Association of Insurance Status With Provision of Recommended Services During Comprehensive Postpartum Visits

Abstract

Importance: Improving care during the postpartum period is a clinical and policy priority. During the comprehensive postpartum visit, guidelines recommend delivery of a large number of assessment, screening, and counseling services. However, little is known about services provided during these visits.

Objective: To examine rates of recommended services during the comprehensive postpartum visits and differences by insurance type.

Design, setting, and participants: This cross-sectional study included 20 071 093 weighted office-based postpartum visits (645 observations) with obstetrical-gynecological or family medicine physicians from annual National Ambulatory Medical Care Surveys from December 28, 2008, to December 31, 2016, and estimated multivariate regression models to calculate the frequency of recommended services by insurance type, controlling for visit, patient, and physician characteristics. Data analysis was conducted from November 1, 2019, to September 1, 2020.

Exposures: Visit paid by Medicaid vs other payment types.

Main outcomes and measures: Visit length and binary indicators of blood pressure measurement, depression screening, contraceptive counseling or provision, pelvic examinations, Papanicolaou tests, breast examinations, medication ordered or provided, referral to other physician, and counseling for weight reduction, exercise, stress management, diet and/or nutrition, and tobacco use.

Results: A total of 20 071 093 weighted comprehensive postpartum visits to office-based family medicine or obstetrical-gynecological physicians were included (mean patient age, 29.7 [95% CI, 29.1-30.3] years). Of these visits, 34.3% (95% CI, 27.6%-41.1%) were covered by Medicaid. Mean visit length was 17.4 (95% CI, 16.4-18.5) minutes. The most common procedures were blood pressure measurement (91.1% [95% CI, 88.0%-94.2%]), pelvic examinations (47.3% [95% CI, 40.8%-53.7%]), and contraception counseling or provision (43.8% [95% CI, 38.2%-49.3%]). Screening for depression (8.7% [95% CI, 4.1%-12.2%]) was less common. When controlling for visit, patient, and physician characteristics, the only significant difference in visit length or provision of recommended services based on insurance type was a difference in provision of breast examinations (14.7% [95% CI, 8.0%-21.5%] for Medicaid vs 25.6% [95% CI, 19.4%-31.8%] for non-Medicaid; P = .02).

Conclusions and relevance: These findings suggest that receipt of recommended services during comprehensive postpartum visits is less than 50% for most services and is similar across insurance types. These findings underscore the importance of efforts to reconceptualize postpartum care to ensure women have access to a range of supports to manage their health during this sensitive period.

Figure 1.. Analytic Sample Selection

Ob/gyn indicates obstetrics/gynecology.

Figure 2.. Services Provided During Comprehensive Postpartum Visits (2009-2016)

Vertical bars represent 95% CIs. Standard errors correct for the complex survey design. Sample size is 20 071 093 weighted visits (645 unweighted observations). National Ambulatory Medical Care Survey notes that National Center for Health Statistics does not consider estimates relying on fewer than 30 observations and/or with standard errors greater than 30% of estimates to be reliable. Referral to other physician has 19 397 174 weighted visits (627 unweighted observations). Medication ordered or provided has 20 013 231 weighted visits (642 unweighted observations). A, Regression estimates of probability of service occurring during visit are reported. B, Regression-adjusted estimates of probabilities are reported; controls are included for whether the visit was paid by Medicaid, year of visit, patient age, patient race/ethnicity, patient comorbidities (asthma, diabetes, depression, hypertension, and obesity), physician specialty (obstetrics/gynecology vs family medicine), office location in a metropolitan statistical area, physician as full or part owner of practice, private solo or group practice, and solo practice. ^aDifference between Medicaid and non-Medicaid estimates is statistically significant with P < .05. ^bEstimates for Medicaid unadjusted estimates have standard errors (shown as part of the 95% CI) that exceed the threshold of greater than 30% of estimates (reported for completeness). ^cEstimates for non-Medicaid unadjusted estimates have standard errors (shown as part of the 95% CI) that exceed the threshold of greater than 30% of estimates (reported for completeness).