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. 72257

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

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)

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

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

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

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

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

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

Postpartum Mothers (N=510) % Mean age -- 28.5 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

Hispanic Ethnicity n % Puerto Rican 125 35% Mexican 108 30% Dominican 81 23% Ecuadorian 18 5% Other 23 6% Yellow = need to update

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

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

Primary Outcome: Timely Postpartum Visit (HEDIS 21-56 day visit) Timely Visit/ Patients within HEDIS Window % Timely Postpartum Visit (HEDIS 21-56 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

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

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

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

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

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

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