Improving women's access to adequate prenatal care - typically
defined as initiating prenatal care within the first trimester of
pregnancy and adhering to recommended prenatal care visits - can
facilitate the identification and subsequent management of high-risk
Late-starting or inadequate prenatal care is connected to a number
of adverse outcomes, including low birth weight, preterm birth,
stillbirth and infant death.
‘Oregon's 2012 shift to an incentivized, accountable-care system for Medicaid beneficiaries led to positive changes for expectant mothers and their babies.’
Oregon's 2012 shift to an incentivized, accountable-care system for
Medicaid beneficiaries led to positive changes for expectant mothers and
their babies, research at Oregon State University shows.
The research found Oregon's implementation of "coordinated care
organizations" resulted in more expectant moms starting prenatal care on
time. It also showed a small narrowing of the gap in prenatal care
quality between Medicaid beneficiaries and those with private insurance.
Ifeoma Muoto, who was a doctoral student working with
Associate Professor Jeff Luck in OSU's College of Public Health and
Human Sciences at the time of the study is now an administrative fellow at Kaiser Permanente Southern
California. Muoto looked at more than a half-million pregnancies in a six-year
period in Oregon and Washington, including 2013, the first year for
Oregon's 16 coordinated care organizations, or CCOs. Washington served
as the control group.
The study's objective was to assess the impact of the CCOs on the
quality of prenatal care among Oregon Medicaid beneficiaries. The
results were recently published in the journal Health Affairs
The study also showed a narrowing, albeit a small one, of the gap in
prenatal care quality between Medicaid beneficiaries and those with
"Prenatal care was one of the performance measures for the new CCOs
and you can't disentangle the measures from the CCO startup, but it's
promising that just in the first year there were significant
improvements," Luck said.
Luck is a member of the Oregon Health Authority's Metrics and
Scoring Committee, which is charged with determining whether CCOs are
"effectively and adequately improving care, making quality care
accessible, eliminating health disparities, and controlling costs."
The committee picked which types of care would be incentivized -
meaning which types of care would serve as benchmarks that CCOs could
meet to earn more funding. Other types of care that are incentivized
include chronic diseases, substance abuse and mental health.
"We hypothesized that the CCOs would have the benefit for prenatal
care that they did," Luck said. "This is early evidence that some of the
care delivery improvements we hoped for really are occurring."
The federal Office of Disease Prevention and Health Promotion's
Healthy People 2020 initiative includes increasing the percentage of
women who initiate prenatal care in the first trimester of pregnancy
from 70.8% to 77.9%.
In Oregon, the rate of pregnant Medicaid beneficiaries starting care
in the first trimester climbed from 73.1% in the pre-CCO period
to 77.3% in the first year of the CCOs. In Washington, the rate
for women on Medicaid rose from 71.7 to 73.6%, a smaller
percentage increase than Oregon's. Although women covered by private
insurance in Oregon had higher levels of timely prenatal care initiation
and prenatal care adequacy, the rates among that group were stable
during the time period studied.
For prenatal care adequacy - initiating care in the first trimester
and having at least nine doctor visits during a pregnancy - there was an
increase from 65.9 to 70.5% for Medicaid-covered women in
Oregon. That increase, though, was not statistically significant
relative to the increase observed among Medicaid-covered women in
Washington, where the improvement was 58.5 to 62.2%.
Luck noted the results indicated care adequacy was "going in the right direction but wasn't yet statistically significant."
"It's possible when we have more years of data we'll be able to make
a more precise estimate," he said. "We also have a parallel project
funded by the Centers for Disease Control using a larger pool of data
from Oregon - not only birth certificates but Medicaid claims data,
claims data from the Oregon Health Plan, which is Oregon's Medicaid
program, and hospital discharge data."
Luck noted the research is particularly important given the
percentage of births to Medicaid beneficiaries. Medicaid births made up
roughly 45% of total U.S. births even prior to an expansion of
the Medicaid program that began in January 2014.