Policy Advocacy Strategy Paper HPM 759
Introduction
Providing access to obstetric care in rural areas is a growing concern. Rural America represents 75% of the nation’s landmass and is home to 22.8% of U.S. women aged 18 years and older (ERS, 2013). An estimated half a million rural women give birth in US hospitals each year. The majority of rural women give birth at their community hospitals and therefore rely on local maternity services (Kozhimannil, 2016). Recent closures of rural obstetric units and entire hospitals have exacerbated concerns about access to care for more than twenty-eight million women of reproductive age living in rural America. Between 2004-2014, nine percent of rural counties experienced the loss of all hospital obstetric services (Hung, 2017). Closures occurred in facilities that were more likely to be smaller in size, privately owned, and in communities with fewer obstetricians and family physicians, as well as in communities where families have lower income and have fewer resources to overcome added barriers to care (Kozhimannil, 2016).
Nationally, about 54 percent of rural counties in the United States lack hospital obstetric services (Hung, 2017). The number is rising as rural hospitals struggle with pressures that are forcing increased rates of closure. As a result, fewer than half of rural women live within a 30-minute drive of the nearest hospital offering obstetric services. Only about 88 percent of women in rural towns live within a 60-minute drive, and in the most isolated areas that number is 79 percent (Rayburn, 2012). Communities that lack obstetrical services often experience an increase in the rate of emergency room births in hospitals or in non-hospital settings, which may not be equipped with infant monitors and equipment that is necessary for delivery. Research shows that preterm and out-of-hospital births rise when a community loses hospital-based obstetrics care (Kozhilmannil, 2018).
Figure
1: Hospital Obstetric Services in US Counties, 2004-2014
Source: Hung, 2017
In particular, rural areas with higher percentages of lower income, color, poor health status, and enrollment in government insurance programs like Medicaid are more vulnerable to losing or not having OB services (Kozhilmannil, 2018). This makes some rural communities with populations that already suffer the worst health burdens the most likely to lose access to needed OB care and more vulnerable to poor outcomes around the time of childbirth. In 2010, Medicaid funded 45% of all births nationally (Markus, 2013), and women giving birth in rural hospitals were more likely than urban women to be covered by Medicaid (51% of rural women compared to 39% of urban) (Kozhimannil, 2014). Maternity care under Medicaid is typically reimbursed with a global fee that covers all care for pregnant women through the post-partum period. The high rate of births covered by Medicaid poses a financial challenge for rural hospitals as Medicaid’s reimbursement for childbirth is half that of private insurers on average (Kozhimannil, 2016). As demonstrated by the closure of obstetrics units and hospitals primarily serving Medicaid patients, the current reimbursement rate for pregnancy related care, even combined with additional grants and funding support, is insufficient to support obstetric services in many areas of the state.
Long – Term Policy Goal
Adopt a legislative policy increasing the rates of Medicaid payments for obstetric services in rural areas to levels roughly comparable to those paid by private insurers.
Medicaid base payments for obstetric services typically falls below what the hospitals charge private insurers or individuals for the services or cost of providing these services, leaving a shortfall for the hospitals. Therefore, if reimbursement costs for Medicaid are inadequate, a hospital may lose money by treating primarily Medicaid patients for these services. On average, the reimbursement rate for vaginal deliveries is $1,943.54 and $2,156.67 for cesarean deliveries. However, the cost to private insurers for childbirth in MT in 2016 and 2017 is $6,042 for vaginal delivery and $8,602 for cesarean deliveries (Rebala, 2017). In other words, the Medicaid reimbursement for childbirth is approximately 25-30% of the reimbursement from private insurance. The disparity between Medicaid and private insurance reimbursement is demonstrative of the financial loss occurring by taking primarily Medicaid patients (Wilson, 2018). For rural hospitals that serve large numbers of women covered by Medicaid, changes in base payment reimbursement rates may have a significant financial impact.
This long-term policy goal would result in an overall stabilization in the number of providers located in rural areas who are providing perinatal care and performing deliveries. Rural areas would be defined as all non-Metro counties, as well as Metropolitan counties with RUCA codes 4-10. Impact of this policy change could be measured using two criteria: the total number of participating Medicaid providers in a rural area providing obstetric services and the number of deliveries performed by targeted providers. Obstetricians and others who give obstetrical care (nurse midwives and family physicians) must be willing to accept Medicaid payment if the state is to ensure access in rural areas. Providers decide whether to participate in Medicaid, in part, based on how Medicaid payment levels compare with those in the private market. By eliminating the disparity in payment between Medicaid and private insurers, the state is in a better position to retain an adequate pool of individuals providing services in rural areas. The intended message to providers is that if they show a clear commitment to rural Medicaid patients, they will be rewarded and encouraged to maintain their participation in the future.
Short- Term Policy Goal
Implement a legislative policy developing a program for supplemental quality payments to providers which incentive provision of evidence-based obstetrical services in rural areas of the state.
This short-term policy goal seeks to increase Medicaid reimbursement for rural deliveries based on quality indicators. While a comprise from the long-term policy goal of overall increases in reimbursement rates for these services in rural areas, it would be a meaningful step in the right direction that most supportive stakeholders are likely to endorse. Through this program, providers would be incentivized to provide obstetric services to women living in rural areas given the increased payment to offset their costs providing services to Medicaid-eligible women.
This proposed policy explores quality measurement strategies for Medicaid services based on federal and national measurement initiatives. Payments would come from a maximum pool of funds per fiscal year devoted to clinicians providing obstetrical services in rural areas who meet performance measures described below. Performance data would be calculated using paid claims data from the state’s Medicaid Management Information System (MMIS) and the online prenatal and postpartum notification forms received from providers. Participating providers would be awarded a performance measure points based on services provided in rural areas of the state such as:
- First prenatal visit within 14 days of a confirmed pregnancy.
- Completion of 90% of routine prenatal checkups.
- Full term (39 weeks gestation), vaginal delivery after spontaneous labor.
- At least one postpartum visit within 21-56 days postpartum
To calculate each provider’s performance payment, a provider’s earned performance measure points during the performance period which are summed and divided by the total number of points for all participating obstetrical providers during the performance period. Each obstetrical provider’s performance payment will be the aforementioned percentage multiplied by the available supplemental pool.
Advocacy Strategy- Key Points
** Where you live shouldn’t determine if you and your baby survive birth.
This message of ethics and fairness will resonate with patients, advocates, and community and state leaders. The problem of ensuring access to obstetrical care for low-income pregnant women has reached critical proportions within most state Medicaid programs, including Montana. Lack of access to rural obstetrics care is associated with a higher rate of poor outcomes, including of preterm delivery and infant mortality. A 1995 Florida study showed that the loss of one OB-GYN in a rural community increased infant mortality by 9.6 percent (Larimore, 1995). Maternal mortality is also significantly higher in rural areas. Figure 2 analysis of CDC data shows in 2015 the maternal mortality rate in large central metropolitan areas was 18.2 per 100,000 live births—but in the most rural areas it was 29.4. Underlying health conditions such as hypertension or diabetes could be factors, alongside poor prenatal care and geographic access of obstetric services. A 2017 report found maternal deaths to be 60 percent more likely in the nation’s most rural areas than in large metro areas, although the role of distance is unclear (Maron, 2017). Also, births that don’t go as planned can lead to mental health problems for some women, including post-traumatic stress disorder and anxiety. Beyond the stress of driving hours to get to a hospital, families face extra costs if they choose to stay in another community until delivery, including time away from work and care for children still at home.
Figure 2: Rural Maternal and Infant Mortality Rates
Source: Amanda
Montanez, Scientific America, CDC PRAMS 2015 Data
** Investing in pregnancy means saving dollars.
Assuring adequate perinatal care for these women is an economic issue as well as an ethical one. This message will resonate with state policymakers and the fiscally conservative who realize that resources committed to prenatal care will save money in the long term. Annually, over $1 billion is spent on hospitalizations related to pregnancy complications (AHRQ, 2003). Prematurity and its resulting low birth weights are major contributing factors leading to complications that result in higher costs, such as transfers to intensive-care unit (ICU) facilities. There is a much higher incidence of prematurity, low birth weights, and transfers to acute-care facilities among females who do not receive prenatal care (Henderson, 1994). By investing in prenatal and labor and delivery services on the front end, the state will see savings on the back end.
** Increasing payments for Medicaid services is a proven method for incentivizing provider participation.
The evidence-base behind this message will resonate with the state policy makers. Experience shows that increasing payment rates for Medicaid services is a proven method for increasing access to primary care services. A recent example is the ACA provision for a mandatory two-year increase in fees for primary care services to Medicare levels for both Medicaid fee-for-service and managed care. As a result, between 2014 and 2016, Medicaid physician fees increased by an average of 4.1 percent, with greater fee increases for primary care and obstetric care than for other services, on average (Zuckerman, 2017). During this time, Montana’s state Medicaid-to-Medicare fee index increased to 1.17 for obstetric services, or approximately 5% increase. As demonstrated by increasing in funding for primary care, higher Medicaid reimbursement rates may lead to the increasing availability of appointments for Medicaid patients, lower overall wait times for appointments, and, therefore, increased access to prenatal care (Polsky, 2015). Many rural states, including Colorado, Idaho, Nevada, Utah, and New Mexico, maintained full or partial continuation of the primary care feed bump and have seen positive effects on physician participation and beneficiary access to care (Zuckerman, 2017).
Stakeholder Analysis
A number of stakeholders have an interest in increasing and/or maintaining access to obstetric services in rural areas of Montana, including state agencies, state medical school, large healthcare systems, and state and national health associations. Appendix A includes a detailed stakeholder analysis of these parties.
The strongest supporters of the short- and long-term policy goals will be the ob-gyn provider associations, including the Montana Midwifery Association (MMA), the Planned Parenthood Advocates of Montana (PPAM), and the American College of Obstetricians and Gynecologists Montana Section (represented by the Montana Medical Association). While less powerful in terms of lobbyist or PACs, these organizations have active grassroots bases and can serve in the champion roll for the policy initiative. The majority of the most influential stakeholders, such as the Montana Hospital Association, the Montana Medical Association, and the Providence Hospital System, will likely be moderate supporters with some level of involvement in the effort, although they will not be our strongest advocates. Both the hospital groups will likely support both the short-and long- term policy goals, especially if it is possible to estimate the potential financial gain to these systems, not only in additional quality payments or enhance payment, but also ability to sustain obstetric services in these communities. The Montana Medical Association may be likely to oppose the short-term policy solution of a quality reporting program due to additional reporting and administrative burden, and therefore may be a proponent only of the full move to increases Medicaid payments for these services.
The stakeholder with the greatest opposition will likely be Montanans Against Tax Hikes. As a conservative think tank in the state, they are unlikely to support any form of legislative that increases state spending and/or growths the scope of government. The organization was created to defeat previous Medicaid expansion efforts and has significant backing from large national funders, like Altria Client Services (aka Marlboro) given the past ‘pay-for’ proposals tied to the state’s tobacco taxes. The group is known to conservative legislatures and may have influence through their lobbyist and significant donor base. While the organization is likely to push back on any kind of expansion, they may be less engaged if a different funding source (i.e. non-tobacco) is identified to support the increase in payments.
Negotiated Agreements
If unable to reach a short-or-long term policy solution, the Worse Alternative to a Negotiated Agreement (WATNA) could result in a continuation of closures of rural hospitals and obstetric units within hospitals. The consequence being more providers of obstetric serves moving out of rural areas and/or opting out of providing these services due to additional reporting burdens and/or low payment rates.
The Best Alternative to a Negotiated Agreement (BATNA) is a successful across-the-board increase of Medicaid payments for obstetric services in rural areas to levels roughly comparable to those paid by private insurers. As an alternative to a permanent increase in payment, establishment of a two-to-five-year increase in payments could be an option. This would allow much needed revenues to enter these communities and time to monitor the impact on access to services, which could help to inform and provider an evidence base for a longer-term policy solution.
Legislative Strategy
The Montana Legislative regular session is 90 days in each odd-numbered year. The primary work of the legislature is to pass a balanced biennial budget. Given that the 2019 session is coming to a close, significant ground work will be done in preparation for the 2021 legislative session. By waiting until 2021, the short-and-long term policy goals may benefit from additional time to develop strategies around coalition building, media outreach, and grassroots mobilization.
Montana has a divided government, with the Republicans controlling the House and Senate, and the Democrats in the Governor’s office. The 2019 Legislature composition is: House 58 Republican, 42 Democrat and Senate 30 Republican, 20 Democrat. Assuming the composition of the 67th session will look like the 66th, appropriate legislators will be identified within the Montana House and Senate for sponsoring legislation. A bipartisan bill is an ideal approach given the contentious response to Medicaid-related legislation. In terms of potential legislative champions, the following members should be considered to target to sponsor the legislation in a bi-partisan manner:
- Representative Edward Buttrey (R) HD 21- Vice Chair of Human Services. Buttrey was elected to Senate District 13, representing Great Falls, Montana, in 2011 and became a member of the Montana House of Representatives, representing District 21, in 2018 due to term limits. While very conservative, Buttrey was the sponsoring Republican on Montana’s Medicaid expansion that passed in the 2019 session.
- Senator Daniel Salomon (R) SD 47- Member of Finance and Claims. Salomon is a Republican member of the Montana State Senate, representing District 47, first elected in 2016. Prior he was a Republican member of the Montana House of Representatives, representing District 93 from 2011 to 2017. While conservative, Salomon was a co-sponsor on Montana’s Medicaid expansion that passed in the 2019 session.
- Representative Bryce Bennett (D) SD50- Minority Whip. Bennett is a member of the Montana State Senate, representing District 50. Bennett served as a minority whip from 2015 to 2016. In the 2013-2014 session, Bennett served as minority caucus leader and have been known to support health and human service-related proposals.
- Jen Gross (D) SD 25- Vice Chair of Public Health, Welfare, and Safety. Gross is a Democratic member of the Montana State Senate, representing District 25, first elected to the chamber in 2016. Gross has a history of successfully sponsoring Medicaid-related legislation.
Once introduced, there are a number of committees that deal with health-related issues in the state that the bill could be referred to. The state has a Joint Appropriations Subcommittee on Health and Human Services. In the House of Representatives, the standing Human Services Committee will be the primary emphasis. On the Senate side, the Public Health, Welfare, and Safety Committee and Finance and Claims Committee will both be a focus. A bill would likely need to be heard by all committees before being heard and voted on by the full House and Senate.
In order to communicate with the legislature, advocates will work with a coalition of stakeholders to engage with individual lobbyists and testify in relevant committees. Potential stakeholders who would have influence with committees include the Montana Hospital Association and the American College of Obstetricians and Gynecologists Montana Section. The advocacy strategy will include requesting meetings with legislators and/or legislative staff to discuss the short-and-long term policy goals and request their support and interest in co-sponsoring legislation. In addition, the communication strategy will engage a number stakeholders association groups with a significant member base to support a letter writing and phone campaign, as discussed in later sections.
Coalition Strategy
The advocacy strategy will include the development of an informal stakeholder coalition with strategic outreach to key policymakers in legislative committees. While no coalition focused on obstetric services exists, there is considerable momentum built in the state around Medicaid expansion which could be built on for these efforts. It will be necessary to create a coalition of stakeholders of both individuals and organizations willing to invest support, and ideally time and resources, to moving forward the short-and-long term policy goals forward. Potential coalition members include the those identified in the previously discussed stakeholder analysis. Coalition members will be recruited through introductory meetings which describe the scope of the issue in the State, the three key messages outlined above, and potential policy solutions. As more coalition members are recruited, the list of coalition members will be shared in future outreach to stakeholders and policymakers to demonstrate the level of support for the policy proposals.
Media
Though media coverage has brought significant attention to the national maternal mortality crisis and lack of access in rural areas, state-level understanding of the scope of the issue is limited. As such, media will be an important part of the advocacy effort. People in the state who are not living in rural areas must see the impact of limited health-care and what this means in practice. Where the problem is not obvious, stakeholders such as hospitals, physician groups, midwives, and reproductive rights organizations will be asked to help bringing the public’s attention to this problem through press attention. Messages must show that limited access to care means long travel times, financial insecurity, and has adverse impacts on health. The stakeholder coalition members can identify possible authors for Op Ed articles in local newspapers, as well as social media platforms. Messages directly from hospital and obstetric providers will be extremely valuable in giving credibility to the issue, especially with policy makers. In addition, individual women and families willing to share their stories will be important to put a “face” on the issue and help to make a personal connection to the policy proposals and lessen resistance.
Grassroots Mobilization
The creation of an informal coalition is not enough to tackle this crisis; reform will likely require greater pressure placed on policymakers, requiring grassroot mobilization. This education and organization will require an illustration of the problem in the state, including both the outcomes and barriers to accessing care. In addition to education, momentum must be built to create change. Voters must be informed and motivated to push their policymakers to act. Assuming awareness of the problem is not enough to motivate constituents to act and to demand change, organizations and affected constituents must combine education efforts with efforts to motivate action through social media campaigns, petitions, and lobbying of elected officials. Similar to the media strategy, engaging individual women and families willing to share their stories will be important to put a “face” on the issue and help to make a personal connection to the policy proposals.
Conclusion
Pregnant, low-income persons living in rural areas face higher health risks than persons those living in urban and suburban areas. The current scheme of Medicaid reimbursements is unsustainable to support continued access to obstetric services in these communities. The provision of higher Medicaid reimbursements will increase the sustainability of obstetric units and hospitals in rural areas. Further, increased payments will increase the number of healthy pregnancies, driving down the ultimate cost to Medicaid and hospitals. The proposed short-and-long term policies will require political will and financing. This advocacy strategy will target Montana policymakers who have a legislative history of supporting similar issues and are well-positioned to make change. It will engage a broad coalition of stakeholders invested in improving access for rural obstetric services and will leverage media and grassroot mobilization to further messaging with key decision makers and the public.
References
Agency for Healthcare Research and Quality. Hospitalizations related to childbirth. HCUP Statistical Brief #11. Rockville, MD: Agency for Healthcare Research and Quality; 2003.
Department of Agriculture, Economic Research Service. “Population and migration: overview”. Available at: http://www.ers.usda.gov/topics/rural-economy-population/population-migration.aspx. Retrieved October 30, 2013.
Gifford, K. and J. Walls (2017). “Medicaid Coverage of Pregnancy and Perinatal Benefits: Results from a state survey.” Available at: http://files.kff.org/attachment/Report-Medicaid-Coverage-of-Pregnancy-and-Perinatal-Benefits. Retrieved February 20, 2019.
Henderson JW. (1994). “The cost effectiveness of prenatal care” Health Care Financ Rev. Summer;15(4):21–32.
Hueston, W. J. and M. Murry (1992). “A three-tier model for the delivery of rural obstetrical care using a nurse midwife and family physician copractice.” J Rural Health 8(4): 283-290.
Hung, P., et al. (2017). “Access to obstetric services in rural counties still declining, with 9 percent losing services, 2004-14.” Health Affairs 36(9): 1663-1671.
Hung, P., et al. (2017). “State Variability in Access to Hospital-Based Obstetic Services in Rural U.S. Counties.” Available at: http://rhrc.umn.edu/wp-content/files_mf/1491503846UMRHRCOBstatevariability.pdf
Kozhimannil, K.B., Hung, P., Henning-Smith, C., & Casey, M. (2018). “Association between loss of hospital-based obstetric services and birth outcomes in rural counties in the United States.” JAMA 319(12):1239-1247.
Kozhimannil, K. B., Casey, M. M., Hung, P., Prasad, S., & Moscovice, I. S. (2016). Location of childbirth for rural women: implications for maternal levels of care. American journal of obstetrics and gynecology 214(5), 661-e1.
Kozhimannil, K. B., Peiyin; Prasad, Shailendra; More. (2014). “Birth Volume and the Quality of Obstetric Care in Rural Hospitals.” The Journal of Rural Health 30(4).
Kozhimannil, K. B., (2014). Rural-urban differences in childbirth care, 2002-2010, and implications for the future. Medical care, 52(1), 4.
Larimore, W. & Davis, A. (1995) “Relation of Infant Mortality to the availability of maternity care in rural Florida.” J Am Board Fam Pract 8(5), 392- 399.
Markus AR, Andres E, West KD, Garro N, Pellegrini C. (2013) “Medicaid Covered Births, 2008 Through 2010, in the Context of the Implementation of Health Reform.” Womens Health Issues. 23(5):e273-e280.
Maron, D.F, (2017) “Maternal Health Care is Disappearing in Rural America.” Scientific America, Feb, 15, 2017.
Medicaid and CHIP Payment and Access Commission. (2017) “ March 2017 Report to Congress on Medicaid and CHIP.” Available at: https://www.macpac.gov/publication/march-2017-report-to-congress-on-medicaid-and-chip/.
Pinto, M., et al. (2016). “Bridging the Gaps in Obstetric Care: Perspectives of Service Delivery Providers on Challenges and Core Components of Care in Rural Georgia.” Maternal Child Health Journal 20(7): 1349-1357.
Polsky, D. et al., (2015) “Appointment Availability after Increases in Medicaid Payments for Primary Care.” New England Journal of Medicine 541, 543.
Rayburn, W. F., Klagholz, J. C., Murray-Krezan, C., Dowell, L. E., & Strunk, A. L. (2012). “Distribution of American Congress of Obstetricians and Gynecologists fellows and junior fellows in practice in the United States.” Obstetrics & Gynecology, 119(5), 1017-1022.
Rebala, P. (2017) “Find Out How Much it Costs to Give Birth in Every State.” TIME http://time.com/money/4995922/how-much-costs-give-birth-state/.
Tong, S.T., Makaroff, L.A., Xierali, I.M. et al. (2013) Matern Child Health J 17: 1576. https://doi.org/10.1007/s10995-012-1159-8
Wilson,
T., (2018) “ Medicaid Approaches to
Addressing Maternal Mortality in the District of Columbia.” The Georgetown
Journal of Gender and the Law. XX:215.
Appendix A
| STAKEHOLDER ANALYSIS | ||||||
| Stakeholder Type Approach to Policy (Strong, Moderate, Neutral) Reasons for position Stakeholder Power & Resources to Effort (Very, somewhat, weak) Likely Invlmnt (Very, somewhat, weak) Ways to influence stakeholder’s position/Ways to Utilize | ||||||
| LIKELY SUPPORTERS | ||||||
| Montana State Office of Rural Health (MORH) | State Agency | Moderate Support | Mission is to improve access to quality healthcare for rural Montanans with a focus on sustainability of rural hospitals. Acknowledges issues of access to obstetric service. | Moderate. Brings a well-respected name but has limited authority to directly influence issue beyond broad education and awareness. No lobbyists but does has access to registered legislative liaison. Possible grassroots mobilization. | Somewhat | Can tie issue to overall rural hospital viability and closures, which is more directly aligned with MORH authority and funding. Use connections with Governor’s office to influence involvement given its part of the state system. If able to get Governor to recognize as a priority, may be able to use MTHHS registered legislative liaison to influence legislation. |
| Montana Public Health Association (MRHA) | State Level Affiliate of National Association | Moderate Support | Mission is to promote a healthy rural Montana by addressing issues of healthcare delivery. Membership is broad and includes those invested in issue. | Strong. Has three lobbyists and a PAC. Close ties within the legislature and executive branch. Has ability to do grassroots mobilization. | Strong | Can use MRHA forum and dissemination to build grassroots involvement and education to state officials, potential opponents, and general public. |
| Montana Hospital Association (MHA) | State Provider Association | Moderate Support | MHA is the principal advocate for the interests of Montana hospitals in their efforts to improve the health status of the communities they serve. Viability of rural hospitals is a crucial part of mission, however they take a critical eye toward anything that could increase rural hospital administrative burden. | Strong. Has six lobbyists, all with ties to both state legislature and Congress, including finance committee. Has PAC. Members could have great stories to help depict impacts of lack of access. | Somewhat | Would likely be willing to support both short- and long-term policy goals. Can tie issue to overall rural hospital viability and closures, as well as the potential for additional resources appropriated for rural hospitals through the program. The program may be a potential business opportunity for MHA to do TA to rural hospitals that would need support developing/ implementing program. Can work to align measures with those that are NQF endorsed and/or already in existing quality programs. Can offer opportunities for the physician community to weigh in on establishment of the program. |
| Planned Parenthood Advocates of Montana (PPAM) | State Provider Association | Strong Support | Planned Parenthood affiliates are significant provider of ob-gyn services in the state and have a recognized priority to maintaining and increasing access to quality obstetric services. | Moderate. PPAM has one paid lobbyist, as well as name recognition (both good and bad). | Very | MMA members could be engaged to show grassroots support for the policy proposal. |
| Montana Midwifery Association (MMA) | State Provider Association | Strong Support | Midwives are a critical provider for rural obstetric services and have a recognized priority to maintaining and increasing access to quality obstetric services throughout the state. | Weak. MMA is not politically active in state politics or policy. Members could have great stories to help depict impacts of lack of access. | Somewhat | MMA members could be engaged to show grassroots support for the policy proposal. |
| American College of Obstetricians and Gynecologists Montana Section/ Montana Medical Association | State Level Affiliate of National Association | Strong Support | The MT Section is part of District VIII of ACOG. As a professional membership organization their mission is dedicated to the improvement of women’s health. ACOG has put out a number of policy papers recognizing the issues around access to obstetric services in rural areas. Members have a clear benefit to additional payments to support their work. | Strong. MT ACOG is represented in the legislature by the MT Medical Association, which has two paid lobbyists that are significantly engaged. | Somewhat | MT section members could be engaged to show grassroots support for the policy proposal. Could entice the national organization’s involvement as a “model” policy option for other states. |
| Montana Medical Association (MMA) | State Provider Association | Moderate Support | As MT’s association of physicians dedicated to improving patient care in the state, MMA has an interest in maintaining access for obstetric services in rural areas. However, physician associations have historically seen some quality reporting initiatives as bureaucratic, burdensome, or conflicting with their ability to practice medicine. | Strong. MMA has two paid lobbyists that are significant engaged. | Somewhat | MMA maybe supportive of an across the board increase in Medicaid rates in rural areas, rather than tied to P4P (i.e. long-term goal). Can use the “moms and babies” angle of why MMA should support the quality program. Can work to align measures with those that are NQF endorsed and/or already in existing quality programs. Can offer opportunities for the physician community to weigh in on establishment of the program. |
| Montana Rural Health Association (MRHA) | State Association | Moderate Support | Mission is to promote a healthy rural Montana by addressing issues of healthcare delivery. Members have been active in NRHA support for federal legislation like the MOMs Act (S.3568) and Improving Access to Maternity Care Act (HR 1209). | Weak. Alignment with MORH makes it somewhat influential and can do a broader scope of advocacy than MORH can. | Strong | Can use MRHA forum and dissemination to build grassroots involvement and education to state officials, potential opponents, and general public. |
| WWAMI Medical School | Medical School through State Universities | Moderate Support | As Montana’s medical school, WWAMI works to improve the health of Montanans by educating future physicians dedicated to providing care across the state, especially in primary care/ family medicine. Rural hospitals often host WWAMI students and graduates often practice in rural areas that need support for obstetric services. | Weak. WWAMI is a recognized name throughout the state and has historically provided broad support for initiatives that improve access to care and population health. May have support from lobbyist for Associated Students of the University of Montana. | Weak | The issue is removed from day to day primary care training and the policy proposal is pretty technical for a group of this nature to weigh in. Can try to engage a student advocate or faculty member in OB-GYN to champion overall organizational interest in the issue. |
| Providence St. Patrick Hospital/ Providence Health & Services Hospitals | Healthcare System | Moderate Support | As large healthcare systems operating rural hospitals and physician practices throughout the State, these entities have a vested interest in financially being able to sustain obstetric services in rural areas. Billings clinic has 11 CAHs in the state, as well as primary and specialty care in non-metro areas of the state. Providence has multiple rural hospitals including birthing center in a non-metro area. | Strong. Providence has significant influence at the regional and state level with both the legislature and Governor’s office. Has one registered lobbyist that is very active. | Somewhat | Can estimate the potential financial gain to these systems, not only in additional quality payments but ability to sustain obstetric services in these communities. |
| LIKELY OPPONENTS | ||||||
| Montanans Against Tax Hikes | Conservative Think Tank | Strong Opposition | As a conservative think tank in the state, they are unlikely to support any form of legislative that increases state spending and/or grow’s the scope of government. | Moderate. The group is known to conservative members and may have influence through their lobbyist. | Strong | While the organization is likely to push back on any kind of expansion, they may be less engaged if a different funding source is identified to support the increased payments. |
