EXAMINING THE IMPACT OF THE MARYLAND GLOBAL BUDGET MODEL ON SEVERE MATERNAL MORBIDITY DISPARITIES

Abstract

Maternal mortality and morbidity are at an all-time high in the United States, and minoritized groups are disproportionately affected. Severe maternal morbidity (SMM), the life-threatening events that occur during hospitalization for childbirth leading to major short- or long-term health consequences, has steadily increased over the past few decades, though approximately half of SMM events are considered preventable. Significant racial disparities exist, with non-Hispanic black women consistently afflicted with SMM rates two to three fold higher than peers. While clinical approaches are a mainstay in addressing the critical need to improve maternal health outcomes and the observed pernicious racial disparities, few strategies have focused on the role of healthcare payment and financing reforms. Value-based payment models (VBP) may be a critical policy lever to improve maternal health quality and advance maternal health equity; however, there is a dearth of evidence in this area. Applying a health equity lens, this innovative quasi-experimental methods study seeks to examine the impact of the Maryland Global Budget Model (GBM) on the SMM incidence of childbearing women in Maryland from 2011-2019. Due to increased care coordination and the redistributive effects of a fully prospective, all-payer, population-based global budget, it was hypothesized that GBM will lead to (1) improvements in population-level prenatal and perinatal health, thereby reducing occurrence of SMM, and (2) increased access and quality of care in safety-net or historically underserved settings, thereby decreasing SMM disparities. Applying causal inference methods, we examine change over time in overall SMM incidence (Aim 1), SMM black-white racial disparities (Aim 2), and prevalence of SMM-related comorbid conditions (Aim 3). Difference-in-difference models find a positive treatment effect of the MD policy intervention in significantly reducing SMM incidence, yielding a decline of 0.04 percentage points in SMM case rate (95% CI: -0.0414, -0.0428). A triple-difference model to assess heterogeneous treatment effect by black race finds evidence of an average treatment effect on the treated of -0.006 percentage points, indicating additional SMM reduction for black individuals receiving care in Maryland during the GBM era. It is also observed that GBM policy implementation impacts the population level SMM-predictive comorbidities, with a modest yet significant decline (-2.18e-11; p<0.001) in the post-period. Taken together, these findings suggest implications for population-level maternal health and health disparities that have not been previously identified. This work adds to the body of literature about the impact of value-based payment for public health impact and advancing equity in health.