1. Reducing Disparities through Payment and Delivery System Redesign for High Risk Postpartum Women
Elizabeth A. Howell, MD, MPP
Vice Chair of Research
Department of Obstetrics, Gynecology, and Reproductive Science
Icahn School of Medicine at Mount Sinai
Funded by the Robert Wood Johnson Foundation RWJF I.D

2. Icahn School of Medicine at Mount Sinai
Elizabeth Howell, MD, MPP, Amy Balbierz, MPH, Vincent Dobrev, Kezhen Fei, MS, Population Health Science & Policy
Joanne Stone, MD, Jennifer Amorosa, MD,* E. Howell, MD – Ob/Gyn
Virginia Walther, MSW, Judy Mason, MSW – Social Work
Social Worker (Brett Barash, LMSW*), Patient Care Coordinator (Mabel Del Orbe)
Healthfirst
Susan Beane, MD, Medical Director
Rashi Kumar, MUP, Senior Program Manager, Clinical Partnerships
Tola Ilegbusi*, Program Analyst, Clinical Partnerships
The New York Academy of Medicine (NYAM)
José A. Pagán, PhD, Norma A. Padrón, PhD* – Health Economists
*Individuals who have transitioned to new positions

3. Opportunity Childbirth number one reason for hospital admission
Postpartum (PP) care offers opportunity to impact current and future health of underserved women
Low income women of color have higher:
Maternal mortality/morbidities
Pregnancy complications/ readmissions
Chronic illnesses (e.g., hypertension, diabetes)
Less likely to get appropriate medical follow-up post-pregnancy putting long term health at risk (e.g., increased risk of Type 2 DM)

4. Evidence of Problem
Significant disparities in receipt of postpartum care
Postpartum Visits LOW among high risk minority mothers
Healthfirst patients (58%); patients w/ HTN (46%) and diabetes (50%)
Earlier study of 312 women w/ gestational diabetes, 60% went for postpartum visit; 42% of those completed glucose test
Postpartum visits HIGH among low-risk white mothers
Low-risk commercially insured, 80-90%
Multiple barriers: poor clinician communication, transportation

5. Project Objectives
Improve quality of care for high-risk postpartum mothers by combining case management intervention and payment reform
Increase rates of timely postpartum care among high risk obstetrical patients
Evaluate the impact of the intervention on receipt of postpartum care, ED Visits, hospitalizations, maternal depression, and cost

6. Intervention: Delivery System Reform
Evidence-based case management intervention*
Aimed at increasing rates of postpartum visits and connecting women with care
Prepare/educates women about GDM, HTN, depression, bolsters support and self-management, increases access to community resources; reduces barriers to f/u care
*Howell et al. Obstets & Gynecol 2012

7. Intervention: Payment Reform
Cost-sharing arrangement between Mount Sinai and Healthfirst) to cover staff, provide clinician education & incentives
Patient Incentives – postpartum visit payments, roundtrip metrocard, raffle
Physician Incentives
Nonfinancial Incentives: clinician education, performance feedback

8. Target Population Postpartum women, age ≥18; insured by Healthfirst
Hypertension
Gestational diabetes
Late registrants for prenatal care
Depressive symptoms
High risk neighborhoods (zip codes) for diabetes and hypertension according to the NYC DOH
Recruited/Enrolled during postpartum hospital stay
Goal: Enroll 510 women w/ Healthfirst Insurance

9. Intervention & Outcomes
Intervention – occurs during postpartum hospital stay (education pamphlet/ partner summary sheet) and 2-week call
Assessments: baseline, 3 weeks, and 6 months postpartum
Primary Outcome: Timely postpartum visit (HEDIS)
Secondary Outcomes:
Maternal ED visit and hospitalizations within 12 months
Depressive symptoms
Glucose testing at PP visit (among GDM patients)
Costs

10. Postpartum Mothers (N=510)%
Mean age years
Latina/Hispanic
357
70%
Black/African American
124
24%
1° Spanish -speaking
150
29%
Born outside of US
238
47%
Educ. ≤ high school
283
55%
Yellow = need to update

11. Hispanic Ethnicity n % Puerto Rican 125 35% Mexican 108 30% Dominican81
23%
Ecuadorian 18 5%
Other 23 6%
Yellow = need to update

12. Health Status (N=510) n % Gestational Diabetes 52 10% Hypertension 109
21%
Late Registrants (>20 wks.) 29 6%
Positive Depression Screen (PHQ-2≥2) 77
15%
Live in high risk neighborhood for DM or HTN
475
93%
Need to update table when I get back

13. Baseline Clinical Characteristics (N=510)%
Primiparous
170
39%
Cesarean Delivery
172
34%
Breastfeeding
446
87%
Past History of Depression 94
18%
Positive Depression Screen
(EPDS ≥ 10 or PHQ-9 ≥ 10) 20 4%
Need to update table when I get back

14. Primary Outcome: Timely Postpartum Visit (HEDIS 21-56 day visit)
Timely Visit/ Patients within HEDIS Window %
Timely Postpartum Visit
(HEDIS day visit)
371/510
73%
Mothers w/ HTN (n=110)
75/103
Mothers w/ GDM (n=52)
39/48
81%
Any Postpartum Visit
406/510
80%
As of 10/26/16, will update when I get back

15. Factors Associated with Timely Postpartum Visit
Being born outside of US*
Speaking Spanish*
Married or living as married*
Not having a comorbid condition*
Partner support*
*p<.05

16. Moms Satisfaction with the Intervention: Results from the Two Week Survey (N=435)%
Reviewed patient education pamphlet
400
92%
99% of them thought it was helpful
Patient or partner reviewed partner education sheet
350
80%
95% of them thought it was helpful
Depression rate is updated

17. Secondary Outcome: Positive Depression Screens*%
At any time point (57 patients /510) 57
11%
Baseline 20 4%
3 week 31 8%
6 Month 26
10%
*EPDS ≥ 10 or PHQ-9 ≥ 10
As of 10/26/16
6 cases of SI overall, 1 case at Baseline 1/510, 3 cases at 3 week 3/351, 2 cases at 6M 2/211

18. Mom ED Visits and Hospitalizations at 3 Week Survey (N=375)%
Maternal ED Visit ≥ 1 time 44
12%
Maternal Hospitalization ≥ 1 time 18 5%
Depression rate is updated

19. Summary
A partnership between a major health system, Medicaid managed care organization, and a policy organization developed and implemented a program focused on delivery and payment system redesign to improve care and reduce disparities in high risk postpartum mothers
Results demonstrate high patient satisfaction and improved rates of postpartum visits among high risk low-income mothers

20. Implications
Insurers, researchers, clinicians, and policy experts should work together to foster health and wellness for postpartum women and reduce disparities
Innovative strategies to combine delivery and payment reform may improve care for vulnerable populations and reduce disparities