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Impact of financial incentives for prenatal care on birth outcomes and spending.

ABSTRACT: OBJECTIVE: To evaluate the impact of offering US$100 each to patients and their obstetricians or midwives for timely and comprehensive prenatal care on low birth weight, neonatal intensive care admissions, and total pediatric health care spending in the first year of life. DATA SOURCES/STUDY SETTING: Claims and enrollment profiles of the predominantly low-income and Hispanic participants of a union-sponsored, health insurance plan from 1998 to 2001. STUDY DESIGN: Panel data analysis of outcomes and spending for participants and nonparticipants using instrumental variables to account for selection bias. DATA COLLECTION/ABSTRACTION METHODS: Data provided were analyzed using t-tests and chi-squared tests to compare maternal characteristics and birth outcomes for incentive program participants and nonparticipants, with and without instrumental variables to address selection bias. Adjusted variables were analyzed using logistic regression models. PRINCIPLE FINDINGS: Participation in the incentive program was significantly associated with lower odds of neonatal intensive care unit admission (0.45; 95 percent CI, 0.23-0.88) and spending in the first year of life (estimated elasticity of -0.07; 95 percent CI, -0.12 to -0.01), but not low birth weight (0.53; 95 percent CI, 0.23-1.18). CONCLUSION: The use of patient and physician incentives may be an effective mechanism for improving use of recommended prenatal care and associated outcomes, particularly among low-income women.

SUBMITTER: Rosenthal MB

PROVIDER: S-EPMC2754543 | biostudies-other | 2009 Oct

REPOSITORIES: biostudies-other

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Impact of financial incentives for prenatal care on birth outcomes and spending.

Rosenthal Meredith B MB Li Zhonghe Z Robertson Audra D AD Milstein Arnold A

Health services research 20090713 5 Pt 1

<h4>Objective</h4>To evaluate the impact of offering US$100 each to patients and their obstetricians or midwives for timely and comprehensive prenatal care on low birth weight, neonatal intensive care admissions, and total pediatric health care spending in the first year of life.<h4>Data sources/study setting</h4>Claims and enrollment profiles of the predominantly low-income and Hispanic participants of a union-sponsored, health insurance plan from 1998 to 2001.<h4>Study design</h4>Panel data an ...[more]

PMID: 19619248

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Project description:The effect of the Affordable Care Act (ACA) dependent coverage provision on pregnancy-related health care and health outcomes is unknown.To determine whether the dependent coverage provision was associated with changes in payment for birth, prenatal care, and birth outcomes.Retrospective cohort study, using a differences-in-differences analysis of individual-level birth certificate data comparing live births among US women aged 24 to 25 years (exposure group) and women aged 27 to 28 years (control group) before (2009) and after (2011-2013) enactment of the dependent coverage provision. Results were stratified by marital status.The dependent coverage provision of the ACA, which allowed young adults to stay on their parent's health insurance until age 26 years.Primary outcomes were payment source for birth, early prenatal care (first visit in first trimester), and adequate prenatal care (a first trimester visit and 80% of expected visits). Secondary outcomes were cesarean delivery, premature birth, low birth weight, and infant neonatal intensive care unit (NICU) admission.The study population included 1?379?005 births among women aged 24-25 years (exposure group; 299?024 in 2009; 1?079?981 in 2011-2013), and 1?551?192 births among women aged 27-28 years (control group; 325?564 in 2009; 1?225?628 in 2011-2013). From 2011-2013, compared with 2009, private insurance payment for births increased in the exposure group (36.9% to 35.9% [difference, -1.0%]) compared with the control group (52.4% to 51.1% [difference, -1.3%]), adjusted difference-in-differences, 1.9 percentage points (95% CI, 1.6 to 2.1). Medicaid payment decreased in the exposure group (51.6% to 53.6% [difference, 2.0%]) compared with the control group (37.4% to 39.4% [difference, 1.9%]), adjusted difference-in-differences, -1.4 percentage points (95% CI, -1.7 to -1.2). Self-payment for births decreased in the exposure group (5.2% to 4.3% [difference, -0.9%]) compared with the control group (4.9% to 4.3% [difference, -0.5%]), adjusted difference-in-differences, -0.3 percentage points (95% CI, -0.4 to -0.1). Early prenatal care increased from 70% to 71.6% (difference, 1.6%) in the exposure group and from 75.7% to 76.8% (difference, 0.6%) in the control group (adjusted difference-in-differences, 0.6 percentage points [95% CI, 0.3 to 0.8]). Adequate prenatal care increased from 73.5% to 74.8% (difference, 1.3%) in the exposure group and from 77.5% to 78.8% (difference, 1.3%) in the control group (adjusted difference-in-differences, 0.4 percentage points [95% CI, 0.2 to 0.6]). Preterm birth decreased from 9.4% to 9.1% in the exposure group (difference, -0.3%) and from 9.1% to 8.9% in the control group (difference, -0.2%) (adjusted difference-in-differences, -0.2 percentage points (95% CI, -0.3 to -0.03). Overall, there were no significant changes in low birth weight, NICU admission, or cesarean delivery. In stratified analyses, changes in payment for birth, prenatal care, and preterm birth were concentrated among unmarried women.In this study of nearly 3 million births among women aged 24 to 25 years vs those aged 27 to 28 years, the Affordable Care Act dependent coverage provision was associated with increased private insurance payment for birth, increased use of prenatal care, and modest reduction in preterm births, but was not associated with changes in cesarean delivery rates, low birth weight, or NICU admission.

Project description:BackgroundGaps in postnatal care use represent missed opportunities to prevent maternal and neonatal death in sub-Saharan Africa. As one in every three non-facility deliveries in Nigeria is assisted by a traditional birth attendant (TBA), and the TBA's advice is often adhered to by their clients, engaging TBAs in advocacy among their clients may increase maternal and neonatal postnatal care use. This study estimates the impact of monetary incentives for maternal referrals by TBAs on early maternal and neonatal postnatal care use (within 48 h of delivery) in Nigeria.MethodsWe conducted a non-blinded, individually-randomized, controlled study of 207 TBAs in Ebonyi State, Nigeria between August and December 2016. TBAs were randomly assigned with a 50-50 probability to receive $2.00 for every maternal client that attended postnatal care within 48 h of delivery (treatment group) or to receive no monetary incentive (control group). We compared the probabilities of maternal and neonatal postnatal care use within 48 h of delivery in treatment and control groups in an intention-to-treat analysis. We also ascertained if the care received by mothers and newborns during these visits followed World Health Organization guidelines.ResultsOverall, 207 TBAs participated in this study: 103 in the treatment group and 104 in the control group. The intervention increased the proportion of maternal clients of TBAs that reported attending postnatal care within 48 h of delivery by 15.4 percentage points [95% confidence interval (CI): 7.9-22.9]. The proportion of neonatal clients of TBAs that reportedly attended postnatal care within 48 h of delivery also increased by 12.6 percentage points [95% CI: 5.9-19.3]. However, providers often did not address the issues that may have led to maternal and newborn postnatal complications during these visits.ConclusionsWe show that motivating TBAs using monetary incentives for maternal postnatal care use can increase skilled care use after delivery among their maternal and neonatal clients, who have a higher risk of mortality because of their exposure to unskilled birth attendance. However, improving the quality of care is key to ensuring maternal and neonatal health gains from postnatal care attendance.Trial registrationThe trial was retrospectively registered in clinicaltrials.gov ( NCT02936869 ) on October 18, 2016.

Project description:BackgroundPatient experience measures are central to many pay-for-performance (P4P) programs nationally, but the effect of performance-based financial incentives on improving patient care experiences has not been assessed.MethodsThe study uses Clinician & Group CAHPS data from commercially insured adult patients (n = 124,021) who had visits with 1,444 primary care physicians from 25 California medical groups between 2003 and 2006. Medical directors were interviewed to assess the magnitude and nature of financial incentives directed at individual physicians and the patient experience improvement activities adopted by groups. Multilevel regression models were used to assess the relationship between performance change on patient care experience measures and medical group characteristics, financial incentives, and performance improvement activities.ResultsOver the course of the study period, physicians improved performance on the physician-patient communication (0.62 point annual increase, p < 0.001), care coordination (0.48 point annual increase, p < 0.001), and office staff interaction (0.22 point annual increase, p = 0.02) measures. Physicians with lower baseline performance on patient experience measures experienced larger improvements (p < 0.001). Greater emphasis on clinical quality and patient experience criteria in individual physician incentive formulas was associated with larger improvements on the care coordination (p < 0.01) and office staff interaction (p < 0.01) measures. By contrast, greater emphasis on productivity and efficiency criteria was associated with declines in performance on the physician communication (p < 0.01) and office staff interaction (p < 0.001) composites.ConclusionsIn the context of statewide measurement, reporting, and performance-based financial incentives, patient care experiences significantly improved. In order to promote patient-centered care in pay for performance and public reporting programs, the mechanisms by which program features influence performance improvement should be clarified.

Dataset Information

Impact of financial incentives for prenatal care on birth outcomes and spending.

Publications

Impact of financial incentives for prenatal care on birth outcomes and spending.

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