National Science Policy Network in collaboration with Journal of Science Policy and Governance announced the memo-writing competition in 2020. Emory has taken another win! Congratulations to the passionate writers, Amanda Engstrom, Gabrielle Delima, Emily Michels, and Jay Qiu, who formulated the strategic memo regarding maternal mortality rates in Georgia. See the memo below.
April 15, 2020
MEMORANDUM FOR THE GEORGIA STATE LEGISLATURE
FROM: Amanda Engstrom, Gabrielle Delima, Emily Michels, Jay Qiu
Emory Science Advocacy Network (EScAN)
SUBJECT: Lowering Preventable Maternal Deaths in Rural Georgia
Georgia’s maternal mortality rate (MMR) is one of the highest in the U.S. and shows few signs of improvement, despite government intervention. Women living in rural areas exhibit significantly higher risk than their urban counterparts and have reduced access to life-saving health care. 60% of Georgia’s maternal deaths are preventable, however the lack of available providers – especially in rural areas – makes it hard to address these avoidable issues. As such, we propose an amendment to the Georgia legal code that allows Certified Nurse Midwives (CNM) to practice independently, removing unnecessary restrictions on low-risk care they are trained to provide. This change can lower systemic and individual costs while allowing an existing workforce to augment preventive care efforts.
I. Statement of Issue
As most other developed countries have decreased their maternal mortality rates (MMR), the United States has seen an almost 60% increase from 2000 to 2017. The Centers for Disease Control and Prevention (CDC) defines maternal mortality as “the death of a woman while pregnant or within 1 year of the end of a pregnancy...related to or aggravated by the pregnancy or its management.” The U.S. 2018 MMR was 17.4 deaths per 100,000 live births – roughly 700 women per year, many of which are preventable. Georgia ranks amongst the highest MMR in the country at 25.9 per 100,000 births, and continues to worsen, while states such as California, Massachusetts, and Nevada have the lowest rates at 4.0, 8.4, and 8.4 per 100,000 births, respectively., Further, women in Georgia’s rural counties – areas with a population less than 35,000 – have up to 50% higher rates than those in urban areas.
Access to care remains the central problem for women in rural Georgia. 93 rural counties are without a hospital labor and delivery unit, and two-thirds of rural women are required to travel for delivery. 75 rural counties are without an Obstetrician-Gynecologist (OB-GYN), and zero rural counties have a maternal-fetal specialist. Despite Georgia’s attempts to curtail these rates and increase the rural workforce, the MMR has not improved.
II. Current Response in Georgia
Georgia has attempted to address the issue with little success reflected in yearly MMR. A study committee, the Maternal Mortality Review Committee (MMRC), as well as new reporting requirements for pregnancy-related deaths, have been implemented. Results of MMRC data collection demonstrate leading causes of death and major contributing factors, such as lack of access to care and little recognition or treatment of early warning signs. The committee also states that 60% of the maternal death cases they examined were preventable. Each year recommendations are reported to decrease MMR through various actions such as early intervention, maternity education, and community involvement.
Financial approaches have also been attempted, such as the Rural Preceptor Tax Credit, which grants physicians a maximum $1,000 tax credit to mentor new providers, and service-cancelable partial loan repayment for physicians, physician assistants, and advanced practice registered nurses (APRN) in underserved rural counties. Funding has been allotted for the improvement of rural birthing hospitals ($2 million), additional OB-GYN residency slots ($1.6 million), and Medicaid reimbursement for rural prenatal care programs ($500,000). Patient-focused approaches are also proposed, such as pending House Bill 800, which allows rural Medicaid recipients in border counties to seek covered out-of-state OB-GYN treatment within 50 miles of Georgia’s border.
Georgia’s efforts are not reaching the in-need areas to the extent that the problem demands. Current incentive programs do not guarantee long-term physician service in rural areas, and women are still dying at alarming rates. We believe that creative solutions can be found within Georgia’s existing workforce and infrastructure.
In this memorandum, we discuss three options: expanding the scope-of-practice (SOP) for Certified Nurse Midwives (CNM) in Georgia, expanding on rural incentive programs, and inaction.
III. Policy Options
Option 1: Amend Georgia Code to increase CNM SOP to allow for independent practice. Georgia is among the most restrictive for CNMs, requiring a written agreement between a physician and up to four CNMs to delineate which responsibilities require physician supervision or approval. While physicians should still handle highly complicated cases, CNMs (licensed as APRNs) will manage low-risk and routine maternal care – including delivery assistance and monitoring of mother and baby – without superfluous physician supervision. 25 states currently allow for CNM independent practice, including states with some of the lowest MMR in the country. Independent practice encourages collaborative care instead of restrictive supervisory contracts. We propose the amendment of GA Code §43-34-25 (2018) to eliminate the requirement for written protocols between physicians and APRNs.
Advantages This amendment allows CNMs to practice to a fuller potential, lessening the burden of care for physicians who must remain available for complicated cases. This change would no longer tie the number of available physicians to the number of CNMs able to practice, and minimizes workforce disruption if supervising physicians leave rural areas. States with independent practice laws draw more CNMs on average than those with more restrictive laws. Studies demonstrate that states with fewer nurse practitioner (NP) restrictions “tend to exhibit an increase in the number and growth of NPs, greater care provision…and expanded health care utilization, especially among rural and vulnerable populations”. Full SOP for APRNs can lower health care costs within the system and promote innovation. Additionally, CNM care of low-risk women results in lower patient costs and more efficient resource use. This amendment will increase access to care for patients by utilizing the already-present and qualified workforce, decreasing the pressure to recruit new providers.
Disadvantages Complicated maternal health cases still require physician care. Continued recruitment of CNMs and physicians will remain necessary, and there may be a need for increased training and administrative support for the increased CNM workload.
Option 2: Amend Georgia Code to increase and extend rural physicians’ tax credits. Current Georgia regulation allows qualifying rural physicians – including OB-GYNs – to claim an additional tax credit of up to $5,000 per year for up to five years. These tax credits help sustain practices where 46% of rural residents are dependent on government health care, which reimburse services at lower rates.,, Extending this credit for an additional five years and increasing the credit to $10,000 for each of those additional years further incentivizes OB-GYNs to continue practicing and living in these communities. Physicians that utilize this tax credit for all ten years are more likely to continue practicing even without the credit, as their careers and patient bases have been long-established. We propose the amendment of GA Code §48-7-29 to extend tax credits for rural physicians from five to ten years and increase the credit to $10,000 for years six to ten.
Advantages The proposed amendment would aid efforts to recruit and retain OB-GYNs in rural communities by offering a financial incentive to maintain practices in these areas of need. Physicians who participate in incentive programs are more likely to remain in rural and underserved communities. In Nebraska, the median length of retention for rural family medicine providers was 4.3 years longer with incentive programs compared to those without. Additionally, bipartisan support is attainable, as there is no requirement for an expansion of Medicaid benefits.
Disadvantages Available data demonstrate that financial incentives are effective for short-term recruitment, however they may not translate into long-term retention.,, This amendment may prolong the presence of OB-GYNs in rural communities, but does not guarantee the practices will remain once incentives cease. Additionally, additional tax credits will decrease annual tax revenue, complicating state budget planning.
Option 3: Inaction. Wait for the effects of recent policy changes, proposed legislation, and MMRC data monitoring.
Advantages Significant funds have already been committed to the investigation and analysis of the cause of high MMR. Additionally, new legislation is proposed to increase the workforce, OB-GYN residency programs, and educational programs statewide.
Disadvantages The majority of fatalities are within the poorest and most rural regions of the state. Despite current efforts, areas most in need still suffer. Access to care remains the largest concern for women in rural areas; without legislation that directly expands access to qualified providers, they will continue to be most affected.
IV. Policy Recommendation
We recommend Option 1, to amend GA Code §43-34-25 to allow CNM independent practice for routine and low-risk care. This amendment to the Georgia Code increases the availability of health care providers statewide and would help reduce patient financial burden. A majority of the country, including states like Utah and North Dakota, has approved independent practice, yet Southern states – many of which rank poorly in terms of maternal mortality – are not represented. Georgia has the opportunity to be a leader in the South, expanding CNMs’ SOP and working toward a better, healthier environment for Georgia’s mothers and babies.
1. WHO, UNICEF, UNFPA, World Bank Group, and United Nations Population Division. “Trends in Maternal Mortality 2000 to 2017.” WHO, 2019. https://apps.who.int/iris/bitstream/handle/10665/327596/WHO-RHR-19.23-eng.pdf?ua=1.
2. CDC Division of Reproductive Health, National Center for Chronic Disease Prevention and Health Promotion. “Pregnancy Mortality Surveillance System.” Centers for Disease Control and Prevention: Reproductive Health, February 4, 2020.
3. Hoyert, Donna L., and Arialdi M. Miniño. “Maternal Mortality in the United States:” National Vital Statistics Reports 69, no. 2 (January 30, 2020): 1–16.
4. Georgia Department of Public Health. “Maternal Mortality.” Georgia Department of Public Health, November 22, 2019. https://dph.georgia.gov/maternal-mortality.
5. Georgia House Budget & Research Office. “House of Representatives Study Committee on Maternal Mortality.” State of Georgia House of Representatives, 2019.
6. Ungar, Laura, and Caroline Simon. “Which States Have the Worst Maternal Mortality?” USA Today, November 1, 2018.
7. World Population Review. “Maternal Mortality Rate By State 2020.” World Population Review, 2020.
8. “Georgia’s Rural Counties.” Georgia State Office of Rural Health, August 2008. dch.georgia.gov.
9. Georgia House Budget & Research Office.
10. Georgia House Budget & Research Office.
11. Georgia Department of Public Health.
12. Georgia Department of Public Health.
13. Laff, Michael. “Tax Incentives Aim to Attract Primary Care Preceptors.” AAFP, June 14, 2016. https://www.aafp.org/news/education-professional-development/20160614preceptorcredits.html.
14. Georgia Board of Health Care Workforce. “Loan Repayment Programs.” Georgia Board of Health Care Workforce. Accessed April 1, 2020. https://healthcareworkforce.georgia.gov/loan-repayment-scholarship-programs/loan-repayment-programs.
15. Boockholdt, Tara. “Maternal Mortality in Georgia.” Georgia House Budget & Research Office, April 2019.
16. Scott, Sandra, “Able” Mable Thomas, Dar’shun Kendrick, Valencia Stovall, Erica Thomas, and Renitta Shannon. Medical assistance; health care services by providers in bordering states to Georgia Medicaid recipients under certain conditions, Pub. L. No. HB 800, 1 (2020). http://www.legis.ga.gov/Legislation/en-S/display/20192020/HB/800 .
17. Midwife Schooling. “States That Allow CNMs to Practice and Prescribe Independently vs Those That Require a Collaborative Agreement.” MidwifeSchooling.com, 2020. https://www.midwifeschooling.com/independent-practice-and-collaborative-
18. Midwife Schooling.
19. Justia Law. “Universal Citation: GA Code § 43-34-25 (2018).” Justia Law. Accessed April 1, 2020. https://law.justia.com/codes/georgia/2018/title-43/chapter-34/article-2/section-43-34-25/ .
20. Yang, Y. Tony, Laura B. Attanasio, and Katy B. Kozhimannil. “State Scope of Practice Laws, Nurse-Midwifery Workforce, and Childbirth Procedures and Outcomes.” Women’s Health Issues 26, no. 3 (May 7, 2016): 262–67. https://doi.org/10.1016/j.whi.2016.02.003 .
21. Xue, Ying, Zhiqiu Ye, Carol Brewer, and Joanne Spetz. “Impact of State Nurse Practitioner Scope-of-Practice Regulation on Health Care Delivery: Systematic Review.” Nursing Outlook 64, no. 1 (September 9, 2015): 71–85. https://doi.org/10.1016/j.outlook.2015.08.005 .
22. Adams, E. Kathleen, and Sara Markowitz. “Improving Efficiency in the Health-Care System: Removing Anticompetitive Barriers for Advanced Practice Registered Nurses and Physician Assistants.” Brookings, June 13, 2018. https://www.brookings.edu/research/improving-efficiency-in-the-health-care-system-removing-anticompetitive-barriers-for-advanced-practice-registered-nurses-and-physician-assistants/ .
23. Altman, Molly R., Sean M. Murphy, Cynthia E. Fitzgerald, H. Frank Andersen, and Kenn B. Daratha. “The Cost of Nurse-Midwifery Care: Use of Interventions, Resources, and Associated Costs in the Hospital Setting.” Women’s Health Issues 27, no. 4 (July 1, 2017): 434–40. https://doi.org/10.1016/j.whi.2017.01.002 .
24. Justia Law. “O.C.G.A. 48-7-29 (2010): Tax Credits for Rural Physicians.” Justia Law. Accessed April 1, 2020. https://law.justia.com/codes/georgia/2010/title-48/chapter-7/article-2/48-7-29/ .
25. National Advisory Committee on Rural Health and Human Services. “Rural Health Insurance Market Challenges: Policy Brief and Recommendations.” Department of Health and Human Services, August 2018.
26. Barnett, Jessica C., and Edward R. Berchick. “Health Insurance Coverage in the United States: 2016.” United States Census Bureau, September 12, 2017. https://www.census.gov/library/publications/2017/demo/p60-260.html .
27. Hart, Ariel. “Doctor Shortage Key to Georgia’s Rural Health Crisis.” Atlanta Journal-Constitution, August 17, 2018. https://www.ajc.com/news/state--regional-govt--politics/georgia-faces-rural-doctor-shortage/JqAwfs1SLiqCwVNronKScM/ .
28. Academy Health. “Rapid Evidence Review: What Are Effective Approaches for Recruiting and Retaining Rural Primary Care Health Professionals?” AcademyHealth: Translation and Dissemination Institute, December 2017. https://www.academyhealth.org/publications/2018-01/rapid-evidence-review-what-are-effective-approaches-recruiting-and-retaining .
29. Pedley, Andrew J. “Analyzing the Impact of Incentive Programs on Retention of Family Practice Providers in Rural Nebraska.” Community and Regional Planning Program: Professional Projects, July 17, 2018, 1–64.
30. Pedly, Andrew J.
31. Academy Health.
32. Misfeldt, Renee, Jordana Linder, Jana Lait, Shelanne Hepp, Gail Armitage, Karen Jackson, and Esther Suter. “Incentives for Improving Human Resource Outcomes in Health Care: Overview of Reviews.” Journal of Health Services Research & Policy 19, no. 1 (January 2014): 52–61. https://doi.org/10.1177/1355819613505746 .