When Title V was first created in 1935 to improve maternal and children’s health, many issues we face today didn’t yet exist. With opioid deaths doubling between 2010 and 2016, the FDA and CMS are both acting to stem this disturbing trend. As one of the largest federal block grant programs, Title V is an integral tool in the ongoing battle against maternal opioid abuse and in promoting the coordination of care of the nation’s mothers, children, and their families. With a reach that provides health services to more than 61 million pregnant women and children, Title V impacts 84% of all pregnant women and 63% of all children.
With such a broad base, the FDA and CMS are improving how they communicate with all those affected by Title V as well as making them aware of new options available to them. Announced last month, CMS is rolling out Maternal Opioid Misuse (MOM), a new care model designed to improve care coordination, behavioral health integration, and access to care for expectant and new mothers with opioid use disorder (OUD). To emphasize the benefits of better coordinated care, MOM creates an interconnected web of medical support options for new and expectant mothers, making available to them a wider array of specialists and improving access to them.
MOM was created to help overcome the barriers impeding the delivery of well-coordinated, high-quality care to pregnant and postpartum women suffering from OUD, including:
- Lack of access to comprehensive services during pregnancy and the postpartum period, even though state Medicaid programs may be able to provide the necessary coverage through state plan amendments or waivers.
- Fragmented systems of care, which miss a critical opportunity to effectively treat women with OUD at a time when they may be especially engaged with the healthcare system.
- Shortage of maternity care and substance use treatment providers for pregnant and postpartum women with OUD covered by Medicaid, especially in rural areas, where the opioid crisis is magnified.
At the rollout of MOM last month, HHS Secretary Alex Azar spoke at length about the “many barriers” that “impede the delivery of well-coordinated, high quality care” to expectant and postpartum mothers struggling with OUD. He expressed concern for those in rural areas who suffer from provider shortages and promised that the new MOM model will work with state Medicare and Medicaid agencies and “front-line providers” to “ensure that mothers and infants afflicted by the opioid epidemic get the care they need.”
States that choose to participate in MOM will be assisted in providing access to behavioral health services, such as medication-assisted treatment, maternity care, relevant primary-care services, and other mental and behavioral health services beyond mere medication assisted treatment. As part of these efforts, CMS plans to award five-year grants totaling $64.6 million to 12 states in 2019. States are invited to apply for these grants and in order to qualify, they must demonstrate that they have partnered with at least one care-delivery partner willing to coordinate their care. Additionally, states will have the flexibility to define a specific set of services that satisfy the following five components:
- Comprehensive care management
- Care coordination
- Health promotion
- Individual and family support
- Referral to community and social services
While state Medicaid agencies focus on developing and implementing coverage and payment strategies, care-delivery partners will need to provide services directly or indirectly through clinical partners that implement a coordinated and integrated care-delivery approach. Care-delivery partners may be a health system or a payer, such as a Medicaid managed care plan (MCP). As these partners work with the state agencies, they must present proposals addressing the five components, and other mentioned aims, that show their ability to achieve the main goals of the MOM model:
- Improve quality of care and reduce expenditures
- Increase access to treatment, service-delivery capacity, and infrastructure based on state-specific needs
- Create sustainable coverage and payment strategies that support ongoing coordination and integration of care
Recognizing the severity of the impact that the opioid crisis is having on pregnant and postpartum women, the FDA is also acting to help stem this deadly tide. They recently announced that a 2-day public advisory committee meeting will happen next month where they will consider ways to make naloxone more broadly available, including the possibility of co-prescribing the opioid overdose antidote with some or all opioid prescriptions.
FDA commissioner Scott Gottlieb said the committee will also evaluate “logistical, economic, and harm reduction aspects of different strategies.” Regarding the possibility of co-prescribing antidotes, Gottlieb said they are going to consider all factors, whether economic or practical, such as manufacturing supply and the risk of drug shortages. A study earlier this year illustrated the complexity of identifying who is most likely to benefit through increasing naloxone availability while trying to maintain affordability, something else that committee will take into consideration.
While states will have the flexibility to determine how best to implement MOM in their unique localities, the diversity of application in these programs will continue to be driven by the unifying concern we all share for the physical and emotional well-being of pregnant and postpartum mothers. Addressing the impediments to providing coordinated care encompassing all aspects of the mother’s care, as well as making this care more accessible and affordable, are at the heart of this new model. With substance use now a leading cause of maternal death, we can join with CMS in taking action to ensure that this deadly tide will be reversed.