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Data: Virginia Medicaid's managed care failing to connect patients with prenatal care

A person holds their pregnant stomach
Shaban Athuman
VPM News
A pregnant person holds their stomach on Tuesday, June 25, 2024 at Downtown in Luray, Virginia.

Secret shopper survey results say the contracted companies are not delivering.

Insurers paid by the state to provide Medicaid coverage may be failing at connecting new pregnant enrollees to the prenatal care they’re entitled to within wait-time standards. In 2023, those companies collectively made more than $500 million from working with Virginia Medicaid — with the expectation that they’d facilitate care for the program’s members.

That’s according to a recently released, unpublicized survey conducted in 2023 for Virginia Medicaid.

The research, commissioned by the Department of Medical Assistance Services, was conducted by Health Services Advisory Group. The secret shopper survey involved staff of the research group calling health care providers listed by provider directories that DMAS and Virginia Medicaid Managed Care Organizations maintain — while posing as new Medicaid enrollees seeking prenatal care.

Medicaid, the joint federal and state health insurance program, covers some low-income Americans and some people with disabilities. In Virginia, the program is administered by the Department of Medical Assistance Services, often referred to as DMAS, Virginia Medicaid or Cardinal Care.

2023 enrollment data shows it covered about 39,000 pregnant people in 2023 out of the total membership of about 2.1 million Virginians that year. It covers about 1 in 3 births in the commonwealth.

More than 95% of calls seeking prenatal care to health care providers that accept Virginia Medicaid MCOs received in a 2023 secret shopper survey did not result in an available appointment.

In practice, the survey indicated 19 out of 20 calls a new Virginia Medicaid member made in 2023 to health care providers that the MCOs say provide prenatal care and accept Virginia Medicaid may not have resulted in that Medicaid member being able to schedule an appointment for the care.

The goal of the survey was to determine if the information that MCOs provide to enrollees is accurate — and if Virginia Medicaid enrollees could actually access care they are entitled to that MCOs are paid to facilitate.

Published in April 2024, the survey found only 13 of the 1,844 calls conducted resulted in an appointment within DMAS’ wait time standards.

That’s less than 1%, indicating that 99 out of 100 calls may have ended in no appointment being available within the three business days to seven calendar days Virginia Medicaid holds as a standard depending on the trimester of pregnancy.

Prenatal care providers, policy researchers and advocates familiar with the research said the data captures the first domino of a potentially devastating chain reaction. Virginia’s poorest pregnant people face barriers to getting prenatal care. As a result, they may then get less or even no prenatal care, which can negatively impact their health outcomes as well as their baby’s.

“I worry that when this happens, a pregnant person will not get the prenatal care they need,” said Kathryn Haines, health equity manager at the Virginia Interfaith Center for Public Policy. “And the result will be a mom who shows up in the ER when she is ready to deliver, and the medical staff, unfamiliar with that mom's particular health history, will not be able to provide care tailored to the needs of that mom and her baby.”

The report looked at the survey’s results alongside other data on MCOs’ performance, and drew similar conclusions.

“The results indicate that members are not receiving timely prenatal care that can potentially reduce the risk of pregnancy complications and maternal adverse outcomes,” it said. “There is alignment in the [Performance Measures] and secret shopper survey results.”

Virginia Medicaid and its partnering MCOs provider directories being full of inaccurate and out-of-date health care provider information appears to be a major force behind the problem, according to prenatal care providers, policy researchers and advocates VPM News/WMRA talked to.

MCOs are insurance companies that provide about 90% of the health insurance coverage that Medicaid provides to enrollees — including pregnant members. The companies are paid a flat fee per enrollee by taxpayers to connect program members to health care and cover its costs.

Using provider information from “DMAS’ enrollment broker,” the report found “deficiencies” like “incorrect or disconnected telephone numbers.” However, researchers found the MCOs’ provider directory data was even less accurate.

Those issues are being compounded by health care provider staffing shortages and explosive growth in the number of Virginia Medicaid members. It’s also impacted by some prenatal care providers not accepting Medicaid due to low reimbursement rates, according to providers, researchers and advocates.

During 2023, Virginia Medicaid contracted with six MCOs:

1. Aetna Better Health of Virginia
2. HealthKeepers
3. Molina Complete Care of Virginia
4. Optima Health
5. UnitedHealthcare of the Mid-Atlantic
6. Virginia Premier Health Plan

The contracted insurers made more than $500 million in collective profit from Virginia Medicaid in the first three quarters of 2023 alone, VPM News/WMRA analysis of DMAS data shows. (The fourth quarter is listed as part of 2024.) That amounted to a profit margin of 4.4%, with 87.3% of the funds allocated to them reportedly being spent on care and 8.3% spent on administration.

None of the MCOs’ answered questions sent by VPM News/WMRA. The Virginia Association of Health Plans, a lobbying and advocacy group for MCOs, reached out instead.

In response to a detailed list of questions, a VAHP spokesperson issued a general statement addressing some of the question topics. They said the secret shopper survey “does not reflect the experience of most Medicaid members” and that it “has other significant limitations that make it difficult to draw systemic conclusions about access to care.”

VPM News/WMRA also sent questions to DMAS. The agency did not answer many of those; it instead provided a more general statement.

The agency noted that, because of the survey’s design, callers could not “provide any personal information or details required for preregistration” and that “was stated as the most frequent reason cases were unable to be offered an appointment or schedule an appointment within the appointment standards.”

“I worry that when this happens, a pregnant person will not get the prenatal care they need.”
—Kathryn Haines, Virginia Interfaith Center for Public Policy health equity manager

The recent secret shopper survey was buried more than 100 pages into a nearly 500-page, unpublicized and previously unreported year-end quality review report released in April 2024. State Medicaid agencies are required by law to commission external quality reviews each year.

The report found that appointments were especially difficult to access after the first trimester. Callers seeking second and third trimester were about three times less likely to end in an appointment.

While the report’s blockbuster findings are about how hard it is for pregnant Medicaid-enrolled Virginians to access care, the survey breakdown includes other significant details.

Less than two-thirds of the calls made in the survey were picked up. And of the calls that were picked up:

  • 46.3% of the respondents indicated that the provider location did not actually provide prenatal care services.
  • 29.6% said the office accepted the MCO.
  • 27.3% said they accepted Virginia Medicaid.
  • 26% said they accepted new patients.

The survey’s findings varied significantly by MCO. Notable highlights include:

  • For available appointments, United did the best with 5.2% of calls ending in an available appointment. Molina did the worst, with 2.9% of cases.
  • Of calls that made it to the health care provider, United had the highest rate of providers accepting the MCO (40.5%). Aetna had the lowest rate: 16.7%.
  • On average, health care providers accepted new patients in 26% of calls that made it to the provider. Virginia Premier had the highest rate at 32.2%. Aetna had the lowest at 14.9%.
  • Of calls that made it to the provider, only 4.6% had “After-Hours Availability” and only 2.3% had “Weekend Availability.”

While the secret shopper survey section of the report describes the survey’s broad and specific objectives and provides an overview of its methodology, an apparent error in the report’s appendix left the prenatal care survey without its full methodology.
The report, conducted by Health Services Advisory Group for DMAS, also included a secret shopper survey for Virginia Medicaid members’ access to primary care providers. And, in the report methodology section, the primary care provider survey’s methodology is included twice: under its own section and the prenatal care survey.

VPM News requested a corrected copy of the methodology multiple times from DMAS and HSAG. Neither provided it.

A DMAS spokesperson said the updated report is “still going through a process internally” and added it “will hopefully be in the next couple days.”

Among the details left unclear by this error are the exact dates the prenatal care survey was conducted. The primary care provider survey was conducted in January and February 2023. (The prenatal care survey is at one point referred to as the “CY 2022–2023 prenatal care secret shopper survey.”)

The specific types of providers categorized as “prenatal care” providers are also not known. The PCP survey’s methodology lists that information.

That survey’s methodology noted it also included a “statistically valid number of unique service locations based on a 95 percent confidence level and ±5 percent margin of error.” It is unclear if the prenatal care survey had the same margin.

The PCP survey methodology can be read under “PCP Secret Shopper Methodology” on PDF page 247; the prenatal care methodology is on PDF page 297.

Providers, advocates anecdotally confirm survey

Prenatal care providers and advocates told VPM News/WMRA that difficulty accessing that care through Virginia Medicaid was an open secret long before the survey results.

“It's totally accurate,” Nurse Stephanie Spencer said of the survey, “because that's the same story that we're hearing from the moms.”

Spencer has been a registered nurse for more than 30 years. She’s also the executive director of Urban Baby Beginnings, a commonwealth-wide maternal health hub that provides pregnancy and postpartum support to reduce barriers to care.

“When you can't get care and you can't get it early, it has other implications as well,” she said. “You have people that are entering into pregnancy with chronic health conditions that have not been addressed — I've seen all kinds of things.”

a portrait of Spencer
Shaban Athuman
VPM News
Stephanie Spencer, founder of Urban Baby Beginnings, is photographed on Sept. 22, 2023 in Richmond.

Research shows that infants whose birthing parent did not receive prenatal care are more likely to have low birth weight, die in infancy and be born prematurely.

Infants born before 37 weeks, known as preterm babies, have higher rates of death and disability, according to the U.S. Centers for Disease Control and Prevention. Those deliveries also have long-term negative impacts on the birthing parent’s health.

In 2022, the most recent year there is public data for, DMAS exceeded the national benchmark for preterm births by 72 births, another recently released DMAS report revealed.

That report also showed DMAS failed to meet the federal benchmark for births covered by Medicaid that get “Early and Adequate Prenatal Care” in 2022. More than 1 in 4 Virginia Medicaid births were to a mom who had not received early and adequate prenatal care that year.

Worse still, more than 1,000 births in 2022 involved a birthing parent who received no prenatal care.

It also found significant disparities in who is getting prenatal care and their health outcomes. Black, Non-Hispanic women had the highest rates of preterm births and newborns with low birth weight. Hispanic women of any race had the lowest rates of early and adequate prenatal care for 2022.

Katie Page is a certified nurse midwife who works at Centra Medical Group Women's Center in Lynchburg. She also works at an area Federally Qualified Health Centers that mostly serve Medicaid members.

“Virginia has a relatively high maternal mortality rate, especially for Black women, we have a fairly high infant mortality rate as well,” she said. “And so not having access to this care, ultimately, is a life-or-death situation for so many people and their children.”

Maternal mortality rates are two times higher for Black women than white women in Virginia, according to the most recent Virginia maternal mortality data.

Kenda Sutton-EL is chair of the Virginia Doula Taskforce and the executive director of Birth in Color, a Virginia reproductive justice organization that also works on maternal health policy. She said those disparities are caused by racism in health care providers.

“There is racial bias in health care,” she said. “The preconceived notions that Black women have a higher pain tolerance, that Black people, when they go to the doctor, all they want is pain pills. This is stopping the quality level of care that should be given to these patients because providers are still thinking about their own biases.”

Limited response from DMAS, managed care orgs

Two of the MCOs contracted by Virginia Medicaid in 2023 — Anthem HealthKeepers Plus (formerly Healthkeepers) and Molina — did not respond to questions from VPM News/WMRA.

United, Aetna and Sentara (which has since taken over Virginia Premier and Optima Health) directed VPM News/WMRA to the VAHP, the lobbying group that represents the MCOs.

VPM News/WMRA sent a detailed list of questions to VAHP, including questions on whether MCOs paid with taxpayer dollars to provide public health insurance should respond to media inquiries about performance themselves.

“The MCOs requested VAHP respond on their behalf because of the ongoing reprocurement process,” said Heidi Dix, senior vice president of policy for the group, about the latter question. “Due to constraints around communications related to Medicaid managed care at this time, it was more appropriate for the association to respond.”

Dix said VAHP and the MCOs it represents “are deeply committed to addressing prenatal care access and other factors that drive maternal and infant health outcomes.”

She also referred to the “unprecedented period of change” in which the prenatal care survey was conducted and issues VAHP has with it.

“It’s important to note that a secret shopper survey does not reflect the experience of most Medicaid members, who have access to care managers and/or care coordinators to assist them in navigating the healthcare system, including appointments,” she said. “The secret shopper survey has other significant limitations that make it difficult to draw systemic conclusions about access to care.”

The survey did not assess overall appointment access, instead looking at the timeliness of new patient appointments, according to DMAS.

(The National Health Law Program, a nonprofit policy and advocacy organization, said in April that secret shopper surveys “produce credible, unbiased, and actionable data that reflect the true experience of an enrollee trying to schedule an appointment.” In May, the federal agency that runs Medicaid introduced a new rule mandating the surveys every year starting in 2029.)

Dix acknowledged the need for “overall improvements in prenatal care,” but attributed the strain to expanding Medicaid enrollment and Medicaid unwinding. She said the solutions to these problems were to “improve provider data accuracy” and “address the national healthcare workforce shortages.”

Mary Olivia Rentner, a media relations manager for DMAS, said access to prenatal care “is an issue of high priority” and highlighted the survey as well as the recent expansion of Virginia Medicaid to cover care from Certified Doulas’ and to people who give birth for a year after delivery.

Rentner pointed VPM News/WMRA to DMAS’ compliance reports in response to questions about what punitive or corrective actions DMAS has taken against MCOs for their prenatal care delivery performance. None of the available reports mentioned “prenatal care.”

Rentner also said that the agency has compliance standards for its contracted MCOs, with penalties for contractors that fail to meet them — including withholding the assignment of Virginia Medicaid members, which would lower the amount of funds paid. She did not elaborate on how that is scored or determined, and added, "None of our MCOs have met this withholding criteria."

Neither the MCOs nor VAHP answered VPM News/WMRA’s question about examples of service improvements since the survey period.

Click here to read the 2023 Virginia DMAS External Quality Review Technical Report

Read the 2022–23 Medicaid and CHIP Maternal and Child Health Focus Study Report

Prenatal care challenges and the future

Katie Page, the certified midwife, said there are two sides to analyzing the secret shopper survey results: “At best, it's just another example of bureaucracy in action. … At worst, it's just continuing to perpetuate inequities, while being able to say, ‘But we tried to do something and blaming [enrollees].’”

Victoria Richardson is a staff attorney focusing on health care policy for the Virginia Poverty Law Center. She also said systemic problems are being blamed on individuals’ supposed failure to get care.

The problem of people not accessing prenatal care is being attributed to “the pregnant individual and how they're not opening their mail, or they're not following up with their appointments or they're no shows and I don't think that's accurate,” she said. “It's not so much that they're not following up with their care, it's just we make it so difficult, and they already have so many difficulties in their day-to-day life.”

Richardson knows about those problems and the importance of both Medicaid and prenatal care firsthand. Her son was born with congenital heart disease and had Medicaid in Virginia. She said she would not have known about the condition her son had without prenatal care. And though he has since died, she said he would not have lived as long as he did without that care.

Richardson also had a placental abruption, a pregnancy complication where the placenta separates from the wall of the uterus before birth. It can stop the baby from getting enough oxygen and cause bleeding to the pregnant person, according to the Mayo Clinic.

“If I didn't feel comfortable going to the doctor's, we both might not have made it,” she said. ”So, from that aspect, I realized that things could have been a lot worse if I hadn't had the privileges that I did have.”

MCOs generate profit when the amount they are paid to connect enrollees to care as well as cover that care is more than the sum of what they pay health care providers for the care and their administrative costs. Accordingly, MCOs achieve greater immediate-term profits the less care enrollees get.

“It's in [MCOs’] best interest, arguably, to make things as cheap and as inaccessible as possible if you think about it,” Richardson said, “because they're getting paid the same regardless of whether somebody is able to access services.”

Dix, of the MCOs’ advocacy group, rejected that idea.

“The suggestion that MCOs are financially incentivized to avoid linking pregnant enrollees to care defies logic,” said Dix. “[I]t is better for everyone when primary and preventive care help promote individuals’ health. Additionally, the MCO’s long-term fiscal incentives align with patients obtaining appropriate care as timely as possible since that is the most cost-effective approach to a person’s health.”

Some research backs that up. While other research casts doubt on those conclusions, prevailing health care wisdom acknowledges preventive care and its massive benefits as a cornerstone of modern medicine.

Dix also said that MCOs in Virginia have profit caps.

“In VA, MCOs are required to spend at least 85 percent of the money provided by the state and federal government on medical care and healthcare quality improvement, rather than on administration, marketing, or profits,” she said. “If these standards – known as Medical Loss Ratios – are not met, MCOs are subject to penalties, which could include contracts being cancelled by the state.”

In a 2016 review of Virginia MCO spending, the Virginia General Assembly’s Joint Legislative Audit and Review Commission found that “DMAS has paid MCOs more than necessary and Virginia’s profit cap is more lenient than other states.”

VPM News/WMRA asked DMAS how profit caps, known as “underwriting gain” caps, have changed since 2016.

DMAS spokesperson Rentner said, “DMAS took the advice of JLARC and changed the contracts to significantly strengthen the underwriting gain limits or ‘profit cap’ as part of DMAS’s continued focus on being good stewards of taxpayer funds” and pointed to DMAS’ new contracts with MCOs for policy specifics. Those specifics can be read on PDF page 333.

Both Dix and policy researchers VPM News/WMRA talked to agreed that Medicaid’s exploding enrollment has worsened the problem.

Program rolls jumped by more than 60% between July 2018 and July 2023.

That growth was driven by expansions in Medicaid eligibility, the policy of continuous enrollment during the early COVID-19 pandemic and 12 months of postnatal coverage for pregnant members.

This has left the agency to do more with less.

While Virginia Medicaid’s budget allocation per enrollee increased between 2018 and 2023, the amount of money per enrollee for DMAS to administer services decreased, VPM News analysis of June enrollment data with General Assembly budgets reveals. Health care provider shortages and low reimbursement rates add to the problem, according to prenatal care providers, policy researchers and advocates VPM News/WRMA interviewed.

The survey offered suggestions to increase access to prenatal care. One is addressing shortfalls in DMAS’ and MCOs’ health care provider data.

“Accurate provider information, including provider specialties and contact information, may result in improved access to care for members seeking well care, preventive healthcare, childhood immunizations, and pregnancy-related care,“ the report said.

Beginning in 2025, DMAS and HSAG will take on the first steps of that with a Network Adequacy Validation to “review and validate the MCO [Network Adequacy Validation] data submitted to ensure accuracy, completeness, and consistency.”

The report also recommended validating the information provided in the MCO directory.

Haines echoed the report’s recommendation, but added that this issue needs to go before the General Assembly in 2025.

Richardson, the health policy lawyer, said that while there are stakeholder meetings for managed care members, it doesn’t seem like many people attend them — or any accountability comes from them.

“Who has time to attend these meetings and actually participate in them,” she asked. “It would be nice to have more meaningful opportunity for input from the people that are actually affected by these policies.”

The Virginia Interfaith Center for Public Policy and other groups are holding a press conference on this issue Tuesday, July 9 at 10:30 a.m.

Henry Brannan covers rural health care in the Shenandoah Valley and Charlottesville area for VPM News and WMRA. The position is in partnership with Report for America.
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