Last week, Governor Henry McMaster recognized Robby Kerr, the departing Director of SC DHHS, for his outstanding service to South Carolina. The ceremony at the State House drew over 300 attendees, reflecting the deep appreciation for his contributions to our state. Director Kerr received the Order of the Palmetto from the Governor, and a beautiful piece of art from the MCO plan presidents.  SCAHP extends its heartfelt thanks to Robby for his years of dedicated leadership and commitment to South Carolina.

Governor Names Next SCDHHS Director

November 11, 2024. Governor Henry McMaster announced  the retirement of South Carolina Department of Health and Human Services (SCDHHS) Director Robert Kerr, effective November 1, 2024.  The SCDHHS administers Healthy Connections, the state’s Medicaid program. Director Kerr served in this leadership role for more than three years, following the governor’s 2021 nomination. Previously, Kerr served as SCDHHS Director from 2003 to 2007, and worked for the Department for 22 years.

The governor named Eunice Medina as Kerr’s successor as SCDHHS Director. Medina has been serving as the Chief of Staff and Deputy Director of Programs at the agency since June 2021. She has 20 years of experience in Medicaid  policy and operations, and previously served as Bureau Chief with the Florida Agency for Health Care Administration, where she managed oversight of the state’s Medicaid MCOs.  Medina’s appointment is now subject to confirmation by the state senate, and the Senate Medical Affairs Committee Chair stated that the confirmation process will be the committee’s first order of business.

Check out the announcement from the governor here.

The SCAHP Q3 Meeting was held at Wild Dunes Resort on October 9.  Our featured speaker was Kobra Eghtedary, PhD.  Dr. Eghtedary is the Director of the State Health Improvement Office at the S.C. Department of Public Health. 

Prior authorizations are considered obstacles by many physicians and patients alike, with 9 in 10 physicians saying in an American Medical Association survey prior authorization has a negative effect on patient outcomes.

To combat that burden, UnitedHealthcare is rolling out a gold-card program that will reward contracted provider groups that "consistently adhere to evidence-based care guidelines" by allowing certain physicians to bypass the prior authorization process.

While some physicians and groups have expressed concern over the program, other physicians are optimistic it could help combat lengthy wait times and existing prior authorization requirements.

Joshua Rosenow, MD. Director of functional neurosurgery at Northwestern Medicine (Chicago): UHC has been the perpetrator of some of the most onerous prior authorization requirements. While the gold-card program does not solve all of the myriad issues with UHC prior authorization, it will hopefully reward practices for successfully navigating UHC's thicket of prior authorization requirements with a year of exemptions. However, this is renewable annually and it is unclear exactly how UHC will recertify practices' gold-card status if they are not submitting prior authorization requests. It is possible that submitting annual data and medical records to maintain gold-card status could be just as time consuming and frustrating as the prior authorization process itself. Moreover, the list of procedures that would be eligible for inclusion in the gold-card program won't be released until Sept. 1, so we don't yet know how applicable this will be to spine and pain practices.

Zeeshan Tayeb, MD. Owner and medical director of Pain Specialists of Cincinnati: The proposal behind the gold-card program from UHC is one that will work to help alleviate pre-certification requirements if the program works as designed. The qualifying criteria for provider enrollment is something that will help raise the standards of care for all patients receiving treatment. It would be an additional incentive if providers qualifying for the UHC gold card enrollment were provided an elevated fee schedule for services.

Manufacturing of novel cell and gene therapy (CGT) products is extremely complex and patient-specific, so it can be a heavy lift to distribute these agents. However, several leading specialty pharmacies have developed dedicated programs focused on the unique financial, delivery, temperature control and patient support challenges associated with providing these therapies.

Orsini an Early Adopter

With three decades of experience in rare disease pharmacy, Illinois-based Orsini Specialty Pharmacy was well positioned to move into the CGT space in 2017, when it began supporting the cell therapy autologous cultured chondrocytes on a porcine collagen membrane (MACI, Vericel), used for the repair of full-thickness knee cartilage defects in adults. A year later, in 2018, Orsini entered the gene therapy channel with a program to support patients who are prescribed onasemnogene abeparvovec-xioi (Zolgensma, Novartis), an adeno-associated viral vector–based gene therapy for pediatric spinal muscular atrophy (SMA). Orsini currently supports six CGTs, including:

• valoctocogene roxaparvovec-rvox (Roctavian, BioMarin), the first gene therapy for hemophilia A;
• etranacogene dezaparvovec-drlb (Hemgenix, CSL Behring), the first gene therapy for hemophilia B; and
• delandistrogene moxeparvovec-rokl (Elevidys, Sarepta), the first gene therapy for Duchenne muscular dystrophy.

“Taken together, we are managing or have managed around 6,500 patients receiving these cell and gene therapies,” said Allison Droba, Orsini’s gene therapy operations manager. Ms. Droba heads a small, tightly focused team that works directly with patients receiving CGT and with Orsini’s larger payor team and pharmacists and program managers who communicate with the manufacturers. “When a new referral comes in, everyone knows about it and it’s all hands on deck,” she said. On average, they can process any new cell and gene patient in five to seven business days and schedule shipment to the appropriate facility.

Rare disease specialty pharmacy programs often take a sequential approach to patient care, with different parts of the process moving from one functional team to another. Orsini’s care team, in contrast, “wraps around the case and the patient and monitors every step, sometimes hour by hour, to ensure the therapy gets to the patient on the time line we have established,” said Eyad Farah, the company’s chief operating officer.

With many CGTs, time is of the essence. Onasemnogene abeparvovec-xioi, for example, has completely transformed the prognosis for SMA, a rare genetic disease that causes progressive loss of muscle control and function. But time to treatment makes an enormous difference: Outcomes are better in infants who are treated before they begin to show symptoms. One real-world study found that the children with the best motor outcomes were those who had received gene therapy at a significantly younger age—a median of 1.7 versus 7.85 months in the overall group (Pediatr Neurol 2023;144:60-68).

“As soon as we get the referral for Zolgensma from the manufacturer hub, we stop everything we’re doing and work on that one first,” Ms. Droba said. “My team gets on the phone with the insurance company to verify benefits, determine whether it is covered under pharmacy or medical benefit and if prior authorization is needed, and immediately informs the physician’s office of what we need to submit. We follow up on that authorization at least two or three times a day; sometimes every hour on the hour.”

Accredo Focuses on Access

Accredo by Evernorth, part of Evernorth Health Services, is another leading specialty pharmacy with deep expertise in gene therapies, including several of the CGTs supported by Orsini as well as others such as lovotibeglogene autotemcel (Lyfgenia, Bluebird Bio) for the treatment of sickle cell disease and voretigene neparvovec-rzyl (Luxturna, Spark Therapeutics) for the treatment of inherited retinal disease.

Its GeneAXS team is solely dedicated to ensuring access to GCTs, which encompasses payor contracting, benefits investigation, fulfillment, patient services and clinical consultation. “This team regularly engages with patients, clinicians and their caregivers, as well as manufacturers, to ensure everyone is coordinated and in sync for each gene therapy order,” said Mark Jacob, the senior director of product management at Accredo. “Our team has expertise in navigating payor contracting, benefits investigation, fulfillment and patient services such as coordinating access to pharmacists, nurses, social workers, nutritionists and others as appropriate.”

Overcoming Payor Hurdles

Both specialty pharmacies stressed that complex insurance authorizations for costly rare disease therapies can be exponentially more challenging for CGTs costing more than $2 million or $3 million. “The approval pathway often has several extra steps for that high dollar amount, and every payor might have a different process,” Mr. Farah said. “Some may take each approval to the president of the business unit.”

The first approval of a new gene therapy with a specific payor is always the most challenging. “We have to learn how they want the drug billed, or if they have a specific letter of agreement designed,” Ms. Droba said. However, the process gets easier with time; the first approval may take a week, and the second several days, “because we know exactly what they’re looking for.

“Sometimes you get a rep on the phone who will rattle off a script and it could be wrong information,” she continued. “I have two benefit verifications done right off the bat for every patient, and if I don’t like what I’m hearing, if something doesn’t sound right, I’ll do a third and keep digging.”

Evernorth Health Services has a financial “benefit protection” platform called Embarc that covers certain gene therapy drugs. Participating health plans and clients pay a per-member, per-month fee to participate; the patient has no copay. “Many gene therapies can cost in the millions of dollars per patient, running the risk of bankrupting a small business with a single claim,” said Leslie Achter, the senior vice president of pharmacy benefit manager account management at Express Scripts by Evernorth. “For a small monthly fee per patient per month, Embarc offers significant protection, while ensuring access to these potentially lifesaving therapies.”

Pay-over-time contracts have been proposed as one model for helping payors manage the enormous up-front cost of gene therapy along with the attendant risk. (How long will the therapy’s benefits persist? What happens if a patient receives a gene therapy while covered by one health plan and then moves to another plan within a short time after Plan 1 has paid for therapy?)

But at this point, Orsini has no gene therapy contracts structured that way. “We have had several conversations on both the payor and manufacturer side, where everyone is thinking that it would make sense to think about pay-over-time or value-based contracts,” Mr. Farah said. “There are also several smaller companies trying to carve gene therapy out from the primary benefit and pooling it as a specific cell and gene benefit sold back to the employers. We haven’t yet had someone come to the table with a viable approach. As an industry we need all stakeholders to come together and agree about how we share the risk associated with these therapies in a way that will be transformative.”

‘Everything Is Personal for Us’

As soon as an approval is completed at Orsini, Ms. Droba’s team determines the delivery time and day and coordinates thawing time with this information, and monitors the therapy’s journey from the manufacturer to their pharmacy, using real-time tracking technology. Gene therapy manufacturers all have their own advanced high-tech systems for temperature control and monitoring of these gene therapies. For example, Novartis uses a system called evo to protect and track the journey of its SMA gene therapy, developed by New Mexico–based Savsu Technologies. “When we log into the portal, we can see not only exactly where the shipment is in real time, but whether the package was tilted and to what degree, and exactly what temperatures have been maintained throughout the shipment,” Ms. Droba said.

Gene therapy is not a nine-to-five job for the specialty pharmacy, she said. “We work on these day and night. Because we have such a dedicated team, all day long we are working on these specific patients, getting to know them and what they need, and building relationships with their families, doctors and care teams,” Ms. Droba said. “Everything is personal for us, and that’s why I feel like we can be as efficient as possible in getting the treatment they need in shortest time possible. [The patients] have enough problems and stress, and we do everything we can to make one part of their situation less stressful.”

Critics continue to say the Georgia Pathways to Coverage program falls short of expectations, but proponents say Georgia’s cumulative approach puts more people on private health insurance plans.

State officials initially indicated roughly 345,000 Georgians could qualify for the program. However, officials later said the estimated adoption rate would reach around 90,000 to 100,000 by 2025.

Less than 4,500 Georgians enrolled in Georgia Pathways to Coverage as of mid-June.

“Every Georgian deserves access to affordable health care,” Laura Colbert, executive director of Georgians for a Healthy Future, said in a recent announcement. “Unfortunately, the Pathways to Coverage program is falling far short of that vision for our state.

“Unfair paperwork requirements and other bureaucratic hurdles are keeping hard-working Georgians from getting covered,” Colbert added. “It’s time to remove these barriers to health coverage for uninsured Georgians, and to look at broader solutions to closing the coverage gap.”

In remarks this week, Republican Gov. Brian Kemp said Georgia Pathways and Georgia Access, a state-based exchange where Georgians can shop for health insurance, provide health coverage to more than 714,000 Georgians who earn less than 138% of the federal poverty level.

Georgia’s Office of the Insurance and Safety Fire Commissioner launched Georgia Access on Nov. 1, 2023, as a state-based exchange on the federal platform ahead of Open Enrollment 2024. Last week, state officials said the Centers for Medicare and Medicaid Services confirmed approval for Georgia to transition to a state-based exchange.

Citing September 2023 U.S. Census Bureau data, Georgia Access’ website indicates that 1.2 million Georgians do not have health insurance. According to remarks provided by his office, Kemp said that “through Georgia Access, 400,000 Georgians who were previously on Medicaid now have private sector insurance that provides better coverage, with more options, while saving taxpayer dollars.”

“To be clear, the rosiest projections for traditional Medicaid expansion estimate 500,000 people under 138 percent of the federal poverty limit would be eligible. Not actually enrolled – just eligible,” the governor added.

What’s more, analysts note that care and coverage are not the same.

“When we discuss Medicaid, it is important to remember that coverage does not mean care,” Chris Denson, Georgia Public Policy Foundation’s director of policy and research, recently told The Center Square via email. “Medicaid is a fundamentally flawed program. In Georgia, providers are paid, on average, 80 cents on the dollar for every Medicaid patient they see. As such, only 60% of Georgia physicians accept new Medicaid patients.

“The promise of Georgia Pathways comes from providing an opportunity for these enrollees to transition one day to commercial health insurance while receiving Medicaid coverage in the interim — by engaging in 80 hours each month of work, educational opportunities, or community service,” Denson added. “Even expanding Medicaid under the Affordable Care Act would only cover Georgians up to 138% of the federal poverty level.

“In Georgia, we provide fully subsidized coverage on the health insurance exchange for individuals up to 200% of the federal poverty level. Which provides a better deal for patients and providers alike.”

With tens of millions of enrollees now dropped from the Medicaid rolls, a group of 189 health care organizations have taken another step they hope will add permanency to the program. The coalition, organized by the Association for Community Affiliated Plans (ACAP) and Families USA, sent a letter on Aug. 13 to congressional leaders calling for 12-month continuous enrollment for adults enrolled in Medicaid and the Children’s Health Insurance Program (CHIP).

They asked for support of the Stabilize Medicaid and CHIP Coverage Act, which was introduced in the House by Rep. Debbie Dingell (D-Mich.) in September 2023 and in the Senate by Sen. Sherrod Brown (D-Ohio) the next month.

Why OIG Did This Audit

• For a covered outpatient drug to be eligible for Federal reimbursement under the Medicaid program’s drug rebate requirements, manufacturers must pay rebates to the States for the drugs.
• Prior OIG audits found that States did not always invoice and collect all rebates due for drugs administered to Medicaid managed-care organizations’ (MCOs’) enrollees.
• This audit, one of a series of audits, determined whether South Carolina complied with Federal Medicaid requirements for invoicing manufacturers for physician-administered drugs dispensed to MCO enrollees.

What OIG Found

South Carolina did not always comply with Federal Medicaid requirements for invoicing manufacturers for rebates for physician-administered drugs dispensed to MCO enrollees. South Carolina did not invoice for, and collect from manufacturers, rebates totaling $14.2 million (Federal share).

• Of this amount, $12.1 million (Federal share) was for single-source drugs and $65,691 (Federal share) was for top-20 multiple-source drugs.
• We also identified rebates totaling $1.9 million (Federal share) for other multiple-source drugs for which we were unable to determine whether, in some cases, the State was required to invoice for rebates.

What OIG Recommends

We recommend that South Carolina:

1. invoice for and collect manufacturers’ rebates totaling $12.2 million (Federal share) for single-source and top-20 multiple-source physician-administered drugs and refund the Federal share;
2. work with CMS to determine whether the claims for other multiple-source physician-administered drugs, totaling $1.9 million (Federal share), were eligible for rebates and, if so, determine the rebates due for these drugs and, upon receipt of the rebates, refund the Federal share of the rebates collected;
3. ensure that all physician-administered drugs eligible for rebates after our audit period are processed for rebates; and
4. continue to review and strengthen its internal controls to ensure that, in line with South Carolina’s existing policies, all physician-administered drugs eligible for rebates are invoiced.

South Carolina generally concurred with all of our recommendations and described corrective actions it had taken or planned to take.

Today, the U.S. Department of Health and Human Services (HHS) announced more than $558 million in funding to improve maternal health, building on the Biden-Harris Administration’s commitment to reducing the nation’s high maternal mortality rate through the White House Blueprint for Addressing the Maternal Health Crisis. The Health Resources and Services Administration (HRSA), an agency of HHS, is awarding more than $440 million in funding to expand voluntary, evidence-based maternal, infant, and early childhood home visiting services for eligible families across the country. In addition, the Centers for Disease Control and Prevention (CDC) announced a new investment of $118.5 million, over five years, to 46 states, six territories, and freely associated states to continue building the public health infrastructure to better identify and prevent pregnancy-related deaths.

In 2022, President Biden signed bipartisan legislation that doubles funding for the Maternal, Infant, and Early Childhood Home Visiting program over five years – the first expansion of the federal home visiting program in nearly 10 years. Through this program, local organizations can provide home visits from nurses, social workers, and other trained health workers who work with families on early and ongoing engagement in prenatal care and postpartum support. They provide support on breastfeeding, safe sleep for babies, learning and communications practices that promote early language development, developmental screening, getting children ready to succeed in school, and connecting with key services and resources in the community – like affordable childcare or job and educational opportunities. The awards announced today reflect the first opportunity for states and jurisdictions to receive federal matching funds in addition to their base grants. Every single state and U.S. territory has seen an increase in funding to their home visiting program since the start of the Biden-Harris Administration.

“As someone who has spent my entire career fighting for the health and wellbeing of women and children, I am committed to addressing a maternal health crisis in which women across America are dying before, during, and after childbirth at higher rates than in any other developed nation. That is why I called on states to extend Medicaid postpartum coverage from two months to 12 months and announced the launch of the White House Blueprint for Addressing the Maternal Health Crisis, an unprecedented whole-of-government strategy to improving maternal care,” said Vice President Kamala Harris. “Today, we are building on this lifesaving work by awarding more than $558 million to improve maternal health across America. This includes a critical $440 million to support pregnant women, new mothers, and their children through home visiting programs that will improve health outcomes, child development, and access to resources for years to come.”

“Bringing home a baby can be stressful. Many new parents face additional challenges such as housing, or income insecurity, which can make the whole situation even more daunting. But we know from decades of research that home visits work – from helping with school readiness and achievement for children to improving health for women,” said HHS Secretary Xavier Becerra. “President Biden and Vice President Harris know how important it is to support children in their most crucial years of development so they can grow up to be healthy, happy adults. We will continue to make resources and support available, and elevate maternal health issues so that more women and families know that help is available.”

“At the Health Resources and Services Administration, we are deeply committed to removing barriers to care for expectant and new moms and babies who face too many hurdles getting the support that they need,” said HRSA Administrator Carole Johnson. “That’s why – thanks to the leadership of the President and Vice President – we were able to work closely with bipartisan leaders in Congress to grow the home visiting program to give more moms and babies a trusted home visiting partner to help their families in ways large and small to be healthy, feel supported, access health care services, nurture their child’s development, and give families every opportunity to thrive.”

HRSA Administrator Johnson announced the awards in conjunction with HRSA’s Enhancing Maternal Health Initiative convening at Wayne State University, in Detroit, Michigan. The Initiative is bringing together moms and babies served by HRSA programs with maternal and infant health community leaders, health officials, HRSA-supported community providers, and others to advance the goals of the White House Blueprint to Address the Maternal Health Crisis.

The home visiting program funds states, jurisdictions, and tribal entities to develop and implement evidence-based, voluntary programs that best meet the needs of their communities. Families choose to participate in home visiting programs from pregnancy up to kindergarten and partner with health, social services, and child development professionals who provide resources, support, and skills to help families and children be physically, socially, and emotionally healthy. The program has demonstrated significant benefits, including improved school readiness and achievement of children, improved health for women, increased health insurance coverage, and prevented child injuries, abuse, and neglect.

For a complete list of Maternal, Infant, and Early Childhood Home Visiting Program awardees, visit https://mchb.hrsa.gov/programs-impact/programs/home-visiting/maternal-infant-early-childhood-home-visiting-miechv-program/fy24-awards.

The CDC’s new $118.5 million five-year investment will continue building the public health infrastructure to better identify and prevent pregnancy-related deaths. This new investment expands support to Maternal Mortality Review Committees (MMRCs) from 46 to 52 states and U.S. territories and freely associated states. MRCs are state- and territory-based multidisciplinary groups that review deaths that have occurred within 1 year of the end of a pregnancy, determine if those pregnancy-related deaths were preventable, and recommend ways to prevent them in the future. This new investment in the Enhancing Reviews and Surveillance to Eliminate Maternal Mortality (ERASE MM) program also advances progress on implementing the White House Blueprint for Addressing the Maternal Health Crisis - PDF. CDC began the ERASE MM program in 2019 to invest in MMRCs and to strengthen and standardize their efforts to review deaths.

“Every pregnancy-related death is a tragedy for the family and the community,” said Wanda Barfield, MD, MPH, director of CDC’s Division of Reproductive Health. “Thanks to MMRCs, we know more about the causes and circumstances around pregnancy-related deaths, and we have actionable recommendations to prevent future deaths. This investment will support more jurisdictions in their critical work to save mothers’ lives.”

Together, these efforts build on both HHS’ and the broader Administration’s efforts to implement the White House Blueprint to Address the Maternal Health Crisis as described in the following Fact Sheet: https://www.whitehouse.gov/briefing-room/statements-releases/2024/07/10/the-white-house-blueprint-for-addressing-the-maternal-health-crisis-two-years-of-progress/.

Michelle Cubbon had her first child, a boy, at St. Catherine of Siena Hospital in Smithtown, New York, a town of more than 100,000 in the middle of Long Island, where the median household income is $143,789 and many residents commute to white-collar jobs in Manhattan. She and her husband, who was also born at St. Catherine, are planning now for a second child. But when she tried to schedule an appointment with her obstetrician, she discovered that the hospital’s maternity unit — a cornerstone of their town for more than a half a century — was shutting down in February 2024.

“I’m back to square one,” said Cubbon.

The reason? High costs of running the maternity care unit and a nationwide staffing shortage left the hospital unable to hire obstetricians. Such closures have hit hardest in rural parts of the US, and are now menacing in politically conservative red states that are wrestling with abortion restrictions. But Cubbon’s experience shows how maternity ward closures can reach into other communities, even in comparatively wealthy, densely populated towns and suburbs outside major cities.

“If we don’t work to fix this broken system, we’re going to continue to see hospital and OB unit closures, which will have disastrous effects,” said Ndidiamaka Amutah-Onukagha, founder of the Center for Black Maternal Health and Reproductive Justice at Tufts University School of Medicine. “Limiting access to care and pushing people further out of their home communities are direct contributors to maternal morbidity. It’s that simple.”

The danger is well known in far-flung communities: 57% of rural hospitals don’t have maternity wards, and many more are in danger of losing their maternal care units. That translates into longer travel times for expectant mothers, who are likely to be 40 or more minutes away from labor and delivery services. In urban areas, by contrast, patients are typically able to get to reach care within 20 minutes.

But the overall proximity advantage enjoyed by city dwellers isn’t the whole story, as urban hospitals that predominantly serve women of color have been disproportionately affected by maternity ward closures. Amutah-Onukagha’s center found that not only are Black communities more likely to lose obstetric units, the racial makeup of patients at a hospital is an even larger determinant of closures than the number of low-income patients insured by Medicaid. The closures are one contributor to the much higher rates of maternal morbidity and mortality that Black women face.

"My hometown of Trenton, New Jersey, is a maternity care desert. The hospital where I and my siblings were born — there are no OB units there to service the residents,” said Amutah-Onukagha. “How is this possible? You can’t give birth in the capital city of one of the wealthiest states in the US?”

Rushing Delivery

A host of challenges, including staffing, costs and declining births, is putting access increasingly at risk. Obstetric units in suburban Cincinnati, Milwaukee and San Diego have already closed in 2024, according to Becker’s Hospital Review, an industry trade magazine. Many women were redirected to hospitals 30 minutes away. Studies have shown that having a drive of more than 30 minutes reduces prenatal visits, while increasing planned cesarean section rates and births that occur en route to the hospital.

While some laboring women, especially those having their first child, may have enough time to make the journey, extended travel can increase the risk, said Holly Meduri, a nurse who helped deliver babies at St. Catherine’s for 22 years before the unit shuttered in February.

“We all have our idealized version of how our labor and delivery is going to go, and then all of a sudden there are problems,” she said. “If you are bleeding or you’re having a real obstetric emergency like the baby’s cord prolapses, those are things that, within minutes, you need to be delivered.”

Prior to closing the maternity ward, the system that owns St. Catherine of Siena, Catholic Health, assessed the impact on medically underserved groups and worked to ensure care wouldn’t be compromised, a spokesperson said.

No Standards

It’s difficult to pinpoint the size of the problem or determine how quickly it’s growing. States don’t have a standard method to disclose changes, and US government data is often incomplete or inaccurate, said Harold Miller, chief executive officer for the Center for Healthcare Quality and Payment Reform, a nonprofit health policy organization.

“If there were a good source of information about labor and delivery service closures, we would be using it rather than trying to assemble the information ourselves,” Miller said. “It’s not even easy to find accurate information about which hospitals have labor and delivery services.”

Most of the available research, including from Miller’s group, focuses on rural areas. But less formal reporting, and a groundswell of attention on social media, shows a broader lens may be needed.

In the first five months of 2024, 19 US hospitals closed or paused their labor and delivery services, according to a list maintained by Becker’s Hospital Review. That compares with 29 for all of 2023. Nearly half of the 2024 closures were in non-rural areas, and six were in communities with household incomes that surpassed the nationwide median.

Maternity Ward Closures Ripple Beyond Rural Areas

The most recent data available, from the March of Dimes, found the loss of obstetric units led to decreased maternity care access in nearly one in 10 counties across the country between 2018 and 2022. There were 2,826 obstetric units in hospitals in 2020, according to research underway from Peiyin Hung at the University of South Carolina, and even those dated numbers may be inaccurate.

Staffing Shortages

Chief among the causes is the shortage of obstetricians and gynecologists, the doctors who focus on the reproductive health of women.

There were about 50,000 OB-GYNs in the US in 2018, about 1,000 fewer than needed, and the total has declined since then, according to the US Department of Health and Human Services. The agency projects the deficit will increase to 5,000 by 2030 as retirements pick up among the nation’s aging physician workforce.

New doctors are unlikely to fill the gap since the number of residency spots funded by the federal government has been largely frozen since 1997. That’s creating a bottleneck in addressing the shortage, said Atul Grover, executive director of the American Association of Medical Colleges Research and Action Institute.

The number of residency applications dipped temporarily after the Supreme Court’s Dobbs v. Jackson decision in June 2022, which rolled back federal abortion protections, Grover said. The ruling creates potential legal ramifications for doctors who perform the procedure on women in medical distress, which can require delicate decisions about when lives are on the line.

And yet the demand for these accredited specialists are among the highest for all physicians, according to AMN Healthcare, one of the nation’s largest health staffing agencies. More pregnancies are occurring in high-risk women, including those who are over age 35, obese or have hypertension, requiring greater expertise.

“Recruitment and retention of this highly trained, skilled workforce is further complicated as many rural and underserved areas do not present as an attractive option,” Amutah-Onukagha said in an email. “Conversely, major cities push talent away with exorbitant cost of living and astronomical insurance rates.”

High Costs

Just keeping the doctors can be difficult — and expensive. At St. Catherine’s, negotiations broke down between the hospital and the obstetricians who used to practice there, and the hospital wasn’t able to hire replacements.

“Despite our best efforts to find alternative options for coverage, as of February 1, there will be no OB-GYN physicians at St. Catherine of Siena to provide maternity services,” a spokesperson said.

Delivering babies is often a money loser, putting them at the top of the list for cuts when hospitals are struggling financially, said Erik Swanson, senior vice president of data and analytics at Kaufman Hall, a health care consulting firm that tracks hospital profit margins. Malpractice insurance rates alone can top $150,000 a year for a single OB-GYN, higher than most surgical specialties.

Maternity wards require specialists, including anesthesiologists and labor-and-delivery nurses, and must be staffed around the clock. Ideally, there should be a one-to-one nursing ratio, said Anne Banfield, a fellow at the American College of Obstetricians and Gynecologists.

The Supreme Court Dobbs decision on abortion can also give hospitals a different cost to weigh, raising legal, moral and ethical questions for doctors who have taken the Hippocratic Oath pledging to do no harm.

There are tight restrictions on the procedure in 14 states currently, and the question of whether it can be performed to protect the health of the woman has been hotly contested. The nation’s top court allowed Idaho to enforce its near-total ban even for women in medical distress for five months in early 2024, until issuing an about-face in June.

Declining Births

Spreading out those fixed costs is getting more difficult. There were 72,000 fewer births in 2023 than a year earlier, according to the Centers for Disease Control and Prevention, even as the number of women aged 15 to 44 grows.

The situation is exacerbated in areas where many patients have Medicaid, the US insurance program for the poor that covers about 40% of births nationwide. It typically only pays a fraction of the cost of care, Grover said.

“When hospitals look at the bottom line, if they’re talking about replacing joints versus delivering babies, they’re going to choose replacing joints all day long,” Banfield said.

Still, some communities have managed to rescue their imperiled obstetric units. In Troy, New York, for example, staffers and community members banded together to save the only maternity ward in Rensselaer County, just east of the capital Albany. Participants in the “Save Burdett Birth Center” campaign organized rallies, issued a community impact survey, and testified at a hearing with the New York Attorney General. As front yards in the region filled with pink lawn signs in support of the facility, the campaign gained the attention of the New York State Assembly, which allocated $5 million to keep the birth center open for another five years.

Nationwide, state and federal officials are taking proactive steps to help make labor and delivery wards viable. In the US Senate, a group of Democratic lawmakers introduced legislation to increase Medicaid reimbursement rates for births in rural hospitals, while California and Virginia have allocated state funds to create new OB-GYN residency spots.

When maternity wards close down, the effects aren’t limited to the communities nearby. Health care workers are forced to adjust, too. Meduri, the St. Catherine’s nurse, retrained to work in the operating room, but it’s not the same.

“I’ve gone from being an expert to the novice,” she said. “It’s a grieving process.”