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

项目摘要 美国的孕产妇健康正处于危机之中，低收入的孕妇和产后妇女（PPP）以及 有色人种在产前、分娩和产后期间的护理质量欠佳。为 最大的产妇保健支付者，涵盖66%的黑人出生和60%的西班牙裔出生，医疗补助计划 在为低收入的有色人种塑造孕产妇健康方面发挥着关键作用， 诸如问责护理组织（ACO）等护理提供模式，以改善PPP的成果和公平性 通过改善护理一体化、协调和质量改进激励措施，大规模开展工作。尽管越来越多 州政府对Medicaid ACO的兴趣，Medicaid ACO和ACO模型类型对 PPP是非常有限的。然而，确定最佳ACO模型设计对于尚未建立的35个州至关重要。 实施医疗补助ACOs和其他国家希望改革他们的ACOs。R01将通过以下方式填补这些空白： 评估创新，全州马萨诸塞州（MA）医疗补助ACO，其目的是整合医疗， 行为和社会服务，并提高护理质量和协调，在16个行政长官办公室根据两个不同的 ACO模式类型：（1）初级保健医生（PCP）领导的ACO，其中专家（例如，OB/GYNs）不属于 （2）卫生系统和医疗补助管理式护理计划合作伙伴关系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，因此 新的嵌套自然实验，我们将利用结合定性方法，检查 Medicaid ACO计划如何影响PPP的医疗保健质量和公平性。具体目标是（1）评估 MA的Medicaid ACO计划对PPP护理敏感措施质量的影响，包括产前 措施，分娩相关措施，产后措施，使用差异中的差异方法 使用索赔数据，其中子分析将检查种族/民族邮政编码组的差异效应，（2） 使用相同的方法，评估PCP领导的与卫生系统伙伴关系Medicaid ACO模型对PPP的影响 目标1中的成果和分析方法，以及（3）评估如何努力解决孕产妇保健成果 正在MA Medicaid ACO中实施和优先化，以及这如何因模型类型而异， 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，用于改善孕产妇健康的不同组织方案 卫生保健和公平的ACO，以及如何纳入或排除OB/GYN和专家从ACO 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Medicaid ACO如何提高护理质量， 他们最脆弱的人群之一-购买力平价-通过基于价值的护理是必要的， 在孕产妇健康危机的这一时刻，我们必须努力树立成功的榜样，大规模地改善健康和公平。

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.