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Do Medicaid ACOs boost patient care access in pregnancy?

Despite limited change in birthing outcomes, a statewide Medicaid ACO was linked to better patient care access, especially in the postpartum period.

Sara Heath
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Published: 04 Sep 2024

Medicaid accountable care organization enrollment could be an effective way to increase patient access to care for pregnant people, according to a new Health Affairs paper.

Particularly, enrollment in a Medicaid ACO was linked with better access to postpartum visits, postpartum depression screenings and all-cause office visits among pregnant beneficiaries, the researchers said. Although the analysis showed no improvement in key birthing outcomes, the researchers said the data provides a strong argument for implementing Medicaid ACO models in the 38 states that do not currently have them.

These findings come as health policymakers consider ways to leverage Medicaid payment programs to improve the nation's dismal maternal health outcomes.

Medicaid pays for 41% of U.S. births, the researchers said, and alternative payment models like ACOs could help reverse trends of poor maternal care access and birthing outcomes among Medicaid beneficiaries.

ACOs accomplish 3 things

First, ACOs incentivize clinicians to boost perinatal care quality in an effort to meet ACO performance metrics. Second, ACO models incentivize better pregnancy outcomes in an effort to tamp down on healthcare costs. Finally, ACOs compel better care coordination and integration, which might have a significant impact on pregnant people who see multiple different types of providers.

In a study of the Medicaid ACO program in Massachusetts, which was implemented in 2018 via an 1115 waiver, the researchers outlined how ACOs improved maternity care and where the potential is yet to be realized.

The researchers compared care access and clinical quality measures from before and after ACO implementation among both ACO and non-ACO patients, revealing that the program improved patient access to care.

For example, ACO participation was linked with a 1.1-percentage-point increase in the odds of getting a timely postpartum visit and a 5.81-percentage-point increase in the odds of getting a postpartum depression screening. ACO participation was also linked to more all-cause office visits during the prenatal period and more office visits during the 60-day postpartum period.

These improvements were likely the function of certain ACO requirements as well as patient engagement strategies geared toward better outcomes.

Researchers suggest a redesign to improve quality outcomes

Still, there was little difference in clinical quality outcomes observed. Besides a reduction in cesarean deliveries, there was no statistically significant impact on severe maternal morbidity, pre-term birth or postpartum glucose screening among ACO patients.

"This suggests that although the ACO may have positively affected process measures related to service use and engagement, this did not translate into changes in more intermediate outcomes. Thus, simply increasing care engagement may be necessary but insufficient for improving health outcomes; improving the patient experience during these visits (for example, increasing patient-centeredness, cultural appropriateness, and time spent with the patient) may be most important," the paper concluded.

Factors like structural racism, implicit bias and social determinants of health might also affect birthing outcomes, the researchers suggested.

Moving forward, the Massachusetts Medicaid ACO models, plus the models in practice in other states, might consider a redesign. Adding more maternal health measures to ACO contracts, bolstering care coordination for pregnancy and reconsidering how different features affect maternal outcomes will be key, the researchers suggested.

Despite the potential for future growth, the researchers indicated that these most current findings related to care access and Medicaid ACOs are important.

"They suggest that expansion of Medicaid ACO models has the potential to improve engagement in prenatal and postpartum care for Medicaid enrollees," the researchers recommended. "This may be particularly relevant to the thirty-eight states without Medicaid ACOs, which may consider Medicaid ACO implementation as a way to increase value-based care and improve maternal health care engagement."

Sara Heath has covered news related to patient engagement and health equity since 2015.

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