By Elizabeth A. Howell, MD, MPP
This post originally appeared on the Health Affairs blog.
Pregnancy and childbirth can exacerbate many health risks, especially among underserved women or those who have a hard time getting health care. Diabetes, hypertension, and depression are all serious health conditions that occur frequently during pregnancy and childbirth, and are more common (during pregnancy and overall) among racial and ethnic minority women. Many women with these conditions have worsened health throughout the life course.
Yet pregnancy and the postpartum period present an opportunity for providers to intervene and improve the health trajectories of these women by connecting them to healthcare, helping them manage chronic conditions, and setting them and their children on the road to a healthier future. Improving care for underserved women is an underlying theme of my work at the Icahn School of Medicine at Mount Sinai, where my colleagues and I have introduced an evidence-based intervention to prioritize getting Medicaid-insured women in for a postpartum visit—and using that visit as a chance to manage other medical issues and connect these women with follow-up care. The intervention design was recently published in the Maternal and Child Health Journal, and is based on our previous work in this area.
Nationally 80 percent or more of commercially insured women who give birth have a timely postpartum visit, as defined by Healthcare Effectiveness Data and Information Set (HEDIS) guidelines. However, this rate is closer to 60 percent among those insured by Medicaid managed care plans. Among patients at Mount Sinai Hospital on the Healthfirst Medicaid Managed Care plan, the rate was only 58 percent. There are many potential reasons for these disparities—nationwide and at Mount Sinai—including transportation issues, child care demands, and poor clinician-patient communication that affect women in different plans differently.
One thing we know is that if you reduce the barriers for women to get to the doctor, they’re more likely to receive the postpartum care they need from their health care provider. Our intervention aims to reduce barriers in multiple ways: by educating women about the health risks and the importance of postpartum care; by helping them navigate the health care system; by linking them with community resources, such as community-based organizations that offer family support; and by providing financial incentives to providers who help make sure women return for care after childbirth.
This work, supported by the Robert Wood Johnson Foundation’s Finding Answers: Solving Disparities Through Payment and Delivery System Reform program, combines a social work and case management intervention with a new payment system designed to align provider incentives and to expand the resources available to clinicians and patients. The intervention is implemented in both English and Spanish; 66 percent of mothers in the Healthfirst managed care plan are Latina.
First, a social worker and a care coordinator are provided to new mothers through a cost-sharing arrangement with Healthfirst. These staff members make sure patients who give birth at Mount Sinai receive attention, education about comorbidities and postpartum care, and assistance in getting that care. We also provide affiliated ob-gyn clinics and clinicians with education and performance feedback on postpartum care. Postpartum patients are assessed for diabetes, postpartum depression, and high blood pressure. Providers who meet performance standards—providing a timely postpartum visit to Healthfirst-enrolled mothers—also receive a small payment incentive.
So far, the combination of delivery system and payment redesign seems to be working—the postpartum visit rate for Healthfirst patients at our hospital was up to 71 percent partway through 2016. Our patients, many of whom are socially isolated, say they appreciate the extra contact and a chance to discuss their concerns with our bilingual care coordinator. The postpartum period is a crucial inflection point for the health of both mother and child, and we hope that our final results will bear out our conviction that combining payment reform, education, and care delivery coordination can move the needle for our most underserved patients.
Elizabeth A. Howell, M.D., M.P.P. is Associate Dean for Academic Development and a Professor in the Departments of Population Health Science & Policy; Obstetrics, Gynecology, and Reproductive Science; and Psychiatry at the Icahn School of Medicine at Mount Sinai. She is also Mount Sinai Health System Vice Chair for Research in the Department of Obstetrics, Gynecology, and Reproductive Science.