Conclusions
Implications of Survey Findings: Demographics of Doula Workforce in Washington State
Overall conclusion:
In order to best serve birthing individuals in Washington state through Medicaid reimbursement, the state must continue to diversify its doula workforce.
A majority of birth doulas identify as White only
• Given the proportion of Medicaid births by African American and Hispanic individuals, the number of birth doulas who share these racial/ethnic backgrounds is not sufficient.
• American Indian/Alaska Native individuals have the highest pregnancy-related maternal mortality ratios, followed by people who are multiracial and Asian or Native Hawaiian/Pacific Islander. These individuals could benefit from doula support, but there are not enough birth doulas with shared racial/ethnic backgrounds to meet their needs.
Doula services are concentrated in King County and the bordering Pierce and Snohomish counties
• Medicaid patients who reside in the Peninsula/Coastal, South, Central, and parts of Eastern Washington regions may have limited options when it comes to selecting a birth doula.
• Some birth doulas who serve Washington state birthing individuals live in Oregon and Idaho. The HCA should consider whether they will be eligible for Medicaid reimbursement.
Less than 15% of birth doulas have provided doula services to tribes or tribal nations
• There could be a small number of birth doulas who have the skills and connections to serve tribes or tribal nations.
• The HCA will need to work with tribal nations to see if additional birth doula trainings are needed.
Few respondents speak a language other than English
• The state may need more birth doulas who can communicate in languages other than English.
No respondent openly identified as transgender
Few respondents openly identified as gender non-conforming
Few respondents openly identified as gay or lesbian
• The state may need more birth doulas who identify as transgender, gender non-conforming, and/or gay or lesbian to better support birthing individuals with similar gender identities and sexual orientations.
Implications of Survey Findings: Requirements for Reimbursement
Overall conclusion:
The HCA needs to explore pathways for trained, non-certified doulas to be reimbursed through Medicaid and find ways to ensure that doulas are adequately prepared to serve the Medicaid population.
If the HCA requires cultural competency trainings, as Oregon does, it must consider affordability and accessibility, particularly for rural, low-income, and/or time-constrained doulas.
Less than half of respondents were certified at the time of this survey
• If the HCA were to require certification, as Minnesota does, a large proportion of birth doulas would not be eligible for Medicaid reimbursement.
More than half of respondents would be willing to pay for additional training to be eligible for Medicaid reimbursement, while 37% said it depends on cost
• If the HCA requires doulas to complete additional training, as Oregon does, it must consider affordability and accessibility, particularly for rural, low-income, and/or time-constrained doulas.
Implications of Survey Findings: Doula Services and Reimbursement Rates
Overall conclusion:
The HCA should consult community-based doula programs and other stakeholders who provide doula services to the Medicaid population before deciding on the number of visits covered. A final decision should inform the reimbursement rate.
Almost half of respondents offer clients two prenatal visits, birth support, and two postpartum visits (2-1-2); 17% offer 3-1-3.
Some respondents noted that Medicaid clients may require additional support.
• The 2-1-2 decision package bundle, which Oregon adopted, may not be sufficient for Medicaid patients. Minnesota offers up to six maternity support visits.
$852.65 is the average amount respondents would accept for a 2-1-2 package.
Respondents said they must be paid a “livable wage”
• Birth doulas are unlikely to support low reimbursement rates like those offered to doulas in Oregon and Minnesota.
• Birth doulas may consider Washington state’s proposed reimbursement rate of $688 per birth for non-FQHC clients and $1,606 per birth for FQHC clients acceptable.
Implications of Survey Findings: Billing Methods and Timely Payments
Overall conclusion:
The HCA should explore how birth doulas can bill for services through community organizations or by billing managed care organizations (MCOs) directly.
Birth doulas expressed the most support for billing through a community organization or billing an MCO directly
• Community organizations would need to set up billing systems, which could be an onerous and complicated task. There would also need to be enough community organizations to work with birth doulas across Washington state.
• If birth doulas bill MCOs directly, they may encounter difficulties while navigating the system. The HCA should provide clear instructions and a knowledgeable support person who can help guide them.
Less than 30% of respondents have an NPI
• If Washington state requires an NPI, more than half of survey respondents would need to register for one. Oregon asks doulas to enroll as state Medicaid providers, which requires obtaining an NPI.
• There may need to be education around what the purpose of an NPI is.
Most respondents would expect timely payments within 30 days of service, regardless of billing method
• Birth doulas may end up waiting more than 30 days for payment, which could affect how they provide for their families.
• Untimely payments could limit birth doulas’ willingness to serve the Medicaid population.