Hospital Encounters Within 1 Year Postpartum Across Insurance Types, Oregon 2012-2017.

BACKGROUND: Little is known about the timing and frequency of postpartum hospital encounters and postpartum visit attendance and how they may be associated with insurance types. Research on health insurance and its association with postpartum care utilization is often limited to the first 6 weeks. OBJECTIVE: To assess whether postpartum utilization (hospital encounters within 1 year postpartum and postpartum visit attendance within 12 weeks) differs by insurance type at birth (Medicaid, high deductible health plans, and other commercial plans) and whether rates of hospital encounters differ by postpartum visit attendance and insurance status. METHODS: Time-to-event analysis of Oregon hospital births from 2012 to 2017 using All Payer All Claims data. We conducted weighted Cox Proportional Hazard regressions and accounted for differences in insurance type at birth using multinomial propensity scores. RESULTS: Among 202,167 hospital births, 24.9% of births had at least 1 hospital encounter within 1 year postpartum. Births funded by Medicaid had a higher risk of a postpartum emergency department (ED) visit (hazard ratio: 2.05, 95% CI: 1.99, 2.12) and lower postpartum visit attendance (hazard ratio: 0.71, 95% CI: 0.70, 0.72) compared with commercial plans. Among Medicaid beneficiaries, missing the postpartum visit in the first 6 weeks was associated with a lower risk of subsequent readmissions (adjusted hazard ratio 0.77, 95% CI: 0.68, 0.87) and ED visits (adjusted hazard ratio: 0.87 (0.85, 0.88). CONCLUSIONS: Medicaid beneficiaries received more care in the ED within 1 year postpartum compared with those enrolled in other commercial plans. This highlights potential issues in postpartum care access.

Postpartum Hospital Readmissions With and Without Severe Maternal Morbidity Within 1 Year of Birth, Oregon, 2012-2017.

Postpartum readmissions (PPRs) represent a critical marker of maternal morbidity after hospital childbirth. Most severe maternal morbidity (SMM) events result in a hospital admission, but most PPRs do not have evidence of SMM. Little is known about PPR and SMM beyond the first 6 weeks postpartum. We examined the associations of maternal demographic and clinical factors with PPR within 12 months postpartum. We categorized PPR as being with or without evidence of SMM to assess whether risk factors and timing differed. Using the Oregon All Payer All Claims database, we analyzed hospital births from 2012-2017. We used log-binomial regression to estimate associations between maternal factors and PPR. Our final analytical sample included 158,653 births. Overall, 2.6% (n = 4,141) of births involved at least 1 readmission within 12 months postpartum (808 (19.5% of PPRs) with SMM). SMM at delivery was the strongest risk factor for PPR with SMM (risk ratio (RR) = 5.55, 95% confidence interval (CI): 4.14, 7.44). PPR without SMM had numerous risk factors, including any mental health diagnosis (RR = 2.10, 95% CI: 1.91, 2.30), chronic hypertension (RR = 2.17, 95% CI: 1.85, 2.55), and prepregnancy diabetes (RR = 2.85, 95% CI: 2.47, 3.30), all which were on par with SMM at delivery (RR = 1.89, 95% CI: 1.49, 2.40).

Not all Medicaid for pregnancy care is delivered equally.

OBJECTIVES: Pregnant beneficiaries in the two primary Medicaid eligibility categories, traditional Medicaid and pregnancy Medicaid, have differing access to care especially in the preconception and postpartum periods. Pregnancy Medicaid has higher income limits for eligibility than traditional Medicaid but only provides coverage during and for a limited time period after pregnancy. Our objective was to determine the association between type of Medicaid (traditional Medicaid and pregnancy Medicaid) on receipt of outpatient care during the perinatal period. METHODS: This retrospective cohort study compared outpatient visits using linked birth certificate and Medicaid claims from all Medicaid births in Oregon and South Carolina from 2014 through 2019. Pregnancy Medicaid ended 60 days postpartum during the study. Our primary outcome was average number of outpatient visits per 100 beneficiaries each month during three perinatal time points: preconceputally (three months prior to conception), prenatally (9 months prior to birthdate) and postpartum (from birth to 12 months). RESULTS: Among 105,808 Medicaid-covered births in Oregon and 141,385 births in South Carolina, pregnancy Medicaid was the most prevelant categorical eligibility. Traditional Medicaid recipients had a higher average number of preconception, prenatal and postpartum visits as compared to those in pregnancy Medicaid. DISCUSSION: In South Carolina, those using traditional Medicaid had 450% more preconception visits and 70% more postpartum visits compared with pregnancy Medicaid. In Oregon, those using traditional Medicaid had 200% more preconception visits and 29% more postpartum visits than individuals using pregnancy Medicaid. Lack of coverage in both the preconception and postpartum period deprive women of adequate opportunities to access health care or contraception. Changes to pregnancy Medicaid, including extended postpartum coverage through the American Rescue Plan Act of 2021, may facilitate better continuity of care.

Diagnosis of Perinatal Mental Health Conditions Following Medicaid Expansion to Include Low-Income Immigrants.

Importance: For some low-income people, access to care during pregnancy is not guaranteed through Medicaid, based on their immigration status. While states have the option to extend Emergency Medicaid coverage for prenatal and postpartum care, many states have not expanded coverage. Objective: To determine whether receipt of first prenatal care services and subsequently receipt of postpartum care through extensions of Emergency Medicaid coverage were associated with increases in diagnosis and treatment of perinatal mental health conditions. Design, Setting, and Participants: This cohort study used linked Medicaid claims and birth certificate data from 2010 to 2020 with a difference-in-difference design to compare the rollout of first prenatal care coverage in 2013 and then postpartum services in Oregon in 2018 with a comparison state, South Carolina, which did not cover prenatal or postpartum care as part of Emergency Medicaid and only covered emergent conditions and obstetric hospital admissions. Medicaid claims and birth certificate data were linked by Medicaid identification number prior to receipt by the study team. Participants included recipients of Emergency Medicaid who gave birth in Oregon or South Carolina. Data were analyzed from April 1 to October 15, 2023. Exposure: Medicaid coverage of prenatal care and Medicaid coverage of postpartum care. Main Outcomes and Measures: The main outcome was the diagnosis of a perinatal mental health condition within 60 days postpartum. Secondary outcomes included treatment of a mood disorder with medication or talk therapy. Results: The study sample included 43 889 births to Emergency Medicaid recipients who were mainly aged 20 to 34 years (32 895 individuals [75.0%]), multiparous (33 887 individuals [77.2%]), and living in metropolitan areas (32 464 individuals [74.0%]). Following Oregon's policy change to offer prenatal coverage to pregnant individuals through Emergency Medicaid, there was a significant increase in diagnosis frequency (4.1 [95% CI, 1.7-6.5] percentage points) and a significant difference between states in treatment for perinatal mental health conditions (27.3 [95% CI, 13.2-41.4] percentage points). Postpartum Medicaid coverage (in addition to prenatal Medicaid coverage) was associated with an increase of 2.6 (95% CI, 0.6-4.6) percentage points in any mental health condition being diagnosed, but there was no statistically significant difference in receipt of mental health treatment. Conclusions and Relevance: These findings suggest that changing Emergency Medicaid policy to include coverage for prenatal and 60 days of postpartum care for immigrants is foundational to improving maternal mental health. Expanded postpartum coverage length, or culturally competent interventions, may be needed to optimize receipt of postpartum treatment.

Differences between rural and urban residence in the detection and treatment of perinatal mood and anxiety disorders.

BACKGROUND: Perinatal mood and anxiety disorders are common, serious complications of pregnancy. Disparities exist by race and income in the prevalence and treatment of these conditions, and overall treatment rates remain low. Outside of pregnancy, a small body of literature suggests that rural residency may contribute to higher rates of depression for those who identify as women. However, among more diverse populations, evidence suggests urban residency may be associated with higher rates of depression among women of color. It is not known whether these trends hold for mood and anxiety disorders during pregnancy and postpartum. OBJECTIVE: We examined differences in the detection and treatment of perinatal mood and anxiety disorders by rural and urban residents and assessed if the observed differences varied by maternal race or ethnicity. STUDY DESIGN: We conducted a cross-sectional study using linked Medicaid claims and birth certificate records from Oregon and South Carolina from 2016 to 2020. We identified perinatal mood and anxiety disorder diagnoses during the perinatal period (pregnancy and within 60 days postpartum) using International Classification of Disease 10th edition codes and enumerated receipt of pharmacotherapy and psychotherapy treatment using Medicaid claims. We used logistic regression models controlling for relevant clinical and sociodemographic characteristics to estimate associations between rural residence and mood disorder detection and treatment. RESULTS: Among the 185,809 births in our sample, 27% of births (n=50,820) were to people who lived in rural areas and 73% (n=134,989) to those in urban areas. The prevalence of any perinatal mood and anxiety disorders diagnosis was higher for urban residents (19.5%) than for rural residents (18.0%; P<.001). Overall treatment rates were low among people with a perinatal mood and anxiety disorder (42% [n=14,789]). In our adjusted models, those living in urban areas had higher odds of a perinatal mood and anxiety disorder diagnosis (adjusted odds ratio, 1.059 [95% confidence interval, 1.059-1.059], P<.001). We found a significant interaction between maternal race and rurality (P<.001). When we stratified by race, we found that among those who identified as Black, the odds of a perinatal mood and anxiety disorder diagnosis were increased for urban residents (odds ratio, 1.188 [95% confidence interval, 1.188-1.188]), whereas among those who identified as White, there were no such increased odds (odds ratio, 1.027 [95% confidence interval, 0.843-1.252]). CONCLUSION: We saw small but meaningful differences between rural and urban residents in perinatal mood and anxiety disorder diagnosis rates. We detected an interaction between race and rural vs urban maternal residence that impacted the observed differences. By elucidating the intersection between race and other sociodemographic factors, we hope more targeted and meaningful investments can be made in the communities most in need.

Safe Neighborhoods and Supportive Communities Protect Children from the Health Effects of Adverse Childhood Experiences (ACEs).

Protective factors such as safe, stable, nurturing relationships and environments can prevent the long-term effects of adverse childhood experiences (ACEs). Recently, policymakers and practitioners have sought to better understand environmental level influences on exposure to ACEs, given the crucial role of social determinants of health in alleviating racial health inequities. Thus, this study seeks to understand how ACEs can be mitigated through neighborhood-level factors; it examines the relationships among ACEs, safe and supportive neighborhoods, and overall health status by race/ethnicity using a national data sample. Data were obtained from 30,530 households with children who participated in the 2018 National Survey for Children's Health, a nationally representative survey. Using multivariable logistic regression, safe and supportive neighborhoods were assessed as potential moderators of the association between ACEs and overall health status by race/ethnicity. Two separate models were run for each moderator, controlling for sex, age, and gender of the child. The presence of a safe neighborhood weakened the association between ACEs and overall health status. This was demonstrated by lower odds of experiencing poor health. The presence of a supportive neighborhood showed a similar pattern. However, these patterns varied when disaggregating the data by race/ethnicity. This study underscores the importance of community-level prevention and intervention efforts to mitigate the health effects of ACEs. Public health efforts seeking to prevent poor health outcomes should consider the socio-environmental influences on health behaviors across the lifespan and continue to address the varying needs of historically disadvantaged populations.

Association of Pharmacist Prescription of Contraception With Breaks in Coverage.

OBJECTIVE: To assess whether pharmacist prescription of combined hormonal contraception is associated with 12-month contraceptive continuation rates or breaks in contraceptive coverage. METHODS: We conducted a retrospective cohort study of all short-acting, hormonal contraceptive users (pill, patch, ring, injectable) in Oregon's All Payer All Claims database from January 1, 2016, to December 31, 2018. We captured contraceptive use using diagnosis and National Drug Classification codes. We used logistic regression to measure the association between prescription by a pharmacist and 12-month contraceptive continuation rates and breaks in contraceptive coverage. Model covariates included age, rurality, and payer. RESULTS: Our study sample consisted of 172,325 contraceptive users, of whom 1,512 (0.9%) received their prescriptions from a pharmacist. Pharmacists were significantly more likely than clinicians to prescribe to women between the ages of 25 and 34 years (50.5% vs 36.9%, P<.05), in urban settings (88.4% vs 81.7%, P<.05), and with commercial insurance (89.2% vs 59.5%, P<.05). We found that the rate of 12 months contraceptive continuation was higher among the population receiving a pharmacist prescription (34.3% vs 21.0%, P<.01). In an adjusted model, the odds of contraceptive continuation at 12 months were 61.0% higher for individuals with any pharmacist prescription (adjusted odds ratio [aOR] 1.61, 95% CI 1.44-1.79) compared with those with clinician prescriptions. Over 6 months, most contraceptive users in both groups experienced a break in coverage, defined as a gap of 1-29 days between prescriptions (61.6% vs 61.9%, P=.89). Breaks in contraceptive use were not significantly associated with prescriber type (aOR 1.03, 95% CI 0.90-1.18). CONCLUSION: Compared with clinician prescriptions, pharmacist prescription of contraception is associated with increased odds of 12-month contraceptive continuation rates. However, the frequency of breaks in contraceptive coverage was similar among pharmacist and clinic-based prescribers. FUNDING SOURCE: Arnold Ventures.

Disparities in postpartum contraceptive use among immigrant women with restricted Medicaid benefits.

BACKGROUND: The Emergency Medicaid program offers restricted Medicaid benefits for people who meet the same financial eligibility criteria as Traditional Medicaid recipients but do not meet the citizenship requirements for enrollment in Traditional Medicaid. By federal law, Emergency Medicaid covers care for life-threatening emergencies or a hospital admission for childbirth. No prenatal or postpartum care is covered. Most of the women enrolled in Emergency Medicaid are Latina. OBJECTIVE: We assessed postpartum visits and receipt of postpartum contraception and compared the outcomes for Emergency (restricted benefit) Medicaid recipients with those of Traditional (full-benefit) Medicaid recipients in Oregon and South Carolina, 2 states with similar-sized immigrant populations. STUDY DESIGN: We conducted a retrospective cohort study using linked Medicaid claims and birth certificate data of live births covered by Medicaid (Traditional and Emergency) between January 1, 2010 and September 30, 2017, in Oregon and South Carolina. Our analysis was at the individual level. Primary outcomes were postpartum visit attendance and receipt of postpartum contraception within 2 months. We examined differences in demographic and delivery characteristics by Medicaid type. If women received postpartum contraception, we compared the timing of receipt (immediate postpartum, ≤1 month, 1-2 months, and 2-6 months after delivery) by the type of Medicaid. Among women using contraception, we described the type of contraceptive received at each time point, stratified by Medicaid type. Associations between Medicaid type (Traditional vs Emergency) and postpartum visit attendance and contraception use were assessed using adjusted absolute predicted probabilities from logistic regression models. We ran models for the entire cohort and conducted a subanalysis restricted to only Latina women. RESULTS: Our study included 375,544 live births to 288,234 women, with 12.7% of births among Emergency Medicaid recipients. Women enrolled in Emergency Medicaid tended to be older (age >35 years; 18.1% vs 7.2%; P<.001) and were more likely to be multiparous (76.8% vs 60.8%; P<.001) and Latina (80.3% vs 9.5%; P<.001) than their Traditional Medicaid peers. Among women enrolled in Emergency Medicaid, the probability of having a postpartum visit was 6.1% (95% confidence interval, 5.9-6.4) compared with 58.8% (95% confidence interval, 58.6-58.9) for women covered by Traditional Medicaid. After 6 months following delivery, 97.6% of Emergency Medicaid recipients had no evidence of contraceptive use compared with 55.6% of Traditional Medicaid enrollees (P<.001). In our adjusted model, Emergency Medicaid recipients were also significantly less likely to receive postpartum contraception than Traditional Medicaid enrollees (1.9% vs 35.5%; 95% confidence interval, [1.8-2.1] vs [35.4-35.7]). We examined the role that race may play in postpartum contraceptive use by conducting a subanalysis restricted to Latina women only.Latinas with births covered by Emergency Medicaid had a 1.9% (95% confidence interval, 1.8-2.0) adjusted probability of postpartum contraception use within 2 months compared with 39.8% (95% confidence interval, 38.7-39.9) among Latinas enrolled in Traditional Medicaid. CONCLUSION: Women enrolled in Emergency Medicaid experience large disparities in postpartum care and contraceptive use. Policies that restrict Medicaid coverage following delivery exacerbate inequities in postpartum care, potentially leading to worse health outcomes for low-income immigrants and their children.

Medical contraindications to combined hormonal contraceptive use among women using methods prescribed by a pharmacist.

OBJECTIVE: To determine whether pharmacist prescription of combined hormonal contraception is associated with inappropriate prescription to women with medical contraindications. STUDY DESIGN: We conducted a retrosopective cohort study of all short-acting, hormonal contraceptive users (pill, patch, ring, injectable) in Oregon's All Payer All Claims database from January 1, 2016 to December 31, 2018. Our primary outcome was the proportion of women receiving a combined hormonal method who had a Medical Eligibility Category (MEC) 3 or 4 condition. We identified potential contraindications using International Classification of Disease codes. We conducted descriptive analyses of contraindication prevalence and prescription error rate by prescriber type. We used a multivariable logistic regression model to test the association between pharmacist prescriber and population characteristics. RESULTS: Our study sample consisted of 439,240 contraceptive users, of which 3782 (0.86%) received their prescriptions from a pharmacist. Women aged 25 to 29 were more likely than women over age 35 to receive contraception from a pharmacist (adjusted odds ratio (aOR) 2.74, 95% confidence interval [CI] 2.44-3.08). Pharmacist prescriptions were slightly less likely in rural areas (aOR 0.78, 95% CI 0.69-0.89) and among women on Medicaid, relative to those with commercial insurance (aOR 0.21, 95% CI 0.19-0.24). Among women given contraception in a clinical setting, 4.25% had evidence of an MEC 3 or 4 contraindication, compared to 0.9% for women seen by a pharmacist. Rates of prescribing a combined method to women with a potential contraindication were not meaningfully different by prescriber type (2.16% for clinicians vs 0.74% for pharmacists). CONCLUSION: Rates of contraceptive prescribing with a contraindication were relatively low and did not differ between clinicians and pharmacists. IMPLICATIONS: Pharmacists can safely screen for medical contraindications to combined hormonal contraception.

Association of Expanded Prenatal Care Coverage for Immigrant Women With Postpartum Contraception and Short Interpregnancy Interval Births.

Importance: Access to prenatal and postpartum care is restricted among women with low income who are recent or undocumented immigrants enrolled in Emergency Medicaid. Objective: To examine the association of extending prenatal care coverage to Emergency Medicaid enrollees with postpartum contraception and short interpregnancy interval births. Design, Setting, and Participants: This cohort study used a difference-in-differences design to compare the staggered rollout of prenatal care in Oregon with South Carolina, a state that does not cover prenatal or postpartum care. Linked Medicaid claims and birth certificate data from 2010 to 2016 were examined for an association between prenatal care coverage for women whose births were covered by Emergency Medicaid and subsequent short IPI births. Additional maternal and infant health outcomes were also examined, including postpartum contraceptive use, preterm birth, and neonatal intensive care unit admission. The association between the policy change and measures of policy implementation (number of prenatal visits) and quality of care (receipt of 8 guideline-based screenings) was also analyzed. Statistical analysis was performed from August 2020 to March 2021. Exposures: Medicaid coverage of prenatal care. Main Outcomes and Measures: Postpartum contraceptive use, defined as receipt of any contraceptive method within 60 days of delivery; short IPI births, defined as occurring within 18 months of a previous pregnancy. Results: The study population consisted of 26 586 births to women enrolled in Emergency Medicaid in Oregon and South Carolina. Among these women, 14 749 (55.5%) were aged 25 to 35 years, 25 894 (97.4%) were Black, Hispanic, Native American, Alaskan, Pacific Islander, or Asian women or women with unknown race/ethnicity, and 17 905 (67.3%) lived in areas with urban zip codes. Coverage of prenatal care for women in Emergency Medicaid was associated with significant increases in mean (SD) prenatal visits (increase of 10.3 [0.9] prenatal visits) and prenatal quality. Prenatal care screenings (eg, anemia screening: increase of 65.7 percentage points [95% CI, 54.2 to 77.1 percentage points]) and vaccinations (eg, influenza vaccination: increase of 31.9 percentage points [95% CI, 27.4 to 36.3 percentage points]) increased significantly following the policy change. Although postpartum contraceptive use increased following prenatal care expansion (increase of 1.5 percentage points [95% CI, 0.4 to 2.6 percentage points]), the policy change was not associated with a reduction in short IPI births (-4.5 percentage points [95% CI, -9.5 to 0.5 percentage points), preterm births (-0.6 percentage points [95% CI, -3.2 to 2.0 percentage points]), or neonatal intensive care unit admissions (increase of 0.8 percentage points [95% CI, -2.0 to 3.6 percentage points]). Conclusions and Relevance: This study found that expanding Emergency Medicaid benefits to include prenatal care significantly improved receipt of guideline-concordant prenatal care. Prenatal care coverage alone was not associated with a meaningful increase in postpartum contraception or a reduction in subsequent short IPI births.

Cesarean birth and maternal morbidity among Black women and White women after implementation of a blended payment policy.

OBJECTIVE: To test whether Minnesota's blended payment policy had differential effects on cesarean use and maternal morbidity among black women and white women in Minnesota, as compared to six control states. DATA SOURCES/STUDY SETTING: Claims data from births to Medicaid fee-for-service beneficiaries, 2006-2012, in Minnesota (policy state) and six control states (Wisconsin, Iowa, Illinois, Oregon, Idaho, and Montana). STUDY DESIGN: The key study intervention was Minnesota's blended payment policy, which established one single payment rate for uncomplicated vaginal and cesarean births in 2009. The primary outcome was cesarean birth, and secondary outcomes were maternal morbidity (composite), postpartum hemorrhage, and chorioamnionitis. Policy effects were assessed using race-stratified comparative interrupted time series analysis. PRINCIPAL FINDINGS: Following policy implementation, cesarean use decreased among both black and white women in Minnesota compared to control states; this decline was larger among black women (-2.88 percent 3-year cumulative decline, from a prepolicy cesarean rate of 22.2 percent) than among white women (-1.32 percent, P = .0013). Postpartum hemorrhage increased, with larger increases among black women (1.20 percent 3-year cumulative increase), compared with white women (0.48 percent, P < .001) in Minnesota compared with control states. CONCLUSIONS: Policy-related declines in cesarean use after Minnesota's blended payment policy were larger in black women. Increases in postpartum hemorrhage signal potential unintended consequences of policy-related cesarean reduction.

Project Nurture Integrates Care And Services To Improve Outcomes For Opioid-Dependent Mothers And Their Children.

Children born to women with substance use disorders are at high risk for early foster care placement, which is associated with long-term adverse outcomes for children and places additional pressure on state budgets. Poor outcomes for drug-dependent mothers and their children may be further exacerbated by a lack of coordination between the health care and human services sectors. Project Nurture is an innovative model in Portland, Oregon, that integrates maternity care, substance use treatment, and social service coordination for Medicaid beneficiaries. This study assessed the impact of Project Nurture on a range of patient and child welfare outcomes. Among the "treatment" population of opioid-dependent women enrolled in Medicaid, Project Nurture was associated with reductions in child maltreatment, placement of children in foster care, and increases in both prenatal visits and maternal lengths-of-stay in the hospital, compared to opioid-dependent women enrolled in Medicaid in Oregon counties not served by the project. These results suggest that models based in a clinical setting that engage the human services sector may improve overall outcomes, even though the difficulty in sharing savings across sectors presents challenges to sustainability.

A Medicaid Alternative Payment Model Program In Oregon Led To Reduced Volume Of Imaging Services.

The patient-centered medical home model aspires to fundamentally restructure care processes, but a volume-based payment system may hinder such transformations. In 2013 Oregon's Medicaid program changed its reimbursement of traditional primary care services for selected community health centers (CHCs) from a per visit to a per patient rate. Using Oregon claims data, we analyzed the price-weighted volume of care for five service areas: traditional primary care services, including imaging, tests, and procedures; other services provided by CHCs that were carved out from the payment reform; emergency department visits; inpatient services; and other services of non-CHC providers. We further subdivided traditional primary care services using Berenson-Eggers Type of Service categories of care. We compared participating and nonparticipating CHCs in Oregon before and after the payment model was implemented. The payment reform was associated with a 42.4 percent relative reduction in price-weighted traditional primary care services, driven fully by decreased use of imaging services. Other outcomes remained unaffected. Oregon's initiative could provide lessons for other states interested in using payment reform to advance the patient-centered medical home model for the Medicaid population.