United States: CMMI's Transforming Maternal Health Model: Considerations For State Medicaid Agencies

Summary

On December 15, 2023, the CMS Innovation Center (CMMI) announced a new voluntary model for state Medicaid agencies called Transforming Maternal Health (TMaH). TMaH was developed in response to the profound maternal morbidity and mortality experienced in the United States and stark maternal health inequities. TMaH adds to CMMI's recent portfolio of Medicaid and CHIP-focused models – including the States Advancing All-Payer Health Equity Approaches and Development (AHEAD) model and the recently announced Innovation in Behavioral Health (IBH) model. Lessons learned from CMMI's "Strategy Refresh" concluded that more of CMMI's models should emphasize Medicaid participation, and with Medicaid paying for over 40% of the births in the United States (in some states, that number reaches more than 60%), CMMI's focus on the Medicaid population for a maternal health model is critical. TMaH follows several other Medicaid-focused maternal models tested by CMMI, including the Maternal Opioid Misuse (MOM) Model and Strong Start for Mothers and Newborns Initiative.

TMaH offers states funding, technical assistance, and a pre-implementation period to develop the model's elements, including a value-based payment (VBP) approach to provide whole-person care to individuals during pregnancy, birth, and postpartum. Targeted, state-specific technical assistance from CMMI is designed to support state Medicaid-led initiatives and encourage state-level collaboration, which could include aligning and building on Medicaid programs' existing efforts.

TMaH Model and Overview Requirements

Model Design and Requirements

TMaH is organized into requirements and goals that align to three distinct pillars (Access to Care, Infrastructure, and Workforce Capacity; Quality Improvement and Safety; and Whole-Person Care Delivery). States can synergize initiatives across the maternal healthcare delivery system and create and/or build on partnerships with a broad base of stakeholders – including but not limited to maternal health providers, hospitals, birth centers, community-based organizations (CBOs), Medicaid managed care organizations (MCOs), Perinatal Quality Collaboratives, and others. The Model recognizes the centrality of MCOs to implementation in Medicaid managed care states, though eligibility for TMaH is not limited to those states. Components of each pillar include:

• Access to Care, Infrastructure, and Workforce Capacity Pillar—As shown by the three-year pre-implementation period, a key aspect of the Model is making investments in foundational maternal care resources. States will be required to address access challenges and develop strategies to increase the availability of doulas, midwives, and Birth Centers, as well as have the option to expand coverage for perinatal community health workers. Participation in TMaH will require that states plan for and execute data infrastructure and value-based payment arrangements.
• Quality Improvement and Safety Pillar—Another key requirement of TMaH is to support state Medicaid programs and clinicians in implementing standard, evidence-based practices that are known to improve clinical quality outcomes for pregnant persons. Participating states will be required to establish expectations for partners to carry out and/or support increasing the uptake of "patient safety bundles" as well as work with hospitals and health systems to achieve the "Birthing-Friendly" quality designation by CMS.Participating states and their partners will be able to use the Model's learning platform to share insights on workflows and protocols that have demonstrated improved outcomes.
• Whole-Person Care Delivery Pillar—A central tenet of TMaH is a care approach that is individualized for Medicaid enrollees, informed by comprehensive assessments to screen for risks (such as perinatal depression, anxiety, substance use, and health-related social needs [HRSNs]) to link members to care during pregnancy. Participating states will be required to assist with access to remote patient monitoring for diabetes and hypertension. These required TMaH activities, as well as options to expand services (i.e., group perinatal care, oral care) and delivery modalities (i.e., telehealth, home visits, mobile clinics) are intended to give State Medicaid Agencies the flexibility to ensure comprehensive care needs can be met for its pregnant members.

More Model Details

• In recognition of nationwide maternal health inequities, CMMI will require participating states to develop and implement a health equity plan to address health disparities. In collaboration with MCOs, providers, CBOs, and others, State Medicaid Agencies will work to address HRSN screening and referrals, gaps in care delivery, transportation challenges, and ensure resources are culturally competent.
• CMMI indicates TMaH will encourage states to expand 12-month postpartum Medicaid coverage for the 11 states that have yet to do so.

Considerations for State Medicaid Agencies

States will want to consider their existing maternity initiatives and what more they may contemplate implementing through participation in TMaH, utilizing the available funds and technical assistance support to accelerate ongoing initiatives. Specific considerations for each pillar of the model include:

• Access to Care, Infrastructure, and Workforce Capacity Pillar: States will want to consider how the Model supports existing goals to cover holistic maternity care providers and aligns with broader initiatives, such as incorporating doulas and community health workers in their HRSN strategies at the Medicaid and state levels. While the Model largely speaks to the direct maternal workforce, states may also want to consider their internal Medicaid employee capacity to support the planning and implementation of TMaH.
• Quality Improvement and Safety Pillar: States will want to consider how existing quality metrics around patient safety and shared decision-making could be leveraged for TMaH, as well as how the pre-implementation period could be used to revise patient safety protocol standards and the use of patient-reported outcome measures (PROMs) as part of a refined maternal quality strategy.
• Whole-Person Care Delivery Pillar: States will want to consider how the Model aligns with a state's goals and existing implementation of care management models for high-risk pregnancies in their Medicaid and CHIP programs as well as existing gaps in care coordination that can be addressed through more provider and social service networks that utilize community health workers and/or home visiting programs. The Model's requirements for HRSN screening and remote patient monitoring for pregnant members could potentially be expanded to other member populations, or for an existing screening initiative, pregnant members could be highlighted as a new population of focus.

States will want to consider not only how to align TMaH implementation in their Medicaid and CHIP programs, but also where there are unique opportunities or processes in CHIP. For example, states may be able to use part of the cooperative agreement award to bolster funding for health service initiatives (HSIs) that are designed to improve children's health. Also, CHIP-specific authorities such as the From-Conception-to-End-of-Pregnancy option may be used to provide coverage to pregnant immigrant populations.

Initial Questions for CMMI

While states await more information on the Model from CMMI, they are starting to generate questions about how it will be implemented and what flexibilities states will have when designing their specific programs. Some questions for CMMI include:

• Is it permissible to participate in TMaH and other CMMI models, including any of the newer models also aimed at state Medicaid program participation?
• How flexible will CMMI be in the implementation of this model? Including but not limited to:
  • Will states have flexibility in how they allocate funding across the three pillars (vs. an even distribution)?
  • Will states be able to maintain current "design" of a related element if already implemented in the state, while also reserving the ability to adjust an intervention over the course of the 10-year TMaH implementation?
• What are the required vs. flexible components of the value-based alternative payment model (APM)?
• What activities will states be allowed to fund through the cooperative agreements?
• Must all TMaH model elements be implemented by the start of the seven-year Implementation Period?
• What are the evaluation requirements for TMaH? Specifically:
  • How will success of TMaH be measured? What specific metrics will states need to achieve? How will metrics be reported to CMMI and using what data?
  • Will states have the opportunity to align TMaH evaluation and measurement with existing state approaches and measures?
• Related to the health equity plan, will CMMI prescribe an approach or will SMAs have the ability to craft the health equity plan in recognition of observed state-specific inequities and/or priority approaches a state is leading related to reducing disparities? Does CMMI plan to measure the plan's effectiveness? If so, by what standard?

Next Steps and More Information

CMS will release a NOFO that will include further details on TMaH and, importantly, the formal application for states interested in participating in Spring 2024. States will submit their applications in Summer 2024, and CMS intends to award Cooperative Agreements to as many as 15 state Medicaid agencies by Fall 2024. TMaH is expected to launch in January 2025.

More information from CMMI on TMaH can be found here. Manatt has published other resources on CMMI's GUIDE and MCP models for reference

The content of this article is intended to provide a general guide to the subject matter. Specialist advice should be sought about your specific circumstances.