The state will allocate the money across eight GROW regions to expand prenatal and postpartum services and modernize rural clinics, creating concern among providers about whether funds will reach hospitals directly.

[…]

On December 18, the Primary Care Collaborative (PCC) and Upstream USA hosted a webinar on improving access to contraceptive care through primary care. Panelists included Angeline Ti, MD, MPH (Wellstar Douglas Family Residence Program; Upstream USA), Jessica Marcella (previously HHS Office of Population Affairs) and Julia Strasser, DrPH, MPH (Jacobs Institute of Women’s Health, GWU Milken) with Ann Greiner (PCC) moderating.

Greiner opened the webinar by highlighting the issue of “contraceptive deserts,” where 19 million women lack access to a full range of contraceptive options, often due to limited OB-GYN availability. She emphasized primary care’s critical role in bridging these gaps, as many women rely on primary care clinicians for routine health needs.

Marcella then emphasized primary care’s accessibility and continuity and the need for systemic support to sustain contraceptive services. This reinforced primary care’s potential to expand equitable access to reproductive health care.

Dr. Ti discussed primary care’s strengths in providing patient-centered contraceptive care, addressing barriers like geographic and financial challenges and the need for systems to support high-quality services. She also noted family medicine residents’ eagerness to provide this care, underscoring the need for a supportive culture within our health system.

Dr. Strasser highlighted the variations in contraceptive care across specialties, noting the importance of primary care in contraception access, especially in underserved areas. She called for training and policy support to help primary care clinicians expand their roles.

Ti then discussed barriers to comprehensive contraceptive care, including insufficient residency training, short appointment times and lack of patient awareness. She emphasized the need for robust training, adequate appointment time and proactive screening for contraception care.

Continuing this conversation, Strasser highlighted the impact of COVID-19 on the health care workforce, noting the drop in physicians providing contraception in 2020, though it rebounded in 2021. She stressed the need for supportive policies to help primary care clinicians manage these challenges.

Marcella also emphasized that access to contraception affects not only pregnancy outcomes but also financial stability and overall health. She underscored primary care’s role in helping patients navigate these challenges.

Regarding federal reform, Marcella called for funding for patient-centered care, training and public education, and emphasized the need for full insurance coverage, particularly for underserved populations. She pointed to resources like MediCal eligibility criteria and family planning guidelines.

Strasser discussed policies addressing systemic racism and mistrust in reproductive health care, suggesting expanding programs like the Teaching Health Center Graduate Medical Education Program (THCGME) to increase Medicaid acceptance and training. She also called for easing scope-of-practice restrictions for advanced practice clinicians.

Ti emphasized balancing quality metrics with patient satisfaction while avoiding coercion or bias. She highlighted challenges like prior authorization for IUDs and implants and suggested the need for hands-on procedural training to reduce these barriers.

Strasser stressed that contraception promotes self-determination and bodily autonomy and called for a robust primary care workforce to provide a full range of contraceptive methods. She emphasized that while only 60% of U.S. counties have an OB-GYN or nurse midwife, over 90% have family medicine physicians.

Marcella discussed the Affordable Care Act’s strides in covering contraception without cost sharing but noted gaps, such as the lack of coverage for some methods and populations, like those on Medicare due to disability. She also highlighted insurance affordability as a barrier to access.

Strasser then addressed potential Medicaid cuts, including block granting and work requirements, which could reduce eligibility and access to care. She warned that increased administrative burdens could further limit clinician participation in Medicaid, reducing access to contraceptive care.

Marcella pointed out the impact of state budget deficits on Medicaid reimbursement rates for family planning services and emphasized the need to advocate for family planning amidst competing health priorities.

Ti suggested that professional boards could improve contraceptive care by adding more related questions to board exams and requiring specific training. She also recommended offering accessible resources, such as webinars, and collaborating across boards to share strategies for supporting providers.

PCC is also looking for feedback on the webinar and the primary care community’s interest in strengthening efforts to scale contraceptive care. To provide feedback, please watch the webinar and respond to the survey below.

PCC supports the Helping MOMS Act, as an important step to confronting the maternal mortality crisis.

PCC supports H.R. 3345 as an important step to confronting the maternal mortality crisis. It would:
Extend Medicaid postpartum coverage for 12 months on a permanent basis; and
Temporarily increase the Federal Medical Assistance Percentage (i.e., federal matching rate) for pregnancy-related services in states that choose to do so.

Read the full letter here.

PCC supports H.R. 3345 as an important step to confronting the maternal mortality crisis. It would:

– Extend Medicaid postpartum coverage for 12 months on a permanent basis; and

– Temporarily increase the Federal Medical Assistance Percentage (i.e., federal matching rate) for pregnancy-related services in states that choose to do so.

WASHINGTON, March 8, 2021 The Primary Collaborative (PCC), along with a number of its members and members of the Bridging the Chasm Collaborative, is releasing a women-first agenda today, International Women s Day. This agenda closes the healthcare gaps that contribute to preventable maternal deaths and chronic illness later in life among all women, especially Black, Indigenous, and other women of color. PCC believes that primary care can play a key role in closing care gaps often evident in the year after women give birth but that can affect them for a lifetime.

The agenda is presented in two articles published today in the journal Women s Health Issues: Bridging the Chasm between Pregnancy and Health over the Life Course: A National Agenda for Research and Action, and an accompanying commentary, It s Time to Eliminate Racism and Fragmentation in Women s Health Care. The agenda comes as Congress considers legislation to tackle huge racial inequities in maternal health with the 2021 Black Maternal Health Momnibus Act.

The broad coalition of clinicians, researchers and advocates that formulated the agenda includes PCC members – Black Women s Health Imperative, Mathematica, Johns Hopkins Community Physicians – and is led by the Boston University Schools of Public Health and Medicine.

Many women, especially women of color, fall into a healthcare chasm after they give birth. That gap is a major factor in preventable deaths and chronic illness for these women, said Ann Greiner, PCC s president and CEO and a contributing author to the journal articles. Primary care can step into that gap and provide the care that these mothers need after giving birth and stave off pregnancy-related conditions that can affect them for a lifetime. Providing such care can address fragmentation and improve healthcare equity.

The journal articles present remedies to the structural chasms in women’s health care, with key roles for advocates, policymakers, researchers, healthcare leaders, educators, and the media (see more below).

The United States has an abysmal record when it comes to Black maternal health. We know that change comes through both practice and policy. The Bridging the Chasm agenda sets the strategy for addressing structural racism in systems of care and identifies the policy changes required to eliminate needless inequities in Black maternal outcomes, says Linda Goler Blount, MPH, president and CEO of the Black Women s Health Imperative and another contributor to the journal articles.

The agenda is the product of two years of collective work, launched at an innovative national conference hosted at Boston University in 2018. The conference brought together women with lived experiences of complicated pregnancies, clinicians, researchers, health system innovators, policymakers, and private sector advocates to identify the gaps in care after pregnancy and other systemic issues, and to outline an agenda for transformation. A group of dedicated stakeholders the Bridge the Chasm Collaborative co-created the resulting agenda.

The Gaps

• The healthcare system is divided into reproductive functions and all the rest. Pregnancy and birth have long-term effects on health, but, even after clear warning signals, follow up care after pregnancy is exceedingly poor, as low as 50% for gestational diabetes among insured women (and lower for women on Medicaid), and 26% for gestational hypertension.
• Healthcare and insurance policies support birthing people when they are pregnant and for about 8 weeks postpartum then new mothers fall into a chasm of disconnected health care at best, and no health care at worst. Medicaid coverage for mothers ends after 60 days, while children remain covered by public insurance (CHIP). Well childcare for the first three years of life is routine, but no such system exists for mothers.
• Inequities between Black and White women extend from maternal mortality to chronic illnesses that place women at risk during reproductive years and beyond. Black women across the income spectrum and from all walks of life die from preventable pregnancy-related complications at 3 to 4 times the rate of non-Hispanic White women, and experience severe maternal morbidity (life-threatening complications) at twice the rate. Among pregnant and postpartum women, Black women had a 50% greater risk than Whites of dying from heart disease.
• Women s needs and voices are often ignored or simply not central to their healthcare experience, and disrespect and racism (interpersonal and structural) are common in reproductive health care for Black women. In the 2019 Giving Voice to Mothers survey, 27.2% of women of color with low socioeconomic status reported verbal or physical abuse during maternity care, compared with 18.7% of White women.

The Agenda

• Hold healthcare institutions and clinicians responsible for ending the epidemic of disrespect for women of color, linking progress to accreditation.
• Provide infrastructure support to community-based organizations run by and for Black, Indigenous, and other women of color.
• Extend holistic, team-based care to the postpartum year and beyond, with integration of doulas and community health workers on teams.
• Expand Medicaid coverage across the full postpartum year and support the development of Medicaid pay-for-performance policies that require linkage to primary care.
• Preserve maternal narratives and data across providers and specialties.
• Align research with women s lived experiences and center their voices in the design, conduct, and dissemination of findings.

In their commentary, the authors note that the Momnibus Act offers an ideal platform on which to build key planks of the Bridge the Chasm Agenda, investing in mothers not only during but long after pregnancy.

For many, this year’s back-to-school season during a protracted pandemic is fraught with health risks and questions about student and teacher safety. Parents and teachers are concerned about the spread of the coronavirus in schools and between schools and homes. Primary care can help families navigate these uncharted waters. This webinar examined the role of primary care for children in the risk assessment, prevention, and treatment of COVID-19 as well as in addressing related behavioral health needs and inequities in care. The webinar also addressed planned vaccinations.

Panelists:

• Chip Hart | Consulting group director, PCC Pediatric EHR Solutions
• Nathaniel Beers, MD, MPA, FAAP | President, HSC Health Care System (Washington, D.C.)
• Ashraf Affan, MD | President, Angel Kids Pediatrics (Jacksonville, Florida)

Moderator: Sarah Greenough, MPP | Director of Policy, Primary Care Collaborative

Wide disparities in obstetrical outcomes exist between women of different race/ethnicities. The prevalence of preterm birth, fetal growth restriction, fetal demise, maternal mortality and inadequate receipt of prenatal care all vary by maternal race/ethnicity. These disparities have their roots in maternal health behaviors, genetics, the physical and social environments, and access to and quality of health care. Elimination of the health inequities due to sociocultural differences or access to or quality of health care will require a multidisciplinary approach. We aim to describe these obstetrical disparities, with an eye towards potential etiologies, thereby improving our ability to target appropriate solutions.

BACKGROUND:
The black-white maternal mortality disparity is the largest disparity among all conventional population perinatal health measures, and the mortality gap between black and white women in New York City has nearly doubled in recent years. For every maternal death, 100 women experience severe maternal morbidity, a life-threatening diagnosis, or undergo a life-saving procedure during their delivery hospitalization. Like maternal mortality, severe maternal morbidity is more common among black than white women. A significant portion of maternal morbidity and mortality is preventable, making quality of care in hospitals a critical lever for improving outcomes. Hospital variation in risk-adjusted severe maternal morbidity rates exists. The extent to which variation in hospital performance on severe maternal morbidity rates contributes to black-white disparities in New York City hospitals has not been studied.

OBJECTIVE:
We examined the extent to which black-white differences in severe maternal morbidity rates in New York City hospitals can be explained by differences in the hospitals in which black and white women deliver.

STUDY DESIGN:
We conducted a population-based study using linked 2011-2013 New York City discharge and birth certificate datasets (n = 353,773 deliveries) to examine black-white differences in severe maternal morbidity rates in New York City hospitals. A mixed-effects logistic regression with a random hospital-specific intercept was used to generate risk-standardized severe maternal morbidity rates for each hospital (n = 40). We then assessed differences in the distributions of black and white deliveries among these hospitals.

RESULTS:
Severe maternal morbidity occurred in 8882 deliveries (2.5%) and was higher among black than white women (4.2% vs 1.5%, P < .001). After adjustment for patient characteristics and comorbidities, the risk remained elevated for black women (odds ratio, 2.02; 95% confidence interval, 1.89-2.17). Risk-standardized severe maternal morbidity rates among New York City hospitals ranged from 0.8 to 5.7 per 100 deliveries. White deliveries were more likely to be delivered in low-morbidity hospitals: 65% of white vs 23% of black deliveries occurred in hospitals in the lowest tertile for morbidity. We estimated that black-white differences in delivery location may contribute as much as 47.7% of the racial disparity in severe maternal morbidity rates in New York City.

CONCLUSION:
Black mothers are more likely to deliver at higher risk-standardized severe maternal morbidity hospitals than are white mothers, contributing to black-white disparities. More research is needed to understand the attributes of high-performing hospitals and to share best practices among hospitals.

Awareness of the broader contexts that influence health supports respectful, patient-centered care that incorporates lived experiences, optimizes health outcomes, improves communication, and can help reduce health and health care inequities. Although there is little doubt that genetics and lifestyle play an important role in shaping the overall health of individuals, interdisciplinary researchers have demonstrated how the conditions in the environment in which people are born, live, work, and age, play equally as important a role in shaping health outcomes. These factors, referred to as social determinants of health, are shaped by historical, social, political, and economic forces and help explain the relationship between environmental conditions and individual health. Recognizing the importance of social determinants of health can help obstetrician�gynecologists and other health care providers better understand patients, effectively communicate about health-related conditions and behavior, and improve health outcomes.

The Impact of Primary Care Practice Transformation on Cost, Quality, and Utilization reviews PCMH results from 45 peer-reviewed reports and additional government and state evaluations. Implementation of the PCMH and high performing primary care differs depending upon the needs and preferences of those delivering, receiving, and paying for related care.

The sixth annual PCPCC report, authored by the Robert Graham Center of the American Academy of Family Physicians and published with support from the Milbank Memorial Fund, employed broader search terms and more rigorous search criteria that evaluated studies, reports, and evaluations published between November 1, 2015 to February 28, 2017. It also features examples and data from PCMH programs, such as Blue Cross Blue Shield of Michigan, which leads one of the oldest PCMH programs, now in its eighth year with seven years of data; the Comprehensive Primary Care Initiative launched by the Center for Medicare and Medicaid Innovation; and state primary care initiatives including Colorado, Minnesota, and Oregon.