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Abstract Background Racial inequities in severe maternal morbidity (SMM) and mortality constitute a public health crisis in the United States. Doula care, defined as care from birth workers who provide culturally appropriate, non-clinical support during pregnancy and postpartum, has been proposed as an intervention to help disrupt obstetric racism as a driver of adverse pregnancy outcomes in Black and other birthing persons of colour. Many state Medicaid programs are implementing doula programs to address the continued increase in SMM and mortality. Medicaid programs are poised to play a major role in addressing the needs of these populations with the goal of closing the racial gaps in SMM and mortality. This study will investigate the most effective ways that Medicaid programs can implement doula care to improve racial health equity. Methods We describe the protocol for a mixed-methods study to understand how variation in implementation of doula programs in Medicaid may affect racial equity in pregnancy and postpartum health. Primary study outcomes include SMM, person-reported measures of respectful obstetric care, and receipt of evidence-based care for chronic conditions that are the primary causes of postpartum mortality (cardiovascular, mental health, and substance use conditions). Our research team includes doulas, university-based investigators, and Medicaid participants from six sites (Kentucky, Maryland, Michigan, Pennsylvania, South Carolina and Virginia) in the Medicaid Outcomes Distributed Research Network (MODRN). Study data will include policy analysis of doula program implementation, longitudinal data from a cohort of doulas, cross-sectional data from Medicaid beneficiaries, and Medicaid healthcare administrative data. Qualitative analysis will examine doula and beneficiary experiences with healthcare systems and Medicaid policies. Quantitative analyses (stratified by race groups) will use matching techniques to estimate the impact of using doula care on postpartum health outcomes, and will use time-series analyses to estimate the average treatment effect of doula programs on population postpartum health outcomes. Discussion Findings will facilitate learning opportunities among Medicaid programs, doulas and Medicaid beneficiaries. Ultimately, we seek to understand the implementation and integration of doula care programs into Medicaid and how these processes may affect racial health equity. Study registration The study is registered with the Open Science Foundation ( https://doi.org/10.17605/OSF.IO/NXZUF ).

Abstract Background Promoting appropriate pharmacotherapy requires understanding the factors that influence how clinicians prescribe medications. While prior work has focused on patient and clinician factors, features of the organizational setting have received less attention, though identifying sources of variation in prescribing may help identify opportunities to improve patient safety and outcomes. Objective To evaluate the relationship between the number of clinicians who prescribe medications in a facility and facility prescribing intensity of six individual medication classes by clinician specialty: benzodiazepines, antipsychotics, antiepileptics, and antidepressants by psychiatrists and antibiotics, opioids, antiepileptics, and antidepressants by primary care clinicians (PCPs). Design We used 2017 Veterans Health Administration (VHA) administrative data. Subjects We included patient-clinician dyads of older patients (> 55 years) with an outpatient encounter with a clinician in 2017. Patient-clinician data from 140 VHA facilities were included (n = 13,347,658). Analysis was repeated for years 2014 to 2016. Main measures For each medication, facility prescribing intensity measures were calculated as clinician prescribing intensity averaged over all clinicians at each facility. Clinician prescribing intensity measures included percentage of each clinician’s patients prescribed the medication and mean number of days supply per patient among all patients of each clinician. Key results As the number of prescribing clinicians in a facility increased, the intensity of prescribing decreased. Every increase of 10 facility clinicians was associated with a significant decline in prescribing intensity for both specialties for different medication classes: for psychiatrists, declines ranged from 6 to 11%, and for PCPs, from 2 to 3%. The pattern of more clinicians less prescribing was significant across all years. Conclusion Future work should explore the mechanisms that link the number of facility clinicians with prescribing intensity for benzodiazepines, antipsychotics, antiepileptics, antidepressants, antibiotics, and opioids. Facilities with fewer clinicians may need additional resources to avoid unwanted prescribing of potentially harmful or unnecessary medications.

Abstract Background Perinatal Mood and Anxiety Disorders (PMADs) affect one in five birthing individuals and represent a leading cause of maternal mortality. While these disorders are associated with a variety of poor outcomes and generate significant societal burden, underdiagnosis and undertreatment remain significant barriers to improved outcomes. We aimed to quantify whether the Patient Protection Affordable Care Act (ACA) improved PMAD diagnosis and treatment rates among Michigan Medicaid enrollees. Methods We applied an interrupted time series framework to administrative Michigan Medicaid claims data to determine if PMAD monthly diagnosis or treatment rates changed after ACA implementation for births 2012 through 2018. We evaluated three treatment types, including psychotherapy, prescription medication, and either psychotherapy or prescription medication. Participants included the 170,690 Medicaid enrollees who had at least one live birth between 2012 and 2018, with continuous enrollment from 9 months before birth through 3 months postpartum. Results ACA implementation was associated with a statistically significant 0.76% point increase in PMAD diagnosis rates (95% CI: 0.01 to 1.52). However, there were no statistically significant changes in treatment rates among enrollees with a PMAD diagnosis. Conclusion The ACA may have improved PMAD detection and documentation in clinical settings. While a higher rate of PMAD cases were identified after ACA Implementation, Post-ACA cases were treated at similar rates as Pre-ACA cases.

Abstract Background Maternal mental health conditions (MMHCs), which include depression and anxiety disorders during pregnancy and through five years postpartum, are among the most common obstetric complications in the United States overall and in Texas in particular. In the context of potential expansion of postpartum Medicaid coverage from 60 days to one year, we sought to capture the societal, financial burden of untreated MMHCs. Methods We estimated the economic impact of untreated maternal mental health conditions (MMHCs) among births in Texas in 2019 using a cost-of-illness model. Results We found that MMHCs affected 13.2% of mothers and, when left untreated, cost $2.2 billion among mothers and children born in Texas in 2019 when following the birth cohort from conception through five years postpartum. We found that MMHCs affected 17.2% of mothers enrolled in Texas’ Medicaid for Pregnant Women and cost $962 million. In addition, the prevalence of MMHCs and resulting costs varied considerably among women of different races and ethnicities. Employers and health care payers, including Medicaid, bore most of these costs. Conclusions The Texas Health and Human Services Commission’s (HHSC) efforts to increase awareness about MMHCs and increase access to care represent an important step toward improving maternal and child health and maximizing benefits to Texas HHSC, employers, and insurers.

Abstract Background National estimates of perinatal mood and anxiety disorders (PMAD) and serious mental illness (SMI) among delivering women over time, as well as associated outcomes and costs, are lacking. The prevalence of perinatal mood and anxiety disorders and serious mental illness from 2006 to 2015 were estimated as well as associated risk of adverse obstetric outcomes, including severe maternal morbidity and mortality (SMMM), and delivery costs. Methods The study was a serial, cross-sectional analysis of National Inpatient Sample data. The prevalence of PMAD and SMI was estimated among delivering women as well as obstetric outcomes, healthcare utilization, and delivery costs using adjusted weighted logistic with predictive margins and generalized linear regression models, respectively. Results The study included an estimated 39,025,974 delivery hospitalizations from 2006 to 2015 in the U.S. PMAD increased from 18.4 (95% CI 16.4–20.0) to 40.4 (95% CI 39.3–41.6) per 1000 deliveries. SMI also increased among delivering women over time, from 4.2 (95% CI 3.9–4.6) to 8.1 (95% CI 7.9–8.4) per 1000 deliveries. Medicaid covered 72% (95% CI 71.2–72.9) of deliveries complicated by SMI compared to 44% (95% CI 43.1–45.0) and 43.5% (95% CI 42.5–44.5) among PMAD and all other deliveries, respectively. Women with PMAD and SMI experienced higher incidence of SMMM, and increased hospital transfers, lengths of stay, and delivery-related costs compared to other deliveries (P

Abstract Background Incorporating behavioral health care into patient centered medical homes is critical for improving patient health and care quality while reducing costs. Despite documented effectiveness of behavioral health integration (BHI) in primary care settings, implementation is limited outside of large health systems. We conducted a survey of BHI in primary care practices participating in the Comprehensive Primary Care (CPC) initiative, a four-year multi-payer initiative of the Centers for Medicare and Medicaid Services (CMS). We sought to explore associations between practice characteristics and the extent of BHI to illuminate possible factors influencing successful implementation. Method We fielded a survey that addressed six substantive domains (integrated space, training, access, communication and coordination, treatment planning, and available resources) and five behavioral health conditions (depression, anxiety, pain, alcohol use disorder, and cognitive function). Descriptive statistics compared BHI survey respondents to all CPC practices, documented the availability of behavioral health providers, and primary care and behavioral health provider communication. Bivariate relationships compared provider and practice characteristics and domain scores. Results One hundred sixty-one of 188 eligible primary care practices completed the survey (86% response rate). Scores indicated basic to good baseline implementation of BHI in all domains, with lowest scores on communication and coordination and highest scores for depression. Higher scores were associated with: having any behavioral health provider, multispecialty practice, patient-centered medical home designation, and having any communication between behavioral health and primary care providers. Conclusions This study provides useful data on opportunities and challenges of scaling BHI integration linked to primary care transformation. Payment reform models such as CPC can assist in BHI promotion and development.