NR 555 Week 2 Outcome Measure Appraisal Example

Outcome Measure Appraisal: The Postpartum Visit Measure in One State's Medicaid Quality Report, Its Exact Definition, Who Its Continuous Enrollment Rule Removes and Where Each Number Is Born

Student Name

College of Nursing, Chamberlain University

NR 555: Health Policy: Advancing Health Equity & Outcomes

Instructor Name

Month Day, Year

Outcome Measure Appraisal: The Postpartum Visit Measure in One State's Medicaid Quality Report, Its Exact Definition, Who Its Continuous Enrollment Rule Removes and Where Each Number Is Born

The Indicator in Its Own Words

The measure appraised here is the postpartum care rate in our state's Medicaid managed care quality report. The report defines it as the percentage of deliveries of live births in which the birthing person had a postpartum visit on or between 7 and 84 days after delivery. It is adapted from a widely used health plan performance measure of prenatal and postpartum care, and the state reports it by managed care plan and, since last year, by race and ethnicity. The statewide rate was 67% last year, with 58% for Black enrollees and 74% for white enrollees.

Two places counting the same event can draw its boundaries differently. A hospital system tracking "postpartum follow-up" might count a nurse phone call or a visit at two weeks for an incision check; the state measure counts a qualifying visit in the window, identified from claims codes. A clinic that reports high follow-up and a plan that reports a low postpartum care rate may both be right, because they are measuring different things. Anyone using the measure should quote its definition, not a paraphrase.

Who the Denominator Admits

The denominator is the most important part of this appraisal. To be counted, a delivery must be to an enrollee who was continuously enrolled in the same plan from shortly before delivery through about 60 days after it. The purpose is reasonable: a plan should be measured only on people it had a fair chance to serve.

The effect is less neutral. A person who loses Medicaid coverage, switches plans or has a gap in enrollment during that window is removed from the denominator entirely. Coverage changes around childbirth are common (Daw et al., 2017). In our state's data, about 2,300 deliveries last year were excluded by the continuous enrollment rule, and 900 of them were to Black enrollees, who made up 28% of included deliveries but 39% of excluded ones. The people most likely to have missed a postpartum visit because their coverage lapsed are the ones the measure does not count. The published gap of 16 points is therefore probably smaller than the true gap among everyone who gave birth under Medicaid.

Other exclusions matter less but should be read line by line. Deliveries resulting in stillbirth are excluded; so are enrollees in certain specialized plans. None of these removes a group as large or as unevenly distributed as the continuous enrollment rule.

Where the Number Is Born

The visit is identified from claims or encounter data submitted by clinics to managed care plans, using codes for postpartum visits, some of which are recorded only once for a bundle of prenatal, delivery and postpartum care. When care is billed as a global package, the postpartum visit may not generate its own claim, so plans supplement claims with medical record review for a sample of deliveries. That means the number is born partly in a billing office and partly in a chart reviewer's audit.

Race and ethnicity are born elsewhere: in the Medicaid application, where applicants may select a category or leave it blank. About 7% of deliveries last year had missing or unknown race, which limits the precision of the split.

There is also a lag. Claims can arrive months after a visit, and the measure is reported annually, so the rate published this year describes deliveries that occurred up to a year and a half ago.

What the Measure Can and Cannot Show

The measure can show whether enrollees who stayed covered received a postpartum visit within 12 weeks, and it can compare plans and groups on that basis. It cannot show the quality of the visit, whether depression screening or blood pressure checks happened, or whether a person who lost coverage received care elsewhere. It cannot show outcomes, such as complications detected or missed. And because of the enrollment rule, it cannot describe the whole population of people who gave birth under Medicaid.

Braveman (2006) emphasized that the measurement of disparities depends on the way groups and outcomes are drawn, and that choices which look technical can change the size of a gap. The continuous enrollment rule is such a choice.

How the Measure Could Mislead a Program

A measure with this denominator can reward the wrong behavior. A managed care plan whose enrollees churn off coverage at high rates will have fewer hard-to-reach members in its denominator and may report a higher postpartum care rate than a plan that keeps its members enrolled. A plan that helps enrollees keep coverage through the postpartum period, which is good for them, could see its rate fall, because it now counts people who were previously excluded and who face more barriers. If the state ties plan payments to the rate without adjusting for these effects, it could penalize the plans doing the most for continuity.

The same problem affects comparisons over time. The 12-month extension will keep more enrollees continuously covered, bringing into the denominator people who would have been excluded. If their visit rates are lower, the statewide rate could fall or stall even as more people receive care. A reader who sees a flat rate after the extension might conclude it failed, when in fact the measure is now counting people it used to miss. Reporting the number of included deliveries alongside the rate, and the rate for newly included enrollees separately in the first year, would prevent that misreading.

Recommendations

For this course's work on the postpartum gap, the measure should be used with three adjustments. First, report alongside the published rate the number and share of deliveries excluded by the enrollment rule, by race. Second, where possible, calculate a supplementary rate that includes all Medicaid-covered deliveries, counting any postpartum visit found in claims, even after a plan change. Third, treat the published gap as a lower bound. The state's recent extension of postpartum coverage to 12 months should reduce enrollment gaps and make the measure more complete, which means part of any apparent change in the gap next year may come from who is counted rather than from who is seen.

Evidence from Medicaid expansion supports the concern. Broader eligibility has been associated with more postpartum coverage and more outpatient visits after birth (Gordon et al., 2020), which suggests that coverage rules shape both the care people receive and who appears in the measure.

References

Braveman, P. (2006). Health disparities and health equity: Concepts and measurement. Annual Review of Public Health, 27, 167-194. https://doi.org/10.1146/annurev.publhealth.27.021405.102103

Daw, J. R., Hatfield, L. A., Swartz, K., & Sommers, B. D. (2017). Women in the United States experience high rates of coverage "churn" in months before and after childbirth. Health Affairs, 36(4), 598-606. https://doi.org/10.1377/hlthaff.2016.1241

Gordon, S. H., Sommers, B. D., Wilson, I. B., & Trivedi, A. N. (2020). Effects of Medicaid expansion on postpartum coverage and outpatient utilization. Health Affairs, 39(1), 77-84. https://doi.org/10.1377/hlthaff.2019.00547