Medicaid study uncovers rise in costly ER visits due to possible gaps in postpartum care

The researchers, whose findings are summarized in the Sept.18 Journal of Women's Health, say they found that Medicaid-insured, low-income women with gestational diabetes, gestational hypertension or preeclampsia during their pregnancies were measurably more likely to have an ER visit in the six months following birth than those without such complications. Young women in particular, under 25 years of age and with these complications, had an even greater chance of going to the ER. The researchers also found that the majority of ER visits occurred before the recommended six-week postpartum appointment, indicating the need for earlier postpartum follow-up for women with pregnancy complications.

The findings, the investigators say, should prompt at least a closer look at hospital discharge planning after delivery and access to postpartum care for Medicaid beneficiaries to better address their needs. "Our results offer clues to opportunities to improve the postpartum and longer-term health of many low-income women," says study lead author Ashley Harris, M.D., M.H.S., a senior clinical fellow in the Johns Hopkins University School of Medicine's Division of General Internal Medicine. "Further study might lead to interventions and programs that target these women for intensive discharge planning and follow-up care that could improve access to care and prevent ER use," she adds.

Medicaid, like most forms of insurance, covers a postpartum visit six weeks after childbirth, offering a chance to address health conditions that arose or worsened during pregnancy and steer new mothers toward a healthy recovery. However, says Harris, many women -- particularly those who rely on government-sponsored programs such as Medicaid -- face multiple social and economic barriers that cause them to miss these visits, including lack of childcare, schedule demands, difficulty accessing care and lack of understanding about the long-term health risks associated with pregnancy complications.

Rather than receiving care at regular checkups, Harris says, some patients turn to the ER, where care is more costly, less efficient, less equipped to deal with chronic conditions or able to promote long-term preventive health behaviors.

For the study, Harris, along with Wendy Bennett, M.D., M.P.H., an assistant professor of medicine in the Johns Hopkins University School of Medicine's Division of General Internal Medicine, and their colleagues analyzed information from a claims database for one of the seven Medicaid managed care programs in Maryland.

The dataset included Medicaid insurance claims for every live birth delivery between 2003 and 2010, as well as outpatient, inpatient and ER visit claims during pregnancy, six months preconception and 12 months after delivery.

The authors also mined the database for information about patients' age, race/ethnicity, history of cesarean delivery, and preconception conditions including type 2 diabetes, chronic high blood pressure, obesity, asthma, mental health issues and substance abuse.

The researchers identified 26,047 pregnant women who had at least 100 days of continuous Medicaid coverage during pregnancy and at least 90 days of continuous Medicaid coverage postpartum. About 20 percent of the pregnancies were complicated by gestational diabetes, gestational hypertension or preeclampsia. About 70 percent of the women had become eligible for Medicaid because of their pregnancy.

Overall, about a quarter of all the patients visited the ER within six months of delivery. However, the researchers' analysis shows that those who had experienced one or more of the three pregnancy complications considered for the study were 14 percent more likely to go to the ER than those who hadn't had those complications. Importantly, being under 25 years old increased the odds of an ER visit by 20 percent. The analysis also showed that 60 percent of the ER visits that occurred among these women were prior to the commonly recommended six-week visit and continued on well after.

In addition, having a cesarean delivery or having any of the identified preconception health issues further increased the chances that those with complicated pregnancies would seek care at the ER (a 24 percent and 63 percent increase, respectively), the authors say.

Together, Harris says, these findings suggest that postpartum patients, particularly young, low-income women who experienced complicated pregnancies, may need better hospital discharge planning and earlier postpartum care. What's covered at the six-week visit with the obstetrician might not be enough to address the issues particular to this population, she says.

Potentially helpful interventions, says Bennett, might include early postpartum home or community-based visits that not only address recent pregnancy complications, but also promote long-term health behavior changes (such as postpartum weight loss and contraception needs) and tackle some of the social challenges, such as health care access and housing. Sending providers to patients, rather than the other way around, and coupling baby to patient, could begin to address barriers that limit patients' ability to access appropriate care both short term and longer term.

Bennett is currently studying the feasibility and impact of joint maternal-child visits, in which new mothers bring their babies for well-baby checkups and receive their own checkups at the same time. "In our study, patients are thrilled that they are able to get their own postpartum care and their baby's care at the same time, and then they get all their questions answered, sort of like one-stop shopping," Bennett says.

There are over 3.9 million births per year in the U.S., and the Centers for Disease Control and Prevention reports that Medicaid covers 50 percent of all births in the nation. "This is a large and potentially captive group of women who could benefit from further study of effective postpartum interventions that minimize preventable ER visits," says Bennett.