III.B.3.  Health Care Delivery System

III.B.3.a.  System of Care for Mothers, Children, and Families

The Arkansas Title V Program is committed to providing leadership in the improvement of health care systems to advance the health of Arkansas mothers, children, and families, particularly those in vulnerable and underserved populations.

The state’s centralized healthcare system is in the capital city, Little Rock, with 6.6% of the state’s population. The city is situated in the middle of the state and is the site for the ADH Central Office, five large hospitals including the UAMS, DHS, and other state agencies focused on improving the health of women and children. Cities of moderate size in the corners of the state are home to sizable medical communities and are the locations of UAMS’s Regional Programs.

Health Services Infrastructure & Workforce: The state’s Title V MCH administrative office is housed within the Family Health Branch of the Arkansas Department of Health (ADH). ADH provides programs and services statewide through 92 local health units, at least one in each of Arkansas’s 75 counties. The state is divided into five public health regions (Northwest, Northeast, Central, Southwest, Southeast) in which family planning, maternity, and well woman services are offered.

Family planning and maternity clinics are an essential part of the state’s system of care. The ADH Women’s Health Section (WHS) strives to maintain statewide family planning and maternity programs to ensure that public health services are available with quality care for all Arkansans. The ADH has 92 family planning, and 60 maternity clinics located within the LHUs. Maternity clinics provide prenatal clinic visits and education/counseling, postpartum services, treatment, and referrals.

Across the state, there are 117 hospitals, 27 of which are identified as Critical Access Hospitals. Twenty counties are served by a single Critical Access Hospital. Fifty-five of Arkansas’s 75 counties have a local community hospital. This leaves 20 counties without a single hospital.

Forty-seven community hospitals have fewer than 100 acute care beds. (Arkansas Hospital Association 2024 Hospital Statistics Report). 

Currently, Arkansas has 33 birthing hospitals providing labor and delivery services. In recent years, labor and delivery department closures presented challenges in access to care due to increased travel time. The statewide medium travel time to a birthing hospital in 2022 was 16 minutes, ranging from 2 minutes to 73 minutes. One analysis showed 28% of mothers traveled 30 minutes or more and 8% of mothers traveled 60 minutes or more for delivery services. Several counties in rural areas do not have a birthing hospital.

The current number of physician practices in Arkansas is insufficient in providing needed medical services to the population. Seventy-three of the state’s 75 counties are designated as either full or partially medically underserved areas (Delta Regional, n.d.; Health Resources, n.d.). Additionally, Arkansas is experiencing a physician shortage. Physicians and other health care provider shortages are common. In 2023, the Arkansas Medical Board licensed 4,656 primary care physicians. Arkansas ranked 43rd in the nation for number of PCPs (241.4 per 100,000 population). There are only 346 obstetricians and gynecologists and 31 licensed lay midwives in the state, and Arkansas ranked 49th in the number of obstetricians, gynecologists, and midwives (30.4 per 100,000 females ages 15 and older). Arkansas was one of nine states in the country that did not offer a doula certification. However, with the passage of Act 965 in 2025, doula certification will be offered through the Arkansas Department of Health and will allow for reimbursement from Medicaid and private insurance for defined services.

Mental health is an important public health issue for women and children, and Arkansas faces a significant shortage of mental health care providers. In 2021-2022, approximately 30% of Arkansas women between the ages of 18-44 reported their mental health was not good 14 or more days in the past month (Arkansas state rank = 46). About 40% reported being told by a health professional that they had a depressive disorder, including depression, major depression, minor depression or dysthymia (Arkansas state rank = 43). In 2021, PRAMS data showed 20% of mothers reported experiencing postpartum depression. Children also experience mental health issues. Data from the 2023 National Survey of Children’s Health showed one in five (20.3%) Arkansas adolescents aged 12-17 currently experience depression or anxiety. Although the Arkansas teen suicide rate has decreased in recent years, it remains above the U.S. rate (AR = 11.6 per 100,000 teens ages 15-19, U.S. = 10.5). Arkansas needs more mental health providers, ranking 31st in the nation (289.6 per 100,000 population). The Kaiser Family Foundation’s (KFF’s) analysis of HRSA’s Health Professional Shortage Areas - HPSA, 2022) data found Arkansas had 91 mental health care HPSA designations covering 1.2 million people and only 30% of the number of mental health providers needed were met.

The shortage of health care professionals will be exacerbated during the next 10 years, as a third of all active physicians will be 65 or older during that time-period, with many retiring (Arkansas Foundation for Medical Care, 2018).

The UAMS is a centralized point of referral for medically complicated patients and provides medical and health education for the entire state. Except for the cities of West Memphis and Helena on the eastern border that depend on the city of Memphis, Tennessee, all state communities relate to UAMS and Little Rock hospitals as major sources of highly specialized medical care. The UAMS's Regional Program provides family medicine residency training in communities around the state, thus improving the distribution of primary care physicians. Family physicians provide most of the state's medical care and are by far the most numerous specialty practitioners in Arkansas. Specialists in obstetrics, pediatrics, internal medicine, surgery, and others have practices in the more urban communities. While Arkansas is geographically small compared to some states, the travel time from cities such as Fayetteville or Texarkana to Little Rock is two to four hours of travel time. For families with few resources, these distances represent significant barriers to access specialized care.

The state has 12 Federally Qualified Health Centers (FQHCs) at more than 230 local sites that provide primary and preventive healthcare services to medically underserved areas in both rural and urban settings. Arkansas also has 109 rural health clinics that increase local access and allow patients to receive care within their communities.

In Arkansas, there are 820 pediatricians to care for all children across the state, and Arkansas ranked 39th in the nation (83.7 per 100,000 children ages 0-21). The state has two freestanding pediatric hospitals within the Arkansas Children’s Health System. Arkansas Children’s Hospital (ACH), located in the central region, treats children up to age 18 from across the state and surrounding areas. This private, nonprofit hospital works to meet the health needs of all children and supports efforts to improve the overall health and well-being of the state’s youngest children. ACH is the state’s only pediatric Level 1 Trauma Center and Level IV neonatal intensive care unit. The hospital ranks nationally among several pediatric subspecialties including cancer, cardiology, and neonatal care. In 2018, Arkansas Children’s Northwest (ACNW) opened in Springdale in Northwest Arkansas. ACNW is a Level IV pediatric trauma center located in the fastest growing area of the state and allows more CSHCN access to pediatric specialty care.

The ADH works closely with hospitals across the state to ensure that standards of care are met. Apart from this regulatory relationship, ADH also partners with the Arkansas Hospital Association (AHA) on issues of common interest at the systems level, including the development of the breastfeeding toolkit for hospital use, the state’s Infant Mortality Collaborative Improvement and Innovation Network initiatives, and the Arkansas Maternal and Perinatal Outcomes Quality Review Committee. The ADH Family Health Branch also administers the Arkansas Maternal Mortality Review Committee and oversees the newborn screening and infant hearing programs. In collaboration with the Department of Education, the Family Health Branch staff supports the work of public schools through professional development and resources designed to address the needs of the whole child in the school setting.

In 2016, state leaders provided statewide education and technical assistance by implementing the American College of Obstetricians and Gynecologists maternal safety bundles recognized by the 39 birthing Arkansas hospitals operating at that time. This statewide initiative, implemented by the Arkansas Perinatal Outcomes Workgroup through Education and Research (POWER), is administered by the University of Arkansas for Medical Sciences (UAMS), the state’s only academic medical center, and is funded by the Arkansas Medicaid program. Maternal safety bundles in postpartum hemorrhage, hypertension, and racial and ethnic disparities have been implemented statewide in numerous hospitals across the state. In 2022, Arkansas became an AIM state. The state received HRSA grant funding to support the work of the Arkansas Perinatal Quality Collaborative (ARPQC), the AIM-coordinating organization for the state. The ARPQC provides technical and capacity-building support to Arkansas hospitals in their implementation of maternal safety bundles. Currently, the ARPQC’s initiatives include safe reduction of primary cesarean birth, obstetric emergency preparedness, and congenital syphilis prevention.

TMF, the Quality Innovation Network-Quality Improvement Organization (QIN-QIO) for this Centers for Medicare and Medicaid Services (CMS) region, subcontracts with the Arkansas Foundation for Medical Care (AFMC) to assist Arkansas Medicaid providers to improve patient care and compliance. AFMC works side-by-side with Arkansas Medicaid and other partners on various quality improvement initiatives through provider and patient education and awareness.

Integration of Services: Arkansas’s Medicaid transitioned from a fee-for-service system to an organized care delivery model for the highest need behavioral health and developmental disability populations. In 2022, the Provider‑led Arkansas Shared Savings Entity (PASSE) Program introduced care‑coordination services. The PASSE system had already transitioned to full‑risk status in March 2019. PASSEs are responsible for integrating physical health, behavioral health, and developmental disability services. Members are assigned a care coordinator who is responsible for creating a plan for each person. PASSE currently serves 55,000 Arkansas Medicaid clients.

A little more than 40% of births in Arkansas are covered by Medicaid, and Arkansas is one of three states that have not taken advantage of the federal option to extend postpartum Medicaid coverage from 60 days to 12 months after birth. The state’s “continuous coverage” options for low-income postpartum Arkansans include fee-for-service Medicaid, the Arkansas Health and Opportunity for me program (ARHOME) Medicaid expansion program, or “a low-cost subsidized health plan on the federal health care marketplace”.

The Arkansas Medicaid Patient-Centered Medical Home Program (PCMH) has evolved from its inception in 2014 into the first recipient of the Center for Evidenced-Based Policy’s Innovation Award in November 2023. AR PCMH is an evidenced-based model of care to identify and access medical and non-medical services to help Arkansas children with and without special health care needs and their families to achieve their maximum potential. Enrollment into the PCMH program is voluntary for AR Medicaid Providers, with a current rate of 89% enrolled in the primary care case management Program. At the foundation of the PCMH is the Triple Aim of primary care delivery for the beneficiary’s experience of the health care services to improve, the beneficiary’s health to improve, while reducing the cost of the health care services. Keeping these goals at the forefront of the program, the evidence-based innovation of PCMH changed the relationship with the enrolled practices through a well-attended strategic advisory group two-hour bimonthly virtual meeting to discuss methods to achieve PCMH goals.

Another evidence-based innovation was monthly data dissemination to the practices that identified quality metrics that were met at a minimum level of achievement of the established targets. This data sharing, tracking, and open communication enabled the practices to meet higher levels of achievement of the established targets from pre-pandemic year 2019 to post-pandemic year 2021. PCMH providers and care coordinators use the data to understand their beneficiaries, identify gaps in metrics, and address health care service utilization and over utilization. The concentrated metrics for PCMH are preventive medical care, prescribed medication, therapy and chronic disease management, and high-cost service utilization such as acute hospital and emergency departments.

Professional boards of medicine, nursing, and other disciplines are other entities that provide support to the health care system. These disciplines, along with dentistry, pharmacy, chiropractic care, and hospital administration are represented on the Arkansas Board of Health.

Financing of Services: The health care delivery system in Arkansas is multi-faceted. The state system includes a variety of private and public providers in addition to individual, private, and public payers. Consumers of health care services have many choices, and work continues statewide to ensure better health status and outcomes for women and children. Sources of health insurance for women and children in Arkansas include the following:

Henry J. Kaiser Family Foundation estimates based on U.S. Census Bureau’s American Community Survey, 2023.

Beginning January 2023, Arkansas’s Medicaid program covered pregnant women with incomes of up to 214% of the federal poverty level. This coverage expires 60 days postpartum.

The Title V MCH program is still a gap filler in areas lacking providers and in areas where providers are not taking Medicaid patients or uninsured patients. The irony is that with Arkansas Works, some providers can fill the offices with privately insured patients and do not have an incentive to take Medicaid or no-pay patients. Despite the availability of coverage, some of the populations have not yet enrolled. Forty-three percent (43.4%) of the family planning patients served by the ADH in the local health units are without insurance of any kind. 

DHS houses programs that are important to improve MCH in the state. DHS’s Division of Medical Services (DMS) administers the Medicaid Program, which serves approximately two-thirds of children in the state. Most children are covered based on income eligibility through ARKids First A or B. Medicaid funded 41% of births in Arkansas and in the nation in 2023. Out of the 35,264 births in Arkansas in 2023, 14,450 were paid by Medicaid.

Transitioning from pediatric to adult care is a priority of ADH for all youth and young adults in Arkansas, including those with disabilities, chronic health conditions, or other needs. DHS is also home to the state’s Title V CSHCN program in the Division of Developmental Disabilities Services (DDS). ADH’s Title V Director is working to improve collaboration with this division, which includes maintaining an important partnership with the Division’s Medical Director. Services for CSHCN are closely associated with specialty services of the UAMS Department of Pediatrics.