Kansas legislators lift veil on Medicaid doula services, reimbursement rates

Cathy and Jesse Watts look after their 2-year-old while at an appointment with their doula on Aug. 29, 2024, in Topeka. (Anna Kaminski/Kansas Reflector)

TOPEKA — The addition of doula services to Kansas’ Medicaid program spurred confusion among legislators and prompted scrutiny of reimbursement rates for Medicaid services.

Doula services, which support a person throughout pregnancy, were added to the state’s Medicaid program effective July 1 . In an Aug. 27 legislative hearing, lawmakers used doula services as a touchstone for concerns about reimbursement rates under KanCare, as Medicaid is known in Kansas.

While new to KanCare, doula services have had roots in Kansas for years.

Abriona Markham, executive director of the two-year-old Topeka Doula Project , is a community-based doula, which is one of four types of doulas. The others are prenatal doulas, labor and delivery doulas and postpartum doulas. Community-based doulas offer connections to resources and social services in addition to the nonclinical support they provide as someone goes through their pregnancy.

Markham specializes in supporting teen mothers, recently or actively incarcerated mothers and low-income mothers.

“Those are the underrepresented populations, right? They’re the populations that don’t technically get a say-so in their care,” Markham said. “So what do doulas do? We educate. We give autonomy back to birth. We put community back in birth. We let them know they’re in charge.”

Many of Markham’s clients are covered under KanCare, she said.

On a Friday in late August, Markham met with Cathy Watts, who is expecting her third child. She is in her third trimester, which is further along than she got with her past few pregnancies, she said. Markham is Watts’ doula.

“She listens to me,” Watts, 23, said.

This pregnancy is the first time Watts has recruited doula services, and at 34 weeks, they discussed each decision she would have to make on delivery day. That included whether Watts wanted an epidural and who would cut the umbilical cord — she chose her husband, Jesse.

The Watts’ tell Markham about their doctor’s appointments so they can better understand what’s going on, what choices they have and act as their advocate.

“We’ve got somebody that will stand their ground regardless,” said Jesse Watts, 24.

Doulas must undergo at least 30 hours of training with a national program and obtain a professional services recommendation in Kansas in order to bill KanCare. They are not doctors or nurses and do not replace the roles of physicians. Instead, doulas offer their services from a supportive role, said Shalae Harris, clinical director for the Kansas Department of Health and Environment, the agency that administers KanCare.

The doula works with physicians and a patient’s care team and will accompany a patient during their labor and delivery, Harris said at the Aug. 27 hearing.

“The doula is there the entire time supporting — rubbing a back maybe, answering questions and being that advocate in the room to work with the professionals,” she said.

Several lawmakers and medical community members expressed concern at the hearing with where the money to fund the added doula services was coming from.

Doula services under KanCare are estimated to cost roughly $351,000 in their first year. Just less than $140,000 of that comes from the state, said Jill Bronaugh, the KDHE spokeswoman.

The services have been billed as a way to improve maternal health outcomes and reduce both maternal and infant mortality rates. Twenty-one states have doula services covered under their Medicaid programs, and an estimated 43 have explored doula services, said Yvonne Case, KDHE operations director.

“It’s the maternal morbidity rates that are driving this and particularly with disparate groups,” Case said.

A January meta-analysis from the American Journal of Obstetrics and Gynecology found that patients who have a doula are 68% less likely to have a cesarean delivery, or a C-section. Research has shown that maternal morbidity and mortality disproportionately impacts low-income mothers.

Medical organizations have said the addition of doula services under KanCare caught them by surprise, and the August hearing exposed some frustration with physicians’ reimbursement rates under KanCare. This came after legislators attempted to raise Medicaid reimbursement rates in April , which wasn’t applied evenly, said Rachelle Colombo, executive director of the Kansas Medical Society.

“We’re going to find ourselves with a physician community that is somewhat disenfranchised and surprised that this isn’t going to be applied across the board,” Colombo said.

She questioned where the money for the added doula services was coming from when physicians have been requesting reimbursement hikes for years.

“The rate of the doula reimbursement is surprisingly high because it’s not a clinical service and you have low reimbursement for obstetrics and gynecology, so it seems at odds,” Colombo said.

Doulas can be reimbursed for multiple services under KanCare. The reimbursement rate for doula services at a delivery totals nearly $1,300, which is on par with other states’ Medicaid coverage, according to KDHE.

KDHE is conducting a comprehensive reimbursement rate study for all Medicaid services — not only doula or physician services — and its results will be provided to the Legislature, said Bronaugh, the KDHE spokeswoman.