Medicaid reimbursement
(Alex Pasarelu/Unsplash)
Attitudes and beliefs toward Medicaid reimbursement
86.5% of survey respondents agreed that Medicaid reimbursement for birth doulas in Washington state will positively impact the doula workforce
94.8% of survey respondents agreed that the policy will benefit low-income people who are giving birth
92.3% of respondents agreed that birth doulas in the state should receive Medicaid reimbursement
Reimbursement rate, prompt payment, and billing methods
If asked to provide 2 antepartum visits, labor support, and 2 postpartum visits per birth, respondents indicated that, on average, they would be willing to work with 18 clients per year at the rate of $852.65 per birth.
Most birth doulas would expect to be paid within 30 days of completing their service package (69.1% of 152 respondents).
About 71% of 155 respondents said they would be interested in working as a salaried employee for an organization that connects Medicaid patients with birth doulas.
Out of 155 responses, a majority of doulas would prefer to bill the HCA – or rather a managed care organization – directly (80.7%) or have a community organization bill on the doula’s behalf (69.7%).
Fewer than half are in favor of having a licensed provider bill on the HCA on the doula’s behalf (48.1% of 156 respondents).
Perceived benefits of Medicaid reimbursement
Survey question:
“Will Medicaid reimbursement benefit birth doulas in Washington state?”
(Taiying Lu/Upslash)
Themes from survey responses
1. Medicaid reimbursement will increase access to birth doulas and make the work more sustainable.
Respondents described a belief that Medicaid reimbursement for birth doulas would help increase access to their services and make their work with low-income populations more sustainable.
1a. Medicaid reimbursement could provide a sustainable income for birth doulas serving low-income populations.
Several respondents indicated that Medicaid reimbursement would allow doulas who already offer free services to low-income populations an opportunity to increase their income instead of taking a financial loss. This can disproportionately affect doulas of color.
Being a doula does not “include health benefits, paid time off, or sick leave.” Doulas invest their “time and energy” into clients and taking on a client for free can result in loss of paid work time, especially if doulas juggle more than one job to make ends meet. For doulas who have children, the on-call nature of the birth profession can be challenging and costly. If doulas are paid a “living wage” through Medicaid reimbursement, it could be beneficial and potentially lead to more consistent income.
“There are doulas that provide free services and this means they are taking a loss in order to support birthing people. They deserve a fair payment even if people can’t afford it.”
(Mustafa Omar/Unsplash)
2. Medicaid reimbursement could increase awareness about the value that doulas bring to the birth space.
Medicaid reimbursement could lead to more awareness about doulas, what they do, and how their work benefits birthing individuals of all backgrounds. This could “help legitimize the doula profession as something valuable to all” and “bring knowledge of what a doula is and does to the mainstream community.”
“By making birth doulas available to those with Apple Health, it removes the stigma that doulas are only for wealthy white women. By removing that stigma, doulas will be seen as a helpful and needed resource in the birth space.”
Perceived barriers of Medicaid reimbursement
Survey question:
“Are there any potential barriers that birth doulas could face when the HCA begins Medicaid reimbursement for their services?”
(Bruno Nascimento/Unsplash)
Themes from survey responses
1. Navigating a bureaucratic system that offers insufficient and untimely payments could prohibit birth doula participation.
Doulas expressed concern over the bureaucracy of receiving payment through Apple Health (Medicaid), potentially insufficient reimbursement rates, and untimely payments. Respondents want to be “paid our worth” and cited low rates in states that have already begun reimbursing doulas through Medicaid. If rates are too low, doulas might not be willing to participate since they can make more money through other higher-paying, private clients.
How quickly Apple Health will reimburse doulas is a potential barrier for doulas who rely on their birth work for income and “live paycheck to paycheck.” If doulas have to wait until all visits are complete (prenatal, labor and delivery, and postpartum) to bill for their services, it could leave the doula without an income for longer than they are used to. Non-Medicaid clients would be able to pay a certain amount upfront.
“If we have to wait for months to be reimbursed for our work, it may not be livable or worthwhile for us.”
If doulas bill Apple Health (Medicaid) directly, there are concerns about how they will navigate a complicated billing system. Some respondents expressed hesitation at the prospect of partnering with licensed providers or community organizations in order to get reimbursed.
If licensed providers bill Apple Health on behalf of doulas, this could influence the power dynamics of the working relationship. Relying on providers for payment might limit doulas’ ability to advocate for their clients.
“If they are being supervised or reimbursed by doctors they may have barriers. Some doctors do not believe doulas are useful and that may hinder their payment.”
(Carlo Navarro/Unsplash)
2. The HCA could create restrictions that diminish a birth doula’s autonomy, impact how they conduct their work, and limit who can participate.
Respondents noted that the doula space is currently unregulated. They identified potential requirements, rules, and regulations imposed by “agencies unfamiliar with the scope and nature of effective doula care” as potential barriers. Some respondents worried about a spillover effect: Government regulation intended for Medicaid reimbursement could eventually change the way doulas interact with and charge private clients.
Although respondents noted that the HCA has not established any requirements for doulas to work with the Medicaid population and get reimbursed, some worried that whatever stipulations are put in place will force doulas to “jump through hoops” and potentially “favor those who are certified and/or benefiting from privileged identities.”
“The potential barriers would fall under the potential restrictions made around the care a doula provides. I want the freedom to build a relationship with my client in the way that I see fit and I would be nervous to have the thing that I treasure most about my work become mechanized.”
— Participant 193
“I have very little faith in a government program that will most likely lay down more red tape for the Birth Workers, cause delays in reimbursement, and potentially inflict more discriminatory pain on the communities that I’m trying to support.”
— Participant 14
3. The system in place to reimburse doulas through Medicaid could become inaccessible and unaffordable for birth doulas.
Respondents warned that registration fees, requiring certification and trainings, and system navigation could become inaccessible and/or too costly. This could deter doulas from participating in the Medicaid reimbursement program, making the pool of doulas available to birthing individuals smaller.
3a. Requiring certification and additional training may create barriers for birth doulas who want to be reimbursed through Medicaid
Some respondents said that current certification should not be a requirement in order for the doula to be reimbursed through Medicaid. It could be a “hurdle” for doulas who do not wish to be certified and doulas who have experience but cannot obtain certification because of time and cost.
If the HCA required doulas to be certified, respondents expressed concerns about which certifying organizations would be recognized. If trainings are required, a couple respondents said, they should be available to people regardless of geography.
“… a lot of doula training programs are expensive or center white, cis, hetero people and therefore people in marginalized communities are either unable to train or certify because of cost barriers or get training from orgs with racist or homophobic practices that don’t properly serve marginalized communities.”
— Participant 86
“Many of our current doulas are trained but not certified in Yakima County. It would be beneficial to offer training programs locally that allow community members to be trained and certified more efficiently.”
— Participant 195