Weekly Scoping Review Due Items: Group 1 (Temi, Kristen, Kayla) - Medicaid reimbursement for postpartum mental health services since 1965: A scoping review

Weekly Scoping Review Due Items: Group 1 (Temi, Kristen, Kayla) - Medicaid reimbursement for postpartum mental health services since 1965: A scoping review

by Temi Kapula -

Medicaid reimbursement for postpartum mental health services since 1965: A scoping review

Ntemena Kapula, Kayla Karvonen MD, Kristen Azar RN MSN/MPH FAHA

Abstract 

Background: Postpartum mental health conditions are common and have important health consequences for birthing people and their infants. Disparities in diagnosis and treatment of postpartum mental health conditions by race, SES, and insurance status have been previously described. Given the increased risk of postpartum mental health conditions, such as postpartum depression, among those eligible for public health insurance, reimbursement policies by the Centers for Medicaid and Medicare (CMS) for such services play a crucial role in either ameliorating or exacerbating disparities among vulnerable and marginalized groups.    

Objectives: We sought to characterize the historical CMS (I.e. Medicaid) reimbursement policies for mental health services in the postpartum as well as provide a scoping review of studies evaluating the impact of CMS reimbursement policies on postpartum mental health outcomes.

Eligibility criteria: We will first characterize the historical CMS reimbursement policies for mental health services in the postpartum period by evaluating data regarding Medicaid reimbursement for postpartum mental health conditions since 1965. Postpartum mental health conditions included: mood disorders (depression, bipolar disorder), anxiety-related disorders (post-traumatic stress disorder, generalized anxiety disorder), and schizophrenia. Both counseling and medication were considered as treatments for postpartum mental health conditions. We will next review PubMed and CINHAL to identify studies that have evaluated the impact of these reimbursement policies on postpartum mental health outcomes.

Sources of evidence: Publicly available data included U.S. Center for Medicare and Medicaid Services (CMS) website (CMS.gov), Pub Med and Cumulative Index to Nursing and Allied Health Literature (CINAHL) databases, The U.S. official congressional record (congress.gov), and American College of Obstetricians and Gynecologist (ACOG) website.  

Charting methods: TBD

Results: TBD

Conclusions: TBD, but likely: We found minimal coverage for treatment of postpartum mental health conditions despite its frequency and negative impact on the birthing community. Further, we found a dearth of studies examining and evaluating the effect of Medicaid reimbursement policies and models on postpartum mental health outcomes. Expanded coverage is necessary to promote the health and wellbeing of the Medicaid population and may reduce disparities in mental health exacerbations. In addition to this, policies must be evaluated for impact to ensure that inequities are being addressed and disparities are being eliminated 

Introduction

For many birthing women, the postpartum period is medically vulnerable and mental health conditions are no exception. Postpartum mental health conditions include but are not limited to mood disorders (depression, bipolar disorder), anxiety-related disorders (post-traumatic stress disorder, generalized anxiety disorder), and schizophrenia. There are disparities in the diagnosis and treatment of these mental health conditions, particularly among low-and middle-income women. Additionally, mental health services such as counseling and medical treatments are either stigmatized or too expensive to cover without the help of health insurance plans. (cite)

There is a consensus that the postpartum period starts after the delivery of an infant, but the end is not very well defined.1 The American College of Obstetricians and Gynecologists defines the postpartum period as starting from delivery up to 12 weeks.2 Some researchers suggest that postpartum care be extended to 12 months because not all organ systems have returned to baseline within 12 weeks. This therein lies several discrepancies among investigators, clinicians, and policymakers on the extent of expansion of insurance policies like Medicaid to cover post-partum care for low and middle-income women.

Currently, Medicaid covers more than four in ten births in the United States with coverage up to 60 days postpartum.3 After 60 days women are left without a pathway to coverage. Under the Affordable Care Act (ACA), this coverage was extended to one year, but some states are yet to adopt this expansion among eligible women.

We conducted a scoping review to characterize the historical CMS (I.e. Medicaid) reimbursement policies for mental health services in the postpartum as well as provided a scoping review of studies evaluating the impact of CMS reimbursement policies on postpartum mental health outcomes. There is a dearth of literature on the expansion of Medicaid to cover mental health services during the postpartum period given the mental health challenges women face after giving birth. This review will contribute to the body of literature on what postpartum programs Medicaid has sponsored with an emphasis on postpartum mental health programs.


References

1. Ranji U, Gomez I, 2021. Expanding Postpartum Medicaid Coverage. KFF 2021. URL: https://www.kff.org/womens-health-policy/issue-brief/expanding-postpartum Medicaid-coverage/ (Accessed 26 January 2022).

2. ACOG Committee Opinion No. 736: Optimizing Postpartum Care. Obstet Gynecol 2018;131:e140–50. https://ucsf.idm.oclc.org/login?url=https://doi.org/10.1097/AOG.0000000000002633.

3. Martin JA. Births in the United States, 2019 2020:8.


(Edited by Sepehr Hashemi - original submission Wednesday, January 26, 2022, 9:46 PM)

(Edited by Sepehr Hashemi - original submission Wednesday, January 26, 2022, 9:46 PM)

(Edited by Sepehr Hashemi - original submission Wednesday, January 26, 2022, 9:46 PM)

Re: Weekly Scoping Review Due Items: Group 1 (Temi, Kristen, Kayla) - Medicaid reimbursement for postpartum mental health services since 1965: A scoping review

by William Brown III -
I think the scope and focus are really well defined. The background is relevant to the objectives of the scoping review and lets me know what this scoping review will contribute. You are on the right path for sure. It was also easy for me to understand as someone who knows nothing about this field. I would use stronger and more compelling language (words) in the title, abstract, and last paragraph of the introduction. Are we taking a stroll through a healthcare warzone or are we sounding an alarm and encouraging others to join the fight? inform me, but also compel to care about the topic and this scoping review.

I also don't know the significance of 1965 and why that is important. If it is in your title it must be important.

Title alternatives:

The Critical Role of Medicaid reimbursement for postpartum mental health services: A scoping review
Evaluation of the Impact of CMS reimbursement policies on postpartum mental health outcomes: A scoping review
Policies Impacting Medicaid Reimbursement for Mental Health Services in the Postpartum: A scoping review

Re: Weekly Scoping Review Due Items: Group 1 (Temi, Kristen, Kayla) - Medicaid reimbursement for postpartum mental health services since 1965: A scoping review

by Temi Kapula -
Thank you for your feedback, Will. We will continue to work on the paper as needed. The title revision has been incorporated. 1965 was the first year Medicaid was written into law and we will make this clear.

Re: Weekly Scoping Review Due Items: Group 1 (Temi, Kristen, Kayla) - Medicaid reimbursement for postpartum mental health services since 1965: A scoping review

by Temi Kapula -
METHODS

Scoping Review Design and Study Selection

We conducted a scoping review to characterize the historical CMS (I.e. Medicaid) reimbursement policies for mental health services in the postpartum as well as provided a scoping review of studies evaluating the impact of CMS reimbursement policies on postpartum mental health outcomes. We followed the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines for conducting and reporting items for systematic reviews.1

We used the PICOS terminology to frame this work. Participants are pregnant people in the postpartum period who belong to a socioeconomic group with known disparities in postpartum maternal and infant outcomes and who qualify for Medicaid insurance. Interventions of interest are clinical care services reimbursable by Medicaid. The main comparators are outcomes among others with non-Medicaid insurance/reimbursed services. The two primary outcomes of interest are depression symptomology and utilization of mental health services postpartum.

Search Strategy

To characterize the historical CMS (i.e. Medicaid) reimbursement policies for mental health services in the postpartum, we examined CMS policy documents from 1965 to present published on Kaiser Family Foundation, U.S. Center for Medicare and Medicaid Services (CMS) website (CMS.gov), Planned Parenthood, Medicaid.gov, The U.S. official congressional record (congress.gov), and American College of Obstetricians and Gynecologist (ACOG) website.

To examine the impact of CMS reimbursement policies on postpartum mental health outcomes, we searched the following databases for primary studies: MEDLINE® via PubMed and CINAHL® from January 1, 1986 through February 1, 2022. We developed a search strategy for MEDLINE, accessed via PubMed®, based on medical subject headings (MeSH®) terms and text words of key articles that we identified a priori (Appendix 1). Our basic search concepts were ("Medicaid" [TIAB] OR "Affordable Care Act" [TIAB]) AND (maternal health [TIAB] OR perinatal[TIAB] OR postpartum [TIAB] OR pregnancy[TIAB]) AND (mental health [TIAB] OR depression [TIAB]). We first identified potentially eligible studies based on title and abstract. One reviewer reviewed the titles and abstracts based on pre-specified inclusion/exclusion criteria. Two reviewers independently reviewed the papers identified for full text review. All discrepancies for study inclusion were resolved by consensus.

Study Selection

Study Design. We included studies that assessed impact of CMS funded postpartum services in the U.S., in our target population as defined below. Studies were included if they were of experimental or quasi-experimental design, assessed the primary outcome of depression symptomology and utilization of postpartum mental health services at least 3 months postpartum and were published in English. Studies were excluded if they discussed prenatal coverage of Medicaid did not include mental health service coverage during the postpartum period. Studies that were non-experimental in design were excluded, as were studies published only as abstracts.

Target population.  Female adults (age 18+) who delivered a baby, reported postpartum depression symptoms and are eligible for Medicaid. It is important to note that Medicaid eligibility criteria differs by state as some states. (cite) However, some eligibility requirements that apply country wide include low-income families, receive Supplemental Security Income (SSI), must be residents of the state in which they receive Medicaid, US citizens and lawful permanent residents. (cite) Low-income status is determined by the Modified Adjusted Gross Income (MAGI) methodology. (cite) The MAGI methodology considers taxable and tax filling relationships to determine financial eligibility for Medicaid.

Intervention Inclusion/Exclusion. We included any studies that met the criteria above and examined the impact of any services reimbursed through CMS/Medicaid available in the postpartum period to address mental health of birthing people.

Data Extraction and Quality (Risk of Bias) Assessment

Data were extracted and summarized. We reported study characteristics and intervention characteristics, using categories to describe components of included studies to facilitate cross-study comparisons. Primary outcomes were reported for all studies.

All three researchers independently assessed the risk of bias of the XX number included studies using the Cochrane Risk of Bias tool. The specific domains include random sequence generation, allocation concealment, blinding, incomplete outcome data, selective reporting, and other source of bias. Any disagreement will be resolved by discussion among the three reviewers.


RESULTS
Search Results
The PRISMA flow diagram for this study is shown in Figure 1 below. The search strategies yielded 135 potentially relevant citations from PubMed. After excluding duplications and screening titles and abstracts for eligibility, 35 studies were retained for full-text evaluation. Of them, XX studies were excluded according to the inclusion and exclusion criteria. A total of X studies (cite) were included in this scoping review.

Figure 1: Study diagram of study selection (attached)

Characteristics of Included Studies
 This scoping review included x studies [citations] with a total of XX participants. TheX studies included were conducted in were published between 2012 and 2022. Participants were postpartum women aged ≥18 years. The sample sizes ranged from X to Y. The X included studies (criteria met?). Of them, X studies used X mental health services, X studies explicitly states clinical outcome, and X studies examined Medicaid expansion effects. X studies had X study design, X were policy briefs and X were study design.

Risk of Bias
TBD

Clinical outcomes covered by Medicaid
TBD

Utilization of Postpartum mental health services with Medicaid coverage
TBD