By Hannah Shields
Wyoming Tribune-Eagle
CHEYENNE, Wyo. 鈥� Amid Wyoming鈥檚 growing maternity desert crisis, a Casper Republican state lawmaker has suggested increasing Medicaid payments to OB-GYNs to make up for the state鈥檚 declining birth rate.
Wyoming鈥檚 fertility rate has declined by 21.3% in the last decade, according to data from the March of Dimes, a nonprofit organization that provides research, education and advocacy for maternal and infant health care.
At least nine Wyoming hospitals, including Cheyenne Regional Medical Center, have seen a decline in delivery trends, according to data provided by the Wyoming Department of Health (WDH).
The Legislature鈥檚 Joint Labor, Health and Social Services Committee held a two-day meeting in Casper earlier this week to discuss gaps in health care services. Representatives from the WDH gave a presentation on both EMS (emergency medical services) and maternity care gaps.
WDH policy analyst Franz Fuchs said these two areas have one common theme: a critical gap between fixed costs and low revenue.
鈥淲e pay for the capacity, but the volume is not there to sustain a lot of these services on the revenue side,鈥� Fuchs said.
Sen. Charles Scott, R- Casper, asked for two bill drafts at the end of Tuesday鈥檚 meeting to raise state and federal payments in the Medicaid program for EMS services and obstetrics. Scott recalled testimony from WDH representatives, who said the declining birth rate in Wyoming contributed to a lack of economic activity for maternity care services.
Scott鈥檚 first bill draft, which he said would likely require an appropriation, would raise state and federal Medicaid payments to the maximum federal amount for obstetrics. His second bill draft would similarly raise Medicaid payments for EMS services.
Volunteerism in EMS services has declined significantly, according to public testimony, and rural areas across the state are struggling to sustain them. Fuchs said such volunteerism is declining across the U.S., and more services are having to staff with paid positions.
鈥淭he days of volunteers in our systems are gone,鈥� said Wyoming Primary Care Association Director Jen Davis. 鈥淧eople are needing to work multiple jobs.鈥�
Gaps in maternal care
The March of Dimes defines a 鈥渕aternity desert鈥� as an area with no hospitals or birth centers, and no obstetric providers.
In Wyoming, WDH officials created four categories of maternity care deserts: longstanding (meaning there was never capacity for maternity care to begin with), new (meaning this is a new maternity care desert), warning (meaning the area is at risk of becoming a maternity desert) and no maternity care desert.
Fuchs said new maternity care deserts pose a significant amount of concern, since these are areas where hospitals recently shut down labor and delivery services.
There are currently warning signs of a maternity desert in the Lander area of Fremont County, where there鈥檚 a decline of births at the county鈥檚 last remaining hospital, Fuchs said. There鈥檚 another warning situation in Campbell County, but it鈥檚 鈥渇airly stable.鈥� The number of providers in Campbell County is 鈥渞elatively low per capita,鈥� Fuchs said, but the situation has not degraded.
The closure of labor and delivery services is a symptom of broader financial stress for hospitals, Fuchs noted. Hospitals will close their least-profitable centers in order to stay afloat.
鈥淎nd labor and delivery is not a particularly profitable cost center for hospitals,鈥� Fuchs said.
The issue largely stems from hospitals relying on expensive contracts for traveling nurses to make up nursing staff shortages. WDH Director Stefan Johansson told lawmakers Monday morning the department has struggled over the last several years to maintain adequate staffing levels in its direct-care facilities.
Fuchs said other contributing factors to the closure of labor and delivery service units are the decline in births at hospitals, comparatively low Medicaid reimbursement rates and hospital administration challenges.
On the topic of provider recruitment challenges, Rep. Mike Yin, D- Jackson, brought up recent legislative action restricting abortion access in Wyoming that contains legal penalties against providers. Such bills can act as a deterrent when it comes to recruitment, he said.
This year, lawmakers successfully overrode the governor鈥檚 veto of a bill regulating surgical abortions. House Bill 42 requires abortion centers to become licensed as an ambulatory surgical center 鈥� it currently only affects Wellspring Health Access in Casper, Wyoming鈥檚 sole abortion clinic.
Licensed physicians at a surgical abortion center are required to report each surgical abortion to the WDH. Physicians must also prove they have admitting privileges to a hospital within a 10-mile radius of the surgical abortion center.
A physician found in violation of this law can be charged with a felony, punishable by one to 14 years of imprisonment.
Another new law requires pregnant women to wait at least 48 hours after having an ultrasound before they take an abortion pill. Physicians must provide a document to the woman that states the date, time and place of the ultrasound; the name of the provider who ordered the ultrasound; the name of the provider who performed the ultrasound; and confirmation of the gestational age of the unborn baby.
A person found in violation of this law is guilty of a misdemeanor, punishable by up to six months imprisonment, a fine up to $9,000 or both.
鈥淲e haven鈥檛 mentioned the policies that the state has passed recently, where we threaten to put providers in jail,鈥� Yin said. 鈥淚s that a conversation that you鈥檝e had with providers, where that risk has prevented recruitment?鈥�
Fuchs replied that the WDH has not held those conversations with providers.
Both the ambulatory surgical center and ultrasound requirements are currently on hold as the new laws are being challenged in court.
EMS gaps
Medicare patients make up around 40-50% of EMS calls, according to Fuchs. But if the call doesn鈥檛 involve a transport to the hospital, the ambulance provider doesn鈥檛 get paid.
There are approximately 78,000 calls in the state per year, and 51,000 of those are reimbursable, Fuchs said. Approximately 34% of calls do not qualify for reimbursement. These calls typically involve EMS responders treating an older person who fell, but who does not need to be transported to the hospital.
Most older people are covered by Medicare, but it only pays for an ambulance transport of a patient to the hospital when medically reasonable and necessary.
Fuchs said Medicaid does pay for non-transport, or 鈥渢reat-and-release,鈥� EMS calls.
鈥淲e pay for community paramedicine, which is where somebody might have a scheduled appointment with an EMT to check on them. But the problem is that volume is very, very low,鈥� Fuchs said. 鈥淢edicaid, in general, is not a big player in this market, and we pay maybe 10-15%, depending on the county.鈥�
The other issue is the cost of ambulance readiness. Fuchs said there鈥檚 a 鈥渉uge mismatch鈥� between the cost of readiness and the number of calls an ambulance provider can actually bill. There is an estimated $30 million annual gap between costs and potential revenue, according to the WDH.
Most local ambulance providers depend on a mix of subsidies to cover this gap, including:
- Tax dollars, either directly through county property tax mills, a service district or combined fire/EMS agency
- Hospital-based revenue, such as cross-trained emergency department/ambulance personnel and critical access hospital cost-based Medicare payments
- Grants, fundraising; and
- Volunteers.
Since the 1970s, Wyoming鈥檚 rural EMS systems have had a 鈥渟trong reliance鈥� on volunteers, but volunteer labor is shrinking, Fuchs said. Rural areas with a shortage of volunteer EMS responders face longer wait times for ambulance calls.
鈥淚f you consider volunteer labor as a subsidy, that subsidy source is not going to be sustainable in the future compared to others,鈥� he said.
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