Medicaid Accountable Care Organizations Can Increase Engagement and Quality of Care Among Pregnant and Postpartum Patients

A new study found that Medicaid ACOs in Massachusetts were associated with increased prenatal and postpartum visits, postpartum depression screenings, and timely postpartum care.

Despite recent declines in maternal mortality nationwide, the United States continues to experience a significant maternal health crisis, shaped in part by unfair access to quality health care for too many pregnant and postpartum people, especially those covered by Medicaid.

Medicaid Accountable Care Organizations (ACOs) have the ability to address this inequity in care by improving both coordination and quality of care for pregnant patients during and after their pregnancy, according to a new study led by the Boston University School of Public Health (BUSPH).

Published in the journal Health Affairs, the study examined changes in health care during pregnancy and after delivery after the implementation of Medicaid ACOs in Massachusetts and found that this value-based care model was linked to increased prenatal and postpartum visits, postpartum depression screening rates, and the likelihood of a timely postpartum visit.

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The results provide valuable insights and data on the maternal health benefits of ACOs for pregnant and postpartum women enrolled in Medicaid. Nearly half of all pregnant women in the United States are covered by Medicaid, but only 12 U.S. states currently have active statewide Medicaid ACOs.

The need is urgent: Pregnant women enrolled in Medicaid are at risk 82 % higher rates of serious maternal complications—and therefore maternal mortality—than pregnant patients insured in the private sector. Rates of premature birth are also higher in this group, and 40 % of Medicaid enrollees do not receive postpartum care.

“Our findings suggest that expanding Medicaid ACO models, particularly in the 38 states that do not currently have a Medicaid ACO, has the potential to improve engagement in prenatal and postpartum care,” said study leader and corresponding author Dr. Megan Cole, associate professor of health law, policy, and management at BUSPH and co-director of the Medicaid Policy Lab. “Increased engagement in care provides more opportunities to address patients’ physical, behavioral, and social needs, which is particularly important given that many Medicaid patients lack adequate engagement in prenatal and postpartum care.”

The BUSPH and Boston Medical Center research team took advantage of an opportunity to evaluate the effects of a statewide Medicaid ACO program on measures of quality of care during pregnancy and postpartum in a natural, real-world setting when Massachusetts formed 17 ACO as part of its Medicaid program in 2018, one of the most comprehensive Medicaid ACO programs in the country that aimed to better coordinate and integrate the physical, behavioral and social care of Medicaid patients.

Under the program, participating Medicaid providers were tasked with improving the cost and quality of care for Medicaid patients, where providers could receive financial incentives for performance measures such as timely prenatal care and depression screenings. The ACO program may have been particularly beneficial for pregnant and postpartum Medicaid patients.

The team used live claims data from Medicaid-covered deliveries in Massachusetts to examine changes in quality of care during pregnancy and postpartum for more than 65,000 unique deliveries, comparing measures between ACO and non-ACO pregnant patients, from 2016 to 2020 (before and after implementation of the Medicaid ACO program).

Although there were positive changes in engagement in care and process-based quality measures, the team did not observe any changes in delivery or health results, such as SMM or preterm delivery, nor prenatal or postpartum emergency room visits.

The lack of improvement in outcome measures suggests that there are opportunities to reform and redesign ACOs – in Massachusetts and other states – in ways that prioritize and improve maternal health outcomes, the researchers say.

“Our findings are encouraging, but they challenge us to dig deeper,” said the study’s lead author, Dr. Lois McCloskey, a clinical professor of community health sciences at BUSPH. “What is it about ACOs and how they are structured and led that leads to greater engagement in care? We’re using qualitative methods to shed light on this question. And beyond that, we want to understand how the care provided by ACOs can be improved and make a difference in the health outcomes of pregnant women and postpartum . »

Ultimately, says Dr. Cole, “efforts to improve maternal health through health care delivery reforms must occur alongside broader efforts to address the social and structural determinants of maternal health inequities.”