Background: Prenatal care (PNC) is an important preventive health service that can influence the health of the four million women who give birth annually in the United States, and the health their infants. Despite efforts to increase women’s access to PNC services, significant disparities in PNC utilization and maternal/child health outcomes by insurance type and race/ethnicity persist in the United States. The past decade has witnessed several major health reforms at both national and state levels. However, the impact of these reforms on the quality of PNC, and on disparities in PNC utilization is not known. In 2012, the state of Oregon established Coordinated Care Organizations (CCOs) as comprehensive providers of care for Oregon’s Medicaid beneficiaries. CCOs are characterized by a global budget payment mechanism and financial incentives for high quality care. Timely initiation of PNC – which has been associated with improved maternal and infant health and utilization outcomes – is one of seventeen quality metrics for which CCOs can receive incentive payments.
Objectives: The first objective of the current study was to estimate the impact of CCO implementation on the probability of initiating PNC in the first trimester, and on PNC adequacy among Oregon Medicaid beneficiaries. The second objective of the study was to determine if the implementation of CCOs influenced disparities in PNC utilization between Medicaid and privately-insured women, and between non-Hispanic White women and Hispanic/non-Hispanic Black women.
Study Design: This quasi-experimental retrospective observational study drew from two data sources: Oregon Vital Records (Birth Certificate statistical files) from the department of Health Analytics of the Oregon state public health department and Washington State’s Linked Birth- CHARS (Comprehensive Hospital Abstract Reporting System) data from the Washington State department of health. A difference-in-differences approach examined PNC utilization before and after CCO implementation. Washington State served as the control group, as its Medicaid financing and delivery systems remained unchanged. Multivariable linear probability analysis was used to control for confounding factors, including maternal age, race/ethnicity, education, parity, marital status, smoking history, previous preterm birth, and maternal morbidity.
Population Studied: All births in Oregon and Washington from 2008 – 2013, which were covered by either Medicaid or private insurance, were included in the analysis. Since CCOs started operating mid-year in 2012, June through December 2012 was considered a transition period and births during this period were excluded from the analysis.
Principal Findings: CCO implementation was associated with a significant increase in the probability of PNC initiation in the first trimester and a reduction in insurance-type disparities in first trimester PNC initiation and PNC adequacy among Oregon Medicaid beneficiaries. Racial/ethnic disparities did not change following CCO implementation.
Conclusions: The implementation of CCOs in Oregon had a positive impact on the timeliness of PNC initiation among Medicaid beneficiaries, and also reduced disparities in PNC quality between Medicaid and privately-insured women.
Implications for Policy or Practice: The ongoing health system transformation in Oregon provides an ideal setting to assess the impact of a novel health service delivery model on PNC utilization. If Oregon is successful in this bold and unprecedented move, it could serve as a model for other Medicaid and commercial health plans seeking to improve PNC quality. Further study on the longer-term effects of CCO implementation on PNC quality as well as the effect of CCOs on other health care domains, is warranted.