Good Health

Since 2018, we strengthened the capacity of over 600 health facilities to offer an appropriate range of high-quality, client-centered health services, particularly in MNCH and family planning. We supported training for 945 health workers on integrated management of neonatal and childhood illnesses, 568 health workers on family planning, and 336 skilled birth attendants. Just last year, over 3,200 heath workers in over 500 health facilities received coaching and mentoring in clinical and information systems priorities. 

As a result, new local governments are better able to meet the needs of their local constituents for basic MNCH and family planning services. Service use has increased, and more women and their families are accessing potentially life-saving interventions such as safe delivery and essential newborn care. Progress to date shows that the health system is adapting successfully to federalism. 

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Prioritizing Maternal and Child Health in the U.S.

Eighty-eight years ago, U.S. President Franklin D. Roosevelt established an agency to address the worsening health of mothers and babies during the Great Depression. Today, the Maternal and Child Health Bureau (MCHB), part of the U.S. Health Resources and Services Administration (HRSA), is the oldest part of the nation’s public health system—and a sprawling one. Its fiscal year 2024 proposed budget is just under $16 billion, and its patchwork of mandates, added to through various legislation over the decades, ranges from perinatal health to capacity building in quality assurance.

Now under an executive order, MCHB is taking a step back to reimagine its vision and develop a streamlined strategic plan for the next decade to strengthen the health of mothers, children, and families. The need is great. The maternal mortality rate jumped from 17.4 per 100,000 births in 2018 to 23.8 in 2020. Maternal mortality is three times worse for Black women than white women. The infant mortality rate is the worst of our economic peers, more than double the rate of Portugal and Spain. Black infant mortality is more than double that of white infants.

Equity underlies MCHB’s objectives as this venerable agency overhauls bureaucracy and pursues a digital transformation to make it more efficient. And as part of its ambitious 10-year strategic plan, the agency tasked Abt with helping craft these new goals and objectives.

Abt engaged with interested parties in focus groups and interviews, gathering input from people who focus on maternal and child health and those who serve disenfranchised communities, including people with lived experience. We brought perspectives from working with other agencies grappling with maternal and health issues. For example, after scanning federal agencies working on those topics, we created a matrix that showed where MCHB could encourage collaborative partnerships, such as the National Institutes of Health, Administration for Children and Families, and Centers for Disease Control and Prevention.

The resulting plan, released in 2022, helps position MCHB to be a leader in addressing maternal and child health, including initiatives like the White House Blueprint for Addressing the Maternal Health Crisis.

Among other things, we conducted an organization assessment to determine readiness to implement the strategic plan and recommend transformations MCHB needs to meet the new goals. With different offices operating from different legislative authority, MCHB needed to align programs with collective objectives. The underlying expectation is ambitious: make real change for the more than 60 million people MCHB supports. The goals:

• Assure access to high-quality and equitable health services to optimize health and well-being for all MCH populations
• Achieve health equity for MCH populations
• Strengthen public health capacity and the workforce for MCH
• Maximize impact through leadership, partnership, and stewardship.

MCHB names equity as a goal in and of itself, an issue that interested parties were adamant about. “Public agencies have responsibility for programs and related inequalities,” said one interviewee. “There is an untapped opportunity at this time of an historical reckoning on racism in practices and policies. MCHB should become more anti-racist.” Added another: “We must center equity in our work.”

Interested parties also called for more and better data. “There is a need for more data capacity—better data, analysis, and use,” said one. “We (need more) racial/ethnic specific data overall and from programs. These data are critical in tackling equity.” But other focus group members noted that much of what MCHB does is hard to measure because it’s qualitative not quantitative. It’s “important to remember the adage: Not everything measured is worthwhile,” said one focus group member. “Not everything worthwhile can be measured.”

MCHB and Abt will continue collaborating on ways to come up with meaningful metrics. Data will be one way, but not the only one, to show that the new strategy is working for equitable improvement in the health of mothers, children, and families.

Abt looks forward to supporting MCHB as it transforms to realize its ambitious new vision.

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Improving Child Nutrition in the U.S.

How do kids in the U.S. who get subsidized school lunches fare in the summer when school’s out? Not well. Except for some who were part of a decade-long Food and Nutrition Service pilot grant program, the Summer Electronic Benefit Transfer (Summer EBT) program.

Families in 10 diverse states and three Tribal Organizations received support in the summer from the U.S. Department of Agriculture Food and Nutrition Service to buy the same kind of groceries approved for the Supplemental Nutrition Assistance Program (SNAP) and the Women, Infants, and Children (WIC) programs. “Fruits and vegetables aren’t cheap,” notes one Summer EBT parent, and the benefit “allowed us to have better quality food.”

The results were clear: A $60 monthly benefit reduced the most severe category of food insecurity by a third compared with those who received no funds. The benefit also meant more nutritious eating—with children in the program consuming 12 percent more fruits and vegetables and 23 percent more whole grains than those not in the program.

How do we know? Abt’s decade of evaluations. We assessed the benefits and examined approaches that worked in different contexts for families, retailers, and grantees. The findings paved the way for Congress to pass a bipartisan bill in December 2022 that created a permanent nationwide program for more than 29 million families. That’s impact.

States, Tribal Organizations, and Territories will start to roll out their Summer EBT programs in 2024, and the knowledge we accumulated provides a playbook for how to do it. We generated insights that states can consider implementing, plus an intuitive, interactive digital dashboard to help officials understand granular program use and trends. It includes information from grantees who know local needs, thus enabling customized solutions.

Top recommendations:

• Allow for flexible food choices. If electricity is unreliable, for example, consumers can’t buy food that requires refrigeration. This can require training retailers.
• Use spatial analysis and mapping data. States, Tribal Organizations, and Territories need to know where eligible households live, how far they have to travel to shop at a participating store, and whether transportation is available. They may need to enlist more retailers.
• Decide which communication tactics will increase use of benefits: outreach via text messages or mobile apps; an online shopping app; or using schools to send out information.
• Monitor redemption rates. To boost redemption rates, text benefit balances twice a month and send other texts weekly. Buying is higher after texts.

The evaluations showed that Summer EBT is beneficial—and the way forward for States, Tribal Organizations, and Territories. In the future, millions of children nationwide will be well served, both figuratively and literally.

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When a cancer patient on chemotherapy missed several appointments and was hospitalized repeatedly, a social worker at the patient’s cancer clinic decided to investigate. It turned out that the patient had no car, lived alone, and had trouble paying for taxi rides to the clinic, 30 miles from his home. He relied on his closest hospital emergency department when his nausea led to dehydration, and emergency department (ED) staff often admitted him to the hospital.  

When the clinic’s oncology team met for one of its frequent huddles as part of its coordinated care effort, the team discussed the transportation challenges. The oncologist described a more potent, though more costly, anti-nausea drug. And the financial counselor found foundation support to cover the higher drug copays. The result: lower costs through avoidance of expensive ED visits and hospital admissions and better care at no additional cost to the patient. 

The incident was not enough to make a major dent in overall Medicare costs in the U.S., but is an example of how lower costs don’t have to conflict with high quality of care. That’s one of the lessons from Abt’s evaluation of the Centers for Medicare and Medicaid Services’ (CMS) innovative Oncology Care Model (OCM), which covers care for Medicare beneficiaries undergoing chemotherapy.

Cancer is the second leading cause of death in the U.S., resulting in more than 600,000 deaths annually. An estimated 1.9 million individuals were diagnosed with cancer in 2022. With the median age of patients 66, Medicare covers a big proportion of care, which was estimated at $200 billion in 2020 and is expected to rise to $246 billion by 2030. And chemotherapy is likely the costliest treatment component, with some new treatments costing more than $10,000 a month.

CMS launched OCM to assess whether investing in higher-quality care for oncology patients would help mitigate rising costs of cancer care. Under OCM, oncology practices were able to bill Medicare for enhanced oncology services for a chemotherapy episode. An episode includes all payments for health services provided during a six-month period, starting when patients begin chemotherapy. CMS made performance-based payments if practices met cost and quality goals.

Abt’s evaluation of the model found that patient care ratings of their cancer care teams began at a high nine out of 10, and that the high levels were sustained amid other changes during OCM’s six-year span. For example, practices reported increased activity in screening for pain and depression. The study found statistically significant cost savings for Medicare, though not enough to cover the costs of the new payments under OCM (for enhanced oncology services and performance-based payments) to the approximately 200 oncology practices that participated in the model. 

“The return on investment [from OCM] is not necessarily monetary,” says one participating oncologist. “It’s the satisfaction of high-quality care and sense of pride that we have an organization that can provide for patients in every way.”

Participating oncology practices transformed their practices to be more person-centered, with 60 percent of practices surveyed describing OCM as an opportunity and impetus to make meaningful improvements:

• Better and faster access to clinicians, including a dedicated phone line, especially for supportive care (e.g., pain, nausea, other side effects)
• Reorganized care teams, workflows, and communication to support patients more holistically
• Patient navigation through confusing treatment protocols
• Attention to psychosocial needs, pain, and depression
• Person-centered end-of-life care
• Expanded same-day and after-hours supportive care
• More financial counseling about treatment plans, out-of-pocket costs, and resources to cover them.

The evaluation’s equity analyses showed that the proportion of low-income patients treated under OCM didn’t drop over time. This meant the models didn’t avoid low-income patients to increase the odds of success, despite incentives to do so. Evidence also indicated that adherence to high-cost drugs improved for historically underserved populations; better financial counseling and connections to resources may have been the reason.

Our evaluation also showed that total episode payments rose 23.8 percent overall between 2015 and 2020. But OCM payments increased more slowly, by 21.8 percent. This translated into a savings of $499 per episode.

High-risk cancers are where the greatest reductions in total episode payments occurred. Savings amounted to $1,092 for lung cancer total episode payment, about $1,531 for lymphoma,  $1,166 for high-risk breast cancer, and $1,290 for colorectal/small intestine cancer. Our finding that practices achieved the biggest impacts on certain high-volume, high-risk cancers helped inform the design of CMS’ new Enhancing Oncology Model, which launches this summer. It focuses on seven high-risk types of cancer instead of the more than 20 included in OCM.

More work remains to improve quality and rein in costs for cancer care. Abt's mix of qualitative and quantitative analysis provides policymakers with the insights needed to refine future cancer-care models. And that might bring us ever closer to achieving those goals.

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