Improving Quality of Care for Low-Income Pregnant People through Medicaid Accountable Care Organizations: A Natural Experiment

项目总结 美国的孕产妇健康正处于危机之中，低收入孕妇和产后人群(PPP)和 在产前、分娩和产后期间，颜色体验的护理质量不佳。作为 最大的产妇保健支付者，覆盖66%的黑人出生和60%的西班牙裔出生，医疗补助计划 在塑造低收入有色人种购买力平价的孕产妇健康方面发挥了关键作用，有重要的机会 提供护理服务的模式，如责任护理组织(ACOS)，以改善PPP的结果和公平 通过改善护理整合、协调和质量改进激励措施实现规模化。尽管不断增长 国家对医疗补助ACO的兴趣，关于医疗补助ACO和ACO模型类型影响的经验证据 PPP非常有限。然而，确定最优ACO模型设计对于35个还没有这样做的州来说是至关重要的 实施了医疗补助ACO和其他希望改革ACO的州。R01将通过以下方式填补这些空白 评估创新的、全州范围的马萨诸塞州(MA)医疗补助ACO，旨在将医疗、 行为和社会服务，并改善护理质量和协调，在两个不同的 ACO模式类型：(1)由初级保健医生(PCP)领导的ACO，其中专家(如妇产科医生)不参与 ACO和(2)健康系统和医疗补助管理保健计划伙伴关系ACO，其中PCP和 专家是ACO的一部分。由于患者不选择Medicaid ACO或模型类型，这创建了一个 新颖的嵌套式自然实验，我们将利用它与定性方法相结合，来检验 医疗补助ACO计划如何影响PPP的医疗质量和公平性。具体目标是(1)评估 MA的医疗补助ACO计划对包括产前在内的PPP护理敏感措施质量的影响 使用差异法的措施、分娩相关措施和产后措施 使用索赔数据，其中子分析将检查按种族/民族邮政编码分组的差异影响，(2) 评估PCP主导与卫生系统伙伴关系的医疗补助ACO模式对PPP的影响，使用相同的 目标1中的结果和分析方法，以及(3)评估如何努力解决孕产妇健康问题 在MA Medicaid ACO中进行了操作和优先排序，以及这如何随型号类型、 与临床医生、护理协调员和领导层进行半结构化访谈；访谈将进一步 捕捉这些努力的成功和挑战，不同的组织计划用于改善孕产妇 ACO的医疗保健和公平，以及如何将OB/GYN和专家纳入或排除在ACO之外 影响PPP的护理管理和协调。随着越来越多的州和医疗补助提供者实施ACO， 几乎没有证据可以指导他们。了解医疗补助ACO如何提高医疗质量 他们最脆弱的人群之一-购买力平价-通过基于价值的护理势在必行 在这一孕产妇健康危机的时刻，为成功的典范和大规模改善健康和公平而干杯。

PROJECT SUMMARY Maternal health in the US is in crisis, where low-income pregnant and postpartum people (PPP) and PPP of color experience suboptimal quality of care across the prenatal, delivery, and postpartum periods. As the largest payer of maternity care, covering 66% of Black births and 60% of Hispanic births, the Medicaid program plays a critical role in shaping maternal health for lower-income PPP of color, with significant opportunity for care delivery models such as Accountable Care Organizations (ACOs) to improve PPP’s outcomes and equity at scale through improved care integration, coordination, and quality improvement incentives. Despite growing state interest in Medicaid ACOs, empirical evidence on the effects of Medicaid ACOs and ACO model types on PPP is very limited. Yet, identifying optimal ACO model designs is critical for the 35 states that have not yet implemented Medicaid ACOs and for other states looking to reform their ACOs. This R01 will fill these gaps by evaluating the innovative, statewide Massachusetts (MA) Medicaid ACO, which aims to integrate medical, behavioral, and social services and improve care quality and coordination across 16 ACOs under two distinct ACO model types: (1) a primary care physician (PCP)-led ACO, where specialists (e.g., OB/GYNs) are not part of the ACO and (2) a health system and Medicaid managed care plan partnership ACO, where PCPs and specialists are part of the ACO. As patients do not select into a Medicaid ACO or model type, this creates a novel nested natural experiment, which we will leverage in combination with qualitative methods, to examine how Medicaid ACO programs affect health care quality and equity for PPP. Specific aims are to (1) evaluate the effect of MA’s Medicaid ACO program on quality of care-sensitive measures for PPP, including prenatal measures, delivery-related measures, and postpartum measures, using a difference-in-differences approach with claims data, where sub-analyses will examine differential effects by racial/ethnic zip code group, (2) evaluate the effect of PCP-led vs. health system partnership Medicaid ACO models on PPP, using the same outcomes and analytic approach as in Aim 1, and (3) assess how efforts to address maternal health outcomes are being operationalized and prioritized within MA Medicaid ACOs, and how this varies by model type, by conducting semi-structured interviews with clinicians, care coordinators, and leadership; interviews will further capture successes and challenges of these efforts, different organizational programs used to improve maternal health care and equity for the ACO, and how inclusion or exclusion of OB/GYNs and specialists from the ACO affects care management and coordination for PPP. As more states and Medicaid providers implement ACOs, little evidence is available to guide them. Understanding how Medicaid ACOs can improve quality of care for one of their most vulnerable populations—PPP—through value-based care is imperative both to value-based model success and to improving health and equity at scale in this moment of maternal health crisis.