Kaiser Health News

These Appalachia Hospitals Made Big Promises to Gain a Monopoly. They’re Failing to Deliver.

Published

8 months ago

September 29, 2023

Brett Kelman and Samantha Liss
Fri, 29 Sep 2023 09:00:00 +0000

JOHNSON CITY, Tenn. — Five years ago, rival hospital companies in this blue-collar corner of Appalachia made a deal. If state lawmakers let them merge, leaving no competitors, the hospitals promised not to gouge prices or cut corners. They agreed to dozens of quality-of-care conditions, spelled out with benchmarks, and to provide hundreds of millions of dollars in charity care to patients in need.

Today, Ballad Health's 20 hospitals remain the only option for hospital care for most of about 1.1 million residents in a 29-county region at the nexus of Tennessee, Virginia, Kentucky, and North Carolina. But Ballad has not met many of the quality benchmarks nor provided much of the charity, spurring discontent among those with no choice but to rely on Ballad for their care.

Two dozen states, from Florida to Washington, have at some point passed so-called COPA laws that allow hospital systems to merge into monopolies, disregarding warnings from the Federal Trade Commission that such mergers can become difficult to control and may decrease the overall quality of care. In the case of Ballad, the nation's largest-known COPA deal, public records suggest that is exactly what happened.

Documents released by the Tennessee Department of Health show:

Ballad has not fulfilled the annual charity care obligation it made to Tennessee, falling short by about $148 million over a four-year span. In those same years, Ballad took thousands of patients to court to collect unpaid bills.

Ballad failed to meet about 80% of benchmarks designed to monitor and improve its quality of care — including rates of infection and death — in the most recent year for which data is available. Federal health officials cited some of these same problems this year in issuing one-star ratings to three Ballad hospitals, including a flagship, Johnson City Medical Center.

“The state of Virginia and the state of Tennessee took a chance on [Ballad] to do the right thing,” said Michele Johnson, executive director of the Tennessee Justice Center, a nonprofit focused on health care for the poor. “And they've proven that they are not worthy of that chance.”

In a two-hour interview with KFF Health News, Ballad Health CEO Alan Levine defended the merger as “hugely successful” for a region rife with poverty and sickness, saying his company had planted seeds of better health that “you can't quantify today.” More specifically, Levine said the enormous pressure of the coronavirus pandemic caused Ballad's slumping quality of care. He attributed charity care shortfalls to Medicaid changes beyond Ballad's control and new preventive care programs that keep patients out of the hospital so they don't need charity.

Levine said the Ballad merger had likely prevented at least three hospital closures and kept giant corporations from swooping into Appalachia to buy up the scraps.

“Our critics say, ‘No Ballad. We don't want Ballad.' Well, then what?” Levine said. “Because the hospitals were on their way to being closed.”

Ballad is centered in Tennessee and Virginia's Tri-Cities region, a cluster of hardscrabble towns and wooded foothills that is home to the famous Bristol Motor Speedway and recognized by Congress as “the birthplace of Country Music.” Census data shows the Tri-Cities poverty rate is about 30% higher than the national average, and residents' general health is below average for the nation and their respective states, according to the BlueCross BlueShield National Health Index.

Ballad launched in 2018 after state officials approved the nation's largest-known Certificate of Public Advantage, or COPA, agreement, which waived anti-monopoly laws so the region's only two hospital systems — Mountain States Health Alliance and Wellmont Health System — could merge. To offset the perils of a monopoly, the COPA requires Ballad to agree to increased oversight by the state and a long list of special conditions, including limiting price increases, maintaining quality, and providing charity care. Ballad also committed to investing $308 million over 10 years to improve the health of the region, some of which it has spent on a low-to-no-cost care network for the uninsured and expanded addiction treatment services.

Even with this spending, Ballad has turned a profit. The company generated net income of more than $143 million and $63 million in fiscal years 2022 and 2021, respectively, while receiving $175 million in pandemic relief funds, according to an S&P Global Ratings independent analysis, which excludes items like gains and losses separate from hospital operations.

The merger was profitable for Levine too. His total compensation has nearly doubled to about $4.3 million since the merger, including some deferred retirement payments, according to reports filed with the IRS. Prior to Ballad, Levine worked as a high-level health official in Florida and Louisiana and was an executive at two larger hospital corporations, HCA Healthcare and Health Management Associates. Federal prosecutors accused both companies of widespread health care fraud during some of the years when Levine was one of their leaders, claims the companies denied but later paid hundreds of millions of dollars to settle.

Nationwide, the COPA model is uncommon but gaining momentum. COPAs have been used in about 10 hospital mergers over the past three decades, including two in Texas and one in Louisiana in just the past three years, and another is being proposed in Indiana. Nineteen states have laws on the books allowing for COPAs, although not all have approved a specific merger, and five other states passed COPA laws and later repealed them, according to The Source on HealthCare Price & Competition, a website by the University of California College of the Law-San Francisco.

Rahul Rao, a deputy director of the Bureau of Competition at the Federal Trade Commission, which consistently opposes COPAs, said removing hospital competition leads to predictable results — rising prices, decreasing quality, and monopolies that are very hard to break up.

Rao said the FTC has for years studied how the Ballad merger is affecting health care in the region but that it is not yet ready to publish its findings.

“States should be very wary and distrustful of COPAs in general,” Rao said. “It's very hard to unscramble the eggs.”

Tennessee began to pave the way for Ballad in 2015 when state Sen. Rusty Crowe (R-Johnson City) co-sponsored a bill allowing for the merger, which was later mirrored in Virginia. Crowe was also working as a contractor for Mountain States Health Alliance when the bill was introduced, and since the merger he has been similarly contracted with Ballad, the lawmaker said.

Tennessee financial disclosure records confirm Crowe was paid by both hospital systems but don't say how much or for what. Crowe, who did not agree to an interview, said in an email that he was hired to “help in the development of wound care and hyperbaric medicine” and that he “complied with all the Senate ethics code requirements regarding any potential conflict of interest.”

Tennessee and Virginia health officials have concluded annually that the merger remains beneficial to the public and, in reports and interviews, credited Ballad for weathering the pandemic and keeping hospitals open.

Dennis Barry, one of the state monitors hired to keep tabs on Ballad, said he believed Ballad had largely lived up to the agreement, or at least the “intent.” Barry dismissed the FTC's position that hospital competition is necessarily beneficial and said no one knows how the region would have fared without the merger.

“In a sense, we'll never be able to determine whether or not this was a good idea or a bad idea,” Barry said. “I view it as an experiment.”

As Ballad fell short of its COPA benchmarks, state officials took steps to relax the oversight of its hospitals, particularly in Tennessee. Both Tennessee and Virginia gave Ballad more time to spend tens of millions to benefit the region, and Tennessee officials have repeatedly waived Ballad's annual charity care obligation. Tennessee in 2021 stopped publishing a “final score” for Ballad's adherence to the COPA terms and in 2022 revised COPA rules so Ballad could oppose the opening of competing hospitals or other medical facilities in the region, according to state documents. A local COPA advisory council, created to hear complaints from residents, no longer hosts public hearings.

Ballad Cites Pandemic Amid Quality Decline

Ballad has failed to meet quality-of-care benchmarks established in the COPA agreement in recent years, according to public reports from the Tennessee government and the hospital system itself. For example, a Tennessee report shows that from July 2021 through June 2022, Ballad hospitals fell short of 61 of 75 benchmarks, including some about sepsis, surgery-related infections, emergency room speed, and rates of readmission and death from heart failure.

The Centers for Medicare & Medicaid Services this year issued one-star ratings to three Ballad hospitals, all of which had ratings of at least two stars before the merger. Because CMS calculates star ratings from data collected over several years, the ratings released this year are the first to grade the Ballad hospitals entirely on post-merger data.

Levine, citing arguments similar to those of other hospital leaders, insisted the CMS five-star rating system is broken because it judges hospitals on a sliver of patients and doesn't account for poor health in the region. He said Ballad fell short of the COPA benchmarks because the coronavirus overwhelmed hospitals and sparked an unprecedented nursing turnover.

But Ballad's hospitals have since rebounded, Levine said, pointing to partial data on the company website — not yet reported by the states — that appears to show improving performance as of this summer. And Levine said internal data showed Ballad was now tracking with the top 10% of U.S. hospitals on some quality-of-care metrics.

“We went way backwards during covid, no question about it. And now we've emerged out of covid,” Levine said. “We're recovering faster than other people.”

Erik Bodin, a Virginia Department of Health official who oversees the agreement with Ballad, said the pandemic caused quality issues at hospitals across the state, including Ballad's, which were “not acceptable” but “to some extent understandable.” Bodin said Virginia still has “concerns” and is “watching very closely” because not all of Ballad's metrics are rebounding.

The Tennessee Department of Health, which has the most robust role in regulating Ballad, declined an interview request and did not answer questions submitted in writing.

Ballad has also cut back on facilities for patients with life-threatening conditions. Citing redundancy with other hospitals, it downgraded the capabilities of trauma centers at Bristol Regional Medical Center and Holston Valley Medical Center and closed the intensive care unit at Sycamore Shoals Hospital. Ballad also shuttered the Holston Valley neonatal ICU. Residents were so angry that protesters gathered outside Holston Valley for eight months.

“I packed a sleeping bag, a backpack, and my laptop bag. I made two signs in my living room,” said Dani Cook, the protest leader and grandmother of a former Holston Valley NICU patient. “And next thing you know, 50 people showed up.”

One month after Holston Valley's trauma center was downgraded, Jeremiah Shane Fields, 37, died at the hospital from chest injuries sustained in a car crash. According to a CMS investigation report obtained by KFF Health News, Fields' blood pressure dropped for hours before his death, but his doctor did not come to his bedside as his condition deteriorated.

Holston Valley's chief medical officer, who is quoted in the report but not named, called the case a “fundamental failure of basic trauma care” in which Fields' doctor was “not following essential standards,” according to the report. Holston Valley was cited for “deficiencies” that were likely to harm patients, which the hospital immediately corrected, the report states.

Fields' family has filed an ongoing lawsuit alleging negligent care, and Ballad Health has denied all wrongdoing in court filings. Molly Luton, a spokesperson for Ballad, said that Fields' death was “an outlier” and “not the result of a systemic issue.”

Fields' mother, Penny Meade, 59, said she believed the hospital could have done more to save her son.

“It used to be wonderful,” Meade said. “But then everything changed. They took it all away, after that merger.”

‘Helping People' vs. ‘Coming After Them'

Ballad has fallen short of the annual charity care commitment in the COPA agreement by about $20 million to $48 million each year, according to Tennessee Department of Health documents. The agency waived this obligation each year after it wasn't met, the documents show.

Charity care comes in two forms: free or discounted care for low-income patients, or the amount left over when Medicaid patients are treated but their entire cost is not covered. Most of Ballad's charity care is from the second scenario, the documents show.

Ballad said in its annual reports it is unable to meet its charity care obligation because after the COPA was negotiated both Tennessee and Virginia increased their Medicaid reimbursement and Virginia expanded Medicaid to cover more people, leaving fewer people uninsured and in need of charity. (Tennessee has not expanded Medicaid.)

Levine added that Ballad's new Appalachian Highlands Care Network provides preventive care to uninsured residents.

“We are doing everything we can, for instance, to manage their diabetes so that they don't end up with a spike and end up in the ER,” Levine said. “That reduces your charity care.”

Some are unconvinced. Chris Garmon, a former FTC economist and a leading expert on COPAs at the University of Missouri-Kansas City, said Ballad had put forth a “strange defense” for its lack of charity care in a state where so many are uninsured.

“Last time I checked, Tennessee had not expanded Medicaid,” Garmon said. “This sounds like Ballad is pushing the envelope, like a toddler, trying to see when their parents will actually institute some discipline.”

As it was falling short of its charity commitment, Ballad filed thousands of debt collection lawsuits against patients in its first two years of operation, according to reporting from The New York Times and Modern Healthcare.

Levine said that Ballad does not sue patients who qualify for charity care and that its lawsuits slowed significantly after it adopted a more generous charity care policy in 2020. Ballad now offers free care to those who live at or below 225% of the federal poverty level, or an income of less than $67,500 for a family of four.

But the company still takes many patients to court. For example, in Tennessee's Sullivan County, one of the most populous areas in Ballad's market, the company has filed about 500 lawsuits since enacting the new charity care policy, court records show.

Wendy McClanahan, 44, said Ballad started garnishing her paycheck this summer over a lingering debt from a 2017 surgery. McClanahan said she was unemployed and unable to afford the bill at the time and she believed it was written off until court papers arrived in the mail.

Ballad will take 25% of McClanahan's paycheck until she has paid off $2,747, court records show. McClanahan said she's working overtime at her office job to make up for the lost income.

“They're supposed to be helping people instead of coming after them,” she said. “It's a lot of money to me, you know, and nothing to them.”

KFF Health News correspondent Bram Sable-Smith contributed to this report.

——————————
By: Brett Kelman and Samantha Liss
Title: These Appalachia Hospitals Made Big Promises to Gain a Monopoly. They're Failing to Deliver.
Sourced From: kffhealthnews.org/news/article/appalachia-ballad-health-copa-monopoly-charity-care-quality/
Published Date: Fri, 29 Sep 2023 09:00:00 +0000

Post Views: 389

Related Topics:Featured Health Kaiser Health News News

Up Next

Facing Criticism, Feds Award First Maternal Health Grant to a Predominantly Black Rural Area

Don't Miss

She Received Chemo in Two States. Why Did It Cost So Much More in Alaska?

Kaiser Health News

KFF Health News’ ‘What the Health?’: Bird Flu Lands as the Next Public Health Challenge

Published

13 hours ago

May 16, 2024

Staff Editor

Thu, 16 May 2024 18:30:00 +0000

The Host

Julie Rovner
KFF Health News

@jrovner

Read Julie's stories.

Julie Rovner is chief Washington correspondent and host of KFF Health News' weekly health policy news podcast, “What the Health?” A noted expert on health policy issues, Julie is the author of the critically praised reference book “Health Care Politics and Policy A to Z,” now in its third edition.

Public health officials are watching with concern since a strain of bird flu spread to dairy cows in at least nine states, and to at least one dairy worker. But in the wake of covid-19, many farmers are loath to let in health authorities for testing.

Meanwhile, another large health company — the Catholic hospital chain Ascension — has been targeted by a cyberattack, leading to serious problems at some facilities.

This week's panelists are Julie Rovner of KFF Health News, Rachel Cohrs Zhang of Stat, Alice Miranda Ollstein of Politico, and Sandhya Raman of CQ Roll Call.

Panelists

Rachel Cohrs Zhang
Stat News

@rachelcohrs

Read Rachel's stories.

Alice Miranda Ollstein
Politico

@AliceOllstein

Read Alice's stories.

Sandhya Raman
CQ Roll Call

@SandhyaWrites

Read Sandhya's stories.

Among the takeaways from this week's episode:

Stumbles in the early response to bird flu bear an uncomfortable resemblance to the early days of covid, including the troubles protecting workers who could be exposed to the disease. Notably, the Department of Agriculture benefited from millions in covid relief funds designed to strengthen disease surveillance.
Congress is working to extend coverage of telehealth care; the question is, how to pay for it? Lawmakers appear to have settled on a two-year agreement, though more on the extension — including how much it will cost — remains unknown.
Speaking of telehealth, a new report shows about 20% of medication abortions are supervised via telehealth care. State-level restrictions are forcing those in need of abortion care to turn to options farther from home.
And new reporting on Medicaid illuminates the number of people falling through the cracks of the government health system for low-income and disabled Americans — including how insurance companies benefit from individuals' confusion over whether they have Medicaid coverage at all.

Also this week, Rovner interviews Atul Grover of the Association of American Medical Colleges about its recent analysis showing that graduating medical students are avoiding training in states with abortion bans and major restrictions.

Plus, for “extra credit,” the panelists suggest health policy stories they read this week that they think you should read, too:

Julie Rovner: NPR's “Why Writing by Hand Beats Typing for Thinking and Learning,” by Jonathan Lambert.

Alice Miranda Ollstein: Time's “‘I Don't Have Faith in Doctors Anymore.' Women Say They Were Pressured Into Long-Term Birth Control,” by Alana Semuels.

Rachel Cohrs Zhang: Stat's “After Decades Fighting Big Tobacco, Cliff Douglas Now Leads a Foundation Funded by His Former Adversaries,” by Nicholas Florko.

Sandhya Raman: The Baltimore Banner's “People With Severe Mental Illness Are Stuck in Jail. Montgomery County Is the Epicenter of the Problem,” by Ben Conarck.

Also mentioned on this week's podcast:

Stat's “My Rendezvous With the Raw Milk Black Market: Quick, Easy, and Unchecked by the FDA,” by Nicholas Florko.
The Stamford Advocate's “Dan Haar: Hackers Stole a Disabled CT Couple's SNAP Food Aid. Now They're Out $1,373,” by Dan Haar.
WKRN's “‘Chaos': Nurses, Visitors Describe Conditions Inside Ascension Hospitals After Cyberattack,” by Stephanie Langston.
KFF Health News' “Medicaid ‘Unwinding' Decried as Biased Against Disabled People,” by Daniel Chang.
KFF Health News' “Why Medicaid's ‘Undercount' Problem Counts,” by Phil Galewitz.

Credits

Francis Ying
Audio producer

Emmarie Huetteman
Editor

To hear all our podcasts, click here.

And subscribe to KFF Health News' “What the Health?” on Spotify, Apple Podcasts, Pocket Casts, or wherever you listen to podcasts.

——————————
Title: KFF Health News' ‘What the Health?': Bird Flu Lands as the Next Public Health Challenge
Sourced From: kffhealthnews.org/news/podcast/what-the-health-347-bird-flu-next-public-health-challenge-may-16-2024/
Published Date: Thu, 16 May 2024 18:30:00 +0000

Post Views: 34

Kaiser Health News

California’s $12 Billion Medicaid Makeover Banks on Nonprofits’ Buy-In

Published

18 hours ago

May 16, 2024

Staff Editor

Angela Hart
Thu, 16 May 2024 09:00:00 +0000

TURLOCK, Calif. — For much of his young life, Jorge Sanchez regularly gasped for air, at times coughing so violently that he'd almost throw up. His mother whisked him to the emergency room late at night and slept with him to make sure he didn't stop breathing.

“He's had these problems since he was born, and I couldn't figure out what was triggering his asthma,” Fabiola Sandoval said of her son, Jorge, now 4. “It's so hard when your child is hurting. I was willing to try anything.”

In January, community health workers visited Sandoval's home in Turlock, a city in California's Central Valley where dust from fruit and nut orchards billows through the air. They scoured Sandoval's home for hazards and explained that harsh cleaning products, air fresheners, and airborne dust and pesticides can trigger an asthma attack.

The team also provided Sandoval with air purifiers, a special vacuum cleaner that can suck dust out of the air, hypoallergenic mattress covers, and a humidity sensor — goods that retail for hundreds of dollars. Within a few months, Jorge was breathing easier and was able to run and play outside.

The in-home consultation and supplies were paid for by Medi-Cal, California's Medicaid health insurance program for low-income residents. Gov. Gavin Newsom is spearheading an ambitious $12 billion experiment to transform Medi-Cal into both a health insurer and a social services provider, one that relies not only on doctors and nurses, but also community health workers and nonprofit groups that offer dozens of services, including delivering healthy meals and helping homeless people pay for housing.

These groups are redefining health care in California as they compete with businesses for a share of the money, and become a new arm of the sprawling Medi-Cal bureaucracy that serves nearly 15 million low-income residents on an annual budget of $158 billion.

But worker shortages, negotiations with health insurance companies, and learning to navigate complex billing and technology systems have hamstrung the community groups' ability to deliver the new services: Now into the third year of the ambitious five-year experiment, only a small fraction of eligible patients have received benefits.

“This is still so new, and everyone is just overwhelmed at this point, so it's slow-going,” said Kevin Hamilton, a senior director at the Central California Asthma Collaborative.

The collaborative has served about 3,650 patients, including Sandoval, in eight counties since early 2022, he said. It has years of experience with Medi-Cal patients in the Central Valley and has received about $1.5 million of the new initiative's money.

By contrast, CalOptima Health, Orange County's primary Medi-Cal insurer, is new to offering asthma benefits and has signed up 58 patients so far.

“Asthma services are so difficult to get going” because the nonprofit infrastructure for these services is virtually nonexistent, said Kelly Bruno-Nelson, CalOptima's executive director for Medi-Cal. “We need more community-based organizations on board because they're the ones who can serve a population that nobody wants to deal with.”

Newsom, a Democrat in his second term, says his signature health care initiative, known as CalAIM, seeks to reduce the cost of caring for the state's sickest and most vulnerable patients, including homeless Californians, foster children, former inmates, and people battling addiction disorders.

In addition to in-home asthma remediation, CalAIM offers 13 broad categories of social services, plus a benefit connecting eligible patients with one-on-one care managers to help them obtain anything they need to get healthier, from grocery shopping to finding a job.

The 25 managed-care insurance companies participating in Medi-Cal can choose which services they offer, and contract with community groups to provide them. Insurers have hammered out about 4,300 large and small contracts with nonprofits and businesses.

So far, about 103,000 Medi-Cal patients have received CalAIM services and roughly 160,000 have been assigned personal care managers, according to state data, a sliver of the hundreds of thousands of patients who likely qualify.

“We're all new to health care, and a lot of this is such a foreign concept,” said Helena Lopez, executive director of A Greater Hope, a nonprofit organization providing social services in Riverside and San Bernardino counties, such as handing out baseball cleats to children to help them be active.

Tiffany Sickler runs Koinonia Family Services, which offers California foster children mental health and other types of care, and even helped a patient pay off parking tickets. But the program is struggling on a shoestring budget.

“If you want to do this, you have to learn all these new systems. It's been a huge learning curve, and very time-consuming and frustrating, especially without adequate funding,” she said.

Brandon Richards, a Newsom spokesperson, defended CalAIM, saying that it was “on the cutting edge of health care” and that the state was working to increase “awareness of these new services and support.”

For nonprofits and businesses, CalAIM is a money-making opportunity — one that top state health officials hope to make permanent. Health insurers, which receive hefty payments from the state to serve more people and offer new services, share a portion with service providers.

In some places, community groups are competing with national corporations for the new funding, such as Mom's Meals, an Iowa-based company that delivers prepared meals across the United States.

Mom's Meals has an advantage over neighborhood nonprofit groups because it has long served seniors on Medicare and was able to immediately start offering the CalAIM benefit of home-delivered meals for patients with chronic diseases. But even Mom's Meals isn't reaching everyone who qualifies, because doctors and patients don't always know it's an option, said Catherine Macpherson, the company's chief nutrition officer.

“Utilization is not as high as it should be yet,” she said. “But we were well positioned, because we already had departments to do billing and contracting with health care.”

Middleman companies also have their eye on the billions of CalAIM dollars and are popping up to assist small organizations to go up against established ones like Mom's Meals. For instance, the New York-based Nonprofit Finance Fund is advising homeless service providers how to get more contracts and expand benefits.

Full Circle Health Network, with 70 member organizations, is helping smaller nonprofit groups develop and deliver services primarily for families and foster children. Full Circle has signed a deal with Kaiser Permanente, allowing the health care giant to access its network of community groups.

“We're allowing organizations to launch these benefits much faster than they've been able to do and to reach more vulnerable people,” said Camille Schraeder, chief executive of Full Circle. “Many of these are grassroots organizations that have the trust and expertise on the ground, but they're new to health care.”

One of the biggest challenges community groups face is hiring workers, who are key to finding eligible patients and persuading them to participate.

Kathryn Phillips, a workforce expert at the California Health Care Foundation, said there isn't enough seed money for community groups to hire workers and pay for new technology platforms. “They bring the trust that is needed, the cultural competency, the diversity of languages,” she said. “But there needs to be more funding and reimbursement to build this workforce.”

Health insurers say they are trying to increase the workforce. For instance, L.A. Care Health Plan, the largest Medi-Cal insurer in California, has given $66 million to community organizations for hiring and other CalAIM needs, said Sameer Amin, the group's chief medical officer.

“They don't have the staffing to do all this stuff, so we're helping with that all while teaching them how to build up their health care infrastructure,” he said. “Everyone wants a win, but this isn't going to be successful overnight.”

In the Central Valley, Jorge Sanchez is one of the lucky early beneficiaries of CalAIM.

His mother credits the trust she established with community health workers, who spent many hours over multiple visits to teach her how to control her son's asthma.

“I used to love cleaning with bleach” but learned it can trigger breathing problems, Sandoval said.

Since she implemented the health workers' recommendations, Sandoval has been able to let Jorge sleep alone at night for the first time in four years.

“Having this program and all the things available is amazing,” said Sandoval, as she pointed to the dirty dust cup in her new vacuum cleaner. “Now my son doesn't have as many asthma attacks and he can run around and be a normal kid.”

This article was produced by KFF Health News, which publishes California Healthline, an editorially independent service of the California Health Care Foundation.

——————————
By: Angela Hart
Title: California's $12 Billion Medicaid Makeover Banks on Nonprofits' Buy-In
Sourced From: kffhealthnews.org/news/article/newsom-medicaid-12-billion-dollar-makeover-nonprofits-bureacracy-calaim/
Published Date: Thu, 16 May 2024 09:00:00 +0000

Post Views: 35

Kaiser Health News

Federal Panel Prescribes New Mental Health Strategy To Curb Maternal Deaths

Published

20 hours ago

May 16, 2024

Staff Editor

Cheryl Platzman Weinstock
Thu, 16 May 2024 09:00:00 +0000

For help, call or text the National Maternal Mental Health Hotline at 1-833-TLC-MAMA (1-833-852-6262) or contact the 988 Suicide & Crisis Lifeline by dialing or texting “988.” Spanish-language services are also available.

BRIDGEPORT, Conn. — Milagros Aquino was trying to find a new place to live and had been struggling to get used to new foods after she moved to Bridgeport from Peru with her husband and young son in 2023.

When Aquino, now 31, got pregnant in May 2023, “instantly everything got so much worse than before,” she said. “I was so sad and lying in bed all day. I was really lost and just surviving.”

Aquino has lots of company.

Perinatal depression affects as many as 20% of women in the United States during pregnancy, the postpartum period, or both, according to studies. In some states, anxiety or depression afflicts nearly a quarter of new mothers or pregnant women.

Many women in the U.S. go untreated because there is no widely deployed system to screen for mental illness in mothers, despite widespread recommendations to do so. Experts say the lack of screening has driven higher rates of mental illness, suicide, and drug overdoses that are now the leading causes of death in the first year after a woman gives birth.

“This is a systemic issue, a medical issue, and a human rights issue,” said Lindsay R. Standeven, a perinatal psychiatrist and the clinical and education director of the Johns Hopkins Reproductive Mental Health Center.

Standeven said the root causes of the problem include racial and socioeconomic disparities in maternal care and a lack of support systems for new mothers. She also pointed a finger at a shortage of mental health professionals, insufficient maternal mental health training for providers, and insufficient reimbursement for mental health services. Finally, Standeven said, the problem is exacerbated by the absence of national maternity leave policies, and the access to weapons.

Those factors helped drive a 105% increase in postpartum depression from 2010 to 2021, according to the American Journal of Obstetrics & Gynecology.

For Aquino, it wasn't until the last weeks of her pregnancy, when she signed up for acupuncture to relieve her stress, that a social worker helped her get care through the Emme Coalition, which connects girls and women with financial help, mental health counseling services, and other resources.

Mothers diagnosed with perinatal depression or anxiety during or after pregnancy are at about three times the risk of suicidal behavior and six times the risk of suicide compared with mothers without a mood disorder, according to recent U.S. and international studies in JAMA Network Open and The BMJ.

The toll of the maternal mental health crisis is particularly acute in rural communities that have become maternity care deserts, as small hospitals close their labor and delivery units because of plummeting birth rates, or because of financial or staffing issues.

This week, the Maternal Mental Health Task Force — co-led by the Office on Women's Health and the Substance Abuse and Mental Health Services Administration and formed in September to respond to the problem — recommended creating maternity care centers that could serve as hubs of integrated care and birthing facilities by building upon the services and personnel already in communities.

The task force will soon determine what portions of the plan will require congressional action and funding to implement and what will be “low-hanging fruit,” said Joy Burkhard, a member of the task force and the executive director of the nonprofit Policy Center for Maternal Mental Health.

Burkhard said equitable access to care is essential. The task force recommended that federal officials identify areas where maternity centers should be placed based on data identifying the underserved. “Rural America,” she said, “is first and foremost.”

There are shortages of care in “unlikely areas,” including Los Angeles County, where some maternity wards have recently closed, said Burkhard. Urban areas that are underserved would also be eligible to get the new centers.

“All that mothers are asking for is maternity care that makes sense. Right now, none of that exists,” she said.

Several pilot programs are designed to help struggling mothers by training and equipping midwives and doulas, people who provide guidance and support to the mothers of newborns.

In Montana, rates of maternal depression before, during, and after pregnancy are higher than the national average. From 2017 to 2020, approximately 15% of mothers experienced postpartum depression and 27% experienced perinatal depression, according to the Montana Pregnancy Risk Assessment Monitoring System. The state had the sixth-highest maternal mortality rate in the country in 2019, when it received a federal grant to begin training doulas.

To date, the program has trained 108 doulas, many of whom are Native American. Native Americans make up 6.6% of Montana's population. Indigenous people, particularly those in rural areas, have twice the national rate of severe maternal morbidity and mortality compared with white women, according to a study in Obstetrics and Gynecology.

Stephanie Fitch, grant manager at Montana Obstetrics & Maternal Support at Billings Clinic, said training doulas “has the potential to counter systemic barriers that disproportionately impact our tribal communities and improve overall community health.”

Twelve states and Washington, D.C., have Medicaid coverage for doula care, according to the National Health Law Program. They are California, Florida, Maryland, Massachusetts, Michigan, Minnesota, Nevada, New Jersey, Oklahoma, Oregon, Rhode Island, and Virginia. Medicaid pays for about 41% of births in the U.S., according to the Centers for Disease Control and Prevention.

Jacqueline Carrizo, a doula assigned to Aquino through the Emme Coalition, played an important role in Aquino's recovery. Aquino said she couldn't have imagined going through such a “dark time alone.” With Carrizo's support, “I could make it,” she said.

Genetic and environmental factors, or a past mental health disorder, can increase the risk of depression or anxiety during pregnancy. But mood disorders can happen to anyone.

Teresa Martinez, 30, of Price, Utah, had struggled with anxiety and infertility for years before she conceived her first child. The joy and relief of giving birth to her son in 2012 were short-lived.

Without warning, “a dark cloud came over me,” she said.

Martinez was afraid to tell her husband. “As a woman, you feel so much pressure and you don't want that stigma of not being a good mom,” she said.

In recent years, programs around the country have started to help doctors recognize mothers' mood disorders and learn how to help them before any harm is done.

One of the most successful is the Massachusetts Child Psychiatry Access Program for Moms, which began a decade ago and has since spread to 29 states. The program, supported by federal and state funding, provides tools and training for physicians and other providers to screen and identify disorders, triage patients, and offer treatment options.

But the expansion of maternal mental health programs is taking place amid sparse resources in much of rural America. Many programs across the country have run out of money.

The federal task force proposed that Congress fund and create consultation programs similar to the one in Massachusetts, but not to replace the ones already in place, said Burkhard.

In April, Missouri became the latest state to adopt the Massachusetts model. Women on Medicaid in Missouri are 10 times as likely to die within one year of pregnancy as those with private insurance. From 2018 through 2020, an average of 70 Missouri women died each year while pregnant or within one year of giving birth, according to state government statistics.

Wendy Ell, executive director of the Maternal Health Access Project in Missouri, called her service a “lifesaving resource” that is free and easy to access for any health care provider in the state who sees patients in the perinatal period.

About 50 health care providers have signed up for Ell's program since it began. Within 30 minutes of a request, the providers can consult over the phone with one of three perinatal psychiatrists. But while the doctors can get help from the psychiatrists, mental health resources for patients are not as readily available.

The task force called for federal funding to train more mental health providers and place them in high-need areas like Missouri. The task force also recommended training and certifying a more diverse workforce of community mental health workers, patient navigators, doulas, and peer support specialists in areas where they are most needed.

A new voluntary curriculum in reproductive psychiatry is designed to help psychiatry residents, fellows, and mental health practitioners who may have little or no training or education about the management of psychiatric illness in the perinatal period. A small study found that the curriculum significantly improved psychiatrists' ability to treat perinatal women with mental illness, said Standeven, who contributed to the training program and is one of the study's authors.

Nancy Byatt, a perinatal psychiatrist at the University of Massachusetts Chan School of Medicine who led the launch of the Massachusetts Child Psychiatry Access Program for Moms in 2014, said there is still a lot of work to do.

“I think that the most important thing is that we have made a lot of progress and, in that sense, I am kind of hopeful,” Byatt said.

Cheryl Platzman Weinstock's reporting is supported by a grant from the National Institute for Health Care Management Foundation.

——————————
By: Cheryl Platzman Weinstock
Title: Federal Panel Prescribes New Mental Health Strategy To Curb Maternal Deaths
Sourced From: kffhealthnews.org/news/article/postpartum-mental-health-federal-strategy-maternal-deaths/
Published Date: Thu, 16 May 2024 09:00:00 +0000

Did you miss our previous article…
https://www.biloxinewsevents.com/medics-at-ucla-protest-say-police-weapons-drew-blood-and-cracked-bones/

Post Views: 43