Study Committee on Services to Pregnant Women final report

              EXECUTIVE SUMMARY In June, 1991, Governor ~ i f e Symington appointed this committee to study barriers to prenatal care for women in Arizona. The Committee heard testimony and reviewed extensively



the studies done nationally and in Arizona on the question. The following is a summary of the Committees findings and recommendations. Arizona ranks among the worst in the percentage of infants born to women receiving late or no prenatal care. Only New Mexico, Texas, and the District of Columbia ranked lower.



A recent Arizona Department of Health Services8 study showed

a marked increase in women receiving inadeauate prenatal care between 1982 and 1989. In Phoenix there was a 147% increase in the percentage of women who had less than 5 prenatal visits and a 277% increase in the percentage who entered care in the third trimester or who had no care at all. The decline is more marked in the inner city area of Phoenix and other high poverty areas. The number of isp panic women



receiving inadequate care increased by 86%; the number of Black women increased by 124%; and the number of white women receiving inadequate care increased by 62%. Most alarming is the finding



that AHCCCS women fared the worst at a time when AHCCCS eligibility was expanding.

A measure of the health status of women and children is the



number of children born at low birth weight.



The low birthweight



2



rate in Arizona &@ been steadily declining from 1970 to 1981. Since 1982 it has been on the increase. If Arizona had



maintained the same level of prenatal care and the same low birthweight rate it had in 1981, at least 211 very low birthweight births would have been prevented in 1987 alone. Seventy infant deaths could have been prevented. In addition to the cost in human life and health, the financial cost to the state is significant. The 211 very low



birthweight babies born in 1987 as a result of deteriorating prenatal care cost the state approximately $8,440,000. The total



cost of healthy births would have been only $1,293,000 for a net savings of $7,147,000. Dr. Patricia Nolan, the former Medical Director for AHCCCS, testified that the entire qHCCCS eligibility process is complicated and unfriendly, and has been designed to keep people off of AHCCCS. Robert Gomez, the Executive Director of El Rio Health Center, found that it took on the average 43 days for women seen at his clinic to complete the AHCCCS eligibility and enrollment process. Public information about eligibility and enrollment is not well-targeted to the women who are in need of care. Of Arizona's fifteen counties, ten had areas, both urban and



rural, designated as primary care health personnel shortage areas. Within these ten counties, thirty-one communities were In



identified as shortage areas for primary care physicians.



1987, twelve communities had no physicians within a thirty minute

3



In Arizona, Hispanic women are 3 5 times more likely to . receive no prenatal care than are white women. Even when Hispanic women are enrolled early and continuously with AHCCCS, they are less likely to receive adequate prenatal care than are white nonHispanic AHCCCS enrolled women. Language and cultural differences are barriers to care for Hispanic women. There is often a wide socioeconomic, cultural, and educational gap between low-income pregnant women and their providers. Providers are not educated about cultural differences that affect prenatal care. Native American women face cultural and language barriers to care as do Hispanic women. Only 60% of Native aerican women in



Pima County received care during their first trimester, while 75% of white women in Pima County received early care. Native



American women were 2.7 times more likely to receive no prenatal care than were white women. Teenagers 15 to 17 years old are twice as likely to receive no prenatal care than are women between the ages of 20 to 34. The frequency of teen pregnancy in Arizona is increasing rapidly. Between 1985 and 1990 there was a 22% increase in the number of births to teenagers. in births to teens. Santa Cruz County saw an increase of 103% Most alarming is the increase in births to Between 1985 and 1990 there was an 63% of these births



.women younger than 15 years.



increase of 67% (110 births to 184 births). were to teens in Maricopa County.



The chance of a teen having a



low birthweight baby is 25% greater than the chance of an adult having a low birthweight baby. Teens lack knowledge of the need 5



for prenatal care. Local school board policies and practices may also discourage teens from remaining in school during their pregnancy. A targeted case management program designed around the unique needs of the high risk group is essential. unintended pregnancies are directly related to late entry into prenatal care. ~ a m i l yplanning counseling and services play an integral part in reducing unintended pregnancies and the resultant low birth weight babies. In 1987, the National Association for Perinatal Addiction Research and Education estimated that 11% of all babies born nationwide have been exposed to illicit drugs at the time of birth.

A 1990 study issued by the U.S.



General Accounting Office



found that 16% of all newborns born nationwide are substanceexposed. Exposure to alcohol prenatally is also a serious problem. The Arizona Department of Health Services estimated



that 1,343 women who delivered babies in 1991 in Arizona used alcohol during pregnancy. With comprehensive treatment programs designed specifically for women and their families these women and their babies can be helped. Current ADHS statistics show that 29% of all drug



abusers are female, yet only 11% of residential treatment center beds are taken by women and very few are available to pregnant women. ~f a substance abuse problem is not dealt with during pregnancy, a woman may not be able to properly care for her 6



children.



Many drug-exposed babies are developmentally



delayed. Others have serious ch'ronic medical problems. Throughout all of the committee hearings and subcommittee meetings much concern was expressed about the lack of education regarding the necessity of prenatal care. Every subcommittee Lack of



found educational deficits in the current system.



knowledge of the need for prenatal care was found to be the most prevalent barrier to care. The Subcommittee on Education was



charged with developing a plan to increase awareness of 1) the symptoms of pregnancy and the necessity for prenatal care, 2) how to access the AHCCCS system and 3) the availability of care. Among the recommendations necessary to eliminate the barriers to prenatal care the Committee proposes the following: Sim~lifvthe AHCCCS Eliuibilitv and Enrollment Process. Jncrease AHCCCS eliaibilitv income level to 185% of the povertv level. tablish a slidinu scale proaram for women whose Jncome is below 250% of the federal wovertv level. Increase output of primarv care uhvsicians, OB/GYNS, nurses and other maternitv care uroviders. Increase incentives to existina and future ~rovidersto ort continued uractice in ruralhnderserved areas. Assure that women in special taruet po~ulations receive Case manauement services that are responsive to the yomen's individual needs. Provide suecialized education on the imuortance of receivina ren natal care to the various suecial p 0~ulationurouus. Reauire the Deuartment of Education to develop policies that ensure that all barriers to continued education for preunant teens are eliminated.

7



Require the state funded medical educational institutions to include in their curriculum courses on the cultural differences of the ~ o ~ u l a t i o nserved. s Increase state fundina for familv ~ l a n n i n q services. Increase fundina for residential druq and alcohol treatment. Fund an Intensive Case Manaqement Svstem



.



"The willingness to protect children is a moral litmus test of any decent and compassionate society. It is also a test of the common sense of any nation seeking to preserve itself and its future



.



Marion Wright Edelman In June 1991 Governor Symington signed into law House Bill

2424 which created this committee to study the barriers that



prevent women from receiving prenatal care; the degree to which current prenatal care services are used; the underserved populations; and the problems women face in establishing eligibility for AHCCCS. This report represents the findings of



the Committee and its recommendations for action by the legislature, state administrative agencies, local communities and the private sector.



Prenatal Health Care in the United States

Early, continuous, and adequate prenatal care can prevent low birthweight and can help to decrease infant and maternal mortality. The National GovernorsE Association report on prenatal care found that women who do not receive adequate prenatal care are twice as likely to have low birthweight babies than are women who do receive adequate prenatal care.' Further, a recent study



conducted by the U.S. Department of Health and Human services found that almost 80% of all women at risk of having a low birthweight baby can be identified during the first prenatal



'. Hill, peachins Women Who Need Prenatal Care, Washington, I : National Governor's Association, 1988, p. 2 citing old & a . 1987. l,

D.C.

9



visit.*



Once this risk is identified, action can be taken that



will substantially improve the chances of a healthy birth. The Children's Health of America's Defense Fund's 1991 report entitled



Children, found that the leading cause of



infant mortality is low birthweight, meaning birthweight of less than 5.5 pounds. In 1988 over 270,000 newborn Americans were In the same



born either prematurely or at a low birthweight.



year, 38,910 babies died before they turned one year of age, and approximately 60% of those deaths were attributed to problems arising from low birthweighta3 The Southern Regional Task Force on Infant Mortality concluded that low birthweight babies are forty times more likely to die during their first month of life than are babies who weigh more. This is due in part to the fact



that these babies are born with premature and underdeveloped lungs, livers, and immune systems. entirely escape this higher risk. Low birthkeight babies never Those who do survive are twice



as likely to suffer one or more disabilities during their lifetime than are normal birthweight babies.& Despite advances in medical technology, the number of babies born at low birthweight is increasing. Between 1972 and 1984 the decreased,



percentage of low birthweight babies born in the U.S.



'. Clement, Speech on Prenatal Care: M December 1, 1988, p. 2.



The Arizona Condition,



3 ~ Rosenbaum, C. Layton, and J. Liu, The Health of America's . Children, Washington, D.C.: Children's Defense Fund, 1988, p. 2.



&I. w ill, p.3. 10

\



but between 1984 and 1988 the rate increased.' all live births were low birthweight.



In 1988, 6.9% of



UNICEF data shows that



between 1980 and 1988 the United States ranked twenty-eighth in the world in percentage of infants born at low birthweightO6 The U.S. fell behind countries such as Egypt, Iran, Romania, and the former Soviet Union and tied with Albania and ~ a r a g u a y . ~ Adequate prenatal care must begin early and include a sufficient number of visits throughout the pregnancy. The



standards set by the American Academy of Pediatrics and the American College of Obstetricians and Gynecologists provide that prenatal care entails 1) monitoring the health status of pregnant women, 2) providing information to foster optimal health and good dietary habits, and 3) providing appropriate psychological and social support.8 The Children's Defense Fund found that in 1988



less than 69% of all births were to women who received adequate prenatal care.' LOW income women fared the worst, and their



children experience infant mortality rates twice as high as other children." In 1988 barely 50% of African-American mothers et. al., The Health of Americafs Children, pp.



IS. Rosenbaum



7-8.

6~

7~



at p. 9. at p 9. . at p. 1. p. 2.



& 8



'd 1.



- at



'OS. Rosenbaum, D. Hughes. E. Butler, D Howard, Incantations . $n the Dark: Medicaid. Manaaed Care. and Maternitv Care. The Milbank Quarterly, Vol. 66, No. 4, 1988, p. 663 citing Eguobuono



11



received minimally adequate care and 13% of African-American babies were born at low birthweight." This is 2.32 times



greater than the percentage of white babies born at low birthweight, 5.6%. Black babies are 2.99 times more likely to be



born at a very low birthweight (less than 3.5 pounds) than are white children. The gap between black and white low birthweights



in 1988 was the widest it had been since the National Center for Health Statistics began reporting the data by race in 1969. 12.9% of teen mothers, a disproportionate number of whom are minorities, received late or no prenatal care.12 In response to the need for greater access to and availability of prenatal care, Congress enaoted several expansions to eligibility for the Medicaid program. States must



extend coverage to all pregnant women and infants with family incomes below 133% of the federal poverty level. States, at their option, may extend coverage to all pregnant women and infants with family incomes below 185% of the federal poverty level.13 One study estimates that of the 9 million uninsured women of childbearing age, two-thirds have family incomes below 250% of



and Starfield, 1982.



"s.

7-8.



Rosenbaum et. al., The Health of America8s Children, pp. 7-8.



'*a at pp.

1J& 3.



at'pp. 7-8.

12



the federal poverty level.14



If all fifty states were to take



full advantage of the Medicaid expansions, more than 500,000 additional pregnant women would be eligible for coverage each year.



the eligible population and 84%.18 In addition, a U.S. Accounting Office study cited by the National Governor's



General



Association found that only 36% of women participating in Medicaid received adequate prenatal care.19 Numerous



organizatiohs, including the National Governorst Association, the

U.S. Conference of Mayors, the General Accounting Office, and



others have conducted studies to identify what barriers exist to participation in prenatal care programs. They have all The lack of



identified substantially the same problems.



financial access to care is regarded as the primary barrier.20 Other barriers listed by the National Governorst Association include difficulty in finding a provider, lack of information about Medicaid eligibility, lack of transportation to health care facilities, shortage of information on how and where to receive care, inconvenient clinic hours, inability to leave work, lack of child care for other children, lehgthy delays in getting appointments, inability to speak English, and fear of consequences such as deportation. Improved outreach and



education are an effective way to overcome these barriers. Outreach workers can help women who are unaware of their pregnancy, who fear doctors and/or medical procedures, who fear others learning of the pregnancy, who lack the knowledge of the



1



8



at ~ p. 4 .



importance of prenatal care and who do not know how to obtain Medicaid services. Improved outreach can improve awareness but barriers exist in the eligibility system even for women who know they are eligible and who seek prenatal care. The National Governors'

A S S O C ~ ~ ~ ~ O identified report ~



the following barriers.



Often



women must visit several different sites to fill out the eligibility paperwork and these sites are almost never the same sites that actually provide medical care. Once women have



reached the correct site they must negotiate very complex eligibility forms. The NGA report found that the average



application form for Medicaid is 14 pages, but the applications can be up to 40 pages." The eligibility forms require



extensive documentation and verification, most of which a woman is not likely to have with her when she applies. After the forms



are completed, the determination of eligibility can take almost two months, and the most common reason for denial of eligibility to participate in public benefits programs is that the applicant "did not comply with required procedures." The Center on Welfare



Policy and Law found that in 1984 one-third of the persons denied for procedural reasons were in fact eligible. 23 The United States Conference of Mayors conducted a survey to



21&



at p. 4 citing U.S.



G.A.O.,



1987 and Hughes et. al.,



1988.

A



at p. 5 citing Gold et. al., 1987.



- at



p. 7.

15



$2,900.



If a child was born prematurely with major complications



the cost skyrocketed to $12,000 and if the chiid is born extremely prematurely the cost further escalated to $27,000.25 Arizona specific data (See BUDGET IMPLICATIONS) indicates that current costs are at least double the 1987 costs. Neonatal intensive care is required for 6% of all Medicaid births, but the cost of neonatal intensive care constitutes 30% of all state ~edicaidmaternity expenditures.26 In 1986-87, the Off ice of



Technology Assessment found that the U.S. health care system saves between $14,000 and $30,000 in neonatal and long term care costs for every low birthweight birth which is averted by prenatal care." The Institute of Medicine of the National



Academy of sciences estimates that every dollar spent on comprehensive prenatal care saves $3.38.28 The Childrenrs infant

.



Defense Fund reported that the difference between the U.S.



mortality rate and the Japanese infant mortality rate costs the U. S. $7 billion annually in lost prod~ctivity.~~



The Status of Prenatal Health Care in Arizona

In 1988 in Arizona the percentage of infants born to women



2 5 ~ . Hill,

26&



p. 3 citing Gold et. al., 1987.



at p. 3 citing Kenney et. al., 1986. p. 3.



2 7 ~ . Clement,



2 8 ~ . Rosenbaum et. a1 , The Health of Americars Children, p. 9 citing Institute of Medicine, @'Preventing Low Birthweight, I@ ~ationalAcademy Press, Washington, D C : .. 1985.



.



July 12, 1992, p. 15.

17



.



DrAntonio, "Dying YoungR1' Los Anueles Times Mauazine,



receiving late or no prenatal care was among the worst of all states in the nation. prenatal care. 10.2% cf '~rizona r women received late or no



Only New Mexico, Texas, and the District of



Columbia were worse.30 In 1987, 66.8 of every 1000 women in the

U.S. and 89.5 of every 1000 women in Arizona received fewer than



five prenatal visits.31 In 1988, 31% of all pregnant women in Arizona did not receive care in the first trimester.32 62.9 babies out of every 1000 live births were born at low birthweight." The Arizona infant mortality rate was 9.7 deaths Approximately 60% of all infants who



per 1000 live births.%



died in Arizona in 1987 were low birthweight The Arizona Department of Health Services recently completed

l



a study of prenatal care rates in Maricopa and Pima counties for

1982, 1986 and 1989. These two counties account for 77% of the Arizona births with Maricopa accounting for 60% and Pima for 17%. There was a marked increase in women receiving inadeauate prenatal care between 1982 (the best year for prenatal care for which data is available) and 1989. In Phoenix there was a 147%



3 0 ~ . Rosenbaum,



The Health of America's



Children, p. 32..



31~abies Business: A Healthv Bottom Line, Greater Phoenix and Affordable Health Care Foundation, 1990, p. 6, citing Children's Defense Fund.

3 2 &



at p. 5 citing Children's



Defense Fund.



"pima County Community Health Committee, Pima Countv Communitv Health Plan for the Year 2000. 1991, p. 65.

3 4



at ~p. 65;



35~abies and Business:



A Healthv Bottom Line, .p. 6.

18



0



increase in the percentage of women who had less than 5 prenatal visits and a 277% increase in the percentage who entered care in the third trimester or who had no care at all. In Pima county



there was a 25% increase in the number of women who received less than 5 visits and a 16% increase in the number beginning care in the third trimester. The prenatal care rates in Pima County in



1982, the base year, were much worse than Maricopa County and therefore the decline was not as dramatic. Further analysis showed that the decline in prenatal care rates was not uniform throughout Maricopa County, but was much more marked in the inner city area of Phoenix and other high poverty areas. The number of Hispanic women receiving inadequate



care increased by 86%; the number of Black women increased by 124%; and the number of white women receiving inadequate care increased by 62%.% In 1989 Arizona birth certificates for the first time included information on the payor of care. Jane Pearson, the



program director for Maternal and child Health for the Office of Women and children's Health for the Arizona Department of Health



~ervices,told the committee on November 19,1991 that AHCCCS women on average received 3.5 fewer prenatal visits than privately insured women.37 The strongest statistical



36Arizona Department of Health Services, "Prenatal Care Reporttt DRAFT, malvsis of 1982. 1986. 1989 Birth Certificate Data for plaricopa and Pima Counties, July 24, 1991

,



37~ationally babies born to Medicaid women are not as healthy as babies born to poor uninsured women. S. Rosenbaun, et.al., ~ncantations in the Dark: Medicaid. Manaaed Care, and Maternitv 19



I



correlation for women who received less than 5 prenatal visits were AHCCCS enrolled, late entry into care, unmarried, Hispanic, and education below the 9th grade.38 The Arizona Department of Health Services (ADHS) operates the Newborn Intensive Care Program (NICP) which provides care for high-risk babies. Currently, 4% of all Arizona births or 3000 57% of all babies Low birthweight is



infants, are enrolled in the ADHS program. enrolled in NICP are low birthweight babies.



a more common reason for NICP admission among African-American infants. In fiscal year 1987, 76% of African-American NICP



infants were low birthweight babies.39 In 1990, one-third of all babies born in Pima County were born to mothers who received inadequate prenatal care.40 Only 67% of mothers received prenatal care during their first trimestere4' Only 64% visited a provider at least nine times during pregnancy, which is considered to be the optimal number of visits necessary for adequate care. 42 The Pima County statistics confirmed what the Department of Care, p 661 citing Utah Health Department 1987 and Oregon Health Dept. 1985 unpublished data. 3 8 ~ nnPrenatal ~~~, Care Reportw DRAFT



3 9 ~ e ~ o rof the Hiah Risk Perinatal Task Force, Arizona t Perinatal Trust and Arizona Department of Health Services, November, 1990, p 4. .

'. O H Strich, producer, Maternal & Infant Health Status, Pima County Health Department, 1992.

I



41. 'd

4 2 ~



20



Health Services Draft report showed, that the health status of mothers and children in Arizona is worsening. In 1987 Pima



County had a low birthweight rate of 63.6 per 1000 births (6.4%). This rate was higher than any rate reported in the previous ten years." Furthermore, the infant mortality rate in Pima County



rose from 8.1 deaths per 1000 live births in 1980 to 9.3 deaths per 1000 live births in 1988



-



an increase of almost 15%.&



In October 1982 Arizona implemented on a demonstration basis a Medicaid program, known as the Arizona Health Care Cost Containment System (AHCCCS). Prior to the implementation of



AHCCCS, the individual Arizona counties provided medical care to indigents. There was no uniform definition of eligibility, and



most counties did not recognize pregnancy as a condition rendering someone eligible. Some prenatal services were provided



through various grant programs including Title V of the Maternal and Child Health Care Block Grant program. According to WIC and Title V statistics, in 1981 Arizona was the worst among all 50 states in the provision of prenatal care.45 Although significantly more women are eligible for prenatal care services under AHCCCS than under the county programs, since 1982 the status of maternal and child health care in Arizona has worsened. The low birthweight rate



had been steadily declining

If



from 1970 to 1981.



Since 1982 it has been on the increase.



43~ima County Prenatal Care Initiative Attachment 1 p 1.

&~d, 1. at p.

4 5 ~ . Clement,



p. 5.

21



Arizona had maintained the same level of prenatal care and the same low birthweight rate it had in 1981, at least 211 very low birthweight births Would have been prevented in 1987 alone.& Seventy infant deaths could have been prevented. 47 In addition to the cost in human life and health, the financial cost to the state is significant. The 211 very low



birthweigh* babies born in 1987 as a result of deteriorating prenatal care cost the state approximately $8,440,000.~~The total cost of healthy births would have been $1,293,000 for a net savings of $7,147,000. 49 clearly, the provision of



comprehensive prenatal care is very cost effective and the potential savings to the state is great. The Pima County study found that the Pima County women who are least likely to receive adequate prenatal care are those Women enrolled in AHCCCS were more likely to using AHCCCS.~~ give birth to low birthweight babies and have more premature deliveries. Furthermore, AHCCCS enrolled women were more likely



to smoke and drink during pregnancy than were privately insured women. 5 1 The committee heard testimony from several of the major



461d. p. 8. at

4 7



at~ p 8. .



481d. p* 10. at

491d. at p. 10. sostrich,Maternal & Infant Health Status, 1992.



22



AHCCCS health plans. Joe Anderson of Arizona Physician's



IPA



stated that 30% of the women who delivered babies through AP/IPA enrolled in the plan for the first time at delivery. Kathy



Byrne, CEO of Mercy Care reported similar statistics for her plan. The infant mortality rate il Arizona has not risen at the r same rate as the increase in low birthweight babies and the decline in prenatal care rates. This is due in large part to the advances in medical technology for the care of sick newborns. significant expense doctors can now save very small and sick infants.52 The relatively steady infant mortality rate is not a reflection of improved public health, but of the availability of very expensive medical technology. At



e Goals of this Committee

The importance and necessity of prenatal care has been studied extensively. It is incontrovertible that early and



adequate prenatal health care is crucial for the health of our women and children. It saves lives and money.



The committee identified the particular problem areas for women needing care as 1) eligibility and enrollment in the AHCCCS program, 2) the needs of special populations / teens, minority groups, and substance abusing pregnant women, 3 ) the availability throughout the state of health care providers and 4) education of women and the entire community on the need for and availability of prenatal health care.

52~.



A subcommittee was formed to address



Clement, p. 8.

23



each of these problems and each subcommittee reported its findings and recommendations back to the whole committee. The recommeridations constitute a comprehensive scheme to improve the health status of women and children which the committee suggests be implemented incrementally as the state budget allows.

AHCCCS



ELIGIBILITY AND ENROLLMENT



Introduction

AHCCCS is Arizonafs indigent medical care program. It is a combined federal Medicaid and state/county funded program. It



pays for approximately 40% of the births in ~lcizona.'~ Although ~edicaideligibility has expanded significantly over the past several years, more AHCCCS eligible women than ever are receiving inadequate prenatal care or no care at all. In studying the



barriers to prenatal care in the eligibility system, the subcommittee found that the problems were not unlike the problems women face in other states.



Barriers to Medicaid Eliuibilitv Nationallv

Studies done nationally of the Medicaid application process found that the application and verification process is extremely complex.54 Women are deterred from applying at the onset of pregnancy because of the bureaucratic and logistical hurdles.



53~estimonyof Patricia Nolan, former Medical Director of AHCCCS, before committee 11-19-91.

5 4 ~ . Shuptrine and V. Grant, Studv of the AFDC / Medicaid Eliaibilitv Process in the Southern States, Report for the Southern Regional Project on Infant Mortality, Sponsored by the Southern Governorst Association and the Southern Legislative Conference, April, 1988, p. 1.



24



They wait to apply until delivery when they can delay care no longer. This defeats all efforts to provide adequate and preventive prenatal care designed to decrease the number of sick, low birthweight babies."



A comprehensive study performed by the Southern Regional

project on Infant Mortality in 1987 looked at eligibility in 17 states for a period of one year.

1 million people denied AFDC



It concluded that of the



/ Medicaid assistance, sixty-three

"failure to comply



percent were denied due to the applicant's with procedural requirements. ltS6



The study also concluded that In the United



this result was not unique to the southern states.



States in the 1985-86 fiscal year, 60% of all AFDC / Medicaid eligibility denials were due to "failure to compLy with procedural



requirement^.^^



In addition, since 1980 the number



of applications denied for "failure to comply with procedural requirementsw has increased by 75%.58 In the past, the federal income and resource limitations for Medicaid were often the same as those for welfare assistance. The resource limitations had not been adjusted since 1979. income limitations were often far below the federal poverty level. In 1986 Congress enacted changes to Medicaid eligibility for

5 5



The



at ~p. 1. at p. 1.



5 6 &



5

5



7

8



at ~p 2. . at ~p. 2.

25



pregnant women which allowed states to 1) raise eligibility to 100 percent of the poverty level, 2) guarantee continuous eligibility 60 days postpartum, 3) allow for presumptive eligibility, and 4) eliminate the resources testOs9 In 1987 Congress further expanded Medicaid, giving states the option to extend eligibility for pregnant women to 185% of the poverty level.60 Ln 1990, Congress mandated eligibility up to 133% of



poverty, mandated continuous coverage for pregnant women throughout their pregnancy regardless of changes in income, expanded the presumptive eligibility provision, allowed for continuous eligibility for infants to age one, mandated expansion of coverage of poor children, and mandated outstationing of eligibility workers at specific locations that provide care to indigent pregnant womenO6' States that have fully implemented the changes have seen improvement in the health status of mothers and children. The Georgia Hospital Association commissioned a colnprehensive study to assess the Medicaid eligibility process and provide recommendations for improvement. The report The



illustrates the complexity of the application process.



documentation and verification required is extensive, and the applicants usually receive little or no help filling out the

59 60



Omnibus Budget Reconciliation Act of 1986 (OBRA-86) Omnibus Budget Reconciliation Act of 1987 (OBRA-87). Omnibus Budget Reconciliation Act of 1990 (OBRA-90); 42 8 1396a(1).

26



6 '



U.S.C.



I



forms.62 The Alan Guttmacher Institute found that applications are normally between 4 and 40 pages long, with an average length of 14 pages." Arizona's application is 12 pages long. In



order to successfully apply for benefits a person must a) be able to read, write, and understand complicated instructions, b) have transportation to the offices/agencies involved, c) have access to a telephone and copying machine, d) have money to pay for documents, copies, transportation and certain initial medical tests, and e) the ability to devote daytime hours to obtaining documents, filling out forms, and attending eligibility interviewsOM These burdens are considerable when one realizes that the population seeking eligibility is not highly educated and of very low income. The Georgia study found that three-fourths of those denied for procedural reasons had not yet reapplied for benefits at the time of the study interview.

31.6% stated they would not reapply



because of discouragement with the application process.



Among



women who were denied for failing to return a verification document the reason most frequently cited was that they did not



6 2 ~ . Shuptrine and V. Grant, Assessment of the Medicaid ~liaibilitv Process in Chatham Countv. Georaia, Report for the ~emorialMedical Center, June 1991, p. 1



63~rown,editor; Prenatal Care: Reachina Mothers. Reachin Infants; committee to Study Outreach to Prenatal Care, Division : o Health Promotion and Diseases Prevention, Institute of Medicine, washington, D C : ~ational .. Academy P r e ~ s ,1988 p. 72.



&s. Shuptrine, Assessment of the Medicaid Eliaibilitv Process in Chatham Countv, Georsia. p. 7,

27



eligibility workers who handle Medicaid applications process applications for the Aid to.Families with Dependent Children (AFDC) and the Food Stamp programs for which sanctions still exist. Eligibility for pregnant woman coverage is much simpler than the other federal benefits programs, but often women must needlessly fill out more complex forms because states including Arizona have not created applications for women who are seeking only pregnancy services. Barriers to AHCCCS Eliuibility Dr. Patricia Nolan, the former Medical Director for AHCCCS, testified that the entire AHCCCS eligibility process is complicated and unfriendly, and has been designed to keep people off of AHCCCS



.

About 38% of the AHCCCS eligible



There are three major AHCCCS eligibility categories that apply to pregnant women.



pregnant women receive Aid to Families with Dependent Children and are automatically eligible for AHCCCS as a result. Their care is funded 68% with federal dollars and 32% with state match. an AFDC eligible woman loses AFDC eligibility during her pregnancy federal law requires that she be evaluated for eligibility under the other federally funded categories. The If



committee heard from advocates and providers that pregnant women are regularly being terminated from AFDC and AHCCCS even though they continued to qualify, causing disruption in their care. The 70~estimony Dr. Patricia Nolan, 11-19-91. of

29



other major federally funded category is referred to as SOBRA, which stands for the Sixth Omnibus Budget Reconciliation Act of 1990, SOBRA expanded eligibility for Medicaid coverage for



pregnant women and infants to 133% of poverty and allowed states to expand eligibility up to 185% of poverty. Arizona has opted



to cover women up to 140% of poverty under this category. Approximately 52% of the AHCCCS births are in this category. The third category is the Medically Needyfledically Indigent, which covers 9.7% of the AHCCCS births. state and county dollars only. Both the Department of Economic Security (DES) and the 15 Arizona counties do AHCCCS eligibility determinations for pregnant women. DES does the eligibility for the federal This category is funded with



categories. The counties do eligibility for the state only funded

-) category ( 1 .



In addition, for the federal categories, the



counties do the initial interviews, verify eligibility and refer the cases to DES for final determination. This system is not



only confusing to the woman, but it is costly for the state. The Joint Legislative Budget Committee staff estimate that about 4% of the MN/MI eligible women are actually eligible for SOBRA and a greater percent might be eligible for AFDC if they were to apply. Shifting these women to the federal categories allows the state to seek federal reimbursement for 68% of the cost of their care. Secondly, there is duplication in the process. There are two eligibility workers processing each case and duplication of paper work,

30



Eligibility for the SOBRA category has been greatly simplified by federal law and can take from 1-15 days to complete. However, eligibility for the MN/MI state funded



program and the AFDC program is very complicated and requires extensive documentation. Robert Gomez, the Executive ~irectorof



El Rio Health Center, studied the time it took for women seen at his clinic to complete the AHCCCS eligibility and enrollment process. 43 days. For the first six months of 1991 the average time was LeAnn Thrapp, a nurse with Indian Community Health



Services, reported that even with the assistance of their advocates the average time it took for their clients to be enrolled was 34 days. The subcommittee found that Arizona women face heavy verification requirements, as do women across the country. In



addition to financial eligibility, women must prove they are pregnant before they can receive care and in some areas of the state it is difficult to obtain free pregnancy testing. Transportation to eligibility offices is a problem for women everywhere due to the limited public transportation system in urban areas and inaccessibility of eligibility offices in the rural areas. In some areas of the state, bilifigual staff are not available to interview non-English speaking women. It is



difficult to recruit bilingual staff because of poor compensation rates. The Arizona Department of Administration does not yet



recognize that being bilingual is a skill that requires 31



additional compensation.



Written information is in formal



textbook vocabulary and not the language understood by the women receiving the information. Even English speaking women have difficulty understanding written eligibility material since it is written at such a high literacy level. The literacy level of the AHCCCS population is



low, and the information is so complicated that even educated people have trouble understanding it. In addition, some women fear the eligibility process because they know that DES will attempt to establish paternity and collect child support from the fathers of their babies. of the witnesses testified that their patients fear the consequences of identifying the fathers of their children. DES Many



can waive this requirement in some cases, but most women are unaware of this possibility, One advocate testified that a pregnant teen who came to her clinic in the last month of her pregnancy thought that if she waited until late in the pregnancy, the father, who is also a teen, would have to pay less. Some



women fear that the eligibility office will refer them to Child Protective Services because of their drug and alcohol use or because they are homeless. Although the majority of the population lives in either the Phoenix metropolitan area or in the Tucson metropolitan area, the rural areas of the state tend to be very rural in nature. is especially true of many of the Indian reservations. service in some of these areas is unreliable. This



Mail



An applicant must

32



respond within ten days to a letter from the eligibility office or else her application will be denied. If she does not get her



mail within ten days or she cannot read the letter, she will miss the deadline and will have to start all over again. Women who



live in urban areas face similar problems, since they often do not have telephones and/or move freq~ently.~' This makes continuing contact with the eligibility offices very difficult. If the eligibility process cannot be completed in one visit to the eligibility office the chances of denial go up. Once a women has been found eligible for AHCCCS she must enroll in one of the AHCCCS health plans to receive care. If she



is eligible under the AFDC or SOBRA categories, she has a right to choose her health plan. plan. AHCCCS allows 14 days to chose a



If she does not receive her enrollment notice or if she is



unable to go into an AHCCCS enrollment office, she is autoassigned to a health plan according to her zip code. Once she



picks a plan or is assigned she is not actually enrolled with the plan for three more days. The entire enrollment process can take as long as three weeks." Although in theory a doctor will be



paid for services provided during this period, as a practical matter most doctors will not treat a women unless she has been' enrolled in the health plan the doctor contracts with. Many witnesses testified about problems with the enrollment



7 1 information confirmed that from 13016% of the eligible ~ ~ ~ population may move in a month.



72~estimony Dr. Nolan, 11-19-91. of 33



be reasonable in the request for documentation. However, the burden of proof that a plan chanae is pecessarv rests with the memberls ~hvsician. Some health plans do not permit a woman to change primary care physicians within the same health plan in order to stay with a doctor of her ~ h o i c e . ~ If transportation is a problem and the location of the AHCCCS-assigned provider is not convenient to the patient, it is unclear whether the new policy will permit a woman to change to a more convenient provider. Although the health plans are



responsible for providing transportation to medical appointments, the committee heard that compliance varied among the plans. Gloria Vaca, a nurse practitioner with Clinica Adelante, a community health center that serves migrant farmworkers, testified that her clients must often travel one to two hours to get to a health care appointment. She reported incidents where



women were transported to their appointments one hour from their homes and no one returned to take them home. Her clients chose



instead to wait for the nurse practitioner to come from Clinic Adelante once a month rather than rely on the health plans1 transportation. Nationally, the U.S. Government Accounting



office (GAO) found that distance to providers and lack of adequate public transportation created barriers to prenatal care in many rural areas around the country.

74



n~estimony of Sylvia Stock before committee, 11-19-91.

74 Brown, editor; Prenatal Care : Infants, p 73 .



Reachins Mothers. Reachinq

35



(county clinics and community health centers) provide care. These public providers are often conveniently located. If the



is not as attractive as the full AHCCCS prenatal care payment. Some health plans will pay conveniently located public providers to care for their pregnant patients, but some will not.



A number of the AHCCCS health plans reported on efforts to

reach out to their members who are pregnant. The health plans



know that SOBRA women are pregnant because she must be pregnant to qualify under SOBRA. their outreach. They can identify these women and focus



There is no similar indicator for AFDC or M N P I



women. This makes it difficult for the health plans to identify pregnant women and get them into care early. In addition, many of the low income women served by AHCCCS need a combination of health care and social services. Some of



the health plans reported efforts to address the social as well as medical needs of their members, but as a practical matter, the AHCCCS HMO model is dependent on a private delivery system which does not contain the coordinated social services available from the public health delivery system. Public information about eligibility and enrollment is not well-targeted to the women who are in need of care. Because the



process is very complicated, it is difficult to simplify the public information for dissemination. Because of the lack of



public information, women depend on word of mouth from their neighbors and often believe (wrongly) that they are not eligible for care. The subcommittee also identified attitudinal problems within the system. Some eligibility staff have a "keep outr1attitude

37



which discourages pregnant women from utilizing the program. This is demonstrated both by attitudes conveyed personally at the various offices and by telephone contact. For example, some



women complain that they have trouble calling offices and getting through ta their workers. Many of these problems with the



eligibility and enrollment process can be solved by making adjustments to the current system. If eligibility and enrollment procedures are simplified and tailored ts the needs of the women using the system, the increased access to prenatal care will result in healthier mothers and healthier babies and less money spent by the state on costly life-saving measures for ill, low birthweight infants.



RECOWEIENDATIONS

The committee recommends that the following measures be taken to simplify the eligibility and enrollment process. The



committee is very aware of the current financial situation of the state, and suggests that the steps which require additional state dollars be implemented incrementally as the state budget allows. CCCS Eliaibilitv and Enrollment

1 .



Sim~lifvthe Eliaibilit~Process Use a short, simple application. Simplify the MN/MI eligibility rules to follow the federal rules. (except for citizenship). Require all notices and information about eligibility to be written at a fifth grade reading level. 76



76 Project SLIM made similar recommendations for the Department of Economic Security processing of all assistance applications.



38



~llow women to apply for AHCCCS at WIC sites, hospitals, doctors8 offices, county clinics, family planning clinics, Head Start offices, and IHS and tribal sites. Allow the staff of the sites to assist with the application, conduct the interview, and collect the documentation necessary to verify eligibility. Allow mail-in applications and interviews by telephone. Eliminate the requirement of face to face interviews. Require applications to be processed within five days. Combine eligibility for WIC and AHCCCS. Implement incentives that encourage eligibility workers to assist applicants with the documentation and verification process. Colocate county and DES eligibility offices. DEFER TO LEGISLATIVE COMMITTEE STUDYING ELIGIBILITY 2 . ~lifv the Enrollment Process Allow women to enroll at eligibility. Allow all women to choose their providers. Allow for automatic plan changes for pregnant women. Allow enrollment by mail or by telephone. Allow enrollment at doctors8 offices, WIC sites, community health centers, and tribal health clinics.

3.



Increase eliaibilitv income level to 185% of the ~overtvl e v e ~ . ~



"(Twenty-four states have increased eligibility levels to 185% of poverty and california , Massachusetts and Vermont cover pregnant women with incomes up to 200% of the federal poverty level, using state funds to cover those above Medicaid eligibility thresholds.) National Governors' Association, Gainins Ground: State Initiatives for P ~ ~ c f ~ Women and Children. Washington D.c., 1992, p. 3. ~ant 39



4.



Jldvertise aaaressivelv the availabilitv of prenatal care throuah AHCCCS. Target high risk areas for outreach and education. Studv whv 30% of women enroll for the first time at,deliverv. Provide fundina for trans~ortationand child care durina the eliaibilitv Drocess. Establish a slidina scale Droaram for womeq qshose income is below 250% of the federal povertv level,



5 .

6.

7.



Justification

The Marvland Proaram The state of Maryland has incrementally elevated the eligibility level to 185% of the poverty level, dropped the assets test, adopted continuous eligibility, and implemented presumptive eligibility in all health departments and community health centers. onto WIC. The state has also made efforts to get women



It made it possible for women to become presumptively



eligible in hospital outpatient departments where many women were going to receive care. Maryland's program is comprehensive in



that it provides case management, health education, nutritional counseling, psychological counseling, home visits, and outpatient drug treatment, all of which are now covered by Medicaid. Maryland incorporated fee increases into the Medicaid fee structure, hired public health nurses to do one-on-one physician recruitment, and initiated an aggressive public information campaign which was coordinated with Blue Cross/Blue



78&



at p.' 6.

40



The Maryland program has had very successful results.



A



U.S. Government Accounting Office study concluded that Maryland



has succeeded in enrolling nearly 100% of the low income pregnant women estimated to be eligible for Medicaid. The Vermont Proaraq Vermont has also increased the eligibility limit to 185% of poverty and has taken several other actions to simplify the eligibility and enrollment process. The Department of Social



Welfare (which administers Medicaid) has collaborated with the Department of Health (which administers WIC) to develop a unified approach to increasing the enrollment in both programs. The



agencies developed a three pronged strategy in which they 1) developed a single page joint application form which can be accepted at either a WIC or a Medicaid eligibility site, 2) required an eligibility determination within ten days, and 3 ) initiated a mass media outreach program which especially targeted to teenagers.79 The Vermont approach has also been quite successful. The



number of low income women receiving prenatal care has increased from 1,245 in 1988 to 1,420 in 1990 to 1,704 in 1 9 9 1 . ~ ~ State officials believe that these statistics are indicative of the success of their policies.

AVAILABIUTY OF PROVIDERS



Statement of the Problew

7 9



at ~ p 7. .

. at p. 7



41



Initial testimony before the committee established that a significant barrier to receiving adequate prenatal care is the inability of women to locate health care practitioners in their community. As with eligibility and evrollment, the problems in

A report



Arizona mirror the problems of the entire nation.



issued in March, 1991 by the Center on Budget and Policy Priorities stated that in 1988, 62% of nonmetropolitan counties nationwide did not have an obstetrician/gynecologist serving the area. The report also cited the American College of



Obstetricians and Gynecologists, stating that in 1988, 22 states had large regions with no practicing ob~tetrician.~~ The American College of obstetricians and Gynecologists and the American Academy of Family Physicians report that many physician members of their organizations are decreasing the obstetrical ~ services they p r ~ v i d e .Other common factors are adversely affecting the availability of prenatal health care providers in nonmetropolitan and metropolitan areas as well, including increased premiums for malpractice insurance, low reimbursement rates from insurers, and growing numbers of women who cannot pay for maternity care



.=



The subcommittee reviewed the research done by the Rural



"L. Summer, Limited Access: Health Care for the Rural Poor, Washington, D C : .. Center on Budget and Policy Priorities, March 1991, p 16. .



m - at p. 17. ~d.



%d. at p. 17. '



42



Health Office at the university of Arizona.&



Of Arizona's



fifteen counties, ten had areas, both urban and rural, designated as primary care health personnel shortage areas. Within these



ten counties, thirty-one communities were identified as shortage areas for primary care



physician^.^^



In 1987, twelve



communities had no physicians within a thirty minute travel zone who were willing to deliver babies. Additionally, the federal



government has designated eleven Arizona counties as medically underserved areas. ~ccordingto Dr. Michael Clement, the OB/GYN



who used to visit Page to consult oh obstetrical care no longer does so. At one time in 1990 all the OB/GYN practitioners in Casa Grande had stopped providing care



."



Demonstrating the effect



of the shortage, the very low birthweight, low birthweight, and inadequate prenatal care rates at Casa Grande hospital at that time were consistently higher than state averages.87 in other areas are apparent as well. Problems



As of December, 1991, there



were 7-8 OB/GYNs providing care to the Yuma community, where



he most recent information available to the committee is from 1987. At that time in rural and underserved areas of Arizona there were 82 licensed physicians, 477 registered nurses, 12 certified nurse practitioners, and eight licensed physician assistants per 100,000 population. R. Gordon; Arizona Rural Health d provider Atlas, Rural Health office, I ,

" ~ t the present time two obstetricians and two general practice physicians provide care in Pinal County, although some women must travel 40 minutes one way to a provider. 87pe~ort of the Hiah Risk Perinatal Task Force. Phoenix: Arizona Perinatal Trust and Arizona Department of Health Services, November 1990, p. 10. 43



there are 2400 births a year.a



In the Globemiami area, only



three doctors were providing obstetrical care for 450-500 yearly birthsgag Mohave County has noticeable problems as well. Kingman experiences 650 annual births, and many of these mothers must be referred to Lake Havasu or to Flagstaff for delivery.90 In 1988, Dr. Clement cited preliminary figures from a study being conducted by the University of Arizona Rural Health Office that indicated that 60% fewer practitioners were providing obstetrical care in rural Arizona than in 1982. The shortage of providers is



not limited to doctors, and includes nurse practitioners, nurse midwives and physician assistants. The State Board of Nursing



reports there are three to five open positions for every nurse practitioner certified by the state.91 The subcommittee found that these existing shortages will be exacerbated by additional factors. It is projected that many of



the physicians serving rural areas will be retiring in the near future, and without a satisfactory number of.new doctors replacing them the problem in the rural underserved areas will only worsen' The subcommittee further cited the high cost of



malpractice insurance and the lack of professional support for



=B. Attico and D. Meyer, Prenatal Care Services to Indian Women in Arizona. Presentation by the Phoenix Area Indian Health Service to the Arizona Legislature Study Committee on Services to Pregnant Women, December 1991, p. 12.

at p 13. .

9 0



at ~p. 13. The Arizona Condition,

44



"M. Clement, Speech on Prenatal Care: December 1, 1988, p. 11.



leave of absence as deterring providers from serving the underserved areas. In addition, the budget crisis in the state



may result in the state-supported schools being inadequately funded to accept and educate the needed recruits to address these shortages. Indian Health Services (IHS) provides care for Native American women, almost 7,000 of whom give birth each year in Arizona. IHS uses certified nurse midwives and obstetricians to IHS also uses a comprehensive system of



provide prenatal care.



community health nurses, whose job it is to make sure that pregnant women go to their appointments and are referred to other providers as is needed. In 1989, approximately 25 obstetricians The



who provided care through IHS chose not to serve any longer. general nursing shortage is also affecting IHS.



IHS is facing



great difficulty recruiting obstetricians and nurses to replace those leaving. This is partially because many assignments are in



very isolated areas and the pay is lower than in private practice, which makes IHS jobs less appealing.92 All three Arizona areas served by IHS have lower low birthweight rates than the national average. In addition, the



Navajo area has one of the lowest infant mortality rates in the nation."



his progress and success is in danger of being



reversed if the shortage of health care providers is not



9 2 ~ e ~ o r t the Hish Risk Perinatal Task Force, at p. 8. of

93~.



attic^, Prenatal Care Senices to .IndimWomen in Arizona.

45



p. 3 .

.



addressed.



These shortages come at a time when IHS has been



making progress in improving maternal and child health for their population.

RECO-ATIOM



of Providers Improving the distribution of primary care providers in underserved areas will require a systematic, community-based approach to recruitment, training, retention and utilization of providers. Recruitment and Traininq 1. Increase output of primary care physicians, OB/GYNs, nurses and other maternity care providers by one of the following two legislative proposals:



A.



Develop an advisory council consisting of representatives from Arizona Colleges and Universities, the Arizona Health Education Centers (AHECS) and other interested parties. The Advisory council will work together to develop implementation strategies and evaluation criteria for the following changes :

1)



Direct state-funded schools to increase recruitment of stqdents from rural and underserved areas. Require schools to increase the percentage of students whose training will focus on community/rural based care rather than the traditional hospital/urban based care to 30% of each medical student class, undergraduate and graduate nursing class, and social work class. ~pproximately 30% of the community/rural-based curriculum will be devoted to experience in multidisciplinary community centers or with other community based providers. Enhance existing community-based health facility and rural hospital rotation programs

46



2)



3)



for Arizona and out-of-state medical students, residents and non-physician practitioner students.

4)



Expand preceptor programs in underserved areas.



f)

2.



Establish a countywide or regional program that would allow employee s,haring from private/public agencies.



Coordinate existing services to develop community based health care plans including multi-disciplinary team members: Non-physician providers: NP, CNM, PA Physician Social Worker

48



Nurse (RN) ~ligibilityworker Health Educator Nutritionist Lay outreach worker

3.



Utilize a case management model to strengthen and streamline coordination of community based services, Utilize existing and developing mobile health care teams which provide services to rural/underserved areas in Arizona (i.e. Blue Cross/Blue Shield, DHS, March of Dimes).

SPECIAL POPULATIONS



4.



Introduction Barriers to prenatal care exist for women of all racial, ethnic, and age groups, however, testimony before the committee established that for some groups the barriers are greater. A



subcommittee studied these special populations to identify their special barriers and to develop targeted solutions. The



committee found that minority women, teens, homeless women, and women who used drugs and alcohol confronted unique barriers to receiving prenatal care. African-Americah Women Numerous studies reviewed by the Committee established that ~frican-Americanwomen consistently receive less care than women of all other races. The number of babies born at low birthweight among the African-American population is disproportionately high.% The studies conclude that non-financial barriers are



"3. Burks, l~Factors. the Utilization of Prenatal Services in by Low-Income Black Women," Nurse practitioner. Vol. 17 No. 4, April 1992, p 34. .

49



the main reasons black women receive inadequate care.



Lack of



awareness of the pregnancy and the need for prenatal care were found to be the most frequent reasons women delayed care.96 African-American women in Arizona are 2.3 times more likely to receive no prenatal care than are white womeneW The low birthweight rate among African-Americans in Arizona in 1988 was 139 infants per 1000 births." This is nearly 2.5 times the low (59 per 1000 births.) The



birthweight rate for white infants.



infant mortality rate among African-Americans is 17.9 infant deaths per 1000 live



birth^.^ This is approximately two times



the white infant mortality rate. Low birthweight rates for children born to black middle class women who received adequate prenatal care are greater than the rates of similarly situated white children. unsure of the cause. Researchers are



Clearly, the &isparate health outcomes for



black children require that special attention be paid to this population. A further risk factor affecting African-American women is that they are more likely than other racial groups to give birth as teenagers.



His~anicWron

9 6



at ~p 49.



v~abies and Business : Children's Defense Fund.



A Healthv Bottom Line.



p. 6 citing



9 8 & at p 6 citing Arizona Department of Health Services . statistics of September 10, 1990.



w ~ d .at p 7 citing Arizona Department of Health Services. .



-



50



In Arizona,- isp panic women are 3.5 times more likely to receive no prenatal care than are white women.loO In Pima



County, only 57% of Hispanic women received care during their first trime~ter.'~' The low birthweight rate among Hispanic women in Arizona is 83 infants per 1000 live births compared to 59 infants per 1000 live births for white childrenlo2 The Hispanic infant mortality rate is 9.9 infant deaths per 1000 live births compared to 9.4 for white infants. lo3 60% of Nationally only



is panic Women began prenatal care in the first trimester



compared to 82% of white women. 104 Testimony before the committee identified language and cultural differenoes as a barriers to care for Hispanic women. There are an inadequate number of Spanish speaking personnel at all points in the health care system. This includes the



eligibility offices, the AHCCCS enrollment sites, the health plans, and hospitals and doctorst offices. lo5 Most of the

I



published material received by ~panish-speaking women is written



lo04q,



at p 6 citing Childrents Defense Fund. .



101~trich, Baternal & Infant Health Status, 1992 "'~abies and Business: A Healthv Bottom Line, p. 6 citing Arizona Department of Health services.

l3 o&



at p. 7 citing Arizona Department of Health Services.



lMs. Rosenbaum, st. al., The Health of Americats Childreq, p.

7. 105~ationally, provider sites do not have a sufficient number of bilingual providers or interpreters. Brown, editor: Prenatal Care: Reachins Mothers. Reachins Infants, p. 76 51



in textbook Spanish that differs greatly from the language the women use and understand. Dr. Patricia Moore of the ASU College of Nursing studied the use of prenatal health services by Hispanic women enrolled in AHCCCS.'~~ Although previous studies have indicated that lack of health insurance and lack of a regular source of medical care are barriers, these factors account for only a small part of the variance.lo7 Hispanics comprise 18% of the state's population,



and account for 42.8% of all births financed by AHCCCS representing the largest single ethnic group served by AHCCCS.'~~ 43% of all births to Hispanic women were financed by AHCCCS lW The women studied were young, less educated and more likely to be single. They were more likely to have been enrolled in The The



.



AHCCCS when they became pregnant than non-Hispanic women. women were generally satisfied with the care they received.



major problems expressed were transportation, child care, waits for appointments, and excessive waits in the doctor's office.



lU~r. Moore's testimony was based on a study entitled Use of Perinatal Health Services bv Mexican-American Women Enrolled in for Public Health Practice, presented to the AHCCCS: ~m~lications American Public Health Association, November 11-15, 1991 in Atlanta, ~eorgia.

lo7p. Moore, Use of Perinatal Health Services bv Mexican-



practice, presented to the American Public Health Association, November 11-15, 1991 ip Atlanta, Georgia, p. 1.

lo8=



at p.2.



l& W



at pp.1,2.

52



The study found that only 41% of Hispanic mothers enrolled in AHCCCS received adequate prenatal care compared to 53% of the white non-Hispanic AHCCCS population; and twice as many received inadequate care.



'



lo



Dr. Moore found that the level of education of the mother had a direct bearing on the level of prenatal care. The higher



the education, the more likely it is that the mother will utilize prenatal care services."' Additionally, there was a



correlation between what the Hispanic culture taught women to believe about the need for care and the level of care they received. The study conclusively found that even when Hispanic women are enrolled early and continuously with AHCCCS, they are less likely to receive adequate prenatal care than are white non-



isp panic AHCCCS enrolled women. 'I2

There is often a wide socioeconomic, cultural, and educational gap between low-income pregnant women and their health care providers. This gap can lead to miscommunication and



misunderstanding, and result in lower quality care. Providers are not educated about cultural differences that affect prenatal care. For example, it is unacceptable among some



Hispanic populations to have a pelvic examination conducted by a



at p.7.

If'=



at p. 7.



l121d. at p.9. 53



man.lI3



Although pelvic examinations are a vital component of



adequate prenatal care, insensitivity to the cultural differences can result in women not attending later appointments.



Native American Women

Native American women face cultural and language barriers to care as do Hispanic women. Michael Slattery an administrator



with the Department of Economic Security, the agency responsible for eligibility, told the committee that his staff report that some Native American women will not discuss their pregnancy publicly, making it difficult to confirm eligibility. The Indian Health Service (IHS), a federally funded program, provides culturally sensitive care to many Native American women. provider. On some reservations IHS is the only health care



Women living on the reservations must travel great



distances to eligibility offices as well as provider sites. There are approximately 6,500 Indian births in Arizona each year, comprising almost 10% of all Arizona births.l14 The Phoenix



Area of IHS (which encompasses more than the metropolitan Phoenix area) has a particularly high birth rate of 37.2 per 1000 population. This rate is more than twice the national rate, and



to some extent is explained by the youth of the Phoenix Area IHS

' 5 population (median age is 20 years) .I



"3~rown, editor; Infants, p. 76.

'14~. Attico, Arizonq, p. 2.



Prenatal Care:



Reachins Mothers. Reachinq



Prenatal Care Services to Indian Women in



at p. 3 .

54



IHS has been successful in reducing the incidents of low birthweight. The low birthweight rates for all three IHS Areas The Phoenix Area has a rate



are lower than the national average.



of 6.1%, the Tucson Area a rate of 4 . 8 % , and'the Navajo Area has a rate of 5.5%. The U.S. average is 6.9%.'16



Low birthweight is not the exclusive indicator of adequate



prenatal care.



Native American women have other significant



health problems, including diabetes and high blood pressure, which adversely affect the health of their babies.l17 Despite



the relatively low rate of low birthweight babies statistics indicate that Native American women do not receive adequate prenatal care.

A study conducted by the Pima County Health



Department indicated that only 60% of Native American women in Pima County received care during their first trimester, while 75% of white women in Pima County received early care.l18 Children's The



Defense Fund found that in Arizona, Native American



women were 2.7 times more likely to receive no prenatal care than were white women. The infant mortality rate for Arizonals



Native American population is 9.9 deaths per 1000 live births, compared to the infant mortality rate for white children of 9.0



'I6=



at p. 3.



'17~abies and Business: A Healthv Bottom Line, p. 6 citing Arizona Department of Health Services. '18~trich,Maternal

&



Infant Health Status, 1992.

%



'19~abiesand Business: Children's Defense Fund.



A Healthv Bottom Line, p. 6 citing

55



deaths per 1000 births.'"



It is not known why the birthweight



of ~ a t i v eAmerican babies is not impacted as directly by prenatal care as the rest of the population. The Indian health care system is now facing challenges which jeopardize its ability to provide adequate prenatal care to the Native American population.

An increasing number of Native



Americans are moving to urban areas and IHS is only funded to provide care for Indians who live on or near a raservationl2l ~lthoughfunding is available for services to non reservation Indians, it is limited. The Phoenix Indian Medical Center (PIMC)



continues to be overloaded with patients. 122 The faoilities and staff are in such short supply that PIMC must refer 1/3 to 1/2 of its obstetrical patients to other facilities in the Phoenix area.'= PIMC facilities are sufficient to handle 800-900



births per year, but the actual workload is closer to 1500-2000 births per year. Further compounding the problem, recent information received by the committee from the Health Care Financing Administration indicates that IHS may lose 30 to 40% of its OB providers within the next year. Given the remote location of IHS facilities and



l

12'~.



Z



0



at p 7 citing Arizona Department of Health Services. ~ . Prenatal Care Services to Indian Women



Attico, Arizona. p. 4.

12 2&



in



at p. 4. at p. 6.



1



2



4



at p 7 ~..

56



the lower pay it will be difficult to replace these providers. Problems have existed in the past and continue to exist with integrating,the IHS system into the AHCCCS managed care system. Under federal law the IHS providers must be allowed to participate in the AHCCCS system. IHS is reimbursed on a fee for The other



service basis for its cost with 100% federal dollars.



AHCCCS plans are reimbursed on a capitated basis with 65% federal dollars and 35% state dollars. l Z 5 Dr. Burton Attico of IHS



reported to the committee that Native American women are not advised that they can chose IHS as their AHCCCS health plan and, as with most AHCCCS women, they are assigned to one of the other capitated health plans. The women continue to come to IHS



facilities for care and IHS does not turn them away, but it is not reimbursed by AHCCCS for the care. This situation further



exacerbates the IHS financial crisis and limits its ability to provide care to non-AHCCCS eligible women. Conflicts between IHS and AHCCCS regarding AHCCCS eligibility have also posed problems. Since IHS has a limited

,



budget, it has always asked indigent Indians to apply for state and county services and those who have insurance to seek private care. Native Americans continue to have problems with



eligibility for the state funded portion of AHCCCS because, in Dr. Atticots opinion, the AHCCCS eligibility offices operated by



the counties continue to refuse to allow the Native Americans to



12'&



at pp. 9-10.

57



apply and enroll. 126



Teen Mothers

'An increasing number of Arizona adolescents are becoming

pregnant and teens as a group do not receive adequate prenatal care. Many teens cite fear as a primary reason they don't They fear doctors, medical procedures, the seek



early care.



pregnancy itself and telling their parents about the pregnancy.12' Teens also have a greater tendency to deny Once they admit to themselves the fact that



their pregnancy.



they are pregnant, they still often conceal it from their parents.129 Out of 404 pregnant teens studied, one-half did not tell their parents they were pregnant for several months.130 The fear of admitting the pregnanoy necessarily leads to late or no prenatal care. Teenagers 15 to 17 years old are twice as



likely to receive no prenatal care than are women between the ages of 20 to 34.13' The chance of a teen having a low



birthweight baby is 25% greater than the chance of an adult having a low birthweight baby.13' at pp. 9-10.



lZ7s. Brown, editor Prenatal Care: Infants, p.78.

at p. 78.



Reachinu Mothers, Reachinq



In addition, teens lack knowledge of the need for prenatal care and the availability of family planning services. Local



school board policies may restrict what the schools can do to educate teens about the benefits of prenatal care. Local school board policies and practices may also discourage teens from remaining in school during their pregnancy. Some witnesses testified that these policies encourage teens to deny they are pregnant until late in the pregnancy in order to stay in school. Another significant reason teens don't receive adequate care



is that it is very likely that they are unmarried and therefore have less support throughout the pregnancy. Between 1980 and



1988 the number of unmarried women giving birth in Arizona increased almost 100%. Unmarried women are three times more



likely than married women to attend fewer than five prenatal visits. 133 The frequency of teen pregnancy in Arizona is increasing rapidly. Between 1985 and 1990 there was a 22% increase in the



number of births to



teenager^.'^^ Santa Cruz County saw an

Most alarming is the Between 1985



increase of 103% in births to teens. 13'



increase in births to women younger than 15 years.



and 1990 there was an increase of 67% (110 births to 184 births).



lf3;[;q,



at p. 6 citing Children's



Defense Fund,



laJSids Count Factbook: Arizonats Children 1992, Phoenix: The . Morrison Instjtute for Public Policy, 1992, p ix.

1 3 5



at p. ix ~ 59



63% of these births were to teens in Maricopa County.136



meless Women Homeless women comprise another group that receives inadequate prenatal care. It is difficult for health plans and



outreach workers to find these women because they dontt have permanent addresses and telephone numbers. Homeless women often dontt seek care because they fear that they might be referred to Child Protective Services and their other children might be taken away from them. The committee reviewed a study of homeless women in New York City and found that of those who gave birth between 1982 and 1984, 40% of the cityts homeless residents received no prenatal care at all compared to 9% of the overall p0pu1ation.l~~ Only

30% of the homeless women made 7 or more visits to providers of



prenatal care.



A separate portion of this report addresses the concerns of

women who use alcohol and drugs during pregnancy. Tarseted Case Manaaement A targeted case management program designed around the unique needs of the high risk group is the central theme of the



enough.'%



Law income women must be supported in their efforts



to meet basic needs such as housing, transportation, food, education, and health care.'39 Throughout the country the success of case management has been proven among high risk pregnant women.

See Justification: The North Carolina Targeted



Case Management Program. Case management entails the assessment of medical, social, educational, and emotional needs and the coordination of service delivery. One case manager is



responsible for the assessment and coordination of all of the client's needs. This case manager must develop a trusting



relationship with the clierlt for optimal effectiveness. This relationship must be based on a sensitivity to and a knowledge of the unique cultural, medical, and emotional needs of the population. Linda Parson, Director of the Phoenix Birthing



Project, explained that "[hlealth behaviors are culture bound, [and] primary prevention efforts that address preventable disease and illness must emerge from a knowledge of and a respect for the culture of the target community to ensure that both the community organization and development effort and any interventions that emerge are culturally sensitive and linguistically appropriate." The Department of Health Services operates two very successful case management programs, Health Start and Teen B.Guyer, fledicaid and Prenatal Care: Necessarv But Not sufficient. JAMA, 1990; 264:2264-2265. Editorial.

139 P. Buescher, M, Roth, D. Williams, and C. Goforth, & i Evaluation of the I m ~ a c t o f Maternitv Care Coordination on Medicaid Birth Outcomes in North Carolina, American Journal of Public Health, Vol. 81, No.12, December 1991, p.1629



61



Teen scDress The Teen Express program was funded by the legislature in 1989 to provide intensive outreach, early intervention and case management to increase the number of teens receiving early prenatal care. When a teen is identified she is enrolled in If potentially AHCCCS eligible she is If she is not AHCCCS eligible, and



prenatal care immediately. assisted with eligibility.



has income below 185% of poverty the program pays for her prenatal care.

62



first year of the baby's



life.



New mothers often need assistance



in learning parenting skills and learning how to cope with the stresses of motherhood. The goal of the case management approach



is to provide the support and training necessary for *he client to become self-reliant and a good parent. A vital component of case management is patient advocacy. These women are often uneducated. The lengthy and complex application forms are difficult to manage without assistance. ., Case managers assist women in completing the necessary paperwork and also with arrangements for transportation to eligibility appointments and securing necessary documents to verify eligibility. Patient advocacy services benefit the women, the state agencies, and health care providers since they help assure that eligibility is properly established early on, which ensures early and ongoing care. 140



Family Planninu Services

Unintended pregnancies are directly related to late entry into prenatal care.14' It is estimated over half of the



pregnancies in the United States are unintended.14* Family planning counseling and services play an integral part in reducing unintended pregnancies and the resultant low birth

140~. Attico, Prenatal Care Services to Arizona. pp. 16-17.



Indian Women



in



l 4 l ~ . Kotch, C. Blakely, S. Brown, F. Wong, editors; A Pound of prevention: The Case for Universal Maternitv Care in the U.S., American Public Health Association, 1992, p.132 citing Brown, et al; Prenatal Care: Reachina Mother. Reachina Infants, 1988.



142



Id.



at p. 132.

64



weight babies.

EECOMMBNDATIONS



Services to Special Po~ulations

1.



Assure that women in special taraet populations receive case manaaement services that are xes~onsiveto the women's individual needs. Provide incentives to the srivate sector to ~u~~ort and coordinate their efforts with the oraanizations alreadv providina services to hiah risk women. Expand fundina for case manaaement services ~rovidedby DHS and AHCCCS such as Health Start and Teen Express. Reauire that AHCCCS health plans contract with case manaaement oraanizations to ~rovideservices for their members. Implement the None-stop shop _pinam approach bv locatinq eliaib~litvoffices, enrollment offices. social service auencies and health care aaencies in close proximitv to one another.

.



2.

'



3.



4.



5.



..



6.



provide ssecialized education on the imsortance of receivina prenatal care to the various s~ecia& population uroups. Education programs must address special linguistic and cultural considerations, and education planners must be cognizant of each group's special needs. Increase public fundina for the ADHS public awareness campaiun which does taraet special population arouns. Advise Native American women that Indian Health Services is a choice of AHCCCS srovider. Fund transsortation.as a necessarv com~onentof health care.



7.

8 . 9.



Reauire the De~artmentof Education to develon policies that ensure that ala barriers to continued education for sreunant -,teensare eliminated. In cooperation with DHS, the Department of Education should develop model programs for use by interested local school districts which encourage pregnant teens to stay in school.

65



10.



Rewire the state funded medical educational institutions to include in their curriculum courses on the cultural differences of the ~orsulationsserved. Reauires AHCCCS and DHS to ex~loreall federal sources of fundina for familv ~lanninaservices. Increases state fundina for familv ~lanninaservices.



11. 12.



Justification The North Carolina Tarseted Case Manaaement Prosram The state of North Carolina has embarked on the most widereaching and ambitious prenatal program in the United States. Not only has the state expanded programming, but it has implemented the measures necessary to critically evaluate the success of the program. The state calls its program "Baby Love,"



and the results are impressive. North Carolina has broadened Medicaid eligibility, made access to services easier, improved autreach, and mandated Medicaid coverage of support services. The cornerstone of the



North Carolina program is a maternity care coordination program which follows case management principles. Simultaneously, the



state initiated a program to evaluate the success of the expansions and to track the quality of the services delivered. This was done by making changes to the reporting system to allow for collection of information on maternity care coordination, the receipt of WIC, and the receipt of child care and family planning services. The State Center for Health Statistics now has the capability to match and analyze vital statistics and program data

66



files.



Finally, the state implemented a maternity problem



documentation log which quantifies data gathered by maternity care coordinators and developed a survey to identify the most effective outreach methods. The improved evaluation tools



identified that 75% of clients learned about the Baby Love program from the staff at various agencies. In addition, 60% of



--



68% received a postpartum examination compared to 43% for



women without care coordination. Family planning services are often instituted at this postpartum visit.



-- 66% of --



the infants born to women receiving care



coordination received a well-child visit compared to 25% of the infants born to women not receiving care coordination. 82% of the infants born to women receiving care



coordination participated in WIC compared to only 40% of infants born to women not receiving care c~ordination.'~~ Clearly, the women receiving care coordination have better

.



access to services.



In analyzing the preliminary data, the



evaluators were careful to control for factors such as maternal characteristics and location of care services provided. The



results strongly show that women receiving care coordination delivered healthier babies.lU Evaluators also analyzed the effect of the length of time of care coordination. They determined that women receiving care



coordination for a longer duration had better birth outcomes. Care was taken to ensure that preterm delivery resulting in shortened program participation did not bias the results. To do



this, evaluators compared birth outcomes with the percentage of the pregnancy for which care coordination was provided. The



results showed that women who received care coordination for more than 50% of their pregnancy had substantially lower rates of low

&'41



at p . 24. at p. 25. 68



exposed.150 Exposure to alcohol prenatally is also a serious problem. The Arizona Department of Health Services estimated



that 1,343 women who delivered babies in 1991 in Arizona used alcohol during pregnancy, 151 The specific effect on the baby varies with the type of substance used by the mother. For example, cocaine has been



found to have addictive effects (which cause 60-90% of infants exposed shortly before birth to go through withdrawal), toxic effects, and teratogenic effects (which disable organ development) Is2



.



The teratogenic effects are very serious, in



that cocaine use inhibits development of the brain and other vital organs, especially during the first trimester.153 Cocaine is also an appetite suppressant, which means the mother might not gain enough weight and the fetus will be deprived of essential nutrition. lS4



150~his figure is from a study conducted in 1987 by the National ~ssociation for Perinatal Addiction Research and Education. In this study, 36 hospitals nationwide (primarily urban hospitals) were surveyed. This amounted to a study of 150,000 births. The substances covered by the study included cocaine, heroin, methadone, amphetamines, PCP, and marijuana. Alcohol was not included. 151Arizona Department of Health Services 1992 Arizona Health Status and Vital Statistics report, Effects of Crack Cocaine Upon Infants," 15*5.Fink, llReported Youth Law News, Special Issue, 1990, p. 38.

13 5&



at p 38. .



1 5 4 ~ .Halfon, "Born Hooked: Confronting the Impact of Prenatal Substance Abuse,I1 Testimony Before the U.S. House Select committee .. on Children, Youth, and Families, Washington, D C , April 27, 1989, p. 6.



70



/



The effects of prenatal cocaine use can include placenta abruptio, spontaneous abortion, premature delivery, growth retardation, reduced brain growth, malformations of the heart and urinary tract, and strokes and cerebral infarctions.lS5 After birth, a cocaine exposed infant can have problems such as irritability and hypersensitivity, movement disorders, altered state regulation (involving sleeping cycles), fine motor deficits, and increased occurrence of Sudden Infant Death Syndrome. lS6 The effects of alcohol use during pregnancy are gaining more recognition. Fetal Alcohol Syndrome (FAS) is the third most



common cause of mental retardation in the United The National Institute on Alcohol Abuse and Alcoholism (NIAAA) describes FAS as "a well defined clinical entity comprising physical, mental, and behavioral'abnormalities; low birthweight; abnormally small head; specific facial abnormalities; heart defects; joint and limb malformation; and mental retardation in most cases. FAS can be diagnosed on the basis of clinical



examination of the infant; it does not require examination of the mother or knowledge of her drinking habits.'llS8 Prenatal



15%d. at p. 6.



-



l 6 ; , pp. 7-8. S 1 9at lS7~ational Institute on Alcohol Abuse and Alcoholism, United States Department of Health and Human Services, Proaram Strateaies for Preventina Fetal Alcohol Svndrome and Alcohol-Related Birth, Defects , Washington, D.C., p 1.

l8 S&



at p. 1. 71



1601. Chasnoff, Congressional Testimony to the U.S. Senate subcommittee on Children, Family, Drugs and Alcoholism, "Falling through the Crack: The Impact of Drug Exposed Children on the Child Welfare Systemtl@ Washington, D.C., March 8, 1990, p. 6. 16'~epartmentof Health Services, Newborns with Diamosed Druq Yithdrawal Svndrorne in California , Sacramento, California, November, 1989, p. 2.

72



staff at CODAMA show that 29% of all drug abusers are female, yet only 11% of residential treatment center beds are taken by women and very few are available to pregnant women.16* Many residential and outpatient programs will not admit pregnant women because the staff do not have obstetrical expertise or because the woman is considered high risk and in need of more treatment resources. Additionally, some clinics and treatment centers are Many residential



concerned about potential malpractice problems.



treatment centers will not take women with other children. Since most women cannot or do not want to leave their children in order to go into residential care, the only option they have is to seek outpatient treatment. Outpatient treatment is less effective



with pregnant women (discussed below) and also requires arrangement for transportation and child care. The traditional program design for drug and alcohol treatment is premised on the profile of a male drug user and treatment proven effective for men. These perceptions are



frequently reinforced by sexually discriminatory attitudes of staff members. women. Male-oriented philosophies are less effective for



Traditionally, drug treatment programs take the approach out." Witnesses before the committee



that "if you use, you're



agreed that with a pregnant woman that approach is contraindicated. The program must also be concerned about the



health of the unborn baby and therefore must encourage women to



16'~estimony of Elaine Smelkinson of CODAMA at subcommittee meeting 6-25-92.

73



for care in residential treatment centers accredited by the Joint Commission on Accreditation of Health Care Organizations. These



problem in addition to the drug or alcohol problem. Additionally, some health plans do not feel transportation to necessaryw and will not drug and alcohol treatment is lfmedically provide it. The Arizona Department of Health Services through its Regional Behavioral Health Authorities provide Medicaid funded drug and alcohol treatment services to women under age 18. However CODAMA staff stated that, teens can not receive drug and alcohol treatment without their parents permission, and in some cases the teen is not willing to involve the parent in the situation. Because of the complexity of the eligibility system AHCCCS eligibility may be disrupted during the pregnancy, thereby interfering with drug and alcohol treatment. Data shows that 83% of women who abuse alcohol and drugs had parents who were addicted to drugs or alcoh01.l~~ Many of these women are coping with poverty, are relatively uneducated, are single parents, and experience emotional problems. most, have been victims of violence as an adult. Many, if not Studies of



addicted women have shown that 40 to 80% of these women were



163 C. Tracy, D. Talbert , J. Steinschneider , "Women, Babies and Drugs: Family-Centered Treatment option^,^^ Network Brief, Center for Policy Alternatives: National Conference of State Legislatures, July 1990, p.9 citing the Prevention and Applied Research Laboratory of Human Behavior Genetics, Emory University School of Medicine.

164J&



at p.9

75



victims of childhood physical and sexual abuse, including incest.'" Studies show that addicted women are more likely



than non-addicted women to have been victims of physical or sexual abuse, and some studies have found this likelihood to be almost five times greater.'& One study in particular showed

86%



that 70% of addicted women reported being beaten as adults. of these women were beaten by their husbands or partners.lb7



~ndividualstrying to help these women must also be sensitive to the fact that many of them are afraid of law enforcement and Child Protective Services (CPS). Project Thrive is a program



funded through the Department of Economic Security which provides services to families with drug and alcohol problems that are at risk for child abuse. However, some mothers fear using the program because of its connection with Child Protective Services. If a substance abuse problem is not dealt with during pregnancy, a woman may not be able to properly care for her children. Many drug-exposed babies are developmentally delayed.



Others have serious chronic medical problems. Testing being conducted by Memorial ~ospitalin Phoenix indicates up to onethird of all drug-exposed babies may have hearing loss. Witnesses testified that even for those who are familiar with services it is difficult to obtain comprehensive services for these children through AHCCCS, the Regional Behavioral Health ~uthoritiesand the schools. 1'd 61. Many of the parents of these



- at p.9

-



citing Benward, 1975.



'&ICI. p.9 at lb71d at p. 9 citing Regan et al. , 1987 A

76



children don't



bring them in for follow-up care.



The health



plans have difficulty locating them because of the lack of up-todate addresses and phone numbers. A nurse working in an



intensive care nursery explained that she attempts to schedule the first pediatrician's appointment for these babies before they



Given the cost involved, the committee recommends that priorities be set to begin serving those at greatest risk of delivering a child who is disabled due to drug and or alcohol exposure. The only consensus on priority was that services

78



should go to the poorest women, those who face geographic barriers, IV drug users, and women who abuse alcohol. Other



considerations discussed were whether there were other children in the family who were drug exposed, whether the mother was a serious abuser, and what type of substance was being abused. The



general sense of the discussion was that it was very difficult to prioritize because the risks to the babies are equally great. Intensive Case Manaaement ~ntensivecase management entails one person being responsible for assessing the care needs of a patient and coordinating all the care that is necessary. It is multi-faceted



in that medical and social services, counseling, emotional and educational needs are coordinated. When the client is a pregnant



substance abuser, intensive case management is most effective when a nurse acts as the case managers since nurses have the medical and technical knowledge to deal with the complex problems of the pregnancy as well as the other non-medical needs. For



maximum effectiveness, the case manager must be sensitive to the cultural and linguistic characteristics of the woman she is helping. Ideally, a case manager should be involved with a mother and child for two years to really make a difference. The success of intensive case management has been demonstrated by both CODAMA and the Phoenix ~irthingProject. In seven months, 22 out of 25



babies born in the CODAMA program were drug free.



A very high



percentage of those born drug free were born to mothers who

79



received residential treatment.



In the ten months of operation



of the Phoenix Birthing Project (a private organization that serves the African American community), 160 pregnant teens/women entered the program. substance abusers. positive for drugs. Fifteen percent of these women were Out of 105 babies born so far, only one was The Phoenix Birthing Project has shown that



intensive case management must continue after delivery to help mothers maintain sobriety and cope with the stresses of recovery and parenting.

RECOMMENDATIONS



1 .



Pronosed Continuum of Services for Chemicallv Denendent Women and Their Families



A.



Jdentification and Referral a. b. Outreach must be improved to encourage high risk women to undergo treatment. Public awareness must be improved so that family and friends are better able to recognize the need for treatment and so selfreferral occurs more frequently. Provider education must be improved so that . all health care personnel are better able to recognize high risk patients and refer them into treatment. All potential referral sources must be able to identify high risk women and refer them to treatment and intensive case management. Referral sources include Behavioral Health authorities, high-risk clinics, hospitals, health plans, providers, detox centers, treatment centers, probation officers, CPS, schools, churches, and family members. e. Case managers must be able to assess and coordinate the service needs of the high-risk pregnant women who are identified.



c.



80



B.



pervices Durina Preanancv a. Intake and assessment with the ability to arrange for immediate prenatal care, prior to screening for eligibility. Assistance in applying for other entitlement programs. Crisis intervention programs.



b. c.



family for one year. c. Coordination between all providers to ensure comprehensive treatment and eliminate duplication. Parenting skills education. Special attention should be paid to teaching mothers about the unique needs of medically fragile infants who have been prenatally exposed to substances. Vocational training and preparation.



d.



e. D .



Services to Substance-Ex~osed Babies a. Agsess the developmental needs of the babies Ensure that comprehensive early intervention strategies are used to prevent life-long disabilities. Home visits 3 to 5 times per week during the first month of the infantsf lives by qualified case managers. Monitor the babiesf development, the frequency and,results of the babies8 checkups, and the babies8 immunizations.



b.



c.



d.



Taraet outreach to women of child bearina aae who abuse 2. substances to encouraae the mevention of Dreanancv.

3. Direct the De~artmentof Health services to coordinate all services to this ~oaulationat the Director's level. Office of Women's and Children's Health, the Division of Behavioral Health, the office of Children's Mental Health, and the Office of Substance Abuse Services should develop and fund a comprehensive program for services to this population. One office within DHS must be ultimately responsible for policy development, program design, and payment for services to this population.



Include in DHS authority the responsibility for establishing comprehensive policy for how services to this population will be provided with Medicaid dollars. Require ,that AHCCCS amend the Medicaid State Plan 4. to include drua and alcohol treatment as Dart of the packaae of services available to all Medicaid eliaible premant women to maximize federal reimbursement for

82



5. provide reimbursement to residential providers for carina for children who come with thejr mothers to treatment.



Beauire AHCCCS submit an amendment to the State 6. Nedicaid Plan to include coveraae for the full arrav of Medicaid reimbursable services so that Medicaid coveraae is available in residential treatment centers.

7 . Develo~aoals for reduction of the number oc aildren born exposed to druas in response to the on developed bv the u~cominaDHS prevalence study. Require the Regional Behavioral Health Entities set goals for the reduction of drug use during pregnancy in their service areas.



8. Pass leaislation to Permit teens to receive druq and alcohol treatment without parental consent;. Justification The Washinaton Proaram In 1989 the state of Washington began implementing a comprehensive treatment program for substance abusers. The



program encompassed much more than just pregnant women, but the legislation did identify pregnant women as a priority population. In the same year changes were maie to the statets prenatal care program. These efforts were coordinated with the substance abuse



treatment program so that the needs of pregnant substance abusers were specifically addressed. 168 The Omnibus Drug Act of 1989 is a wide-reaching piece of drug treatment legislation. Among its provisions was a $5.5



million appropriation for treatment services for low-income,



l6'~akionaI Governors Association, Gainina Ground: State Initiatives for Preunant Women ,and Children, Washington, D.C., 1992, p.60,

t



83



chemically dependent, pregnant and postpartum women; a $12.5 million appropriation for youth assessment and treatment programs; and a $3 million appropriation to assist communities in developing collaborative programming.169 At the same time as the above legislation was enacted, the state passed other legislation that improved services. The Alcoholism and Drug



Addiction Treatment and Support Act was revised to prioritize treatment of low-income, chemically dependent pregnant women and parents.170 The Maternity Care Access Act expanded Medicaid



eligibility for pregnant women to 185% of the poverty level and expanded Medicaid coverage to support services such as psychosocial assessment, nutritional services, health education,

7 transportation, and case management. 1'



In 1990, Medicaid



coverage was expanded to medical stabilization and detoxification of pregnant women and teens and child care services were expanded in order to ensure that lack of child care would not operate as a barrier to women receiving treatment. was charged The Department of Social and Health ~e*rvices with coordinating all of these efforts and it formed an interagency group to develop and implement a care continuum for pregnant substance abusers. Included in the interagency group



169~d. p. 60. at



-



were representatives from Income Assistance, Medicaid, Maternal and Child Health, Substance Abuse, Child Protective Services, and the Office of Research Data ~na1ysis.l~The group reviewed agency policies to find conflicts and resolved these conflicts in the care continuum plan. The cornerstone of the care continuum



was targeted case management.174 To assure implementation of the continuum, the interagency group trained eligibility workers on the needs of pregnant women and worked with the legal community to educate them on the advantages of the new program as an alternative to prose~ution.'~ The program has been very successful. In 1982, only 17% of



those being treated in the alcohol and drug abuse system were female. None were pregnant. Now, 33% of those being treated in



the drug and alcohol abuse system are female and 10% of those women are pregnant. 176 This represents a significant improvement in a very short time. EDUCATION Throughout all of the committee hearings and subcommittee meetings much concern was expressed about the lack of education regarding the necessity of prenatal care. Every subcommittee Lack of



found educational deficits in the current system,



knowledge of the need for prenatal care was found to be the most at p 61. . 174~d. p. 61. - at

='7l



at p. 61.



17%d.



- at



p 61-62. .

85



Encourage businesses and non-profit organizations that do not have their own prenatal/child health media campaign to contribute to the DHS campaign, "The Greatest Love," Encourage sponsors of the campaigns to include the DHS pregnancy hotline number to their spots, and publications. Require DHS develop a method for measuring the current educational level of the public on the need for prenatal care and the effect of any media campaign on improving the knowledge of the community, lnLouise H Warrick, Use of Birth Reaistration Data for . prenatal Health Care Plannina in Marico~a Countv, Columbia University, August 1986, p. 150 86



4



3.



Lav Health Worker Proarams



Expand one-on-one support systems for pregnant women and adolescents in the form of additional lay health worker programs. Successful existing programs include Comienzo Sano, Phoenix Birthing Project and Concimiento.

4.



Continuina Medical Rducation



Survey OB/GYNs, physicians, nurses and non-physician providers through their professional associations to assess those areas relating to maternal health (nutrition, pharmacology, psychosocial risk assessment, procedure for enrolling women in WIC, etc.) about which they need to learn more. Follow up the survey with either continuing medical education classes or articles through the association's newsletter.

5.



Patient Education Material



Develop patient education pamphlets covering basic prenatal care information such as the effects of smoking and drinking, and the need for good nutrition during pregnancy. The pamphlets would be distributed everywhere possible. They would include reference numbers for each of the problems (alcoholics anonymous, pregnancy hotline, etc.) and would be t~rittenin a low literacy level and style.

6.



Increased Accessibilitv to Precmancv Testinq



Increase funding to publicly subsidized health facilities so free pregnancy tests can be offered at these locations. Encourage clinics, primary care centers, and hospitals to implement a "fast tracku system so that individuals requiring pregnancy testing can be helped quickly. Direct the Department of Health Services Office of Women's and Children's Health to further investigate the feasibility of providing pregnancy testing at nontraditional sites, such as stores and pharmacies which offer periodic lab services through Health Waves Laboratories or schools after hours. All pregnancy testing sites should provide immediate follow-up information on the necessity of prenatal care, the procedure for obtaining care if the woman

87



,



does not have a doctor or insurance, and the basic information the pregnant woman needs to know until she can see a doctor, as well as information on family planning if the test is negative. This will require incorporating new individuals, such .as pharmacists, into the group of prenatal education providers. Develop a distribution program for the March of Dimes' pamphlet which contains a coupon for Early Pregnancy Test. The March of Dimes and ADHS will work together to increase the distribution and availability of home pregnancy tests, After the initial pilot program period, the pamphlet will be slightly restructured toward a larger population and will include the Arizona pregnancy hotline number rather than the toll number currently on the pamphlet.

7.



Ex~andHotline Services,



DHS must expand the hotline so that it can meet the increased need generated by increased education and publicity of the Hotline services.

8.



Private Public Partnershin



-



Hold a lnsummitw inviting private and public source who may be interested in funding the recommendations adopted by the Committee. The summit would be sponsored by the Governor office, Chairs of the appropriate Governor's Councils, Legislators and the Directors of DHS, AHCCCS and DES. Participants would include those in the private sector that contribute to philanthropies (i.e. the Valley Givers Association, non-profit organizations, etc). The private sector participants would be presented with an explanation of the need for improving accessibility to prenatal care, the recommendations from the Study committee and an analysis of the cost effectiveness of adequate prenatal care. Justification The Utah Prouranq The state of Utah implemented reforms which removed eligibility barriers to prenatal care, provided for prenatal care coordination, and expanded services. One of the main components



of the reform package was an expansive media campaign meant to

88



educate women on the importance and availability of prenatal care. The campaign was entitled "Baby Your Babyw, and included



public service announcements on television and radio,



Although only 9% of births in Utah are to teenagers, 25% of the calls to the hotline were made by teenagers.'= This is Another



significant because teens are such a high-risk group.



indication of the programfs success is the fact that nearly all women with incomes Zess than 133% of poverty are enrolled in ~edicaid



.



The state of Utah also conducted a study to compare birth outcomes of women who used the hotline and women who didnft use the hotline and to compare the average cost of babies born to women who used the hotline and women who did not use the hotline. The findings were as follows: 86% of hotline users initiated care in the first trimester, while 81% of non-hotline users initiated care in the first trimester. $2,016, while the average cost of delivery to nonhotline users was $2,300.



--



-- The average cost of delivery to hotline users was



78% of pregnant teenagers who called the hotline received prenatal care in the first trimester, while only 64% of teenagers who did not call the hotline began care in the first trimester. 7.1% of babies born to teenage hotline users were born at a low birth weight, while 9% of babies born to teenage non-hotline users were born at a low birth weight. laS The proven success of the Baby Your Baby program has prompted Utah to expand similar programming.



---



BUDGET IMPLICATIONS



The Committee attempted to establish cost estimates for the recommendations of the various subcommittees. The Committee



requested specific information from the AHCCCS Administration, the Department of Health Services, Office of Women's Children's and



Health, the Joint Legislative Budget Committee, and



the Department of Economic Security on some but not all of the recommendations. The various agencies were not able to provide recommendations.



cost estimates for a number of the Committee's



However, the following information is presented as part of the Committee's report with the full knowledge that a more detailed



budget analysis must be completed. The total number of women in Arizona who have no apparent source of payment for prenatal/maternity services is unknown. Various studies have placed the figure anywhere from 5,000 to 18,000 per year.lM Some women are uninsured and others have The Committee is



insurance but it does not cover maternity care.



recommending an incremental approach to making prenatal care financially accessible to all Arizona women. The first step is



to raise AHCCCS eligibility to 185% of the Federal Poverty Level, the current maximum that the Federal government will reimburse. ~ccordingto an analysis by the Joint Legislative Budget



Kotch, et. al. , Pound of Prevention: The Case for Universal Maternitv Care in the U.S., pp. 87-107, 1992.



91



Committee (JLBC), this would make an additional 4,154 women per year eligible for care through AHCCCS at an estimated cost to the state general fund of $11,697,500. These figures are estimates



only and may vary with economic conditions, and the actual cost of care at the time of implementation. women in this range who have insurance. The Committee is also recommending coverage on a sliding scale for women whose income is above 185% and below 250% of the poverty level. The Committee had no information on the cost of They do take into account



implementing this recornendation. The balance of the Budget Subcommittee information reflects the cost estimates for various recommendations and cost avoidance due to the intervention where known. Cost figures were provided



by the Arizona Department of Health Services, office of Women's and Children's I. Health and the ~ o i n tLegislative Budget Committee



Cost Analvsis Tor SOBRA emansion to 185% Cost Avoidance (State) 3,953,625



Estimated Cost (State) 11,697,500



Cost avoidance figures were calculated using the following formula. The JLBC told the Committee that 4154 more women would



receive prenatal care if eligibility were increased to 185% of poverty. It assumed that those women would not have received minimally adequate care otherwise. The Committee used the



Department of Health services figures for the number of preventable very low birthweight babies (under 1500 gms) and preventable low birth weight babies (under 2500 gms). This number 92



was multiplied by the average hospital and physician charges reported to DHS for the Newborn Intensive Care Program and the medical costs for the first year of life for a low birth weight child. This figure represents the cost savings in total dollars



of providing prenatal care to the additional 4154 women and thereby avoiding expensive low birth weight babies. The final



state cost avoidance is 35% of the total figure since the federal government would reimburse approximately 65% of the new born costs. 11. See Addenduq for the complete calculation. Cost Analysis for Selected Recommendations STATE COST 467,403.8 644,903.8 630,024.0 167 ,200.4 1,203,251.7 510 ,514.4 7,000.0 43,044.7 152,355.0 1,503,902.0 55,467.3 5,000.0 1,003,902.0 54,689.9 244,556.1 14,556.1 282,079.7 92,902.2 7,066,656.0 STATE COST AVOIDANCE



INTERVENTION Malpractice premium subsidy+NPs Malpractice subsidy <50 deliveries Mobile Care Integration/One-Stop Case Management In-School Ed Media Campaign Lay Worker Outreach Patient Ed Material Hotline Expansion Free Pregnancy Test Drug Treatment Community Outreach BehavJSocial Risk Ed Family Planning Transportation Mental Health Housing Shelter Teen Outreach OB/GYN NP Training TOTAL



-----



-----



----2,406,503* --1,021,029*



-----



---



---*** ---***



---



4,015,608**



---



---



----564,159* ---



8,007,300



*For every dollar spent on case management, outreach and care coordination two dollars are saved in post delivery neonatal care. 93



** For every dollar spent on family planning services two to 6.6 dollars are saved on prenatal, maternity and neonatal costs. For this report a 1:4 ratio was used.

*** The cost avoidance associated with drug and alcohol treatment programs could not be estimated at this time due to lack of prevalence statistics for Arizona and reliable figures for cost avoidance from published studies.

111. SUMMARY OF COST ANALYSIS COST 1,995,846 1,003,092 11,697,500 4,067,718 18,764,236 6,803,311 CONCLUSION The recommendations contained in this report provide a comprehensive plan for improving the health status of pregnant women and children in Arizona by 1) educating the public and women of child bearing age of the need for prenatal care and how to obtain it; 2) removing financial barriers to care; 3) creating an eligibility and enrollment system that facilitates early entry into care; 4) ensure that culturally sensitive providers are available in our communities; 5) make pregnancy testing and family planning services readily available and, 6) target special high risk populations for coordination of medical, social and educational services. The Committee realizes that the goals of COST AVOIDANCE 3,991,692 4,015,608 3,953,625

INTERVENTION/RECOMMENDATION



Outreach/Case Management Family Planning SOBRA Eligibility to 185% All Other Interventions TOTAL NET COST TO STATE



---



11,960,925



accessible, affordable quality prenatal care for all Arizona women cannot be achieved overnight. Arizona's The Committee urges



leaders both in the public and private sector to 94



Minoritv Report

STUDY COMMllTEE ON SERVICES TO PREGNANT WOMEN Laws 1991, Chapter 193 established the Study Committee on Services to Pregnant Women. The Committee was charged with investigating: 1.

2.



the barriers which prevent pregnant women from receiving services, the degree to which available services are being used, the definition and description of the underserved population in Arizona, and the problems that women encounter while establishing eligibility for state services.



3.

4.



The full Committee met nine times. The first four meetings were spent clarifying the scope of the problem. At the conclusion of the fourth meeting, the Committee broke into five work groups: Availability of Providers, Budget Implications, Education, Eligibility and Enrollment and Special Populations. The findings and proposed recommendations of the work groups were discussed at the remaining four Committee meetings. At the final meeting, the Recommendations were proposed in the Committee report and they were adopted by the members present.

Minoritv Response



As members and active participants of this Study Committee, we oppose the vast recommendations approved by the Committee. We acknowledge and appreciate the extensive hours consumed studying this important issue. However, throughout this process this committee has lost perspective, focus and most importantly identified extensive barriers but provides no prioritization to their solutions. Instead, the report provides an unrealistic broad "plan" without adequate direction. We believe the community will be better served by a targeted approach, which includes such features as high priority issues and a focused application of funding. This minority report provides specific findings as a result of the committee's research and endorses realistic and pragmatic recommendations.



98



Findinag

Reports and testimony received by the Committee indicate that in 1990, of the nearly 69,000 babies that were born in Arizona, 602 families experienced the death of their babies before the child's first birthday and another 410 parents experienced a fetal loss. Additionally, 4,451 babies were born weighing less than 5.5 pounds. Although most of these babies survived, approximately half required newborn intensive care (NICU). Total NlCU costs in 1989 were approximately $75 million. Additionally, study after study has concluded that comprehensive prenatal care begun early in pregnancy drastically improves birth outcomes. In comparison to other states, Arizona ranks 47th for getting women into prenatal care. In 1989, 82.8% of all women who were pregnant in the previous five years had their first prenatal care visits during the first trimester; 11.9% started prenatal care in the second trimester and 4.2% did not seek care until the third trimester or until delivery. The Committee received testimony about what barriers cause these delays. The most prevalent ones were: poverty, cultural differences, age, fear, lack of transportation, shortage of providers, lack of education concerning the importance of prenatal care, the complexity of the AHCCCS eligibility process, inability to receive child care for other children, substance abuse, language barriers, illiteracy, domestic violence and lack of home telephones. Eliminating all these barriers would be the ideal situation. However, this is impossible during difficult financial times. Therefore, it is important to identify the barriers which can be both realistically addressed and which will produce immediate and longterm improvements. In keeping with the focus of the charges of this committee, we believe the following two recommendations signify the most effective and responsible policy recommendations:



Recommendationg 1. Increase public awareness of the importance of early and comprehensive prenatal care through a multi-media publicity campaign jointly sponsored by the state and a variety of private sector sponsors, similar to the successful Baby Your Baby program in Utah.

The benefit of a major media campaign is that it informs women of the importance and availability of early and continuous prenatal care. Utah has closely monitored its media campaign program to determine its effectiveness in raising public awareness of the infant mortality problem and to assess whether birth outcomes have been impacted. A steady increase in the number of calls has been seen during the first four years: in 1988 there were approximately 155 calls monthly, in 1991 there were approximately 1,333 calls monthly. Surveys of hotline callers revealed that nearly 50% of the calls were made by the women in their first trimester; 27% made the call within the first eight weeks of their pregnancy. Additionally, the average cost of delivery is lower for women who called the hotline. Deliveries for hotline callers averaged $2,016 compared with $2,300 for non-hotline callers.

99



2.



Establish presumptive eligibility for pregnant women by rendering immediate provider access to any pregnant woman at the time of application combined with a statewide educational component informing providers and pregnant women of the presumptive eligibility opportunity.

Presumptive eligibility allows a woman to receive prenatal care before her eligibility for Medicaid is determined. Earlv prenatal care often improves the health of the mother and improves birth outcomes. Maricopa County already provides prenatal care to any pregnant woman with an income under 185% of the federal poverty limit (FPL). An average of 1,200 women are seen each month who are enrolled in AHCCCS. The County estimates that up to 80% of these women could qualify for AHCCCS, i.e., would meet the 140% FPL income limit and other eligibility factors. Implementation of a statewide presumptive eligibility program will require careful organization and planning. Outcomes and associated costs must be periodically reviewed to determine the feasibility of program continuation.



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REPRESENT

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100