Executive Summary:

• The Center for Medicare and Medicaid Innovation Center’s recent evaluation report of the first year of implementation of the Maternal Opioid Misuse (MOM) Model has yet to deliver any meaningful data due to low participation.
• Substance Abuse is now the leading cause of maternal mortality in the United States and models like MOM aim to create more comprehensive care, but these models are not helping in the way CMS proposed.
• In year 3 of the MOM Model beneficiaries and stakeholders hope to see increased participation from 50 percent to fully address implementation in the program.

Introduction:

In May of 2023, the Center for Medicare and Medicaid Innovation Center published its second-year evaluation report, noting low enrollment and barriers in providing equitable care, pointing to a challenging first year of implementation in the MOM (Maternal Opioid Misuse) Model. The Center for Medicare and Medicaid Innovation Center created the MOM Model in October 2018 to address pregnant and postpartum Medicaid beneficiaries diagnosed with Opioid Use disorder (OUD). This state-driven initiative focuses on transforming coordinated care for pregnant and postpartum Medicaid beneficiaries and their children while providing support and resources throughout pregnancy and into the first postpartum year.

History of Maternal Opioid Misuse:

Substance Abuse, specifically Opioid Use Disorder, is now the leading cause of maternal mortality in the United States. Women who use opioids during their pregnancy are more likely to experience pre-term labor, preeclampsia, and other complications related to delivery. Postpartum women who use opioids are more likely to experience interpersonal violence, malnourishment, and other social health issues. Infants impacted by opioids during pregnancy are more likely to suffer from low birth weight and neonatal abstinence syndrome (NAS), a group of symptoms caused when an infant is withdrawing from certain drugs. Neonatal abstinence syndrome rates rank highest among Medicaid covered births. Currently, Medicaid pays the largest percentage of hospital charges related to maternal opioid use disorder, as well as a large portion of the $1.5 billion annual cost associated with NAS. Between 2011 and 2014 the mean cost for an infant with NAS covered by Medicaid was about $19,340 per birth.

Background and Funding:

There are eight states currently participating in the MOM model. These include Maine, New Hampshire, Maryland, West Virginia, Tennessee, Indiana, Texas, and Colorado. The second-year evaluation report indicates 593 MOM Model beneficiaries as of May 2023 across the eight participating states. These states were awarded funding for the MOM program in December of 2019. Funding applications were due on May 6th, 2019, with Medicaid agencies and care service sites completing the application together. The CMS Center for Medicare and Medicaid Innovation Center awarded up to $64.5 million over the five-year model to the eight states. Reimbursement amounts however, vary greatly, ranging from $0 of additional payments to $1,189 per member per month for reimbursement for providers.

Goals and Objectives:

There are three primary goals of the MOM model. First, to reduce costs and improve the continuity of care for pregnant and postpartum women diagnosed with OUD, and their infants. Secondly, the model hopes to expand access and infrastructure capacity based on the needs of the states. Finally, the model aims to implement sustainable payment strategies that support ongoing care. The MOM model aims to accomplish these goals by integrating physical, behavioral, and mental health services, drawing on existing Medicaid flexibility to pay for comprehensive care, and investing in institutional changes that address key barriers to treatment and services.

Timeline:

The MOM model is implemented in a five-year action plan with three main periods, pre-implementation (Year 1), transition (Year 2), and full implementation (Year 3-5). Care and services will be provided starting in year 2, and any care not covered by traditional Medicaid will be covered by Innovation funds. By year 3, states will be required to implement delivery, coverage, and payment services. The goal of this timeline is to support the state’s ability to quickly develop and implement coordinated care for mothers diagnosed with OUD.

Current Initiatives in Texas:

The Texas MOM Model, named Texas MOM, is located primarily in the Houston Metro Area at the Harris Health System’s Ben Taub Hospital, and is classified as a centralized services provider. The May 2023 report outlines two new services initiated by Texas MOM in 2023 that will also be implemented in 2024. These new services are central to the adaptation of collaborative and quality care for mothers and newborns suffering from OUD.

The first service includes early initiation of opioid agonist pharmacotherapy. Texas MOM offering this therapy is important because opioid agonist pharmacotherapy is preferred to medically supervised withdrawal, specifically with pregnant mothers. Best practices for this treatment include starting treatment as soon as need is established and continuing throughout all phases of labor, birth, and postpartum.

Further, the Texas MOM model focuses on comprehensive care for both postpartum and pregnant mothers. Studies have shown that because of their complex medical needs, expecting mothers with OUD should receive more frequent care and services. Therefore, the Texas MOM model implemented increased prenatal and postpartum visits as a part of its model. Due to this increase in services, mothers in the Texas MOM program reported higher adherence to prenatal health plans and more positive experiences with their providers.

Shortcomings:

Consistent low enrollment numbers have been a devastating blow to MOM Model awardees. Despite states creating outreach materials and partnering with local managed care organizations, the MOM Model is currently functioning between 0 and 50 percent of the model’s original outreach proposal. Current enrolled beneficiaries range from 0 in Colorado to 243 in Indiana.

Stigma and low accessibility have created an environment of inequitable care to MOM Model beneficiaries. Despite most MOM Model states offering trainings to providers about the sensitivity of OUD, many beneficiaries reported experiencing stigmatized attitudes and behavior by at least one member of their care team.

Conclusion:

As opioid use disorder and maternal mortality rates continues to rise, it is imperative that the CMS Innovation Center start delivering on its MOM Model promises. Despite initial boasting about collaborative services and more comprehensive care, the low enrollment, and shortcomings in providing equitable care, point to a downward spiral of the MOM Model. While the jury is still out on whether the MOM Model will be overall effective in improving prenatal and postpartum services and in turn produce a better quality of life, the innovative strides in Texas point to the potential of a future of more collaborative care for women with OUD and the hope for better outcomes in the Year 3 Evaluation report.