January 30, 1998

Birth outcomes unhurt by TennCare: study

Birth outcomes unhurt by TennCare: study

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Wayne Ray, Ph.D.

A study by Vanderbilt University Medical Center investigators has found that Tennessee's switch to TennCare four years ago has not resulted in a drop in the quality of care received by pregnant women.

The study, published this week in the Journal of the American Medical Association, contradicts the previously stated view that perinatal outcomes would suffer from the move away from the fee-for-service Medicaid program to TennCare, the state's capitated reimbursement system.

"The major results are that, in the populations surveyed, perinatal outcomes remained unchanged," said Wayne A. Ray, Ph.D., professor of Preventive Medicine, and the study's principal author.

Co-authors of the study included Dr. Joseph Gigante, associate professor of Pediatrics, Dr. Gerald B. Hickson, associate professor of Pediatrics, and Edward F. Mitchel Jr., M.S.

Despite speculation and some anecdotal reports that linked TennCare to poorer perinatal outcomes, the study uncovered no changes in outcomes among Medicaid enrollees following the state's transition to TennCare.

"There was no decrease in the proportion of Medicaid women enrolling in the first trimester, no change in the proportion receiving early prenatal care, and no change in the adequacy of care as measured by number and timing of visits," the authors write. "There was no evidence that the risk of either low birth weight or early infant death changed."

The group's quantitative evaluation was based on vital records routinely collected and audited by the Tennessee Vital Statistics Registrar that were unaffected by the change to TennCare. Therefore, the study's methods weren't dependent on the quality of information provided by the managed care organizations that delivered services to TennCare enrollees.

In their comments, the VUMC researchers noted that none of these outcomes changed among the highest risk Medicaid enrollees, as defined by race, age, level of income or first pregnancy.

"Our alternative analysis, which classified all women giving birth in the state by demographic characteristics, found that outcomes were unchanged among unmarried women or women who were young and had low education and income ‹ those traditionally served by Medicaid programs," the authors write.

The study examined births by Tennessee residents in 1993 and 1995, the latest year for which figures are available. There were 72,014 births in 1993 and 72,278 births in 1995. Of those, 37,543 (52.1 percent) in 1993 and 35,707 (49.4 percent) in 1995 were to women enrolled in Medicaid or TennCare at delivery.

In 1993, the year before TennCare was implemented, Medicaid births had high risk of adverse perinatal outcomes ‹ 16.2 percent had prenatal care delayed until after the fourth month of pregnancy, 5.9 percent had an inadequate number of prenatal health care visits, 9.4 percent weighed less than 2,500 grams at birth, 1.6 percent weighed less than 1,500 grams at birth and 0.6 percent died within 60 days. According to the VUMC study, in the two years since TennCare began, none of these outcomes changed.

In 1995, 15.8 percent had delayed prenatal care, 5.6 percent had inadequate prenatal visits, 9 percent were low birth weight, 1.5 percent were very low birth weight, and 0.6 percent died within 60 days.

"There was no evidence that outcomes in 1995 differed from those in 1993," the authors write. "Among women who had one, two or three or more of these high-risk characteristics, outcomes were unchanged."

According to Ray, perinatal outcomes are thought to be one of the more sensitive indicators of quality of care in general.

"Getting pregnant women into health care systems is one thing that health care organizations should be able to do. Focusing attention on outcomes helps measure if this is indeed being accomplished," Ray said.