Variable Uptake of Medicaid-Covered Prenatal Care Coordination: The Relevance of Treatment Level and Service Context

Abstract

Prenatal care coordination programs direct pregnant Medicaid beneficiaries to medical, social, and educational services to improve birth outcomes. Despite the relevance of service context and treatment level to investigations of program implementation and estimates of program effect, prior investigations have not consistently attended to these factors. This study examines the reach and uptake of Wisconsin's Prenatal Care Coordination (PNCC) program among Medicaid-covered, residence occurrence live births between 2008 and 2012. Data come from the Big Data for Little Kids project, which harmonizes birth records with multiple state administrative sources. Logistic regression analyses measured the association between county- and maternal-level factors and the odds of any PNCC use and the odds of PNCC uptake (> 2 PNCC services among those assessed). Among identified Medicaid-covered births (n = 136,057), approximately 24% (n = 33,249) received any PNCC and 17% (n = 22,680) took up PNCC services. Any PNCC receipt and PNCC uptake varied substantially across counties. A higher county assessment rate was associated with a higher odds of individual PNCC assessment but negatively associated with uptake. Mothers reporting clinical risk factors such as chronic hypertension and previous preterm birth were more likely to be assessed for PNCC and, once assessed, more likely to received continued PNCC services. However, most mothers reporting clinical risk factors were not assessed for services. Estimates of care coordination's effects on birth outcomes should account for service context and the treatment level into which participants select.

Gestational age, kindergarten‐level literacy, and effect modification by maternal socio‐economic and demographic factors

“…We drew our sample from Big Data for Little Kids (BD4LK), an integrated data source including all Wisconsin in‐state resident livebirths in 2007‐2012 . The cohort links birth records to four administrative sources: Medicaid claims and encounters (henceforth ‘claims’), a longitudinal social services data system for Wisconsin, Phonologic Awareness Literacy Screening‐Kindergarten (PALS‐K) testing data from Wisconsin public schools (2012‐2016 school years), and public county‐level characteristics .…”

Estimating the effect of Prenatal Care Coordination in Wisconsin: A sibling fixed effects analysis

“…However, only 25 percent of Medicaid‐covered women were assessed for PNCC, which means that three out of four Medicaid‐covered pregnant women in Wisconsin during our sample period had no opportunity to take up or benefit from services. The possible underutilization of PNCC has been highlighted in prior research . These findings underscore the untapped potential of PNCC: There is robust evidence that services are associated with clinically improved birth outcomes, yet the program is widely underutilized by otherwise eligible Medicaid beneficiaries.…”

“…Wisconsin Medicaid covers PNCC services from program initiation up to 60 days postpartum . Although PNCC coverage is state‐mandated, county health departments have autonomy in PNCC provision, so there is considerable county‐level variation in the rates of PNCC assessment and service uptake . Triaging by risk may contribute to this variation; some counties exhibit high PNCC assessment rates with relatively low service enrollment thereafter, whereas other counties appear to specifically target with high‐risk pregnancies and enroll a large portion of those who were assessed.…”

“…Traditional approaches to sibling carryover analyses—including sibling fixed effects approaches—cannot recover unbiased estimators if an outcome for the older sibling predicts the exposure of the younger sibling . Prior birth outcomes have been shown to predict PNCC eligibility, which may bias our fixed effects estimates. However, whether that bias is consequential is uncertain.…”

“…On the whole, evidence suggests that care coordination programs contribute to better birth outcomes . Prior studies have relied on observational data, however, and although recent investigations have used quasi‐experimental methods to bolster internal validity, problems with estimating the effects of care coordination on birth outcomes remain …”