favor of implementing a policy. The cost savings argument is usually seen as separate from the actual impact argument of avoiding preterm births.
So let's jump right into the cost savings first, because it's a little bit more straightforward. Now, South Carolina, who's been working with centering for some years now did a study in 2016, published in Maternal and Child Health Journal That was 7790 participants. And in order to determine cost, they looked at the claims paid data for all of these women. They found some great outcomes and results. But let's talk about the cost savings. The cost savings was $22,667 per preterm birth. So the total savings was about $4 million for $1.7 million invested a $2.3 million return on investment. To look at it another way. There was $2 and 34 cents saved for every $1 spent in order to try to avoid preterm birth through centering where their weaknesses Yes, there are always weaknesses in any study, and this study is no different. Here, the participants were opt in as opposed to a randomized controlled trial. And the racial demographics of the study show a preference of white women for the group prenatal care model, which could potentially be throwing the numbers off also. weakness is the only cost considered here. We're professional and inpatient costs, which are likely and underestimate. And it only looks during the period for the first year of life following birth. And obviously, as we heard from Dr. Good previously, many of these children can be born with chronic conditions, which can require care over their entire lifetime. So this is likely an underestimate of total cost. Now, there's a separate study from the National Academy of Medicine in their 2006 reports, and they found that the total annual National cost related to preterm birth is $26.2 billion annually to break that down 40% of that is cost directly to Medicaid. And the remaining roughly half is to employers private insurance and individuals. Now, the basis that they have for coming up with this number is a lifetime cost estimate for one year worth of us preterm birth the 2006 Report relies on 2003 costs data from medical care, maternal delivery, early intervention services, special education, which is needed more often after preterm birth due to the incidence of disabling conditions, and last household labor and market productivity. And that market productivity part is only about one fifth of that total cost. So they're finding broken down by infant was a total of $51,600 per preterm infant. And that was in $2,003. One nice thing about this study is it allows any states to reverse engineer their yearly share of those costs. So if you're trying to make this argument, you can take a look at the March of Dimes pair stats for your states and the US preterm weekly births for the nation as a whole. Compute your state's portion of us preterm birth and then multiply that by the annual cost estimate to see how much the impact is for your state for Example. Take Ohio, I happen to be in Ohio resident, Ohio using this method covers 3.7% of nationwide preterm births. And that means based on this $26.2 billion annual estimate, Ohio share of that is 960 $8 million in new costs that are accrued each year. Now, some of those are borne by the state, some by citizen, some by insurance, some by hospitals and doctors and charity. So it's not that it's all coming directly out of the state's pocket, but they are things that are being borne by your citizens. And that provides a relatively clear basis to show why the money you invest in reducing preterm birth is saving your citizens money, your government money, not to mention the lives quality of life and health of the children being born in your state. With that, we're going to move over to the research looking directly at impacts. But before we jump into that, let's continue our interview with Angie Truesdell.
Now moving over to the research side, it seems that there's been a wealth of research into the Centering Pregnancy model at this point. What are some of the key benefits that the research shows for adopting a Centering Pregnancy prenatal care approach?
The most well studied outcome is a significantly reduced incidence of preterm birth in the 20 to more than 30% range and that reduced risk and incidents. That lowering of preterm birth is especially meaningful in the black community. Black women in this country suffer preterm birth twice as often as the white women. The preterm birth defects are really remarkable. They're centering because you're seeing a lower preterm birth rate overall, but and especially lowered one for black mom. There's some real power in that group approach that goes beyond the medicine. What we're providing Something that's truly transforming for these women and getting through the stress during their pregnancy.
That's a fantastic intervention. Now, while the majority of research on Centering Pregnancy has shown positive impacts on preterm birth rates and other public health metrics, the 2018 five year strong START study, which was the largest of its kind, concluded the group prenatal care primarily using the Centering Pregnancy model did not impact preterm birth rates or other public health metrics, though it did save money. What would you say to a legislative staffer or an on the ground provider trying to contextualize that finding with all the other positive research?
Yeah, well, I would I would look at the original design of strong start and encourage them to look at that strong start did not require site to work with us to implement their group prenatal care model. The report acknowledges that most group prenatal care is centering Even though they didn't require their grantees to go through our training, our accreditation process to support the system change that has to happen to implement the same centering didn't require them to report data to us so that we can benchmark and set goals together. And so, you know, this isn't a patient intervention. And it's not a sign of setting intervention, like some of the other strong start initiatives. This is a system change intervention. And so it most clinical sites, if they don't have significant support and the system change, then it's not going to be successful. And I can tell you, selecting sites to start centering is a business of its own. We're not sure how well the sites or screen we go through a pretty rigorous readiness assessment process, where sites tell us about their physician and clinical provider mix and the group space and Who's bought into this across their organizations? And so I think it's great that the federal government dabbled in group prenatal care, but I can't say that strong start is indicative of centering.
I think it's going to be very interesting to see where Centering Pregnancy is going from where it is right now. Angie Truesdell. Thank you. And thank you to the centering healthcare Institute for continuing to educate the community about the benefits of centering and for joining us today on emerging state policy.
Thanks so much Spencer.
Time for the impact research. So there was a randomized controlled trial in 2007. That was run by the Yale School of Public Health and Emory University. In terms of the setup, there were 1000 people who were part of the study, and it showed a 33% reduction in preterm birth and a 37% reduction in preterm birth for African Americans. Now it didn't show any cost savings. However, their cost estimates were the costs only at birth through the care that was immediately needed right then it didn't include the first year of life. And it certainly didn't include any lifetime costs, which was a weakness of that particular study.
In 2012, there's a study called the effects of Centering Pregnancy on preterm birth in a low income population. And this was run by the University of South Carolina and the Greenville health system. They were running with about 4000 people in that study, and that showed a 47% reduction in preterm births. And one interesting side note on this, it showed a 58% reduction in very early preterm births. And while we haven't gotten into this much the earlier a child is born preterm, the less time the child has had to develop and the more likely they are to have various developmental issues. So this significant impact on those very early preterm births, it could have a huge impact on the quality of life for those children and could be a huge potential cost savings. The National Academy of Medicine report that we talked about earlier found that one third of all of the costs related to preterm birth were for these very early preterm births. So if you can lower that rates, you have the potential to make a real impact both on quality of life and on cost. North Carolina's implementation 2017 and 2018 showed a 26% reduction in the preterm birth rates, still very significant. That's from centering health care is reported stats and the March of Dimes Paris stats, South Carolina's Centering Pregnancy expansion project, which was 2013 through 2015, is the first to really focus on the racial impact of this. And it noted that for black women, there was a 38% reduction in preterm birth. And significantly, it brought the rate of preterm birth down from 13.4% to 8.3%, which was almost the same as the one rate which was 8%. So 8% versus 8.3%, almost eliminating racial disparity in preterm births. Now, there were some weaknesses to that study, there could have been selection bias because it was a retrospective cohort study looking backwards. And they said a stronger version of it would be a randomized control trial. And we've already talked about one of those just a second ago. Another interesting race focus study was in Puerto Rico. And this study was perhaps on surprisingly, on Hispanic women, and this was with the University of Puerto Rico and Nova Southeastern University. And in terms of impact, it showed an 18.8% reduction in preterm birth rates. And also, I mentioned earlier about the 58% reduction in very early preterm births. This study had a similar finding, showing a 69.8% reduction in very early preterm birth rates. So this is a particular population that can be hugely impacted. If you can reduce those numbers. Now this study was all Hispanic women. So it showed the potential to significantly reduce preterm birth rates with Hispanic women. Now there has been some contrary research and as I just spoke about with Angie Truesdell, the strong START study is probably the single largest piece of contrary research. It ended recently in 2018. It was a five year study. The Urban Institute was involved the American Institutes of research the Center for Medicare and Medicaid Innovation Center for Medicare and Medicaid Services with Department of Health and Human Services. A lot of players huge sample size, shy of 50,000. Long runtime, like I said, five years and they were looking at group prenatal care versus birth centers versus maternity care homes as early interventions to try to reduce preterm birth rates. Now, in terms of their results, they found that group prenatal care, it did save money. It was about 15% cheaper in their study, but it didn't show an improvement in rates. Now compared to some of the studies, this one really has a legion of problems with it. And I say I have a personal love for the Urban Institute. I think they do great work. I listen to their podcast. But in this particular study, things went astray. I can't say who it was, or perhaps it was a little bit on everyone. But first off, they only reached half the number of women they were trying to target, which suggests a core lack of planning and implementation. There was a lack of time for the sites to plan there were many complaints from the sites that they just had to flip the switch immediately, and start without preparation and training time. They noted that providers withheld support for group prenatal care because of perceived competition with individual prenatal care, which meant people probably were not running it the way you would want them to, for a good study. There was opt in and opt out enrollment instead of randomized controlled trial. And there were problems getting study participants to sign up for group prenatal care, significant problems compared to the other interventions. And there were a lot of miscellaneous problems. There was a lot of transport and childcare. There were demands from school and employment that competed language barriers. In some places, people who dropped out early on the group prenatal care didn't meet the suggested number of visits, which would be 10. On average, they only did 5.7 visits. So really, we're talking about a population of women who only received half of the treatment, the treatment being group prenatal care versus individual, they only came to half their visits. Also on the provider side, there was very high staff turnover. There was extremely limited training. And that space issue that we talked about earlier with Angie Truesdell. They noted that it was very common for there to be improper space allotted for these group meetings. So in addition to scheduling issues and lack of retention, they noted that program funds were not able to be used to support transportation services or incentives. They noted there were problems with data collection. Now there was also some selection bias issues compared to the group prenatal care groups, because these were opt in the birth center is really had a prime demographic women who were better educated, healthier, less minority women in more stable relationships and who are less likely to have had prior complications with a birth 10 times less likely to have had a prior low birth weight baby and about only half is likely to have had a prior preterm birth. So it's really no surprise that when people are able to opt in, and when the most healthy women all opt into one group, that that group has better outcomes. Conversely, this meant that the group of prenatal care group were starting with less healthy women who were at higher risk, again, because the lower risk healthier women had selected into the birth center groups instead of group prenatal care. The study initially had seven different awardees who are doing group prenatal care approaches. Of those seven, six of them had acceptance rates so low that no data from those sites was using In the final impact analysis. So to put it another way, the data and implementation quality of six of the seven group prenatal care awardees, and the program was so poor that even the strong START study itself did not consider their data when doing the impact analysis. That literally means that it was so poorly implemented, that they had to ignore 85% of their own awardees. Now, given the many problems I just ran down with this study, women who are going to centering at sites where there is actual preparation, buy in, then you see outcomes that are much more like the other positive research that I've just gone through. This is likely why large organizations like the March of Dimes has thrown their support behind group prenatal care. The March of Dimes has stated that it strongly supports enhanced payment models to make group prenatal care more accessible, noting that group prenatal care has numerous benefits. Additionally, the American College of Obstetricians and gynecologists, their committee on obstetric practice in 2018 noted that it supports expanded use of group prenatal care as an option for patients, and suggests that additional resources are needed to help cover startup costs, noting that enhanced reimbursement is not widely available currently.
There you have it. Centering Pregnancy is a group prenatal care model that has the potential to reduce preterm birth rates by 20 to 30%. improve the health and lives of our children to reduce or eliminate racial disparities, save money for governments, employers and our citizens and Garner bipartisan support. I hope that you have found this episode educational, and are able to help advance expanding prenatal care options in your state. If you enjoyed this episode, please leave us a review on Apple podcasts as that helps make the program more visible to other people. This is an open source podcast, so feel free to use any or all All of our episodes without additional permission, please do drop us a line on Twitter at Spencer the letter J. Cahoon. If you do end up using this episode, you can also find our transcripts at emerging state policy.org which is still under construction, but you certainly can find our transcripts there. thank you to Dr. Valerie good. Angie Truesdell and the centering healthcare Institute, and New Jersey State Senator Thomas Keane. Special thanks to Nick Allen for original music composition. Thank you again for joining us for this episode of emerging state policy.