Panel Paper:
Moving the Needle on Birth Outcomes in Medicaid: Challenges to Improving the Medical Model of Care
*Names in bold indicate Presenter
We used linked birth certificates and Medicaid eligibility/claims to assess birth outcomes and costs among Strong Start participants relative to risk-matched Medicaid comparators. Using participant-level program data, we compared participant outcomes in the three models controlling for medical, demographic, and social risks. Four rounds of qualitative case studies included document review, awardee observations, interviews with awardee staff and providers, and focus groups with program participants. Primary outcomes of interest included rates of preterm birth, low birthweight, C-section, and costs. This mixed methods analysis considers quantitative outcomes in Strong Start MCHs in light of qualitative analysis of program implementation and operations.
Strong Start participants had substantial medical and social risks, including high rates of depression and anxiety, prior preterm birth, obesity, and barriers to attending prenatal care appointments. Strong Start participants in MCHs were more likely to be African American—a demographic group at particular risk for poor outcomes—and also generally had the highest rates of medical risks (e.g. hypertension). MCH programs varied, but all included care coordination and referrals. Some offered additional enhanced services (e.g. nutrition counseling). Strong Start participants praised the support they received from care coordinators but expressed dissatisfaction with the lack of continuity and often impersonal nature of their clinical care. Analyses of Strong Start MCH participants relative to risk-matched Medicaid comparators indicated that outcomes for the two groups were similar. Risk controlled analysis that considered only Strong Start participants showed superior outcomes for all BC participants and for black and white GPC participants relative to MCH participants (p < .05). Although MCH programs differed in service intensity, intensity showed little correlation with outcomes.
Maternity care in the United States is the costliest in the world, yet maternal and infant morbidity and mortality are among the worst among developed nations. MCHs layered additional services, particularly care coordination, on the medical model. A reliance on coordination and referrals to improve outcomes was challenging, as most communities with Strong Start programs did not have sufficient resources to meet the substantial mental health and social needs of low-income pregnant women. Given the lack of a robust social safety net, it is difficult to enhance a medical model of care to meet women’s psychosocial needs.
Layering care coordination on the medical model may improve patient experience, but it adds cost and does not appear to improve outcomes. When developing policies intended to improve beneficiaries’ pregnancy outcomes, Medicaid programs may want to consider the impact of offering transformative models, such as Birth Centers, rather than layering services on a medical model.
