How Medicaid ACOs Can Lead the US Towards Maternal Health Equity
A new study details how Medicaid Accountable Care Organizations can improve maternal healthcare quality and equity in the US by aligning performance mandates with innovative care coordination and social needs support among patients before, during, and after pregnancy.
As the largest insurance program for maternity care, Medicaid is uniquely positioned to shape maternal health in the United States, where maternal mortality rates far outweigh those of other wealthy nations and continue to disproportionately affect Black and Hispanic populations. Medicaid Accountable Care Organizations (ACOs), in particular—networks of healthcare providers and systems that are incentivized to improve healthcare and patient outcomes—have an opportunity to bolster maternal healthcare quality and equity across the country.
However, there is a dearth of research on how health systems and providers implement maternal health strategies and the challenges they face as they aspire to deliver quality, continuous care for pregnant and postpartum people.
To close these gaps, a new study led by researchers at the School of Public Health examines whether Massachusetts’ Medicaid ACOs have addressed or improved maternal healthcare quality and equity in the Commonwealth, and sheds light on the key factors that propelled these efforts.
Published in The Milbank Quarterly, the study provides insight from leaders, clinicians, and care coordinators for six of the 17 Medicaid ACOs in Massachusetts between 2018-2024. It found that these ACOs were able to improve the quality of patients’ maternal care by intentionally and strategically incorporating new maternal metrics and initiatives mandated in their contracts, as well as by providing the necessary resources and infrastructure to meet these requirements. Mandating specific maternal health initiatives, from timely prenatal care to postpartum depression screening, motivated the ACOs to adapt or develop programs that align with maternal health goals.
However, there were formidable challenges in meeting metrics and implementing new initiatives across the continuum of maternal healthcare, which varied depending on the type of ACO model (primary care model or health system-based model). The researchers offer recommendations that Massachusetts and other states can utilize to overcome barriers in maternal healthcare delivery.
“Our findings showed that metrics matter; instituting maternal health-related metrics at an organizational level does prompt ACOs and healthcare organizations to develop the programs needed to meet those metrics and track patients’ engagement,” says study lead and corresponding author Shannon Ogden, a postdoctoral research fellow at the Kaiser Permanente Division of Research who conducted this work as a graduate research assistant at SPH. “The leaders we interviewed also identified remaining gaps in maternal care, so there is still more work to be done to improve maternal healthcare quality and equity across Massachusetts’ Medicaid ACOs.”
MassHealth, Massachusetts’ Medicaid program, launched its first ACO with a section 1115 waiver in 2018, before renewing and expanding the program under a second five-year 115 waiver in 2023. The new study is the first qualitative assessment of how Medicaid ACO programs implemented maternal health initiatives across multiple waiver periods, and it builds upon a previous quantitative study by several of the researchers that linked Medicaid ACOs to improvements in maternity care engagement and quality (but not health outcomes), which varied among different ACO models.
Metrics matter. They drive organization change by prompting new strategic thinking and investment in maternal health. Yet achieving the metrics and needed care coordination and integration varies by ACO design, and sustainable change requires more than metrics.Lois McCloskey, clinical professor of community health sciences
“ACOs are designed to improve coordination of care and integration across physical, social, and behavioral care. For maternal health, this means care that begins in the pre-pregnancy period and extends through pregnancy and the postpartum year,” says study senior author Lois McCloskey, clinical professor of community health sciences at SPH. “Metrics matter. They drive organization change by prompting new strategic thinking and investment in maternal health. Yet achieving the metrics and needed care coordination and integration varies by ACO design, and sustainable change requires more than metrics. Resources must be sufficient. It takes tangible resources to make meaningful change.”
The ACO contracts required just a single maternal health metric—timely prenatal care—during the first waiver period, compared to multiple tactics during the second waiver period, including the metric for timely postpartum visits, and the requirement for postpartum depression screenings. Simultaneously, the Commonwealth also extended Medicaid coverage from 60 days to 12 months after delivery, and began to cover doula services.
ACO leaders and clinicians shared that, with the support of care coordination teams, they were able to engage people in prenatal care sooner, track births, and motivate attendance at postpartum visits after the metrics were introduced. However, they also noted challenges in delivering this care, including system delays in identifying pregnancies. Primary care-led ACOs that were not part of a comprehensive health system especially struggled with tracking patients’ care out of network and over time.
To meet new maternal health requirements during the second waiver, many Medicaid ACOs adapted their existing programs or developed new initiatives and approaches, including tailoring existing programs for patients with complex chronic illness to the needs of mothers with pregnancy and postpartum complications.
“It was very impressive how care coordinators used their ingenuity to address systemic barriers in maternal healthcare, including the siloed nature of medical care,” McCloskey says. “Coordinators were ingenious and dogged in following new mothers after birth to assure they attended their postpartum visit.” However, she says, contracts did not require the same level of follow-up after the immediate postpartum period (6-10 weeks) after birth, “when mothers—especially those with complications—have a lot going on and are most likely to fall through the cracks. It is also when they are most at risk for severe morbidities.
“In fact, it is in this extended postpartum period that one-third of maternal deaths occur, many of them preventable.”
Doula care was also prioritized in ACOs during the second waiver period, as this care has been shown to build trust and improve equity in maternal care. ACOs that already established a doula program or effective care coordination team were able to provide this care, but other ACOs expressed difficulty hiring enough doulas within MassHealth to meet the demand for this specialized service.
Medicaid ACOs also ramped up efforts during the second waiver period to address patients’ social needs—stable housing, adequate food, reliable transportation, and affordable utilities—which can play a significant role in maternal health. Pregnant and postpartum patients were screened for eligibility to participate in the newly established “FLEX Services,” MassHealth’s program that allows ACOs and other healthcare organizations to partner with community organizations to provide these needs. But care coordinators noted barriers to these services, including a lack of provider awareness, as well as burdensome application processes. However, the researchers note that Massachusetts’ subsequent expansion of the FLEX program after the study period ended may have resolved some of these issues.
This shift in focus towards patients’ broader, more holistic health needs inherently supports maternal health, Ogden says. “Helping patients find housing, pay for food, find a job or pay their electricity bills can reduce the risk of poor health outcomes before, during, and after pregnancy.”
To tackle the stated challenges and fully achieve maternal health equity, the research team urges states and healthcare systems to expand maternal healthcare performance metrics and patient tracking, and to invest in innovations needed to strengthen care coordination and integration for pregnant and postpartum people.
“Such strategic direction and investment could contribute meaningfully to the reversal of the alarming maternal morbidity and mortality rates that persist in the US and continue to disproportionately burden Black and brown communities,” McCloskey says.
The study was coauthored by researchers at the W2 Consulting Corporation, Harvard Medical School & Harvard Pilgrim Health Care Institute; and Boston University Chobanian and Avedisian School of Medicine. It is part of a larger body of work led by Megan Cole, associate professor, endowed chair, and division director in the Division of Health Policy and Insurance Research at Harvard Medical School and the Harvard Pilgrim Health Care Institute (and an adjunct professor at BUSPH), and funded by a $3.8 million grant that Cole received in 2024 from the National Institute on Minority Health and Health Disparities.