How Insurance Transitions Impact Estimates of Postpartum Visits

When transitioning health insurance coverage between delivery and the postpartum period, 27.2% of individuals with Medicaid at delivery self-reported a postpartum visit but did not have a Medicaid claim for a visit, with the greatest disparities found among those who transitioned from Emergency Medicaid at delivery to no insurance after delivery and Medicaid at delivery to private insurance after delivery.

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“Our findings suggest that postpartum visit rates may be underestimated at a higher rate in states with greater shares of birthing persons who experience these 2 types of postpartum insurance transitions,” wrote the researchers of the study. “This includes states that have not adopted the ACA [Accountable Care Act] Medicaid expansion, have large shares of undocumented birthing persons, and have not adopted policies to waive the 5-year waiting period for permanent residents.”

This cross-sectional study is published in JAMA Network Open.

In this study, researchers aimed to compare disparities between postpartum visit use reported in the Pregnancy Risk Assessment Monitoring System (PRAMS) and that found in Medicaid claims, to assess whether insurance transitions from Medicaid at the time of childbirth to other insurance types after delivery are associated with levels of data disagreement.

The researchers included individuals in South Carolina who had completed a PRAMS survey and had Medicaid for their delivery care between 2017 and 2020. PRAMS survey data were linked to inpatient, outpatient, and physician Medicaid claims. Insurance transition types included continuous Medicaid, Medicaid to private insurance, Medicaid to no insurance, and Emergency Medicaid to no insurance.

The main outcome of the study was disagreement due to a reported postpartum visit in PRAMS without a Medicaid claim for a visit or having a Medicaid claim for a visit without a reported postpartum visit in PRAMS.

A total of 5049 PRAMS survey requests were sent between 2017 and 2020, and 836 individuals with Medicaid as the principal payer of delivery in PRAMS were identified and included in the study. Of these individuals, 82.9% were aged 20 to 34 years, 85.7% reported a postpartum visit in PRAMS, and 61.6% had a Medicaid claim for a postpartum visit.

Of these individuals, 253 (30.3%) respondents had a data source disagreement (95% CI, 26.1-34.7). Moreover, 230 (27.2%) individuals had a visit in PRAMS without a Medicaid claim (23.2-31.5) and 23 (3.1%) had a Medicaid claim without a visit in PRAMS (95% CI, 1.8-5.2).

Furthermore, individuals who transitioned to private insurance after delivery and those who were uninsured after delivery after having Emergency Medicaid at delivery had an increased probability of data source agreement, by 15.8 percentage points (95% CI, 2.6-29.1) and 37.2 percentage points (95% CI, 19.6-54.8), respectively, compared with individuals who were continuously enrolled in Medicaid.

However, the researchers noted some limitations in the study, including not having a standard to assess the reliability of self-reported PRAMS data and Medicaid claims, possible recall bias, and that these results may not be generalizable to all states due to Medicaid billing differences and eligibility criteria.

Despite these limitations, the researchers believe these findings suggest that estimates of postpartum care use that are used to inform state Medicaid policy decisions may be improved by accounting for insurance transitions after delivery.

“Medicaid claims data are a useful source of information on health care use during the postpartum period; however, results from this cross-sectional study suggest that estimates of postpartum visit use derived from Medicaid claims may undercount postpartum visit receipt by systematically missing care received by individuals with Emergency Medicaid for delivery and those who transition to private insurance during the postpartum period,” wrote the researchers. “These findings suggest that accounting for postpartum insurance transitions when conducting studies using Medicaid claims data may be associated with improved estimates of postpartum health care use and outcomes.”

Reference

Bellerose M, Daw JR, Steenland MW. Differences in self-reported and billed postpartum visits among Medicaid-insured individuals. JAMA Netw Open. 2023;6(12):e2349457. doi:10.1001/jamanetworkopen.2023.49457