Low pay could hamper new MassHealth doula services, advocates say [masslive.com]

Massachusetts’ Medicaid and Children’s Health Insurance Program, MassHealth, announced Friday they will offer doula services for pregnant, birthing and postpartum people next spring. But many advocates remain concerned about potential barriers for doulas, including low reimbursement rates and MassHealth not offering reimbursement for travel.

Doulas are individuals who are trained to support a birthing person before, during and after pregnancy. They provide emotional, physical and educational support.

Kate Symmonds, staff attorney at the Massachusetts Law Reform Institute, said while the rate of pay that MassHealth is offering may be what some doulas are currently charging in the Commonwealth for their care, it’s not enough to ensure the long term stability and success of MassHealth’s program.

She said doulas work long and unpredictable hours at low pay with no benefits in order to serve their clients and individuals in need.

“Doulas have been historically marginalized and undervalued so what doulas are currently charging just isn’t a good measure of what is needed to build a robust and sustainable doula workforce,” Symmonds said. “What we don’t want to see is continuing that trend of undervaluing. Doula work and putting the doula workforce in a position where they’re unable to meet the demand. I think if we’re really serious about expanding access to doula services, we need to get serious about investing in the doula workforce and appropriately valuing doula work.”

Symmonds said she is concerned by the doula workforce, with almost two-thirds of doulas having to turn clients away in part because they were too booked, according to a 2022 study from the Betsy Lehman Center.

Given the fact that Medicaid covered 41% of all births across the country in 2021, according to the Centers for Disease Control and Prevention, Symmonds said there won’t be enough doulas to meaningfully cover the number of MassHealth clients who might need a doula.

“The supply of doulas is going to be entirely inadequate, without additional meaningful investment in the workforce,” Symmonds said.

While Symmonds said she thinks MassHealth is concerned about doula workforce development, she said it is limited in what it can do.

“MassHealth provides services to MassHealth members. It’s not responsible for state investment in workforce development for healthcare providers,” Symmonds said.

The importance of doula services

“There’s no question that doula services improve birth experiences and outcomes for families, and particularly racial disparities in birth outcomes. So we know that this has the potential to really meaningfully address the maternal health crisis in this state,” Symmonds said. “While we’re really excited about this, we also know that the work doesn’t stop here and there’s still a lot more work to do.”

According to a June report published by the Massachusetts Department of Public Health, the rate of life-threatening pregnancy-related complications in Massachusetts nearly doubled from 2011 to 2020. Black patients experienced severe complications two and half times more often than white patients.

Doulas have also been found reduce the number of cesarean and preterm birth and low birthweight infants in turn reducing state costs and some of the health inequities for women of color, according to a 2012 study by the American Journal of Public Health.

“Doula care can mean the difference between having a cesarean section and not,” said Erika Laquer, a birth and postpartum doula, childbirth educator and co-lead for the Massachusetts Doula Coalition.

MassHealth declined a request for an on-the-record comment.

Jacqueline Tuttle, a birth and postpartum doula for the past six years and owner of Yellow Rose Births, said she plans to be a part of the doula coverage under MassHealth but she wishes the reimbursement rates were higher.

“Overall I’m thrilled MassHealth members will have access to doula care, and I think it’ll bring about such positive changes for birthers and providers in our home state,” Tuttle said. “We do still need to properly compensate doulas, though, to avoid the risk of burnout and high turnover. This is heavy emotional and physical work, and I’m blessed to do it.”

Doula Adwapa Asenso agrees. She said the reimbursement rates offered “fall short of reflecting the continuous and relational nature of our work.”

Despite this, she is also planning to become a MassHealth provider based on her “deep-seated belief in supporting my community.”

In order for doulas to become a MassHealth doula provider, they will have to enroll in a almost four hour formal training, among other requirements.

MassHealth is planning to offer doulas up to $1700 per member per perinatal period — $900 for labor and delivery support and $800 for perinatal visits. The $1700 is $200 more than the proposed amount by MassHealth in September and higher than any other state that covers doula services through Medicaid, according to MassHealth.

The rate doesn’t include travel time which Symmonds said makes it more difficult to reach more rural clients who are in “maternity deserts.”

“Across the country, even for states that have been working hard to get kind of more sustainable and equitable rates, I think we’ve still seen that there’s still a lot of room for improvement and that really for the benefit in general to be successful, it’s really important that doulas as a new category of Medicaid provider are really given the support that they need to succeed,” said Amy Chen, senior attorney at the National Health Law Program.

As part of being a MassHealth provider, doulas will have to submit claims for payment.

Symmonds said many doulas haven’t worked with insurance before and it will be a “real learning curve for doulas” and for MassHealth to best understand how to support doulas.

“The bill’s administrative requirements, while seemingly flexible, could add to our workload, which is a concern given that many doulas operate without administrative support,” said Asenso, who is a doula.

Perinatal visits which last more than eight hours require prior authorization, according to MassHealth.

Lorenza Holt, co-lead for the Massachusetts Doula Coalition, said she doesn’t think this is enough time to build a trusting relationship with MassHealth clients and effectively prepare them for labor, birth, postpartum and best infant feeding practices.

“These are not sufficient hours to support vulnerable and at-risk families through the often stressful and complex weeks of prenatal and postpartum adjustments. I am glad more hours can be requested but worry that the suggested process will prove to be cumbersome and inefficient,” Holt said.

Eleven states plus the District of Columbia are actively providing Medicaid coverage of doula services, according to the National Health Law Program. However, doulas and public officials alike said many programs haven’t been successful or are too new to determine their effectiveness.

“There’s not a lot of precedent for what the rate should be, but there is some precedent that lower rates like the under $2,000 range aren’t long-term successful propositions,” Symmonds said.

Symmonds told MassLive in September the main reason certain states have failed to roll out a Medicaid doula coverage program is because the states have failed to build a trusting relationship between doulas and the Medicaid program. Some states have also offered reimbursement rates that were too low which made many doulas not be able to participate in the program.

Oregon, for instance, offered a reimbursement rate of $350 until last year, when the rate was increased to $1500. In comparison, Washington D.C. has a reimbursement rate of $1,950 for doulas.

Symmonds has been working on a bill since 2022 which would create a doula workforce development trust fund of potentially to recruit and train more doulas to keep up with demand.

“We knew that MassHealth was going to be doing this all along. In fact, that’s why we wrote the bill,” Symmonds said. “The bill is going to help make this program sustainable and successful. And if anything, I think MassHealth’s rollout now gives me Increased urgency to work on the bill and to have this bill passed because now that members are going to start being able to actually get their doula services covered, we know how frustrating it’s going to be when they start actually seeking doulas and are unable to find a doula who’s able to give them the care that they need.”

What is the bill?

The bill was drafted by the Massachusetts Doula Coalition and the Massachusetts Law Reform Institute with feedback from the doula community through doula town halls and surveys, according to Symmonds. It was sponsored by Rep. Lindsay Sabadosa, D-Northampton and Sen. Liz Miranda, D-Boston.

The bill, also known as H. 1240, is in the Joint Committee on Health Care Financing. There was a hearing to discuss the bill in September which Symmonds said went smoothly. She said she hopes the committee will give it a favorable report and be called for a vote, though it might also move to another committee.

“My hope is that the legislature will see that this is happening and see the need for this bill and act quickly on it,” Symmonds said.

Sabadosa said she has been having conversations about the doula bill since 2018 and began drafting it in 2019. The bill, she said, has gone through different iterations as MassHealth and the Department of Public Health have oscillated in their support.

“Nobody wanted to talk about it. They were all like, ‘Oh, what a lovely idea. But it’s too expensive.’ So we’ve moved from that to a place where MassHealth and the Department of Public Health are very supportive of the legislation, which is fabulous,” Sabadosa said in September.

Sabadosa said in September she is optimistic about the bill’s future this legislative session and hopes it will pass in the Spring of 2024. While the bill might’ve gone through committees in years past, the legislative session ended before anything was able to be finalized or fully discussed.

While Massachusetts wouldn’t be the first one to cover doula services, the state could be the first to provide a successful program, Sabadosa said.

The bill would allow MassHealth pregnant individuals and postpartum individuals up to 12 months following the end of the pregnancy to access doula services without having to pay out-of-pocket. It mandates that the Department of Public Health work with hospitals to ensure that doulas have access to the delivery room and create a doula advisory committee within Department of Public Health.

Holt, from the Massachusetts Doula Coalition, said she worries hospitals and healthcare systems under the MassHealth model won’t further invest in the integration of doulas.

“We will need to build ways of having all providers, including doulas, being at the same table in productive dialog. Our healthcare systems need to learn how to better understand the role of doula and also be better prepared to hear how families are experiencing the care received,” Holt said. “Well trained and supported doulas can help all in the room in meaningful and impactful ways.”

The doula advisory committee would be made up of 10 to 12 members appointed by the Department of Public Health Commissioner. Two of the committee members would be individuals from the community who have experienced pregnancy as a MassHealth member but aren’t doulas and the rest would be doulas, among other specifications in the bill.

“I’m really thankful to MassHealth for doing something — for going to this uncharted territory. But they’re going to need some feedback. And they’re going to need to build a trusting relationship with the doula community in order to get doula buy in and in order to ensure that the program is working for doulas and for families,” Symmonds said.