Medicaid Accountable Care Organizations may increase care engagement and quality among pregnant and postpartum patients

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

Despite recent declines in nationwide maternal mortality, the United States continues to experience a significant maternal health crisis, in part shaped by inequitable access to quality health care for too many pregnant and postpartum people, particularly those who are 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 Boston University School of Public Health (BUSPH).

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

The results provide valuable insight and data on the maternal health benefits of ACOs for pregnant and postpartum Medicaid enrollees. Almost half of all pregnant people in the US are covered by Medicaid, yet only 12 US states to date have active, statewide Medicaid ACOs.

The need is urgent: pregnant Medicaid enrollees have an 82-percent greater risk of severe maternal complications—and thus, maternal mortality—than privately insured pregnant patients. Preterm birth rates are similarly higher among this group, and 40 percent of Medicaid enrollees do not receive postpartum care.

"Our results suggest that expanding Medicaid ACO models—especially in the 38 states that don't currently have Medicaid ACOs—has the potential to improve engagement in prenatal and postpartum care," says study lead and corresponding author Dr. Megan Cole, associate professor of health law, policy & management at BUSPH and co-director of the Medicaid Policy Lab. "Increased care engagement provides more opportunity to address the physical, behavioral, and social needs of patients, which is especially important given that many Medicaid patients have inadequate engagement in prenatal and postpartum care."

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

Under the program, participating Medicaid providers were tasked with improving 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 could have especially benefited pregnant and postpartum Medicaid patients.

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

Although there were positive changes in care engagement and process-oriented quality measures, the team observed no changes in delivery or health outcomes, such as SMM or preterm birth, nor prenatal or postpartum emergency department visits.

The lack of improvement in outcome measures suggests that there are opportunities to reform and redesign ACOs—in Massachusetts and in other states—in a way that better prioritizes and improves maternal health outcomes, the researchers say.

"Our findings are encouraging, yet prompt us to look further," says study senior author Dr. Lois McCloskey, clinical professor of community health sciences at BUSPH. "What is it about ACOs, and how they are structured and led, that leads to stronger engagement in care? We are using qualitative methods to shed light on that 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 and postpartum people."

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