Assessing the role of Federally Qualified Health Centers in advancing quality and equity of care for pregnant and postpartum Medicaid enrollees

PROJECT SUMMARY Low-income pregnant and postpartum patients (PPP), especially persons of color, experience significant inequities in quality of care and health outcomes across the perinatal period; this is driven, in part, by lack of access to care, inadequate coordination and integration of primary care and maternity care, and failure to

address unmet social needs. Federally qualified health centers (FQHCs) could play a central role in addressing these maternal health challenges, as the unique FQHC model includes providing access to culturally competent care for underserved patients; integrating and coordinating primary and maternity care; and linking

patients to social services. While use of FQHCs versus other outpatient settings for primary care has been associated with improved care quality, the impact of FQHC use for pregnancy care is unknown. Moreover, one key factor affecting the ability of FQHCs to improve perinatal outcomes may include whether the FQHC directly

provides maternity services, with our preliminary data finding that 1 in 3 US FQHCs do not directly provide prenatal care. Yet, there is no known literature on how offering maternity services at FQHCs may impact pregnancy outcomes, despite important policy opportunities to expand services at FQHCs. Our long-term goal

is to identify effective health system reform strategies that improve outcomes and equity for low-income PPP. As an immediate objective, this R01 will use a quasi-experimental, mixed methods approach to study if and how FQHCs may improve access, quality, and equity of care for PPP, using national data on the universe of

Medicaid-covered births. The specific aims are to (1) Characterize Medicaid-enrolled PPP who receive care at FQHCs vs non-FQHC practices (1-A) and compare quality of care-sensitive measures for these groups across the prenatal (e.g., timely prenatal care), delivery (e.g., SMM, preterm birth), and postpartum (e.g., postpartum

linkage to primary care) periods, using entropy balancing to balance on observables (1-B); (2) Among PPP who receive care at FQHCs, evaluate how expanding FQHC services to include maternity care impacts quality of care-sensitive measures using a difference-in-differences study to compare measures for Medicaid-enrolled

PPP at FQHCs that implement maternity care vs FQHCs with continuous maternity care vs FQHCs with continuous referral-only maternity care; and (3) Assess the role of FQHCs in integrating, coordinating, and providing access to care for PPP through semi-structured interviews with health systems and FQHC

leadership, including successes and challenges of FQHCs in integrating and coordinating primary care, maternity care, and social services for PPP, implications for quality and equity, and key policy opportunities and challenges in expanding maternity care at FQHCs. All Aims will examine differential impacts by

racial/ethnic identity. Collectively, these aims will fill critical evidence gaps to help policymakers, Medicaid providers, and managed care plans understand how FQHCs may shape maternal health outcomes and equity at scale, which in turn can inform policy, delivery system design, workforce initiatives, and plan contracting.