Delivering Moms from the Most Common Childbirth Complications: Depression and Anxiety

Bruce Spurlock, President and CEO, Cynosure Health
Joy Burkhard, MBA, Founder and Executive Director, 2020 Mom

First appeared on the California Health Care Foundation blog, July 11, 2017

Every year, half a million babies are born in California. Alarmingly, the most common complications of childbirth are the mother's depression, anxiety, or other mental health disorders. The magnitude of suffering from maternal mental health disorders dwarfs hospital-acquired infections, sexually transmitted diseases, new breast cancer diagnoses, and many other conditions that attract greater media interest, public reporting, and performance incentives and penalties.

Maternal mental health issues arise in up to one in five pregnancies. In California, as many as one in four mothers (27%) have prenatal or postpartum depression (PDF), according to a survey by the California Department of Public Health. It's worse for underserved populations affected by race, poverty, or other social factors that increase the frequency and severity of mental health conditions. Low-income mothers are 1.4 times more likely than wealthier moms to exhibit depressive symptoms before, during, or after pregnancy.

Left undetected and untreated, these conditions can lead to negative health outcomes for the mother, undermine the mother-child bond, and damage the child's long-term physical, emotional, and developmental health. And the financial cost of untreated maternal mental health conditions can be significant because of effects such as greater use of emergency care services and higher rates of absenteeism at work.

While the disorders are highly treatable, few mothers are identified by screening or diagnosis, and among those who are recognized, only 15% receive treatment. And from a cost perspective (including lost income/productivity and negative outcomes for children), untreated maternal depression costs (PDF) an estimated at $22,500 per mother, which in California totals about $2.5 billion a year.

Maternal mental health conditions can occur anytime during or after pregnancy, with onset as late as the baby's first birthday. We are not talking about either of the two ends of this spectrum — a transitory (e.g., two weeks) and less severe condition known as the "baby blues" or the rare but more extreme psychotic episodes that make national headlines. It is the much more common "middle zone" of suffering where one in five women find themselves and don't receive the care they need.

California Task Force Addresses Maternal Mental Health

In California in 2014, the California Legislature passed a resolution calling for a multistakeholder group to study, identify, and recommend solutions to address these issues. The California Endowment and the California Health Care Foundation funded a diverse task force of public health experts, clinicians, consumers, policymakers, and representatives from health plans, purchasers, state agencies, and community-based organizations. The panel included project staff from 2020 Mom, a grassroots nonprofit working to close gaps in maternal mental health in California and nationally; Cynosure Health, a national health care improvement organization; and the Central Valley Health Policy Institute, which focuses on emerging health issues in Central California. Over an 18-month period, the task force explored the barriers, models, and potential solutions that affect a half-million California mothers and their babies each year. California accounts for one in eight births in the US.

This spring, this task force released a formal report and executive summary.

Women with maternal mental health issues face herculean challenges to receiving adequate relief from their suffering. These include:

• Lack of understanding by health care providers about how to follow up with symptomatic women

• Fragmented care systems that foster inconsistent approaches to the problem by obstetricians, pediatricians, and primary care physicians

• Inadequate screening, sometimes caused by the mother's fear that her child will be taken away if the mother gives wrong answers

• Poor access to appropriate treatment

• Stigma that prevents new and expectant mothers from reaching out for help

Despite the availability of effective treatments, the health care system is tragically ill-equipped to identify and help the women who need them. The task force reviewed novel solutions that address social issues, family and generational expectations, travel limitations, and cultural sensitivities. Yet available services are often disconnected and uncoordinated across different care settings.

Two Ambitious Objectives

The task force set two bold aims for tackling this problem across vast expanses of California: By 2021, ensure that 80% of women are screened at least once during pregnancy and the postpartum period, and by 2025, increase that rate to 100%. The goals acknowledge the federal recommendations on screening and set the stage for effective treatment and symptom management. With these targets in mind, the task force developed recommendations to address barriers:

Select one of several maternal mental health screening measures developed by national organizations.

• Promote a "no wrong door" approach to screening so it can be offered by health providers of all types.

• Build capacity by expanding referral resources and telehealth consultation such as MCPAP for Moms, which operates in Massachusetts.

• Persuade insurers to develop programs offering competent maternal mental health care, including arranging specialty care as required.

• Take local action through community collaboratives that can help address social determinants.

• Combat stigma with statewide and local public awareness campaigns spearheaded by the California Department of Public Health.

Maternal mental health conditions disrupt the lives of many more women, children, families, and communities than people realize. It's likely that everyone knows many mothers — and their children — who experience unnecessary suffering from maternal mental health conditions that are treatable if we recognize and build systems to address them during the vulnerable perinatal period. Massachusetts, Maryland, and other states are doing just that. Will California step up, too?

Learn about CHCF's work with partners to develop solutions for delivering mental health care to California's mothers and expectant mothers in need.

I Lost My Daughter and Grandson and Headed to DC

By Millie Pagett

Millie and Ed, holding a picture of Charlene and Shane

We would like to share our experience in National Coalition for Mental Health held in Washington D.C. on May 17 and 18, 2017.

We were honored to be invited by the coalition chair, Joy Burkhard, to share our personal story at a luncheon held at Art Club of Washington on May 17. Over 90 advocates from all over United States were the attendees. They were parents like us, husbands, mothers, survivors, clinicians, and practitioners who came to take part in this coalition. It was a pleasure to meet Jamie Zahlaway Belsito, Joy Burkhard and Maureen Fura from the National Coalition.

At the luncheon, May 17th we shared the loss of my daughter Charlene and grandson Shane who passed away on September 13, 2017 after Charlene suffered Postpartum Psychosis. Reliving our painful tragedy was hard, but our story has to be told. We lost a daughter and a grandson as a result of Maternal Mental Illness, which is the number one complication of Childbearing. Postpartum Depression is a disease and should be treated as seriously as any other medical diagnosis. By telling our story, we wanted everyone to know that Postpartum Depression is real, and could happen to any mother who just had a baby. We are the voice to help promote more awareness, more screening, and early intervention. We strongly feel that there should be more funding, more clinics, and more grants to help these mothers. 

The focus on May 18, was on Congressional meetings to ask State Congressional members to support and allocate the monies earmarked in the 21st Century Cures Act for Maternal Mental Depression. It was time to educate them on what we are doing in our State and how to see the issue of Maternal Mental Health education, support, screening and treatment. 

The preparation meeting was held at Rayburn House. Jamie Zahlaway Belsito did a wonderful job preparing us on our presentation, how to get the message across and telling them how they can support us. We had packets nicely put together for our presentation.

Our California Group Leader was Joy Burkhard, chair of the National Coalition and director of 2020 Mom. Joining us were a therapist from Victorville, survivor mom from Walnut Creek, and an infant feeding occupational therapist from Sherman Oaks. 

Our California Team

We met with representatives of Senator Dianne Feinstein, Senator Kamala Harris, Congressman Steve Knight, Congressman Paul Cook, Congressman Mark De Saulnier and Congressman Dana Rohrabacher, who we met in person.

Ed and Millie with Congressman Dana Rohrabacher

We wouldn't have asked for a better team from California!  Overall, it was an amazing experience. Never in a million years did we think we would fight for what we think need major changes. It was a great day for everyone to come together with a goal in mind, to help in the improvement of mental health care. We met so many wonderful people who were passionate about making a difference. It was a blessing and very grateful for the opportunity. 

We felt encouraged and supported in one of the most difficult thing that we had ever done in our lives, to tell our own personal story of lost and to be the voice to make a change. We put on a fight and together we know we will make an impact in the future of Maternal Mental Health. 

No one should suffer like my daughter Charlene did.💜

Thank you for the opportunity to share our story and be part of this coalition.

The National Coalition Maternal Mental Health, Lobby Day 2017

What does the USPSTF Screening Recommendation Really Mean?

– POLICY –

by Joy Burkhard, MBA
Founder and Director 2020 Mom

It's an exciting development that the USPSTF no longer excludes pregnant women from its depression screening recommendations, and now notes the specific importance of screening pregnant and postpartum women due to negative consequences of untreated depression on fetus/infant development.

Patients are Already Provided Coverage
Insurers currently provide coverage to patients for depression screening in the full adult population.  However, most primary care doctors and OBGYNs continue (and will continue) NOT to screen because of lack of referral and case management support, which is a critical need for them in feeling comfortable when uncovering positive screens.

Provider Payment Still Depends on the Contract
Some are wondering whether this position means that insurers must pay providers for screening. It's an interesting question. The recommendation and ACA don't dictate how an insurer contracts or pays a provider. There are several types of insurance payment mechanisms. The two most well-known payment structures are Fee-for-service (a provider bills for every service s/he provides) and capitation (providers receive a flat payment per month for any/all services provided). Under a fee-for-service type arrangement, an insurer would reimburse for a depression screen. Under a capitation payment, providers are expected to provide all necessary services under their negotiated monthly payment, including depression screening. The USPSTF recommendation doesn't change these structures. Because of the focus on staying healthy, the Centers for Medicare/Medicaid Services (CMS) and others are promoting capitation type arrangements with primary care doctors, including pediatricians who may screen mothers for depression. Separate, and often in place for maternity, an OBGYN agrees to be paid a "global maternity rate" by the insurer for prenatal and postpartum services (through the postpartum visit). Under these types of arrangements, insurers generally expect providers to render all medically necessary screenings and services, which generally would include maternal depression screening and other types of screenings. Insurers are not obligated to pay providers for depression screening outside of this flat rate.
Note, however, that some payers/insurers have addressed this.  For example in Colorado, the state Medicaid program is reimbursing pediatricians and OBGYNs for conducting screening. Our sources tell us that there are challenges, including limitation on the number of times screening can occur (causing challenges as the pediatrician may not know if the OBGYN already screened) and low reimbursement levels, leaving many to not bother billing even if they do screen. Further, there is no measurement currently in place, so there is no evidence that payment is making a difference.  Furthermore, several years ago, Aetna, interested in improving depression screening and treatment rates, began reimbursing primary care providers for depression screening. They found it didn't increase depression screening rates (though those who were already screening were thrilled) pointing to the notion that clear referral and treatment pathways must be in place first, and additional payment really is secondary.

What should Insurers Do?
Insurers are in a unique position to provide this complex case management service (they do so now for many other conditions) but until there is also a way to locate psychiatrists as well as therapists who have training/experience in treating maternal mental health insurers will have difficulty making a dent.  Beyond the general difficulty in knowing who is qualified to treat these moms, there are also general psychiatry shortages, and most reproductive psychiatrists don't contract with insurers because they don't have to.
This is why the federal bill, HR 3235, Bringing Postpartum Depression out of the Shadows Act is critically important.  If passed states could apply for federal grants to implement innovative access solutions, like the Massachusetts telepsychiatry program, MCPAP for moms, which successfully addresses and integrates training of providers, referral pipelines for qualified therapy, and prescription consultation for OBGYNs and other MDs when necessary.  

Screening Rates Must be Measured
There is no measurement in place to capture how often OBGYNs (or others) are screening for depression.  "We don't manage what we don't measure" the adage goes.  It's critical that accreditation bodies and/or states require measurement of screening rates.  Insurers are in the best position to monitor these rates, through a program like the National Committee for Quality Assurance's (NCQA's) Healthcare Effectiveness Data and Information Set (HEDIS) measures, which involve monitoring medical records and/or claim submission data.   Cigna was the first insurer to adopt a HEDIS-like measure developed by external bodies, in 2013 but this measurement process needs to be implemented widely.  When health plans understand what gaps in care exist they invest resources to improve screening and health outcomes and work collaboratively with providers to support their needs.
 
Conclusion
Inclusion of pregnant and postpartum women in the USPSTF position is a critical step in validating the importance of this screen, but much more work is needed to ensure providers are actually able to screen.  2020 Mom is supporting this work through in several ways. Want to know more?  Drop us a line: 
info@2020mom.org