HD9 - Improving Access to Perinatal Care in Rural and Underserved Areas


Executive Summary:
In February 1997, the General Assembly of Virginia adopted House Joint Resolution 617, which requested the Maternal and Child Health Council, in conjunction with other entities, to review current data on improving access to perinatal care in rural and underserved areas of the Commonwealth. The General Assembly Resolution noted that various studies have reported a shortage of prenatal care in certain areas of the Commonwealth and that an analysis of the incentives and disincentives to providing care for the underserved was necessary.

The Assembly's concern is supported by research literature linking continuous prenatal care to healthy birth outcomes. In 1995, 18 percent of the state's pregnant women failed to enter into prenatal care during the first trimester.

The Perinatal/Early Childhood Subcommittee of the Maternal and Child Health Council discussed in detail the definition of the concept "under served." Based on this discussion and a review of the research literature, the Council determined that underserved should be defined based upon both manpower availability and underutilization of services.

Key informant interviews were used as a primary data collection tool to develop strategies for the improvement of care in underserved areas. The survey, which contained both quantitative specific choice questions and open-ended qualitative questions, was completed by fifty-seven respondents representing providers, medical schools, managed care organizations, hospitals and payers of health services.

The results of the survey indicate that ready access to perinatal care in some rural areas is a significant and persistent concern due to manpower shortages. In addition, the data indicate that the underutilization of services and the associated outcome of low birth weight and infant mortality is a great concern, even in areas that have a sufficient number of providers.

The results of the survey also show that multiple strategies must be used to improve access to perinatal care in underserved areas. Collaborative training models in medical and nursing schools are strongly encouraged by the survey respondents. In the opinion of the survey respondents, barriers to care that inhibit broader participation by perinatal providers should be removed. Incentives for collaborative practice should be strengthened. Access to care should be enhanced by transportation programs and education.

Solutions are more likely to be successful when they are locally driven. Reliance on local data has thus been used to determine underserved areas as compared to incomplete manpower data banks. Any statewide plan must rely on the interest and commitment of local communities to seek creative ways to solve perinatal access problems.

Options have been developed through discussions by the perinatal workgroup using findings from the survey of key informants. The options focus on the (1) recruitment of perinatal providers to the designated underserved areas, (2) promotion of collaborative practice arrangements in rural and underserved areas and (3) strategies to encourage women to seek perinatal services. These policy options are all predicated on the designation of underserved areas as determined by this report.

• Direct the Virginia Department of Health to recognize the perinatal underserved areas as defined by this study, and assume responsibility for annual updates, in conjunction with the Regional Perinatal Coordinating Councils.

(1) Recruiting Perinatal Providers to Practice in Under Served Areas

• Recommend legislation that would allow the Board of Directors of the Birth-Related Neurological Injury Compensation Program to reduce the participation fee for all providers practicing in the perinatal underserved areas due to manpower deficiencies. This action requires no funding.

• The Governor and/or the 1998 General Assembly should provide funding to establish and maintain the manpower data base on licensed health care professionals. Previous investigation revealed an estimated cost of $175,000.00 to establish and pilot test all data from licensed health care professionals. Options for funding this program could include any combination of the following:

1. Fund the establishment and ongoing aspects of the program by appropriating monies from the general fund.

2. The 1998 General Assembly could provide the initial program development and pilot, and the annual cost be provided through increasing licensure fees for all health professionals.

3. Increase licensure fees for all health care professionals.

4. Each state agency using the data could provide funds on an annual basis.

5. 1998 general funds provide the initial program development and pilot and 60 percent of the annual cost of maintaining the database. The difference would be supplemented by revenues generated from the sale of the data to private and public agencies.

• Recommend that legislation in the 1998 legislative session be considered to direct the Virginia Department of Health to include the criteria for perinatal underserved due to manpower deficiencies in the state scholarship and tuition reimbursement programs. This action requires no additional funding.

• Recommend that the Virginia Department of Health (VDH) include in the state physician loan repayment programs, the manpower deficiencies criteria for perinatal underserved areas. This should be implemented as soon as possible. Legislation was passed in 1994 to establish this program, but no mechanism for funding was provided. General funds should be appropriated.

(2) Promotion of Collaborative Practice Models in Under Served Areas

• Recommend the State Council of Higher Education convene a task force within calendar year 1998, to develop a collaborative training model for professional education programs. This task force would consist of representatives of medical and nursing schools, Area Health Education Centers, Community Health Centers and private/public hospitals. The purpose of the task force is to develop a core curriculum for collaborative classroom, as well as clinical, practice to be used in every program. The task force could initially contact the W. K. Kellogg Foundation in order to learn about collaborative programs that have been provided through grants.

• Recommend that the Virginia Health Care Foundation give priority in awarding grant funds to innovative projects that utilize collaborative practice models in the delivery of perinatal health care in rural and underserved areas. Recommend that this process begin in FY98. This action requires no additional funding.

• Recommend that the State Corporation Commission convene a task force including representatives of insurance companies, managed care organizations and the Department of Medical Assistance to re-examine the fee and reimbursement differentials for prenatal health care and delivery services, so that providers are more equitably compensated for their services. These organizations will work with representatives of the medical societies, the Virginia Chapter of the American College of Nurse Midwives and the Virginia Council of Nurse Practitioners in order to achieve this goal. This meeting should be convened no later than December 1998. This action requires no additional funding.

• Recommend that further progress be made toward full implementation of the 1998 Joint Legislative and Audit Review Commission (JLARC) recommendations with regard to the basis for determining the local match requirement in the cooperative budget based on ability to pay.

(3) Strategies to Encourage Women to Seek Perinatal Services

• Recommend that VDH direct the Regional Perinatal Coordinating Councils (RPCCs) collaborate with other perinatal programs to implement public education campaigns emphasizing the importance of preconception and prenatal care. The planning phase should begin in FY99 and should not require additional funding.

• The Resource Mothers Programs should be given additional funding from the 1998 General Assembly through general funds to establish and/or expand perinatal services to these areas.

• Recommend the Department of Medical Assistance Services (DMAS) study and make recommendations on Medicaid transportation with special emphasis on rural and underserved areas. The study should be accomplished in one year and recommendations be presented to the General Assembly no later than FY 2000. This is an initial step to address the more complex problem of lack of transportation in the Commonwealth; however, further studies for overall solutions will be needed. Recommend general funds support this study.

• Recommend that the Department of Medical Assistance Services (DMAS) collaborate with other agencies to expand outreach efforts to increase participation by enrolling Medicaid eligible pregnant women.

• The Department of Housing and Community Development (DCHD) should designate the improvement of perinatal care and access to health care as top priorities for the Appalachian Regional Commission (ARC) funding for 1999. The ARC, at the federal level, includes prenatal care and access to health care among its funding priorities. Virginia can also designate these as top priorities. The DCRD should also include the development of primary health care to include perinatal health care as an economic development project which can be given priority for funding from other sources.