- Identify a policy that is not usually intended to be a health policy but that you think may have important health implications.
A policy that has potential impact on health outcomes in the obstetrical world is the differential insurance reimbursement for Medicaid-insured patient services versus those provided to patients covered by private insurers in some states. Many services provided during pregnancy and birth are better reimbursed for those patients with private insurance, leading to a potential difference in care provision for those services that may not provide as much revenue for a given practice. Practices that refuse to take Medicaid-covered clients also may be offering different services based on the reimbursement rates. Existing practice salary systems that use productivity-based models also provide motivation to offer more tests to those who receive the most reimbursement, which has the potential to further potentiate this effect.
- Describe why an evaluation of that policy is informative (primarily about the policy, or primarily a test of hypothesized mediators?)
There have been efforts to improve perinatal outcomes for those covered by Medicaid, including improving the reimbursement structure, however many of these efforts have not examined the actual impact of differential reimbursement on the outcomes themselves (Johnson et al, 2016; Daniel-Robinson et al, 2015). The policy itself is not necessarily the primary predictor affecting perinatal outcomes, but rather the interpretation of the reimbursement structure by providers and practices that provide pregnancy and birth care. If practices (especially for-profit) rely on reimbursement to maintain their business structure, priority will be placed on those patients who will return the most reimbursement, and choices may be made to either accept or deny insurance from those lower-reimbursing insurers.
- Specify the outcomes and populations you think most affected or least affected by the policy.
Outcomes that may be affected by differential Medicaid reimbursement include many birth outcomes, include those most impacted by limited access to care (preterm birth, gestational diabetes, hypertension, perinatal death, etc). Obviously those affected would be lower-income women who qualify for Medicaid coverage; those least affected are those on private insurance.
- Propose a study design to evaluate the policy
One possible way to examine this relationship would be to set up an intervention study randomizing women to Medicaid insurance or private insurance (or two insurance payers using different reimbursement levels) prior to onset of prenatal care and examining both processes of care (tests, procedures, care intensity, provider access) and outcomes of care (birth outcomes) throughout pregnancy and birth. Randomization would limit the confounding effects of other factors that may contribute to poor birth outcomes (other health/healthcare disparities).
Another potential study design would be a systems-level intervention study in which areas (neighborhoods/cities/states) would be randomized to either a single-payer system or to equal reimbursement across insurance payers, compared to the control group the current differential system.
- Describe biggest challenge to implementing and drawing inferences about the impact of the policy on health
Given the multitude of factors identified that contribute to disparities in birth outcomes, the largest challenge that would be faced in exploring the impact of differential reimbursement practices on outcomes would be management of all of these other contributors. Randomization would help mitigate the confounding effects as well as initiation of the study prior to care onset, but care must be taken to factor in demographic and social/behavioral aspects that contribute to poor birth outcomes to fully assess how these policies affect health.