Monthly Archives: May 2025

Preserving and Restoring Rural Obstetrics Services

Image

By Robert L. Moore, MD, MPH, MBA, Chief Medical Officer

“Alone we can do so little; together we can do so much.”

— Hellen Keller

Last year, another Northern California hospital maternity ward closed in the Partnership service area. The closure of the Mad River Hospital in Arcata (Humboldt County) leaves just 23 non-Kaiser hospitals with open maternity units in our 24-county service area. There are now 24 hospitals without maternity services across rural Northern California.

Last spring, Advancing Health in Rural California published a research paper by Harvard master of public health student Sara Howard, describing several underlying drivers of the steadily worsening maternity care access crisis in rural California:

  • Birth volume has decreased by 20% in the past decade, which has cascading impacts on financing and operations for hospitals providing obstetric (OB) services.
  • Financial stability of rural hospitals is decreasing due to a variety of factors besides OB volume.
  • A trend toward RN training programs that focus on specialized care limits the foundation of cross-training experiences, which subsequently limits nurses’ abilities to pivot into OB care when needed.
  • Regulatory barriers prevent flexibility in staffing models that could optimize the capacity for low volume rural hospitals to meet the local service needs
  • Statutory regulations on Alternative Birthing Centers prevent most of these centers from billing Medi-Cal, and consequently they are unable to serve the Medi-Cal population.
  • A pervasive shortage of trained maternity care providers, especially obstetrician-gynecologists (OB/GYNs), midwives, family physicians who do obstetrics (FP-OBs).

In Partnership’s service area, 40% of births are covered by Medi-Cal. This rate grows to over 60% in smaller and rural counties. Partnership has a responsibility to participate in and lead actions addressing this issue to help ensure our members receive the care they need.

Partnership has a wide range of working relationships with a diverse group of stakeholders whose collaboration can drive policy change and implement local initiatives to meet the maternity care needs of rural communities. The stakeholders include:

  • County and state public health agencies
  • Hospitals
  • Rural health centers
  • Tribal health centers
  • Department of Health Care Services (DHCS)
  • Government regulators
  • Elected government representatives
  • Community-based organizations
  • Mental health care teams
  • Trade organizations serving various health care delivery systems

Partnership holds a unique position to address complex, multi-faceted challenges, such as OB access and quality of care, with multiple interventions and projects across different domains, all working towards a common goal. Over the years, Partnership has had a key role of cross-sector collaboration and innovation to enact change in order to improve health outcomes of the communities we serve. Our experiences in addressing opioid overuse, palliative care, substance use disorder (SUD) treatment, transportation, pay for performance, social determinants of health (SDoH), complex care management, and others can be leveraged to address the large and complex maternal health problems in our service area.

Expanding access to safe and high-quality obstetrical care aligns with Partnership’s mission: to help our members, and the communities we serve, be healthy. Safe, accessible, local maternity care serves the entire community. Building key local and regional partnerships improves both the quality of care and member satisfaction. These are foundational components of Partnership’s strategic plan.

Improving access to high-quality maternity services in our service area requires a portfolio of synergistic interventions in these broad categories:

  • Policy changes: governmental, health plan, and local health systems
  • Educational programs that optimize local health care workforce capacity
  • Adjustment of reimbursement models to support diverse settings of care
  • Deepening community partnerships that reinforce collaboration
  • Better data collection and analysis to guide thoughtful decision making

Much has been accomplished in the two years since Partnership’s focus on obstetrical access and quality began. Here are the policy proposals pending in 2025. Additional details on other activities will be referenced in a future newsletter.

Legislative Proposals

In the past two years, state and federal policymakers have been stepping forward with legislative proposals to address the maternity care access issue. Some proposals are more applicable to urban areas, and others propose solutions that target rural areas. Here is a summary of bills introduced in 2025:

  • California Senate Bill 669 (McGuire, 2025) would allow for a pilot project designating  a “standby perinatal unit” in a remote, rural hospital. This model contrasts the standard model of continuous OB unit staffing used in hospitals. This pilot will provide an example of a solution that emphasizes a well-trained, capable local team of professionals who provide high-quality maternity and labor and delivery care. Emphasizing the training and systems required in this model, we believe we can garner support for SB669 by all stakeholders.

•  A key concept for this bill is that family physicians with specialized, supplemental OB training are critical to the success and sustainability of this staffing model in rural hospitals. Urban specialists may be unaware of the enhanced skills and experience that family physicians bring to rural settings; rural communities’ needs are different than urban areas. Our current health systems, policy, and regulations are based on serving dense, urban populations with a broad network of resources. Urban specialists often drive the standard and models of care beyond the city limits. However, when an urban mindset drives solutions for rural areas, the unique rural circumstances and resources may not be fully considered.

  • California Assembly Bill 55 (Bonta, 2025) would change the requirements related to licensing alternative birth centers in California. Medi-Cal requires that birth centers be licensed, but private patients may deliver in non-licensed facilities, which are often accredited by the Commission for the Accreditation of Birth Centers (CABC). To our knowledge, only three licensed birth centers in California exist, compared to dozens of accredited birth centers. The state licensing requirements inherently promote inequitable access to birthing centers. This bill makes multiple changes in licensing requirements, which would allow many accredited birthing centers to start accepting Medi-Cal, making obstetric care more accessible in California.
  • California Senate Bill 228 (Cervantes, 2025): Reassigns responsibility for the California Perinatal Services Program (CPSP) from the California Department of Public Health to DHCS. The original statutory details creating the CPSP program were codified in the 1980s. There are further updates in the CPSP program which might be considered, but more stakeholder input would be valuable. Because of this, just focusing on this change in responsibility to DHCS will be the optimal route to take this year. The transition of these services to managed care plans allows a more seamless and flexible approach to perinatal services that can expand access for patients and improve provider satisfaction with these services.
  • California Senate Bill 626 (Smallwood-Cuevas, 2025): Requires Medi-Cal managed care plans to ensure pregnant patients have care coordination and case management. This would also ensure support for mental health for these patients, and to report on the rates of use of these services on their public website, starting in 2026. The current local codes used by CPSP capture this data nicely, but any change to the use of national billing codes (without ensuring that CPT or HCPCS codes with more specificity are created by the American Medical Association), will make the specificity envisioned by this bill impossible. We believe a coalition that coordinates efforts to develop specific, prenatal case management codes accepted nationwide would improve access to data to assess and adapt perinatal services.
  • United States S. 380 (Hassan, 2025) is a bill which would allocate up to $20 million in grants to support development of training in obstetrical emergencies and newborn stabilization for rural hospitals without dedicated obstetrical units. Some grants would also support the implementation of telehealth services for such rural hospitals.

 

Wisdom: Elders Versus Evidence

Posted on by

By Robert L. Moore, MD, MPH, MBA, Chief Medical Officer

“The only true wisdom is to know that you know nothing.”

— Socrates

Wisdom of the Elders

Tribal community members often hold respect for elders as one of their core values. This respect is shown in many ways such as allowing elders to eat first at communal meals, valuing elders’ knowledge of native languages and traditions, and listening to their wisdom expressed through stories passed down for generations.

These demonstrations of respect were evident at a cultural event recently at the Karuk Kahtishraam Wellness Center in Yreka. Teenagers and young adults watched attentively as one elder taught them how to carve traditional wooden cooking paddles. Another elder displayed his tight-weave basket[1]making skills using willow twigs and aged spruce roots. When lunch was served, tasty frybread tacos and fruit, the elders were invited to serve themselves first. During lunch, several elders recounted stories from their lives, gently conveying the life lessons these stories contained.

Many in the United States use a different word to describe older residents: elderly. Although the difference is subtle, elderly is often used in association with a sense of responsibility to provide care, food, shelter, and entertainment. There is less of a sense respect for the wisdom of their life experiences, more of a sense that interacting with the elderly is necessary from time to time. This is a barrier to older adults feeling a sense of purpose as they age. Dr. Victoria Sweet’s excellent book, “God’s Hotel,” about San Francisco’s Laguna Honda Hospital elaborates on the evolution of modern American society’s conceptualization of our older residents.

Of course, there are exceptions to this. In his famous study of communities around the world where substantial populations live to over age 100, author Dan Buettner found that, in addition to a healthy diet, regular exercise, and six other factors, centenarians had an ongoing sense of purpose for their lives, usually including providing advice and support to the younger members of their families. The term “Blue Zones” is used to describe such communities in the Nuoro province of the Mediterranean island of Sardinia, the Nicoya Peninsula of Costa Rica, and Loma Linda, California.

In our early lives, our brains are wired for “fluid intelligence”: the ability to reason and think abstractly and flexibly. This allows us to learn everything from kinesthetic skills like sports or playing a musical instrument to mental reasoning skills involving creative solutions to mathematical or logical problems. As we age, the integration of what we have learned in our lifetimes — from books, other people and from our own experiences — can be manifested in “crystalized intelligence,” sometimes known as accumulated wisdom. Fluid intelligence generally peaks in our 20s and 30s and then declines steadily, whereas crystalized intelligence peaks in our later decades of life. Crystalized intelligence is helpful for teachers, with history professors actually reaching peak intellectual productivity in their 60s and 70s. Interestingly, our ability to learn new words and even new languages can persist well into our older years because the hippocampus, the seat of memory, continues to grow throughout life.

In his book, “From Strength to Strength: Finding Success, Happiness, and Deep Purpose in the Second Half of Life,” economics professor Arthur C. Brooks notes that high-achieving younger professionals who start to decline in their career should intentionally make the jump from the declining fluid intelligence curve to the rising crystalized intelligence curve.

American society celebrates the success of young entrepreneurs, young performing artists, and young scientists who make important breakthrough discoveries that require fluid intelligence. Success in early life, with its attendant public recognition, can make it hard to give it up to make the jump to the second, crystallized intelligence curve. Interestingly, societal belief systems that emphasize the idea that deceased ancestors support those who are living sometimes have more formal ways of recognizing the development of wisdom as a high goal in the second half of life. Confucian stages of life include the ideas of early education, social engagement with accumulation of wisdom in the middle of life, and tapping into the wisdom of elders, sages, and ancestors. As noted earlier, writings summarizing historic and current-day Tribal community values and beliefs include respect for the wisdom of the elders, and the important influence of one’s ancestors on those living today.

A more codified version of these stages is found in the ancient Hindu theory of Ashrama. Ashrama specifies that life should be lived in four stages, each lasting roughly 25 years:

  • The first, in childhood and young adulthood, is devoted to learning.
  • In the second phase, one focuses on working to build a career and financial stability, as well as to building a family and social connections.
  • In the third phase, one retires from personal and professional duties to consolidate their wisdom through teaching and spiritual practices. Moving from the second phase to the third phase is analogous to the shift from the fluid intelligence curve to the crystallized intelligence curve, noted above.
  • The fourth phase (if one lives long enough!) is devoted exclusively to spiritual understanding.

Clinician Wisdom

What are the implications of this framework to clinicians?

The scientific framework of evidence-based practice, where activities are tested objectively and rigorously, is at odds with a framework that draws on “ancient wisdom.” In fact, the current standard of care is evolving rapidly. The half-life of medical best practice is roughly five years. Put another way, half of today’s best practices for a given disease condition (e.g., which medication or surgical treatment is the safest and most effective) will no longer be the best practice in five years.

New graduates of physician residency programs, better trained than previous generations in evidence-based practice, will view some of the practices of older physicians as out-of-date. In some ways, though, the skills and experiences of older clinicians integrate knowledge that is not out of date and which younger clinicians would benefit from. Physical exam skills, for example, are becoming a bit of a lost art, resulting in over-use of radiology studies. Surgical skills for non-laparoscopic surgery of older physicians are often impressive, as they had a large volume of such cases before the newer surgical methods became available. Conversely, younger surgeons often have more robust experience with robotic surgery.

Clinicians need to track the evidence base for the conditions they commonly treat. Having a sense of curiosity and skepticism when reviewing the medical literature is key to critically evaluating new knowledge. As clinicians age, the wisdom reflected in their clinical judgement can continue to grow, if they systematically keep up with new knowledge.

Leadership Wisdom

This is also true for clinician leaders, although the nature of new knowledge related to leadership is very different.

Our understanding of the psychological and sociological aspects of human behavior is more scientific than previously, both through more advanced social science research methods, and with greater understanding of how this relates to underlying brain structure and function. The book, “Behave: The Biology of Humans at our Best and Worst,” by Robert Sapolsky is an impressive integration of these fields.

However, clinician leaders generally learn new leadership lessons more slowly, since we are often spending time maintaining our clinical knowledge while concurrently learning business operations and health care policy.

Fortunately, some core leadership wisdom is timeless, and so can be gained through literature, movies, and reading philosophy. An additional vital resource is the crystallized intelligence of our “medical elders,” experienced clinician leaders, such as Dr. Paul Farmer, Dr. Fitzhugh Mullen, and Dr. Anthony Fauci, as well as local clinical leaders in your communities.

To grow and age wisely as clinician leaders, we must embrace the opportunity to absorb the wisdom of elders even while we systematically strive to integrate new evidence-based knowledge!