To improve effective contraceptive use and timely postpartum care statewide, Oregon’s Medicaid program successfully used incentive payments and quality measures to increase the rates of effective contraceptive use from 35.4 to 46.8 percent between 2015 and 2018, and timely postpartum care from 61.3 to 68.2 percent between 2018 to 2019.
Oregon implemented the quality incentive measures and incentive payments made to its Coordinated Care Organizations (CCC) to improve uptake of effective contraceptive use (which have failure rates under 13 percent) and timely postpartum care to reduce unplanned pregnancies and improve health outcomes following childbirth among Medicaid enrollees.
In 2010, approximately 46 percent of all pregnancies in Oregon were unintended, similar to the national average rate of 45 percent, and almost 70 percent of Oregon’s unplanned pregnancies were publicly funded. Long-acting reversible contraception (LARCs), a contraceptive method with less than 1 percent failure rates, are highly effective and have the highest continuation rates of reversible contraceptive methods, as additional adherence to an ongoing medication regimen or regular follow-up are not required. Additionally, there are cost savings associated with increased access to contraception, as unintended pregnancies in 2010 cost states more than $6 million. It remains essential for states and providers to honor individual choice when determining if a LARC or other contraceptive option is appropriate.
In 2017, Oregon’s CCOs, networks of various health care providers serving Medicaid enrollees, reported that about 50 percent of enrolled women received a postpartum care visit 21 to 56 days after delivery. The American College of Obstetrics and Gynecologists (ACOG) recommends that all postpartum women contact a maternal care provider within the first three weeks postpartum and as needed for ongoing care. According to ACOG, a comprehensive postpartum visit that includes a full assessment of physical, social, and psychological well-being, should occur no later than 12 weeks after birth.
As part of Oregon’s commitment to pay for better quality care and health outcomes, CCOs can qualify for incentive payments if they meet a pre-established state benchmark or reach their individual improvement targets. The individual target is at least a 10 percent reduction in the gap between the baseline and the benchmark. These initiatives were design to encourage CCOs to focus more on prevention and care management.
Federal Efforts to Improve Postpartum and Contraceptive Care
Improving access to postpartum care and contraception is also a priority for the Maternal and Child Health Bureau (MCHB) and the Centers for Medicare & Medicaid Services (CMS). MCHB has funded the creation of two patient safety bundles, one focusing on a comprehensive postpartum visit and the other on transitioning from maternity to well-woman care. Additionally, CMS’ Adult and Child Core Measure Sets include postpartum care and contraceptive care.
Oregon’s Reproductive Health Incentive Measure
The Effective Contraceptive Use (ECU) measure, created by the Oregon Health Authority (OHA) in 2014, focuses on women ages 15 to 50 who are not currently pregnant and who adopted or continue to use one of the most effective or moderately effective contraceptives. The OHA decided to continue using this measure when CMS formally adopted a contraceptive measure, called the CCW Measure, under the Medicaid Adult Core Set of Health Care Quality Measures.
When developing this measure, the OHA carefully considered the history and risk of reproductive coercion in the United States. The OHA also recommended CCOs use particular strategies to increase voluntary contraceptive use. Those strategies include, but are not limited to:
- Removing barriers to contraception (e.g., providing contraception supplies for longer than three months);
- Improving availability and uptake of LARCs by partnering with local Title X family planning clinics;
- Offering clinician training, such as how to provide effective contraceptive counseling that includes discussing the efficacy and benefits of the chosen method, employing a “teach-back” method, and providing time for the client to review and sign the informed consent form for LARC procedures;
- Adjusting workflows to support and implement the One Key Question initiative, which screens for pregnancy intentions; and
- Creating quality improvement processes.
The OHA relied on administrative claims data to determine if CCOs qualified for incentive payments. Through claims data, the OHA was able to determine the number of CCO enrollees using intrauterine devices (IUDs), implants, contraception injections, contraceptive pills, sterilization, patches, rings, or diaphragms. The OHA also uses claims data to measure surveillance of a contraceptive method. Additionally, the ECU measure stratified enrollees by age group – adolescents ages 15 – 17 and adults 18 – 50. In order to qualify for the incentive payment, CCOs must meet benchmarks or pre-established improvement targets. Meeting the benchmarks or targets applied to all ages (15 to 50), not stratified results. In 2019, the OHA established a 53.9 percent benchmark, which was in the 90th percentile for CCOs in 2017.
Statewide performance on the ECU measure increased from 35.4 percent in 2015 to 46.8 percent in 2018. CCOs have also documented improvements among various racial and ethnic groups. In 2017, effective contraceptive use rates among Latinx was 46.8 percent compared to 37.2 percent in 2015. Effective contraceptive use rates among Black women were at 43.1 percent in 2017 compared to 35.4 percent in 2015. In the Journal of the American Medical Association report, Association of Implementing an Incentive Metric in the Oregon Medicaid Program with Effective Contraceptive Use, researchers found a significant increase in contraceptive use every year among Medicaid enrollees, compared to the control group. As of 2020, the OHA no longer uses this metric as a result of improvements in contraceptive use.
Postpartum Care Incentive Measure
Timeliness of postpartum care is a measure outlined in Oregon’s 1115 demonstration waiver and is reported as a CMS Adult Core Measure. To address decreasing timely postpartum care rates, Oregon replaced an incentive associated with timely prenatal care, which had shown drastic improvements in prior years, with one focused on improving timely postpartum care. This incentive measure pulls data from the Medicaid Management Information System (MMIS), Decision Support/Surveillance and Utilization Review System (DSSURS), and medical records to determine the percentage of live birth deliveries for which there is a subsequent, timely postpartum visit. Timely postpartum visits are defined as postpartum care on or between 21 and 56 days after delivery.
The OHA published a resource with strategies for improving timely postpartum care designed specifically for CCOs, clinics, and the community. These strategies include:
- Delivery changes, such as offering patient education, peer support, and enhanced maternity care models (e.g., maternal medical homes);
- Using email, texts, or apps to remind women to schedule postpartum follow-up; and
- Leveraging payment strategies, such as reimbursement to support dyadic care (e.g., visits where both mother and baby receive care).
These strategies, along with incentive payments to CCOs that reach benchmarks or improvement targets, worked to address the decreasing postpartum care rates. As a result of implementing this measure, the OHA was able to increase timely postpartum care visit rates from 61.3 percent in 2018 to 68.2 percent in 2019.
In addition to increasing postpartum care visits, OHA officials indicated they plan to develop a measure to determine the quality of a postpartum visit. This measure, which may be released as soon as early 2021, will include breastfeeding evaluation and education, postpartum depression screening, postpartum glucose screening for patients with gestational diabetes, and family planning and contraception.
In order to improve effective contraception use and timely postpartum care, Oregon successfully leveraged Medicaid incentive payments and quality measures. These examples can inform other states’ efforts to address unplanned and unintended pregnancies and improve maternal and infant outcomes.
For more information about state Medicaid quality measurement activities for women’s health, explore NASHP’s interactive map State Medicaid Quality Measurement Activities for Women’s Health.
For more information about increasing access to LARCs under Medicaid, read a joint report by NASHP and the National Institute for Children’s Health Quality, Strategies to Increase Access to Long-Acting Reversible Contraception (LARC) in Medicaid.
Acknowledgements: This case study is a publication of the National Academy for State Health Policy (NASHP). This project is supported by the Health Resources and Services Administration (HRSA) of the US Department of Health and Human Services HHS under the Supporting Maternal and Child Health Innovation in States Grant No. U1XMC31658; $398,953. This information, content, and conclusions are those of the authors’ and should not be construed as the official position or policy of, nor should any endorsements be inferred by HRSA, HHS, or the US government.
After months of uncertainty and a three-month federal funding lapse, in early 2018 Congress passed the HEALTHY KIDS and ACCESS Acts, which appropriated federal funds for the Children’s Health Insurance Program (CHIP) through federal fiscal year (FFY) 2027. While the HEALTHY KIDS and ACCESS Acts’ long-term funding stabilizes CHIP programs and helps states develop forward-focused strategies to improve children’s coverage, a decrease in the federal CHIP match rate will require additional state funding beginning this October.
The Affordable Care Act (ACA) increased states’ federal CHIP match rates by 23 percentage points — referred to as the “23 percent bump” — beginning in FFY 2016, which resulted in match rates ranging from 88 to 100 percent. While the HEALTHY KIDS and ACCESS Acts continued to fund the 23 percent bump through FFY 2019, beginning this October it will be phased down to 11.5 percentage points. Subsequently, in FFY 2021 and beyond, the percentage returns to the regular enhanced CHIP match rate that states received prior to the 23 percent bump.
States are currently finalizing budgets for their CHIP programs and must factor in this reduction in the federal match rate to determine the state financing needed to sustain these critical programs. State officials in Alabama estimate that $30 to $35 million in additional state funding will be needed for the state’s CHIP program in FFY 2020, and Oklahoma predicts it will need $14.8 million more. Planning for the phased reduction in the CHIP match rate may pose a particular challenge for states with legislatures that only meet every other year, considering additional state dollars will be needed in FFY 2021 as well.
Some states may consider modifying income eligibility levels for CHIP as a way to address the decreasing federal CHIP match rate, but that is not an option because the 2018 CHIP funding extension includes a requirement that states maintain certain coverage levels for children enrolled in Medicaid and CHIP — called the maintenance of effort (MOE). The HEALTHY KIDS and ACCESS Acts build on the ACA’s MOE provision, which requires states to maintain their Medicaid and CHIP eligibility levels for children that were in place as of March 23, 2010.
Through the ACA, the MOE for children was set to expire at the end of FFY 2019, but the HEALTHY KIDS and ACCESS Acts extend the MOE requirements through FFY 2027. However, beginning Oct. 1, 2019, the MOE protection targets children in families with incomes up to 300 percent of the federal poverty level (FPL). This means that states with Medicaid or CHIP eligibility levels for children above this level have flexibility to lower them to 300 percent of FPL. However, because the majority of states do not provide coverage above 300 percent of FPL, most states will be required to keep their current eligibility levels in place. The intent of the MOE is to help ensure coverage stability for children enrolled in Medicaid and CHIP, and it may become increasingly important if recently reported declines in children’s coverage continue. For more information about the MOE, read 101: Maintenance of Effort (MOE) Requirements for Children in Medicaid and CHIP Fact Sheet.
As state officials weigh these budgetary issues, many states are also seeking to implement initiatives to enhance children’s coverage and care. Some states are developing innovative Health Services Initiatives, strengthening coordination with schools and other community partners to better meet children’s health and behavioral health needs, or improving integrated care for children. In the coming months, the National Academy for State Health Policy (NASHP) will be gathering and sharing information highlighting state efforts to improve children’s coverage and care.
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