The Effects of Medicaid Policy Interventions on Racial Equity in Severe Maternal Morbidity

Study Overview
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Brief Summary
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The goal of this study is to learn about the effects of structural inventions, such as equity-focused Medicaid polices, on severe maternal morbidity (SMM) and mortality and maternal health. The main questions it aims to answer are: What is the effect of Medicaid healthcare quality interventions on SMM? What is the effect of Medicaid healthcare quality interventions + doula care? What are Medicaid beneficiaries' experiences in receiving services and the potential impact of integration of doula services and equity practices? Participants will be asked to describe experiences as a result of structural interventions and focused Medicaid policies.

Official Title
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The Effects of Medicaid Policy Interventions on Racial Equity in Severe Maternal Morbidity

Conditions
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Severe Maternal Morbidity, Maternal Death

Intervention / Treatment
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* Behavioral: Medicaid healthcare quality interventions (equity payment and obstetric bundled payment)
* Behavioral: Doula
* Behavioral: Standard Care


Participation Criteria
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Eligibility Criteria
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Inclusion Criteria: Pregnant and postpartum Medicaid beneficiaries across the US Qualitative: Medicaid beneficiaries who self-identify as Black and/or live in PA Health Equity Zones Doulas who provide care to Medicaid beneficiaries in Pennsylvania Medicaid Managed Care Organization (MCO) administrators in Pennsylvania. Severe maternal morbidity and mortality outcomes will be assessed in healthcare records and for these quantitative outcomes, patients will not be recruited individually Exclusion Criteria: -
Sexes Eligible for Study
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All

Accepts Healthy Volunteers
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Accepts Healthy Volunteers

Study Plan
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How is the study designed?
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Design Details

Primary Purpose: Health Services Research
Allocation: Non-Randomized
Intervention Model: Factorial Assignment
Interventional Model Description: Evaluation of policy interventions at the state level comparing within state and across states over time.
Masking: None (Open Label)


Arms and Interventions

| Participant Group/Arm | Intervention/Treatment |
| --- | --- |
| Other: Medicaid healthcare quality interventions (equity payment and obstetric bundled payment) Only<br>The investigators will employ a quasi-experimental study design to test two hypotheses: H1: SMM rates among Black people will decline after the interventions (equity payment and obstetric bundled payment), relative to people of other race groups within Pennsylvania (PA); and H2: Racial inequities in SMM will decline among those exposed to the interventions in PA, relative to those in similar states. The investigators will collect qualitative data to assess the effects of the Medicaid healthcare interventions on beneficiaries' experiences. | Behavioral: Medicaid healthcare quality interventions (equity payment and obstetric bundled payment)<br>* This study has two components, with the first component being examined in Aim 1 and the first and second components being examine in aim 2. 1) health equity incentive payment program makes available $26 million annually in Medicaid managed care organization (MCO) payments to plans that improve access to timely prenatal care and well-child visits among Black beneficiaries. The equity-focused obstetric care bundled payment model provides incentives for clinicians to improve on a wide range of pregnancy health outcomes, and specifically incentivizes improvements among Black beneficiaries<br>Behavioral: Standard Care<br>* Participants receive standard care without quality interventions or doula care<br>|
| Other: Doula Only<br>The investigators will test two hypotheses: H1: SMM rates among Black people will decline more after the addition of doula care in PA, relative to healthcare quality interventions alone. H2: Racial inequities in SMM will decline more among those exposed to both healthcare quality and doula care interventions in PA, relative to states implementing doula care only. The investigators will collect qualitative data to assess the effects of the Medicaid healthcare and service interventions on beneficiaries' experiences. | Behavioral: Doula<br>* This study has two components, with the first component being examined in Aim 1 and the first and second components being examine in aim 2. health equity incentive payment program makes available $26 million annually in Medicaid managed care organization (MCO) payments to plans that improve access to timely prenatal care and well-child visits among Black beneficiaries. The equity-focused obstetric care bundled payment model provides incentives for clinicians to improve on a wide range of pregnancy health outcomes, and specifically incentivizes improvements among Black beneficiaries. care intervention by coverage of doula services for all Medicaid beneficiaries across Pennsylvania.<br>Behavioral: Standard Care<br>* Participants receive standard care without quality interventions or doula care<br>|
| Other: Medicaid healthcare quality interventions (equity payment and obstetric bundled payment) + Doula<br> | Behavioral: Medicaid healthcare quality interventions (equity payment and obstetric bundled payment)<br>* This study has two components, with the first component being examined in Aim 1 and the first and second components being examine in aim 2. 1) health equity incentive payment program makes available $26 million annually in Medicaid managed care organization (MCO) payments to plans that improve access to timely prenatal care and well-child visits among Black beneficiaries. The equity-focused obstetric care bundled payment model provides incentives for clinicians to improve on a wide range of pregnancy health outcomes, and specifically incentivizes improvements among Black beneficiaries<br>Behavioral: Doula<br>* This study has two components, with the first component being examined in Aim 1 and the first and second components being examine in aim 2. health equity incentive payment program makes available $26 million annually in Medicaid managed care organization (MCO) payments to plans that improve access to timely prenatal care and well-child visits among Black beneficiaries. The equity-focused obstetric care bundled payment model provides incentives for clinicians to improve on a wide range of pregnancy health outcomes, and specifically incentivizes improvements among Black beneficiaries. care intervention by coverage of doula services for all Medicaid beneficiaries across Pennsylvania.<br>Behavioral: Standard Care<br>* Participants receive standard care without quality interventions or doula care<br>|
| No Intervention: Standard Care<br> | |

What is the study measuring?
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Primary Outcome Measures

| Outcome Measure | Measure Description | Time Frame |
| --- | --- | --- |
| Severe maternal morbidity (SMM) | SMM rate based on the Centers for Disease Control algorithm | 20 weeks gestation through 42 days postpartum | 

Secondary Outcome Measures

| Outcome Measure | Measure Description | Time Frame |
| --- | --- | --- |
| All cause mortality | Binary indicator of mortality based on Social Security Administration records | Delivery date through one year after delivery | 
| Follow up for chronic conditions | Percent of persons who receive guideline concordant care for depression, substance use disorders, immunizations, and screening and referral for social determinants of health | 43 days through 1 year after delivery | 
| Provision of evidence care in pregnancy and postpartum | Percent of Medicaid patients among each provider who receive screening and follow up for depression, treatment for substance use disorders, perinatal immunizations, and screening and referral for social determinants of health | During pregnancy and postpartum up to 1 year | 
| Medicaid managed care administrator perspectives on policy interventions | Qualitative self report of perspectives | Year 3 |