Medicaid advisory staff on Thursday said policymakers will need to focus on how to improve care coordination and align state-level policies and programs to speed up a reduction in the number of babies born with neonatal abstinence syndrome.
The rate of babies born with neonatal abstinence syndrome grew about three-fold from 2008 to 2016 for newborn hospitalizations where Medicaid was the expected payer, according to the Medicaid and CHIP Payment and Access Commission staff at a meeting Thursday. The rise in neonatal abstinence syndrome paralleled a rapid increase in the number of pregnant women suffering from opioid use disorder.
Approximately 5.7% of pregnant women covered by Medicaid reported illicit drug dependence or abuse in the past year compared to just 1.9% of pregnant women with other types of health coverage, according to MACPAC analysts.
Newborns exposed to addictive opioids during pregnancy can develop several problems, including neonatal abstinence syndrome.
Buprenorphine and methadone are recommended to treat pregnant women with opioid use disorder to reduce the risk of overdose, death, Hepatitis C and HIV. Women who receive the treatment are more likely to carry to term and give birth to higher weight babies, but newborns are more likely to suffer drug withdrawal.
"We're trading that very high risk, preterm infant for a bigger infant that can have drug withdrawal," said Dr. Stephen Patrick, associate professor of pediatrics and health policy at Vanderbilt University and director of Vanderbilt's Center for Child Health Policy. "That's a good tradeoff."
But access to treatment is a critical barrier for pregnant and postpartum women with substance use disorder. Women often have difficulty accessing medication to treat their opioid use disorder and there's a lack of comprehensive approaches to care, Patrick said. There may also be reimbursement issues, but there isn't much information about those.
Fewer than 25% of treatment facilities provide specialized care for moms suffering from substance use disorder, and only 8% offer dedicated treatment and one or more medications approved for opioid use disorder such as buprenorphine. Even fewer treatment facilities accept Medicaid and offer childcare or residential beds for their patients' children.
Care coordination is a central issue because pregnant women suffering from substance abuse disorder need more than prenatal care, but addiction, behavioral health, child welfare and other services are often siloed. Primary care providers, obstetricians and gynecologists should have a greater role in coordinating care for pregnant women with substance use disorder because their healthcare and social needs are complex.
"This has to be seen as a problem that spans the life," said Dr. James Becker, vice dean for government affairs, healthcare policy and external affairs at Marshall University's Joan C. Edwards School of Medicine and medical director of the Bureau for Medical Services at the West Virginia Department of Health & Human Resources.
States also need to align their public health, child protection and substance use authorities with Medicaid to avoid the risk of doing duplicative work to meet separate but quite similar requirements. Medicaid should take the lead on coordinating care and help states implement evidence-based care, said Olivia Alford, director of the value-based purchasing unit for MaineCare Services.
Several MACPAC commissioners raised concerns that many of the current approaches to improving care coordination for substance use disorder is focused on opioids, even though pregnant women are increasingly using other drugs that cause neonatal abstinence syndrome, such as methamphetamine. Policies and programs should be flexible enough to cope with changes in drug use among people with substance use disorder.
The Center for Medicare and Medicaid Innovation's Maternal Opioid Misuse model kicked off in October 2018 to tackle the disjointed care problems that pregnant and postpartum Medicaid enrollees face when dealing with opioid use disorder. CMMI also launched the Integrated Care for Kids model earlier this year. It covers all Medicaid and CHIP enrollees up to the age of 21 and aims to improve child health, lower inpatient stays, coordinate care and develop state-specific alternative payment models.