Katy B. Kozhimannil, PHD, MPA, is an associate professor in the Division of Health Policy and Management at the University of Minnesota School of Public Health and Director of Research at the University of Minnesota Rural Health Research Center. Her research applies health policy and health services research to the field of women's health, with a focus on maternal and child health. Dr Kozhimannil conducts research to inform the development, implementation, and evaluation of health policy that impacts reproductive-age women and their families. Twitter @katybkoz. E-mail email@example.com
There is a quiet revolution happening among health plans. Mothers and fathers who work for health insurance companies-and who had the support of a doula at the time of childbirth-are beginning to inquire about expanding benefits to include coverage for this evidence-based service.
There is a quiet revolution happening among health plans. Mothers and fathers who work for health insurance companies—and who had the support of a doula at the time of childbirth—are beginning to inquire about expanding benefits to include coverage for this evidence-based service. Because I conduct research on childbirth care, I hear a lot of birth stories (and I love hearing birth stories). Anecdotally, I have seen a pattern arise: behind every health plan innovating in the space of maternity care is a compelling birth story, backed by evidence.
What is a Doula? And Why Do Lots of People Who Work for Insurance Companies Have One?
Doulas are trained professionals who provide one-on-one emotional and informational support during pregnancy, labor and delivery, and postpartum. Doulas are not medical professionals and do not provide medical services, but work alongside nurses, obstetricians, midwives, and other healthcare providers. Strong clinical evidence shows that doula care is associated with lower rates of epidural use and cesarean delivery, shorter labors, higher rates of spontaneous vaginal birth, as well as higher levels of satisfaction. Indeed, in a recent consensus statement focusing on reducing rates of cesarean delivery, the American College of Obstetricians and Gynecologists and the Society for Maternal Fetal Medicine stated, “Published data indicate that one of the most effective tools to improve labor and delivery outcomes is the continuous presence of support personnel, such as a doula…Given that there are no associated measurable harms, this resource is probably underutilized.”
Barriers to Accessing Doula Care
“Underutilized” seems to be an understatement for such an “effective tool.” In a national survey, just 6% of US mothers reported that they had support from a doula when they gave birth in 2011 and 2012. Why do so few women have support from a doula? The primary barrier seems financial. Most health insurance plans don’t cover doula services, and the costs of hiring a doula ranges from $500 to $1500 dollars, or more. For families facing rising out-of-pocket costs for childbirth care, hiring a doula may be a financial impossibility. Cost, though, is not the only barrier to doula services. Geography is another barrier, especially for the half a million women who give birth in rural hospitals each year. Cultural and language access are also crucially important, and unmet equity concerns are evident by the large and persistent racial/ethnic gaps in birth outcomes in the US. Financial, geographic, and cultural barriers to care exist not only for accessing doula support but also for other evidence-based maternity services, including care provided by midwives and in licensed birth centers.
The Case for Insurance Coverage for Doula Services
Understandably, health plans are cautious about the prospects of adding coverage for new benefitsespecially for high-volume conditions like birthand they need good, solid data to make such decisions. Fortunately, relevant data are emerging to support policy and administrative decision making around increasing access to doula coverage through third-party reimbursement. One example from my own work was a recent study showing that women with doula support had lower odds of a nonindicated cesarean. In this study, we also found that about 10% of mothers with no medical indication for the procedure gave birth via cesarean. For private health insurers, the total cost of a cesarean birth, on average, is approximately $10,000 more than the total cost of a vaginal birth. If we suppose that the cost of doula services are approximately $1000, then the decision to cover 10 doula-supported births would be cost-neutral if 1 nonindicated cesarean were avoided among these, a proposition that is within the realm of estimates from our study.
Admittedly, our paper and other published studies of doula care use data that have important and relevant limitations: by the time we analyze and publish them, the data are outdated, and using administrative records always leaves out part of the story. However, health plans can and should use their own data to assess the potential for doula coverage in their own contexts.
Minnesota Experience: Recommendations from Managed Care Organizations
In September 2014, Minnesota’s state statute requiring Medicaid reimbursement for doula coverage went into effect. Minnesota is 1 of 2 states with legislation allowing Medicaid coverage of doula services; the other is Oregon. However, the early implementation of Minnesota’s doula coverage law has been fraught with challenge. On April 13, 2015, as part of a research study evaluating the implementation of the law, we sent letters to the CEOs of all of the Minnesota Managed Care organizations that participate in Medicaid with a request for information regarding the implementation status of the legislation. The responses we received revealed thoughtful insights on implementation, from the payer perspective.
Respondents noted several key challenges with implementation regarding network development, billing, and consumer outreach. In the first year of Minnesota’s experience with Medicaid coverage for doula services, the most frequently mentioned challenge was the requirement that doulas bill for services through a supervising provider and use that provider’s National Provider Identification Number for billing purposes. (This is required because Minnesota’s Medicaid program only reimburses licensed providers, and doulas are certified, but not licensed, in Minnesota.) For example, 1 payer noted that “few, if any, physicians or nurse practitioners have agreed to act as a supervising provider due to quality concerns and liability.” Another organization noted that “most doulas have operated independently, rather than under the auspices of a specific provider or provider group; the women they support receive care from a wide variety of providers and deliver at a variety of hospitals” making the requisite supervisory relationship a challenge.
In addition to highlighting this key challenge, respondents offered several recommendations for improving implementation of the doula benefit under Minnesota Medicaid, and these suggestions may also be applicable to private health plans or self-insured employers considering the possibility of extending benefits to include doula services.
Overwhelmingly, managed care organizations emphasized the complexity of the relationships between members, clinics, medical providers, doulas, health plans, and regulators, but all of the respondents also highlighted their interest in overcoming barriers to improve access to doula services.
The idea to reach out to health plan CEOs to solicit their insights and recommendations for change came from a colleague who works at a health plana colleague who had a wonderful birth experience supported by a doula. As the evidence base around the potential benefits of doula access grows, and as more families experience these benefits, the conversation about inclusion of doula services as a covered benefit has extended beyond the water cooler and into executive suites and legislative discussions, where it belongs, as our country grapples with troubling trends and persistent disparities in birth outcomes.