Kansas seeks ‘once in a generation’ federal funding to improve maternal health outcomes

Veronica Mullet, left, is a certified nurse midwife who worked with Kendra Wyatt at New Birth Co. in Overland Park. Mullet and several midwives from the now-shuttered company have started their own company, Blossom Midwifery and Wellness. (Cami Koons for Kansas Reflector)

Officials at KanCare, the state’s Medicaid program, want to turn Kansas maternity care deserts into “an oasis,” with help from a federal grant.

Melissa Warfield, director of Medicaid policy and research at KanCare, said the agency is finishing its application for the Transforming Maternal Health grant in hopes of being one of 15 states to receive 10 years of support and $17 million from the federal government.

“This is really a once in a generation opportunity for Kansas,” Warfield said.

March of Dimes reported that more than 45% of Kansas counties qualified as maternal health care deserts. That’s 13 percentage points more than the national average.

A recent report from the Commonwealth Fund estimated that 41% of maternal deaths could be averted with an integration of midwife workforce into health care delivery systems, and address some of the maternal workforce shortages in the U.S.

Warfield said these are the same benefits she hopes Kansas will reap by expanding the midwifery workforce and KanCare reimbursement structures, under the grant.

The goal of the program is to create community systems. Warfield said the Medicaid-based midwifery growth would work “hand in glove” with community health care systems, physicians and existing birth care facilities.

The grant aims to reduce low-risk cesarean sections, incidents of severe maternal mortality, low birth weight and Medicaid expenditures, and to improve overall perinatal outcomes.

Warfield said the first step, if awarded, would be to assess the current midwife capacity in the state and the options to include additional levels of midwife licensure.

There are several levels of midwife licensure, certified nurse midwives and certified midwives, which impacts the services they can provide and the amount of reimbursement they can receive.

Kendra Wyatt is the co-founder and CEO of New Birth Co. , a natural birth center in Overland Park that closed at the beginning of September.

Wyatt has worked with legislators and advocated for bills that would change the state’s definition of health care providers to include maternity centers, like her own.

Wyatt said this would bring a lot of midwives “out of the shadows” and allow them to help meet the shortages in the state and get adequately reimbursed for it.

“We’re on the bench,” Wyatt said. “We’re not being activated the way we could.”

A report from Robert Wood Johnson Foundation found midwives and birth centers in state Medicaid programs, on average, are paid 15% to 70% of what hospitals are paid.

That, and low reimbursement rates from private insurance companies, are what Wyatt said necessitated her center’s closure .

Only a percentage of women are eligible for a natural birth. High-risk pregnancies and cesarean section births still need a hospital.

Wyatt’s vision is a hub-and-spoke model, similar to the community-supported model Warfield described, where rural health care facilities can bring in licensed midwives to perform prenatal care and assessments. Women who meet the low-risk criteria to deliver naturally could do so at those facilities.

Other patients can be passed to a different “hub” or hospital that offers specialized care or can perform a cesarean birth. It would give patients the ability to seek at least some of their care at their local facilities.

“I think people who are able to have natural childbirth, we should consider (getting) those folks into birth centers,” Wyatt said. “Let’s keep the higher acuity staff and facility for people who need inductions and epidurals and IVs and all those additional things.”

Wyatt challenges the idea that a hospital has to be able to offer cesarean sections in order to “bring back birth.” A midwife can’t do everything, but Wyatt said they can help alleviate some of the maternal health shortages in rural Kansas.

Christine Osterlund, the state Medicaid director, said part of the solution is to transition to reimburse for outcomes rather than services and level of licensure.

“There still are many codes that our nurse midwives bill for where they do receive less reimbursement than another type of licensed practitioner,” Osterlund said.

She said the Legislature has implemented policies that decrease the amount of “haircutting,” or reimbursing lower-level practitioners at a lesser rate, over the past several years.

“To provide that access to care and safe delivery options, the use of midwives, the use of nurse practitioners and other levels of practitioners, that’s why Medicaid made those decisions,” Osterlund said.

Osterlund said in a standardized system like Medicaid, it can be difficult to develop more alternative reimbursement structures.

“What’s so amazing about this grant is it’s going to provide not only dollars but technical assistance to help Kansas think differently,” Osterlund said.

The goal of maternal care is to have a healthy delivery and postpartum transition. Osterlund said part of the goal with this grant would be to find ways to reward providers who have healthy outcomes, even if it’s not in a traditional setting.

That could apply to midwives who provide care at home or outside of a hospital, or to emergency medical transportation teams who safely deliver a baby.

“(The grant) I think will really move us forward into being one of the leading states in the nation for this type of payment structure,” Osterlund said.

The grant is focused through the state’s Medicaid program, but Osterlund said the benefits extend to anyone in a community that’s able to receive additional care through the grant –– especially communities that are currently in a maternal health care desert.

Warfield said she doesn’t expect major legislative hurdles with the grant’s implementation.

In the past several years, Kansas officials have expanded postpartum Medicaid coverage up to 12 months and added doula services under the program .

KanCare has submitted a letter of intent to apply for the grant, which is due Sept. 20. Warfield said award dates and disbursement are subject to Centers for Medicare and Medicaid Services, but awarded states should begin implementation in early 2025.