Implementation and early effects of medicaid policy interventions to promote racial equity in pregnancy and early childhood outcomes in Pennsylvania: protocol for a mixed methods study.

BACKGROUND: There are large racial inequities in pregnancy and early childhood health within state Medicaid programs in the United States. To date, few Medicaid policy interventions have explicitly focused on improving health in Black populations. Pennsylvania Medicaid has adopted two policy interventions to incentivize racial health equity in managed care (equity payment program) and obstetric service delivery (equity focused obstetric bundle). Our research team will conduct a mixed-methods study to investigate the implementation and early effects of these two policy interventions on pregnancy and infant health equity. METHODS: Qualitative interviews will be conducted with Medicaid managed care administrators and obstetric and pediatric providers, and focus groups will be conducted among Medicaid beneficiaries. Quantitative data on healthcare utilization, healthcare quality, and health outcomes among pregnant and parenting people will be extracted from administrative Medicaid healthcare data. Primary outcomes are stakeholder perspectives on policy intervention implementation (qualitative) and timely prenatal care, pregnancy and birth outcomes, and well-child visits (quantitative). Template analysis methods will be applied to qualitative data. Quantitative analyses will use an interrupted time series design to examine changes over time in outcomes among Black people, relative to people of other races, before and after adoption of the Pennsylvania Medicaid equity-focused policy interventions. DISCUSSION: Findings from this study are expected to advance knowledge about how Medicaid programs can best implement policy interventions to promote racial equity in pregnancy and early childhood health.

Language Disparities in Caregiver Satisfaction with Physician Communication at Well Visits from 0-2 Years.

OBJECTIVE: This study aimed to describe caregiver satisfaction with physician communication over the first two years of life and examine differences by preferred language and the relationship to physician continuity. METHODS: Longitudinal data were collected at well visits (2 months to 2 years) from participants in a randomized controlled trial to prevent childhood obesity. Satisfaction with communication was assessed using the validated Communication Assessment Tool (CAT) questionnaire. Changes in the odds of optimal scores were estimated in mixed-effects logistic regression models to evaluate the associations between satisfaction over time and language, interpreter use, and physician continuity. RESULTS: Of 865 caregivers, 35% were Spanish-speaking. Spanish-speaking caregivers without interpreters had lower odds of an optimal satisfaction score compared with English speakers during the first 2 years, beginning at 2 months [OR 0.64 (95% CI: 0.43, 0.95)]. There was no significant difference in satisfaction between English-speaking caregivers and Spanish-speaking caregivers with an interpreter. The odds of optimal satisfaction scores increased over time for both language groups. For both language groups, odds of an optimal satisfaction score decreased each time a new physician was seen for a visit [OR 0.82 (95% CI: 0.69, 0.97)]. CONCLUSION: Caregiver satisfaction with physician communication improves over the first two years of well-child visits for both English- and Spanish-speakers. A loss of physician continuity over time was also associated with lower satisfaction. Future interventions to ameliorate communication disparities should ensure adequate interpreter use for primarily Spanish-speaking patients and address continuity issues to improve communication satisfaction.

Impact of the COVID-19 Pandemic on Pediatric Preventive Health Care Among North Carolina Children Enrolled in Medicaid.

BACKGROUND: Children enrolled in private insurance had reduced preventive health care during the coronavirus disease 2019 (COVID-19) pandemic. However, the impact of the pandemic on children enrolled in Medicaid has been minimally described. METHODS: We used an administrative claims database from North Carolina Medicaid to evaluate the rates of well-child visits and immunization administration for children ≤14 months of age, and used a quasi-Poisson regression model to estimate the rate ratio (RR) of each outcome during the pandemic period (3/15/2020 through 3/15/2021) compared with the pre-pandemic period (3/15/2019 through 3/14/2020). RESULTS: We included 83 442 children during the pre-pandemic period and 96 634 children during the pandemic period. During the pre-pandemic period, 405 295 well-child visits and 715 100 immunization administrations were billed; during the pandemic period, 287 285 well-child visits and 457 144 immunization administrations were billed. The rates of well-child visits (RR 0.64; 95% CI, 0.64-0.64) and vaccine administration (RR 0.55; 95% CI, 0.55-0.55) were lower during the pandemic compared with the pre-pandemic period. CONCLUSIONS: The rates of well-child visits and immunization administrations among North Carolina children enrolled in public insurance substantially decreased during the first year of the COVID-19 pandemic.

Well Child Visit Attendance for Group Prenatal Care Participants.

OBJECTIVES: Participation in group prenatal care (GPNC) has been associated with increased attendance at prenatal, family planning and postpartum visits. We explored whether GPNC participation is associated with pediatric care engagement by measuring well-child visit (WCV) attendance among infants whose births were covered by Medicaid. METHODS: We used Medicaid claims and vital statistics from the South Carolina Department of Health and Human Services and GPNC site participation records (2013-2018). We compared WCV attendance of CenteringPregnancy GPNC patients to a propensity-score matched cohort of individual prenatal care patients (IPNC) across 21 prenatal care practices using linear probability models. The primary outcome measure was attending 6 or more WCVs in the first 15 months, a Healthcare Effectiveness Data and Information Set (HEDIS) performance measure. RESULTS: No differences in WCV were observed when comparing any exposure to GPNC (one or more sessions) to IPNC. We identified 3191 patients who participated in GPNC and matched these with 5184 in IPNC. Participation in 5 or more GPNC sessions compared to 5 or more prenatal visits was associated with higher rates of WCV compliance over the first 15 months (4.7 percentage point difference [95% CI 3.1-6.3%, P < .001]), with stronger associations between GPNC and WCV attendance for low birthweight infants, for Black infants, and for infants of mothers with no previous live births. CONCLUSIONS: This study suggests GPNC may modestly influence WCV attendance. The potential mechanisms and dose response require further investigation. Gaps in WCV attendance compared to benchmarks persist regardless of PNC model.

Socioeconomic Distress as a Predictor of Missed First Outpatient Newborn Visits.

Objective To determine if the Area Deprivation Index (ADI) can serve as a predictor for patients from geographic regions of high socioeconomic distress as high risk for having no-shows to first-year newborn visits. Methods We assessed the no-show rate per patient from a large public safety-net hospital in Cleveland, Ohio, and the ADI of the census-designated tract for each patient's home geographic identifier (GEOID), aggregated into quintiles, and calculated differences in no-show-rates across census-designated tracts of different ADIs. Results A total of 2944 newborns from an approximate 18-month follow-up period between 2015-2017 were included. Large differences in no-shows per individual patient record (chi-square = 225, p = <0.001, df = 4) were found across quintiles of ADI. Heat-mapping indicated that census tracts with the highest ADIs and highest rates of no-show appointments encompass Cleveland's inner-city region. Conclusion The ADI is demonstrated to identify communities at high risk of no-show newborn appointments. Mapping these communities and their socioeconomic distress levels represented by ADI and missed appointment rate for each community can provide future direction for interventions targeted towards these communities to reduce no-show rates and improve overall community infant health.

Timeliness of Immunizations in CenteringParenting.

OBJECTIVE: To evaluate the timeliness of immunizations of children in CenteringParenting (Centering), a group well-child model, compared to children in individual well-child care. METHODS: We conducted a retrospective cohort study of infants born October 1, 2014 to February 18, 2019 with a 2-month and subsequent well-child visit, both Centering or individual, at an academic pediatric practice in an urban, low-income community. In Centering, same age infants/mothers and a provider meet for 10, 2-hour group visits, and facilitated discussions. Providers are trained in group facilitation and participate in both Centering and individual visits. Primary outcome was timeliness of immunizations at 7, 13, 19, and 25 months. Analyses were by intention to treat. RESULTS: The study population included 1735 children (Centering n = 342, individual n = 1393). By 25 months, 62% of children in Centering were up to date with all recommended immunizations compared to 44.2% of children in individual care, a 17.8% higher rate (P < .001). By 25 months, children in Centering made 3 additional well-child visits (9.2 vs 6.2, P < .001). Mediation analysis showed 82% of the effect on up to date status was due to increased attendance to well-child visits (P < .001); the remaining 18% was due to a Centering effect beyond the visit increase. CONCLUSIONS: Our study showed a strong association of CenteringParenting with timeliness of immunizations and adherence to well-child visits compared to individual visits in a low income community. These findings warrant further exploration of the impact of Centering in reducing health disparities in communities at risk.

Five-Year Outcomes Among Medicaid-Enrolled Children With In Utero Opioid Exposure.

The health of women and children affected by opioid use disorder is a priority for state Medicaid programs. Little is known about longer-term outcomes among Medicaid-enrolled children exposed to opioids in utero. We examined well-child visit use and diagnoses of pediatric complex chronic conditions in the first five years of life among children with opioid exposure, tobacco exposure, or neither exposure in utero. The sample consisted of 82,329 maternal-child dyads in the Pennsylvania Medicaid program in which the children were born in the period 2008-11 and followed up for five years. Children with in utero opioid exposure had a lower predicted probability of recommended well-child visit use at age fifteen months (42.1 percent) compared to those with tobacco exposure (54.1 percent) and those with neither exposure (55.7 percent). Children with in utero opioid exposure had a predicted probability of being diagnosed with a pediatric complex chronic condition similar to that among children with tobacco exposure and those with neither exposure (20.4 percent, 18.7 percent, and 20.2 percent, respectively). Our findings were consistent when we examined a subgroup of opioid-exposed children identified as having neonatal opioid withdrawal symptoms.

Caregiver and Clinician Perspectives on Missed Well-Child Visits.

PURPOSE: Despite the benefits of well-child care visits, up to one-half of these visits are missed. Little is known about why children miss them, so we undertook a qualitative study to elucidate these factors. METHODS: We interviewed 17 caregivers whose children had missed well-child visits and 6 clinicians, focusing on 3 areas: the value of well-child visits, barriers to attendance, and facilitators of attendance. Transcripts were analyzed with a grounded theory approach and thematic analysis. RESULTS: Caregivers and clinicians identified similar important aspects of well-child visits: immunizations, detection of disease, and monitoring of growth and development. Both groups identified similar barriers to attendance: transportation, difficulty taking time off from work, child care, and other social stressors. CONCLUSIONS: Further work to explore how addressing social determinants of health might improve attendance of well-child visits is needed.

Parental Perceptions of Culturally Sensitive Care and Well-Child Visit Quality.

OBJECTIVE: Incorporating culturally sensitive care into well-child visits may help address pediatric preventive care disparities faced by racial and ethnic minorities, families with limited English proficiency, and immigrants. We explored parents' perspectives about the extent to which their children's pediatric care is culturally sensitive and potential associations between culturally sensitive care and well-child visit quality. METHODS: We conducted cross-sectional surveys with parents attending a well-child visit for a child ages 3 to 48 months. To measure culturally sensitive care, we created a composite score by averaging 8 subscales from an adapted version of the Clinicians' Cultural Sensitivity Survey. We assessed well-child visit quality through the Promoting Healthy Development Survey. Multivariate linear regression was used to understand associations between demographic characteristics and parent-reported culturally sensitive care. We used multivariate logistic regression to examine associations between culturally sensitive care and well-child visit quality. RESULTS: Two hundred twelve parents (71% of those approached) completed the survey. Parents born abroad, compared with those born in the United States, reported significantly higher culturally sensitive care scores (+0.21; confidence interval [CI]: 0.004, 0.43). Haitian parents reported significantly lower culturally sensitive care scores compared with non-Hispanic white parents (-0.49; CI: -0.89, -0.09). Parent-reported culturally sensitive care was significantly associated with higher odds of well-child visit quality including receipt of anticipatory guidance (adjusted odds ratio: 2.68; CI: 1.62, 4.62) and overall well-child visit quality (adjusted odds ratio: 2.54; CI: 1.59, 4.22). CONCLUSIONS: Consistent with prior research of adult patients, this study demonstrates an association between parent-reported culturally sensitive care and well-child visit quality. Future research should explore best practices to integrating culturally sensitive care in pediatric preventive health care settings.

Well-Child Visits of Medicaid-Insured Children with Medical Complexity.

OBJECTIVE: Well-child visits (WCVs) help optimize children's health. We measured annual WCVs for children with medical complexity (CMC) and correlated WCVs with hospitalizations. STUDY DESIGN: This was a retrospective analysis of 93 121 CMC aged 1-18 years continuously enrolled in 10 state Medicaid programs in the Truven MarketScan Database between 2010 and 2014. CMC had a complex chronic condition or 3 or more chronic conditions of any complexity identified from International Classification of Diseases, Ninth Revision codes, and the use of 1 or more chronic medications. We measured the number of years with 1 or more WCVs. The χ2 test and logistic regression were used to assess the relationships of WCV-years with the children's characteristics and hospitalization. RESULTS: Over 5 years, 13.4% of CMC had 0 WCVs; 17.3% had WCVs in 1 year, 40.8% had WCVs in 2-3 years, and 28.5% had WCVs in 4-5 years. Fewer children received WCVs in 4-5 years when enrolled in Medicaid fee-for-service compared with managed care (20.9% vs 31.5%; P < .001) and when enrolled due to a disability compared with another reason (18.2% vs 32.2%; P < .001). The percentage of CMC hospitalized decreased as the number of years receiving WCV increased (21.5% at 0 years vs 16.9% at 5 years; P < .001). The adjusted odds of hospitalization were higher in CMC with WCVs in 0-4 years compared with CMC with WCVs in all 5 years (OR range across years, 1.1 [95% CI, 1.0-1.2] to 1.3 [95% CI, 1.3-1.4]). CONCLUSIONS: Most Medicaid-insured CMC do not receive annual WCVs consistently over time. Children with fewer annual WCVs have a higher likelihood of hospitalization. Further investigation is needed to improve the use of WCVs in CMC.

Chinese, Vietnamese, and Asian Indian Parents' Perspectives About Well-Child Visits: A Qualitative Analysis.

OBJECTIVES: Well-child visits are a critical component of pediatric health care; however, disparities in attendance and quality of care exist for Asian children. Limited research has explored Asian immigrant parents' perspectives about their well-child visit experience. METHODS: Qualitative interviews were conducted with Chinese, Vietnamese, and Asian Indian immigrant parents. Participants were recruited from community-based organizations in the Boston area. Interviews focused on parents' perceptions about well-child visits, including individual attitudes, social and cultural factors affecting their opinions, perceived behavioral control, and improving visits for Asian immigrant families. Data were coded and analyzed using thematic analysis. RESULTS: Fifty-one parents participated. Although participants reported attending well-child visits, they thought language barriers and unfamiliarity with US preventive health care may limit attendance for other Asian immigrant families. Some reported high-quality visits, while others described them as "too simple," recollecting health care experiences from their countries of origin where more tests were completed. Participants described seeking advice about their children's preventive care from elder family members. Many expressed the importance of culturally concordant health care providers and culturally sensitive care, while others thought that culture was less relevant. Differences emerged among the 3 subgroups around culturally concordant care and traditional medicine. CONCLUSIONS: Querying parents about their past health care experiences and providing information about well-child visits may be useful when caring for immigrant families. Social influences on children's health outside of the parent-provider-child triad may also be important. Further work should explore how to deliver culturally sensitive care that considers not only a family's language preferences but also their unique cultural identity.

Behavioral Health Screening among Massachusetts Children Receiving Medicaid.

OBJECTIVE: To assess the impact of a Massachusetts Medicaid policy change (the Children's Behavioral Health Initiative; CBHI, which required and reimbursed behavioral health [BH] screening with standardized tools at well child visits and developed intensive home- and community-based BH services) on primary care practice examining the relationship of BH screening to subsequent BH service utilization. STUDY DESIGN: Using a repeated cross-sectional design, our 2010 and 2012 Medicaid study populations each included 2000 children/adolescents under the age of 21 years. For each year, the population was randomly selected and stratified into 4 age groups, with 500 members selected per group. Two data sources were used: medical records and Medicaid claims. RESULTS: The CBHI had a large impact on formal BH screening and treatment utilization among children/adolescents enrolled in Medicaid. Screening increased substantially (73%: 2010; 74%: 2012) since the baseline/premandate period (2007) when only 4% of well child visits included a formal screen. BH utilization increased among those formally screened but decreased among those with informal assessments. CONCLUSIONS: CBHI implementation transformed the relationship between primary care and BH services. Changes in regulation and payment resulted in widespread BH screening in Massachusetts primary care practices caring for children/adolescents on Medicaid.

Timely Health Service Utilization of Older Foster Youth by Insurance Type.

PURPOSE: To evaluate the impact of a policy change for older foster care youth from a fee-for-service (FFS) Medicaid program to health maintenance organization (HMO) providers on the timeliness of first well-child visits (health care physicals). METHODS: A three-year retrospective study using linked administrative data collected by the Michigan Departments of Human Services and Community Health of 1,657 youth, ages 10-20 years, who were in foster care during the 2009-2012 study period was used to examine the odds of receiving a timely well-child visit within the recommended 30-day time frame controlling for race, age, days from foster care entry to Medicaid enrollment, and number of foster care placements. RESULTS: Youth entering foster care during the HMO period were more likely to receive a timely well-child visit than those in the FFS period (odds ratio, 2.46; 95% confidence interval, 1.84-3.29; p < .0001) and days to the first visit decreased from a median of 62 days for those who entered foster care during the FFS period to 29 days for the HMO period. Among the other factors examined, more than 14 days to Medicaid enrollment, being non-Hispanic black and having five or more placements were negatively associated with receipt of a timely first well-child visit. CONCLUSIONS: Those youth who entered foster care during the HMO period had significantly greater odds of receiving a timely first well-child visit; however, disparities in access to preventive health care remain a concern for minority foster care youth, those who experience delayed Medicaid enrollment and those who experienced multiple placements.