Factors affecting prenatal and postpartum care for Medicaid beneficiaries

Objective: Analyze disparities in prenatal and postpartum care for an insured, but vulnerable, population. Design: Individual-level data were obtained for women who met the NCQA’s Health Plan Employer Data and Information Set (HEDIS) denominator criteria for prenatal and postpartum quality of care measures. Two measures were collected for prenatal care (timeliness of initial prenatal visit and frequency of ongoing prenatal care) and one for postpartum care (one or more postpartum visits within a specified timeframe). We modeled compliance on each measure separately as a binomial logistic function with member characteristics, comorbidities, health services utilization, primary care provider type, and health plan as explanatory variables. Adjusted odds ratios were computed from the logistic regression results. Population: Massachusetts Medicaid Managed Care members meeting HEDIS criteria for prenatal and postpartum care in 2006 (n=1,882 live births). Findings: Several individual characteristics were important predictors of quality care. Teenagers were less likely to receive postpartum care than were older women. Higher illness burden (CDPS score) was associated with frequency of ongoing prenatal care, even after controlling for the number of contacts with the health care system. Smoking was not significant, but substance abuse reduced the likelihood of receiving quality care across all measures. Black and Hispanic women were both less likely than White, non-Hispanic women to meet HEDIS criteria for frequency of prenatal care, and Hispanic women were less likely to receive postpartum care. Having an OBGYN increased odds of timely prenatal care but did not affect ongoing prenatal care or postpartum care. Conclusions: Our findings provide evidence of disparities in quality of prenatal and postpartum care among Medicaid Managed Care members in Massachusetts. Although all women in our study had health insurance coverage during and after their pregnancy, we found that teenage mothers, women with substance use disorders, and racial and ethnic minorities were less likely than others to receive timely and appropriate care. Policy implications: Compliance with the NCQA’s HEDIS ambulatory quality measures is the standard by which health plan quality is measured and health plans are compared. Although member- and provider-level characteristics may influence the likelihood of compliance with quality guidelines in the ambulatory setting, HEDIS scores are not typically risk-adjusted. Plans serving vulnerable subpopulations may do poorly on quality measures unless they make special efforts to target their difficult-to-reach members, including teenage mothers, racial and ethnic minorities, and women with a substance use disorder.