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Enhanced prenatal care programs delivered through Medicaid

Health Care: Maternal and Infant Health
Benefit-cost estimates updated May 2017.  Literature review updated December 2016.
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Enhanced prenatal care programs delivered through Medicaid provide non-clinical services that support maternal wellness and infant health during the prenatal period, such as care coordination, health education, risk assessment, psychosocial support, or nutritional counseling. These programs are delivered in the primary healthcare setting and provided by either a nurse or a social worker. Women are eligible for these programs during their pregnancy, with some benefits continuing through the first 12 months postpartum. Participants typically receive program benefits for 3-16 months, including both prenatal and postpartum services.

All programs included in this analysis were implemented by Medicaid in their respective states. All women in treatment and comparison groups receive clinical prenatal care (treatment as usual).
BENEFIT-COST
META-ANALYSIS
CITATIONS
The estimates shown are present value, life cycle benefits and costs. All dollars are expressed in the base year chosen for this analysis (2016). The chance the benefits exceed the costs are derived from a Monte Carlo risk analysis. The details on this, as well as the economic discount rates and other relevant parameters are described in our Technical Documentation.
Benefit-Cost Summary Statistics Per Participant
Benefits to:
Taxpayers $841 Benefits minus costs $5,981
Participants $595 Benefit to cost ratio $15.42
Others $0 Chance the program will produce
Indirect $4,961 benefits greater than the costs 98 %
Total benefits $6,396
Net program cost ($415)
Benefits minus cost $5,981
1In addition to the outcomes measured in the meta-analysis table, WSIPP measures benefits and costs estimated from other outcomes associated with those reported in the evaluation literature. For example, empirical research demonstrates that high school graduation leads to reduced crime. These associated measures provide a more complete picture of the detailed costs and benefits of the program.

2“Others” includes benefits to people other than taxpayers and participants. Depending on the program, it could include reductions in crime victimization, the economic benefits from a more educated workforce, and the benefits from employer-paid health insurance.

3“Indirect benefits” includes estimates of the net changes in the value of a statistical life and net changes in the deadweight costs of taxation.
Detailed Monetary Benefit Estimates Per Participant
Benefits from changes to:1 Benefits to:
Taxpayers Participants Others2 Indirect3 Total
Health care associated with preterm births $30 $0 $0 $15 $45
Subtotals $30 $0 $0 $15 $45
From secondary participant
Infant mortality $270 $595 $0 $4,882 $5,747
Health care associated with NICU admissions $541 $0 $0 $272 $813
Subtotals $811 $595 $0 $5,154 $6,560
Adjustment for deadweight cost of program $0 $0 $0 ($208) ($208)
Totals $841 $595 $0 $4,961 $6,396
Detailed Annual Cost Estimates Per Participant
Annual cost Year dollars Summary
Program costs $1,792 2014 Present value of net program costs (in 2016 dollars) ($415)
Comparison costs $1,383 2014 Cost range (+ or -) 10 %
Per-participant program cost estimates are based on costs of Maternity Support and Case Management programs in Washington State (Washington State Department of Health, September 2016). Participants typically receive program benefits for 3-16 months, including both prenatal and postpartum services. Both groups receive treatment as usual. The costs of treatment as usual are the average costs of usual prenatal care in Washington State (Washington State Department of Health, September 2016).
The figures shown are estimates of the costs to implement programs in Washington. The comparison group costs reflect either no treatment or treatment as usual, depending on how effect sizes were calculated in the meta-analysis. The cost range reported above reflects potential variation or uncertainty in the cost estimate; more detail can be found in our Technical Documentation.
Estimated Cumulative Net Benefits Over Time (Non-Discounted Dollars)
The graph above illustrates the estimated cumulative net benefits per-participant for the first fifty years beyond the initial investment in the program. We present these cash flows in non-discounted dollars to simplify the “break-even” point from a budgeting perspective. If the dollars are negative (bars below $0 line), the cumulative benefits do not outweigh the cost of the program up to that point in time. The program breaks even when the dollars reach $0. At this point, the total benefits to participants, taxpayers, and others, are equal to the cost of the program. If the dollars are above $0, the benefits of the program exceed the initial investment.

***We report this outcome twice: once for mothers (designated as the primary participant) and once for infants (designated as the secondary participant). We do this because the outcome is associated with costs and benefits for both mothers and infants, and the amount of the cost or benefit is different for mothers than it is for infants.

Meta-analysis is a statistical method to combine the results from separate studies on a program, policy, or topic in order to estimate its effect on an outcome. WSIPP systematically evaluates all credible evaluations we can locate on each topic. The outcomes measured are the types of program impacts that were measured in the research literature (for example, crime or educational attainment). Treatment N represents the total number of individuals or units in the treatment group across the included studies.

An effect size (ES) is a standard metric that summarizes the degree to which a program or policy affects a measured outcome. If the effect size is positive, the outcome increases. If the effect size is negative, the outcome decreases.

Adjusted effect sizes are used to calculate the benefits from our benefit cost model. WSIPP may adjust effect sizes based on methodological characteristics of the study. For example, we may adjust effect sizes when a study has a weak research design or when the program developer is involved in the research. The magnitude of these adjustments varies depending on the topic area.

WSIPP may also adjust the second ES measurement. Research shows the magnitude of some effect sizes decrease over time. For those effect sizes, we estimate outcome-based adjustments which we apply between the first time ES is estimated and the second time ES is estimated. We also report the unadjusted effect size to show the effect sizes before any adjustments have been made. More details about these adjustments can be found in our Technical Documentation.

Meta-Analysis of Program Effects
Outcomes measured Primary or secondary participant No. of effect sizes Treatment N Adjusted effect sizes (ES) and standard errors (SE) used in the benefit-cost analysis Unadjusted effect size (random effects model)
First time ES is estimated Second time ES is estimated
ES SE Age ES SE Age ES p-value
Low birthweight births*** Primary 5 51826 -0.087 0.017 25 0.000 0.000 26 -0.087 0.001
Preterm birth (< 37 weeks)*** Primary 3 32638 -0.089 0.035 25 0.000 0.000 26 -0.089 0.011
Small for gestational age (SGA)*** Primary 3 25588 -0.037 0.032 25 0.000 0.000 26 -0.037 0.252
Very low birthweight birth (< 1500g)*** Primary 2 26241 -0.224 0.040 25 0.000 0.000 26 -0.224 0.001
Infant mortality Secondary 2 35194 -0.088 0.049 1 0.000 0.000 2 -0.088 0.075
Low birthweight births*** Secondary 5 51826 -0.087 0.017 1 0.000 0.000 2 -0.087 0.001
NICU admission Secondary 1 10715 -0.114 0.027 1 0.000 0.000 2 -0.114 0.001
Preterm birth (< 37 weeks)*** Secondary 3 32638 -0.089 0.035 1 0.000 0.000 2 -0.089 0.011
Small for gestational age (SGA)*** Secondary 3 25588 -0.037 0.032 1 0.000 0.000 2 -0.037 0.252
Very low birthweight birth (< 1500g)*** Secondary 2 26241 -0.224 0.040 1 0.000 0.000 2 -0.224 0.001

Citations Used in the Meta-Analysis

Arima, Y., Guthrie, B.L., Rhew, I.C., & De Roos, A.J. (2009). The impact of the First Steps prenatal care program on birth outcomes among women receiving Medicaid in Washington State. Health Policy (Amsterdam, Netherlands), 92(1), 49-54.

Buescher, P.A., Roth, M.S., Williams, D., & Goforth, C.M. (1991). An evaluation of the impact of maternity care coordination on Medicaid birth outcomes in North Carolina. American Journal of Public Health, 81(12), 1625-9.

Hillemeier, M.M., Domino, M.E., Wells, R., Goyal, R.K., Kum, H.C., Cilenti, D., . . . Basu, A. (2015). Effects of maternity care coordination on pregnancy outcomes: propensity-weighted analyses. Maternal and Child Health Journal, 19(1), 121-7.

Korenbrot, C.C., Gill, A., Clayson, Z., & Patterson, E. (1995). Evaluation of California's statewide implementation of enhanced perinatal services as Medicaid benefits. Public Health Reports, 110(2).

Nason, C.S., Alexander, G.R., Pass, M.A., & Bolland, J.M. (2003). An evaluation of a Medicaid managed maternity program: the impact of comprehensive care coordination on utilization and pregnancy outcomes. Journal of Health and Human Services Administration, 26(2), 239-67.

Willems Van Dijk, J., Anderko, L., & Stetzer, F. (2011). The impact of prenatal care coordination on birth outcomes. Journal of Obstetric, Gynecologic, & Neonatal Nursing, 40(1), 98-108.

For more information on the methods
used please see our Technical Documentation.
360.664.9800
institute@wsipp.wa.gov