Payment policies to optimize care and improve equity for postpartum people in the United States

Abstract

The United States is in the midst of a maternal health crisis; severe maternal morbidities and mortality have increased 40% in the last decade, largely concentrated among rural, low income, and racialized birthing people. Half of maternal deaths occur in the year following childbirth. In addition, three-quarters of all birthing people report challenges during the postpartum year, including breastfeeding difficulties, fatigue, pain, and depression and/or anxiety. The postpartum period is a crucial time for detection and prevention of maternal health complications. Yet in the United States, postpartum care is often limited, by payment policies, to one visit at six weeks postpartum with limited content. This is insufficient and misaligned with the timing and medical, mental health, and support needs of postpartum patients. Complicating this inadequacy are rampant racial, geographic, and income-based disparities in access to care and maternal outcomes. This dissertation first describes disparities in postpartum care content at the intersection of income (health insurance type), geography (rural or urban location), and race and ethnicity. Then it examines the impact of a state Medicaid program’s value-based payment model on maternal health care outcomes. Finally, it applies a cluster-analytic approach to identify and evaluate patterns of postpartum care utilization as a way to better understand different types of postpartum patients and better predict and prevent adverse health outcomes based on patterns of care. This dissertation found that inequities in the content of postpartum care received were extensive across patients’ insurance type, rural or urban residence, and racial and ethnic identities, and that these disparities were compounded for patients with multiple intersecting disadvantaged identities. A state Medicaid value-based payment model for maternity care added to an existing hospital program was not associated with significant changes in maternal health care outcomes or improvements in disparities. Finally, distinct postpartum care utilization patterns were identified and associated with particular health outcomes, which may help target future clinical and policy efforts. In summary, this dissertation provides evidence to support the use of standardized tools around postpartum care content in order to reduce inequities along income, rurality, and race and ethnicity, while also using better-targeted care management and intervention strategies to improve postpartum health outcomes. These changes should be accompanied by evidence-based payment incentives that are specific to maternity care settings and directed to providers of postpartum care.