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 Material Information
Title: Association Between Perinatal Medical Expenses and a Waiver to Increase Florida Healthy Start Services Within Florida Medicaid Programs: 1998 to 2006
Series Title: Matern Child Health J DOI 10.1007/s10995-011-0811-z
Physical Description: Journal Article
Creator: Staras, Stephanie
Kairalla, John A.
Hou, Wei
Sappenfield, William M.
Thompson, Daniel R.
Ranka, Deepa
Shenkman, Elizabeth A.
Publisher: Springer
Publication Date: May 11, 2011
 Notes
Abstract: To assess the association between perinatal care expenditures and a Medicaid waiver to increase Florida Healthy Start services among Florida Medicaid non-managed care organization (non-MCO) program enrollees. We assessed perinatal care expenditures from Medicaid claims and encounter data among non-MCO enrollees with increased risk pregnancies who gave birth in Florida during 1998-2006. We used a pre-post design to compare adjusted perinatal medical expenditures among women who received Healthy Start care coordination (n = 41,067) to women who were not contacted by the Healthy Start program after screening (n = 24,282). We calculated adjusted average costs and difference-in-differences using marginal estimates from multivariable linear mixed regression models. From the pre-waiver (January 1998-July 2001) to the late-post waiver (July 2004-December 2006), all prenatal medical costs increased $274 among care coordination participants and decreased $601 among women not contacted by the Healthy Start program, equaling a $875 increased cost difference between care coordination and no contact groups. During this same time period, delivery related expenditures increased $395 less among care coordination participants compared to women not contacted by Healthy Start. Additionally, infant medical care costs during days 29-365 decreased by an average of $240 less among the care coordination compared to the no contact group. The Medicaid waiver may have decreased delivery costs, but medical costs were increased following the waiver when considering all perinatal care. Further exploration of factors associated with the decreased delivery costs may help develop more efficient prenatal support programs.
Acquisition: Collected for University of Florida's Institutional Repository by the UFIR Self-Submittal tool. Submitted by Stephanie Staras.
Publication Status: Published
General Note: PMID: 21559775
Funding: The research was supported in part by funding from the Florida Agency for Health Care Administration. The authors wish to thank Cheryl L. Clark, DrPH, RHIA and Marie Melton from the Florida Department of Health for useful conversations regarding Healthy Start operations. We also thank Charmy Chhichhia, J. Roger Clemmons, and Briony Tatem, MS from the Institute for Child Health Policy for data management and technical assistance. Publication of this article was funded in part by the University of Florida Open- Access Publishing Fund.
 Record Information
Source Institution: University of Florida Institutional Repository
Holding Location: University of Florida
Rights Management: All rights reserved by the submitter.
System ID: IR00000453:00001

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Matern Child Health J
DOI 10.1007/s10995-011-0811-z


Association Between Perinatal Medical Expenses and a Waiver

to Increase Florida Healthy Start Services Within Florida

Medicaid Programs: 1998 to 2006


Stephanie A. S. Staras John A. Kairalla Wei Hou *
William M. Sappenfield Daniel R. Thompson *
Deepa Ranka Elizabeth A. Shenkman




The Author(s) 2011. This article is published with open access at Springerlink.com


Abstract To assess the association between perinatal
care expenditures and a Medicaid waiver to increase
Florida Healthy Start services among Florida Medicaid
non-managed care organization (non-MCO) program
enrollees. We assessed perinatal care expenditures from
Medicaid claims and encounter data among non-MCO
enrollees with increased risk pregnancies who gave birth in
Florida during 1998-2006. We used a pre-post design to
compare adjusted perinatal medical expenditures among
women who received Healthy Start care coordination
(n = 41,067) to women who were not contacted by the
Healthy Start program after screening (n = 24,282). We
calculated adjusted average costs and difference-in-differ-
ences using marginal estimates from multivariable linear
mixed regression models. From the pre-waiver (January
1998-July 2001) to the late-post waiver (July 2004-
December 2006), all prenatal medical costs increased $274
among care coordination participants and decreased $601
among women not contacted by the Healthy Start program,
equaling a $875 increased cost difference between care
coordination and no contact groups. During this same time
period, delivery related expenditures increased $395 less


S. A. S. Staras (E) D. Ranka E. A. Shenkman
Department of Health Outcomes and Policy, College
of Medicine, and the Institute for Child Health Policy,
University of Florida, 1329 SW 16th Street, Room 5241,
Gainesville, FL 32610, USA
e-mail: sstaras@ufl.edu

J. A. Kairalla W. Hou
Department of Biostatistics, University of Florida,
Gainesville, FL, USA

W. M. Sappenfield D. R. Thompson
Division of Family Health Services, Florida Department
of Health, Tallahassee, FL, USA


among care coordination participants compared to women
not contacted by Healthy Start. Additionally, infant medi-
cal care costs during days 29-365 decreased by an average
of $240 less among the care coordination compared to the
no contact group. The Medicaid waiver may have
decreased delivery costs, but medical costs were increased
following the waiver when considering all perinatal care.
Further exploration of factors associated with the decreased
delivery costs may help develop more efficient prenatal
support programs.

Keywords Prenatal care Perinatal care medical
expenses Medicaid Florida Healthy Start


Introduction

In the United States, approximately 12% of children are
born before 37 completed weeks of gestation pretermm) and
6% are born weighing less than 2,500 grams (low birth
weight) [1]. During the past 20 years, national rates of low
birth weight and preterm births have increased by
approximately 10% [1]. Children born preterm or low birth
weight are at increased risk of morbidity and mortality
throughout childhood [2-7]. Adjusted to 2008 dollars [8],
estimated annual medical expenditures are $30.8 billion for
preterm births and $14-$16 billion for low birth weight
infants [9, 10].
The Healthy Start initiative consists of federal and
state supported programs focused on using care coordi-
nators to connect women with prenatal care and addi-
tional services (e.g., transportation or tobacco cessation)
[11]. Most evaluations of Healthy Start and other case
management programs find little effect of these types of
programs on birth outcomes [12-15]. But, a few studies


Published online: 11 May 2011


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have found improved birth outcomes among participants
of Healthy Start or other case management programs [16-
18]. Most studies did not evaluate medical expenditures
[19], but the few that did found reduced medical costs for
delivery and infant care in the first 60 days among case
management participants compared to non-participants
[17, 18].
In Florida, in addition to the six federally funded
sites, the state supports a Florida Healthy Start program
focused on providing prenatal care, infant care, and
additional services statewide. In July 2001, Florida
Healthy Start services were included as Medicaid reim-
bursable costs with a Medicaid 1915(b)(1) waiver [20].
The long-term goal of the Medicaid waiver was to
reduce poor birth outcomes, and consequently, reduce
medical expenditures within Medicaid. Our research
objective was to determine whether including Healthy
Start services as Medicaid reimbursable costs was asso-
ciated with reduced perinatal expenditures among women
at increased risk of poor birth outcomes enrolled in
Florida Medicaid non-managed care organization (non-
MCO) programs.


Methods

Florida Healthy Start Background

Florida law requires physicians to offer all pregnant
women the Healthy Start Screening, a tool designed to
measure a woman's risk for poor perinatal outcomes by
assessing nutrition, psychosocial health, drug and alcohol
use, and domestic stability [21]. Screen scores of >4 sug-
gest an increased risk of poor perinatal outcomes, and
qualify women for referral to the Healthy Start program.
Additionally, health care providers may refer women to the
Healthy Start program regardless of their completion of or
score on the screening.
Women referred to Florida Healthy Start are contacted
by one of the Florida Healthy Start coalitions (community-
based non-profit agencies coordinating the program) or one
of the county health departments. If the woman can be
contacted and agrees to participate, a care coordinator
evaluates her risk factors and assets. Based on this initial
assessment, four possible determinations can be made: (1)
no need for services, (2) tracking of risk factors throughout
pregnancy, (3) providing select Healthy Start services, and
(4) providing ongoing care coordination. Women referred
to care coordination are assigned a coordinator who works
with the families throughout pregnancy to select and
facilitate delivery of services including transportation
assistance, parenting education, and smoking cessation
counseling [22].


Study Design

We used a pre-post design with an intervention group and a
comparison group to evaluate the economic influence of
the waiver. We defined four time periods of study: (1) a
pre-waiver period from January 1, 1998 to July 1, 2001; (2)
a transition period to encompass waiver roll-out from July
2, 2001 to March 23, 2002; (3) an early post-waver period
to reflect initial program experiences from March 24, 2002
through July 1, 2004; and (4) a late post waiver period to
reflect experiences with a more mature program from July
2, 2004 through December 31, 2006. For simplicity, and
because the transition period is a short time period repre-
senting a mix of waiver implementation, results for the
transition period are not presented. The Institutional
Review Board at the University of Florida approved the
study protocol.

Study Population

Using Florida birth and fetal death certificates, we identi-
fied women giving birth between January 1, 1998 and
December 31, 2006. We limited the study to 349,554 births
for whom we could link: (1) the child's birth certificate or
fetal death record; (2) the mother's Healthy Start screen
and services file, (3) the mother's Medicaid enrollment and
claims and encounter data, and (4) the child's Medicaid
enrollment and claims and encounter data. We could not
include births to mothers in Medicaid MCO programs
(n = 56,632) because we could not assess expenditures
since the State did not collect itemized claims and
encounter data for Medicaid MCO programs until 2009.
Thus, both the mother and child must have been enrolled in
Florida Medicaid non-MCO programs to be included in our
analysis.
We restricted our focus to women at increased risk of
poor birth outcomes, defined as births to women eligible
for risk assessment based on their Healthy Start screen
score of >4 (n = 111,476) (Fig. 1). To limit the influence
of very high cost births, we excluded multiple births and
births to women eligible for Medicaid based on medical
need (n = 3,334). We also excluded enrollees who did not
report White, Black, or Hispanic race/ethnicity (n = 1,973)
because other racial/ethnic groups were too small to
maintain model stability. After removing births missing
covariate information, we had data for 102,989 births.

Intervention and Comparison Groups

The intervention group included births to women who
received Healthy Start care coordination (n = 41,067).
Because of the small sample size (n = 566), we were
unable to assess costs among births to women who


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Fig. 1 Selection of care coordination and no contract group from linkable Florida births between 1998 and 2006


received at least one Healthy Start service, but did not
receive care coordination.
Because the waiver was implemented statewide in July
2001, a temporal comparison group of women unexposed
to the waiver was not available. Therefore, we defined the
observational comparison group as births to women who
completed the Healthy Start screening form, but did not
have further contact with the Healthy Start personnel or
services (n = 24,282). Thus, these women did not have an
opportunity to participate or be evaluated by Healthy Start
personnel. Hereafter, the comparison group is referred to as
the no contact group.
We excluded births to women who had some contact
with the Healthy Start program, but did not receive any
services: 14,663 had records of attempts to contact by
phone or had an incomplete initial assessment, and 16,649
were contacted by phone, but not assessed by a care
coordinator. We also excluded births to women who were


determined ineligible or declined after care coordinator
assessment, because these women likely have more
resources and less need for services (n = 5,762).

Economic Outcome Measures

Using the paid amounts in the Medicaid claims and
encounter data, we assessed eight measures of medical
expenditures associated with the perinatal period. Because
the study period spans 9 years and medical expenditures
increase each year, all expenditures were adjusted for
inflation with the urban medical care consumer price index
to 2008 dollars [8].
Prenatal and postpartum visits were restricted to claims
meeting the prenatal and postpartum definitions suggested
by the Health Employer Data and Information Set (HEDIS)
technical specifications [23]. We estimated the prenatal
period by subtracting the number of gestation weeks


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(clinical estimate on birth certificate) from the date of birth.
Prenatal period expenditures assessed were: (1) medical
claims during the prenatal period; (2) claims for prenatal
care visits; and (3) only claims for prenatal visits consid-
ered early by HEDIS, i.e., within the first 42 days of
Medicaid enrollment or during the first trimester [23].
Postpartum period expenditures were assessed for the
mother during the 8 weeks following delivery, and inclu-
ded (1) all medical claims during the period, and (2) claims
for postpartum visits [23].
There was not a reliable strategy to separate mother and
child expenditures for claims during the days prior to the
mother leaving the hospital following delivery, because
infant claims are billed under the mother's Medicaid iden-
tification number until the mother leaves the hospital.
Therefore, postpartum total medical expenditures may
include newborn expenditures, and some infant claims will
not be included in the first few weeks following birth. Thus,
to account for the different certainty in completeness of the
claims data, and the high cost of poor perinatal outcomes
during the neonatal period [9], we assessed infant expendi-
tures during two time periods: 2-28 days and 29-365 days.

Covariates

Based on risk factors in the literature for increased medical
costs related to high-risk pregnancies or poor birth outcomes
[1, 24, 25], we selected twelve covariates from the available
data. From Medicaid enrollment files, we collected mother's
age at child's birth and mother's race/ethnicity. From birth
certificate files, we collected: (1) mother's highest education
level achieved; (2) mother's marital status; (3) mother's
county of residence; (4) estimated gestation weeks calcu-
lated from the mother's last menstrual period (when esti-
mated gestation age was not available, we used the clinical
estimate of gestation age (n = 7,136)); and (5) infant's birth
weight. From the Healthy Start services file, we obtained the
women's screening score. From the Medicaid claims and
encounter data, we calculated: (1) timely initiation of pre-
natal care (using the HEDIS definition of during first tri-
mester or first 42 days enrolled in Medicaid [23]); (2)
receipt of postpartum care defined by HEDIS [23]; (3)
Mother Chronic Illness and Disability Payment System
health score [25]; and (4) the number of pregnancy com-
plications measured by a score of 0-9 with 1 point assigned
for each of nine ICD-9 codes, 640-643 and 645-649
(includes hemorrhage, hypertension, infections, and other
conditions complicating pregnancy).

Statistical Analysis

We estimated expenditures for each time period using
marginal means from a multivariable mixed model


adjusted for the covariates described previously. Using
these adjusted expenditure estimates, we calculated and
tested within period differences between care coordination
and no contact groups, pre- to post-waiver differences
within each group, and difference-in-difference estimates
comparing the pre- to post-waiver differences between
groups. All analyses were performed using SAS (Cary,
NC) version 9.2.
A mixed model analysis was used to account for the
correlation between births to the same mother, because
about 6% of women had more than one birth during the
9-year time period (accounting for 11% of study births).
Expenditure outliers were retained in the analyses. Because
health care expenditures can be highly skewed, we used a
log-transformation to convert the dollar amounts into log
amounts to approximate a normal distribution for analysis.
To facilitate interpretation, we used Duan's smearing
retransformation to convert the log amounts back to dollar
amounts [26].


Results

Distributions of characteristics were relatively stable
throughout the 9 years of the study; therefore, overall
distributions are presented for simplicity (Table 1). Chi-
square tests of the differences between the women
receiving care coordination and no contact are significant at
the 0.05 level for eight of eleven characteristics; due to the
large sample sizes, however, these tests may not represent
clinical differences. For example, we would have a 90%
chance of detecting a difference between group frequencies
of 15% and 16%. Women receiving care coordination were
more likely than non-contacted women to be non-Hispanic
White, have a Healthy Start screen score higher than four,
receive timely prenatal care, and have at least one maternal
complication. We control for the small differences between
group characteristics (Table 1), as well as mother's county
of residence, through multivariable adjustment of all
expenditure estimates.

Prenatal Period Expenditures

Within all time periods studied, average medical expendi-
tures during the prenatal period were between $319.92 and
$1,245.29 higher among care coordination participants
than among the no contact group (Table 2). Compared to
the pre-waiver period, adjusted average medical costs
increased among the care coordination group: increase of
$484.35 by the early post-waiver and $274.08 by the late-
post waiver (Table 2). In contrast, medical costs among the
no contact group decreased following the waiver: decrease
of $441.03 by early post-waiver and $601.02 by the late


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Table 1 Characteristics for study population from 1998 to 2006 by
intervention subgroup
Care coordination No contact
N = 41,067 N = 24,282
Percentage Percentage

Mothers' characteristics
Mother's race**
Non-Hispanic White 36.0 29.1
Non-Hispanic Black 53.2 58.9
Hispanic 10.9 12.0
Mother's age
11-17 years 18.2 16.6
18-20 years 28.9 30.5
21-35 years 48.3 48.6
>36 years 4.6 4.3
Mother's education
Less than high school 50.4 49.9
High school 35.9 37.0
At least some college 13.7 13.1
Mother married* 15.1 16.0
Mother's Healthy Start screen score**
4 43.2 48.5
5 30.1 28.8
6 16.3 14.5
7 or more 10.4 8.3
Received timely prenatal care** 70.6 66.8
Mother's CDPS score**


Number of maternal complications**
0 29.2
1 34.8
2 22.7
>3 13.3
Postpartum care** 83.5
Infants' characteristics
Gestation weeks**
Very and moderate 4.0
preterm
Late preterm 10.6
Term 76.6
Post term 8.8
Birth weight
Very low 1.7
(<1,500 grams)
Low (1,500- <2,500 grams) 9.2
Normal (>2,500 grams) 89.1

Chi-square test significant at P < 0.05
** Chi-square test significant at P < 0.001


post-wavier. The difference of these changes resulted in
increased costs among the care coordination group com-
pared to the no contact group ($925.37 early post-waiver
and $875.10 late post-waiver).
Similarly, costs for HEDIS prenatal visits were between
$85.16 and $200.08 higher among the care coordination
group compared to the no contact group within each time
period studied (Table 2). Following the waiver, expendi-
tures for HEDIS prenatal visit expenditures decreased
within both groups (Table 2); comparing the late post-
waiver to the pre-waiver period, prenatal care expendi-
tures were $181.75 less among the care coordination
group and $281.77 less among the no contact group. Thus,
by late post-waiver, costs among the no contact group
decreased $100.02 more than the care coordination group.
Similarly, by the early post-waiver, costs among the no
contact group decreased $114.92 more than the care
coordination group.
In contrast, early prenatal care expenditures were lower
among women receiving care coordination compared to
women who were not contacted during all time periods
with differences of $25.71-$290.99 (Table 2). Between the
early post-waiver and pre-waiver periods, early prenatal
care costs decreased by $33.50 for the care coordination
group and increased by $160.21 for the no contact group.
Thus, the short-term waiver effect suggests an average
savings of $193.67 following the waiver. But, the long-
term waiver effect suggests that the no contact group had
increased cost savings compared to the care coordination
group for early prenatal care expenditures (Table 2). From
the pre-waiver costs to the late post-waiver time period,
early prenatal care costs had decreased $327.81 for the care
coordination group and $399.43 for the no contact group.

Delivery and Postpartum Period Expenditures

In both groups, estimated average delivery expenditures
increased from the pre-waiver period to the late post-
wavier period (Table 3). Delivery related expenditures
were consistently lower (range $93.88-$488.86) among
care coordination participants compared to the no contact
group. Delivery expenses increased less among the care
coordination group than the no contact group between
the pre-waiver and early post-waiver ($182.33), and
between the pre-waiver and late post-waiver ($394.98)
(Table 3).
During the pre-waiver period, postpartum visits expen-
ditures were lower among care coordination participants
than the no contact group (Table 3). Among both groups,
postpartum visit expenditures increased following the
waiver. We found little or no evidence of either a short- or
long-term waiver effect on postpartum period expenses
(Table 3).


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Table 2 Adjusteda average prenatal care period expenditures and differences between intervention and comparison groups by waiver period
Pre-waiver Early post-waiver Late post-waiver Difference Early-post Difference Late-post
(Jan. 1, 1998- (March 24, 2002- (July 2, 2004- waiver minus waiver minus
July 1, 2001) July 1, 2004) December 31, 2006) pre-waiver pre-waiver

All medical
Care coordination $4,031.05 $4,515.40 $4,305.13 $484.35** $274.08**
No contact $3,711.13 $3,270.11 $3,110.11 -$441.03** -$601.02**
Difference $319.92** $1,245.29** $1,195.02** $925.37** $875.10**
All prenatal visitsC
Care coordination $1,486.34 $1,409.66 $1,304.59 -$76.68** -$181.75**
No contact $1,401.18 $1,209.59 $1,119.41 -$191.59** -$281.77**
Difference $85.16** $200.08** $185.18** $114.92** $100.02**
Early prenatal care"'d
Care coordination $836.23 $802.77 $508.41 -$33.50* -$327.81**
No contact $933.56 $1,093.76 $534.12 $160.21** -$399.43**
Difference -$97.32** -$290.99** -$25.71* -$193.67** $71.61*

* Significant at P < 0.05
** Significant at P < 0.001
a Expenditures were calculated with marginal estimates from multivariable linear regression models adjusted for mother's age at child's birth;
mother's race/ethnicity; mother's highest educational level achieved; mother's marital status; mother's county of residence; gestation weeks at
birth; infant's birth weight; Healthy Start Screen score; HEDIS timely initiation of prenatal care [23]; HEDIS receipt of postpartum care [23];
Mother Chronic Illness and Disability Payment System health score [25]; and number of pregnancy complications
b Difference is the difference in costs among care coordination participants compared to women not receiving Healthy Start services. A positive
difference indicates higher costs among the care coordination group and a negative difference indicates lower costs among the care coordination
group
' Prenatal visits were identified using HEDIS definition of valid prenatal codes
d Early prenatal care is care during the first trimester or first 42 days of enrollment in Medicaid


Infant Medical Expenditures

Prior to the waiver, infant medical cost differences between
the care coordination and no contact group were small
($1.38-$46.18), and not statistically significant. After the
waiver, infant medical costs were higher among care
coordination group compared to no contact group
(Table 4); average costs were $73.84-$88.08 higher during
days 2-28, and $216.75-$286.61 higher during days
29-365. From the pre-waiver to the late post-waiver, infant
expenditures during days 2-28 decreased among the no
contact group ($70.87) and remained relatively stable in
the care coordination group. The difference of these
changes resulted in increased cost by the post-waiver when
comparing the care coordination and the no contact groups
($86.70).
Compared to the pre-waiver, infant expenditures dur-
ing days 29-365 within both groups increased by the
early post-waiver and decreased by the late post-waiver
periods. Yet, average cost changes from pre-waiver to
late post-waiver indicated cost savings among no contact
group compared to the care coordination group
(Table 4).


Perinatal Care Medical Expenditures

To summarize the influence of the 2001 Medicaid waiver
on adjusted average perinatal medical expenditures, we
compiled waiver differences for each mutually exclusive
category of expenses. Specifically, for prenatal and post-
partum care costs, we selected only all medical expendi-
tures because these are comprehensive measures. From the
pre-waiver to early-post waiver periods, care coordination
participants had increased cost differences compared to
non-contacted women for prenatal period care ($925),
postpartum period care ($73), and infant costs (2-28 days:
$72 and 29-365 days: $170). Yet, compared to the no
contact group, the women receiving care coordination had
a costs savings of $182 in delivery costs by the pre-waiver
period. Similarly, from the pre-waiver to late-post waiver
periods, care coordination participants had increased cost
differences compared to non-contacted women for prenatal
period care ($875) and infant costs (2-28 days: $87 and
29-365 days: $240). The women receiving care coordina-
tion had a costs savings of $11 in postpartum period care,
and $395 in delivery costs compared to the no contact
group by the late post-waiver period.


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Table 3 Adjusteda average delivery and postpartum care period expenditures and Differences between intervention and comparison groups by
waiver period
Pre-waiver Early post-waiver Late post-waiver Difference Early-post Difference Late-post
(Jan. 1, 1998- (March 24, 2002- (July 2, 2004- waiver minus waiver minus
July 1, 2001) July 1, 2004) December 31, 2006) pre-waiver pre-waiver

Delivery
Care coordination $4,681.42 $4,944.76 $5,002.84 $263.34** $321.43**
No contact $4,775.29 $5,220.96 $5,491.71 $445.67** $716.41**
Difference -$93.88* -$276.20* -$488.86** -$182.33* -$394.98**
All medical-postpartum
Care coordination $3,207.72 $3,012.46 $3,132.54 -$195.26** -$75.17
No contact $3,292.30 $3,023.93 $3,228.62 -$268.37** -$63.68
Difference -$84.58* -$11.47 -$96.07 $73.11 -$11.49
Postpartum visits
Care coordination $968.36 $1,107.13 $1,182.89 $138.77** $214.54**
No contact $1,009.95 $1,125.48 $1,212.01 $115.54** $202.06**
Difference -$41.60* -$18.35 -$29.12 $23.25 $12.48
* Significant at P < 0.05
** Significant at P < 0.001
a Expenditures were calculated with marginal estimates from multivariable linear regression models adjusted for mother's age at child's birth;
mother's race/ethnicity; mother's highest educational level achieved; mother's marital status; mother's county of residence; gestation weeks at
birth; infant's birth weight; Healthy Start Screen score; HEDIS timely initiation of prenatal care [23]; HEDIS receipt of postpartum care [23];
Mother Chronic Illness and Disability Payment System health score [25]; and number of pregnancy complications
b Difference is the difference in costs among care coordination participants compared to women not receiving Healthy Start services. A positive
difference indicates higher costs among the care coordination group and a negative difference indicates lower costs among the care coordination
group
' Postpartum visits were identified using HEDIS definition of valid postpartum codes


Conclusions

Among Florida Medicaid non-MCO participants, the 2001
Florida Medicaid waiver is associated with an average
$395 delivery cost savings among the Healthy Start care
coordination participants compared to women not con-
tacted by the Healthy Start program. These delivery cost
savings are offset, however, by increased costs following
the waiver among care coordination compared to the no
contact group for medical care during the prenatal period
($875) and first year of life ($327). While the observed
program was not cost neutral, identifying factors related to
the delivery cost savings may aid development of effective
and efficient prenatal care programs.
The potential delivery cost saving found following the
Florida Medicaid waiver is consistent with and expands
understanding of case management based prenatal care
[17, 18]. For example, among North Carolina Medicaid
enrollees between 1988 and 1989, care coordination was
associated with a $277 cost savings in infant medical care
during the first 60 days of life [17]. Because costs are
substantially higher among newborns with medical prob-
lems than without medical problems [27], our findings of
delivery cost savings are also consistent with the reduced
number of poor birth outcomes observed among Florida


Healthy Start participants compared to non-participants in
Hillsborough County [16]. Yet, the delivery cost savings
may be caused by other factors, such as fewer Cesarean
deliveries or shorter than recommended length of maternal
hospital stays [24, 28, 29].
Our study adds to the mixed literature on whether
moderate delivery cost savings compensate for additional
costs of prenatal care [17, 30]. Similar to another care
coordination study [17], when we consider only HEDIS
prenatal visits, the average delivery costs savings ($395)
outweigh the additional average cost increases for prenatal
visits ($100). Yet, similar to findings from an expanded
prenatal care program [30], the increase in all prenatal
medical costs in the care coordination group following the
waiver ($875) outweigh the delivery-related cost savings.
Additionally, our results expand understanding of the
influence of case management programs on infant costs
beyond 60 days to the first full year of life [17, 18]. Con-
sistent with the lack of reduction of poor birth outcomes in
other Healthy Start programs [12, 13], the potential cost
benefits seen at delivery disappear by the end of the first
year.
Our total average perinatal expenditure estimates range
from $8,086 to $8,700 (found by summing the costs of all
prenatal visits, all postpartum visits, delivery, and infant


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Table 4 Adjusteda average infant all medical expenditures and differences between intervention and comparison groups by waiver period
Pre-waiver Early post-waiver Late post-waiver Difference early-post Difference late-post
(Jan. 1, 1998- (March 24, 2002- (July 2, 2004- waiver minus waiver minus
July 1, 2001) July 1, 2004) December 31, 2006) pre-waiver pre-waiver

2-28 days
Care coordination $951.17 $1,066.78 $967.00 $115.60** $15.83
No contact $949.79 $992.93 $878.92 $43.14 -$70.87*
Difference $1.38 $73.84* $88.08** $72.46 $86.70*
29-365 days
Care coordination $3,161.32 $3,614.16 $2,732.18 $452.85** -$429.13**
No contact $3,115.14 $3,397.42 $2,445.57 $282.28* -$669.57**
Difference $46.18 $216.75* $286.61** $170.57 $240.43**
* Significant at P < 0.05
** Significant at P < 0.001
a Expenditures were calculated with marginal estimates from multivariable linear regression models adjusted for mother's age at child's birth;
mother's race/ethnicity; mother's highest educational level achieved; mother's marital status; mother's county of residence; gestation weeks at
birth; infant's birth weight; Healthy Start Screen score; HEDIS timely initiation of prenatal care [23]; HEDIS receipt of postpartum care [23];
Mother Chronic Illness and Disability Payment System health score [25]; and number of pregnancy complications
b Difference is the difference in costs among care coordination participants compared to women not receiving Healthy Start services. A positive
difference indicates higher costs among the care coordination group and a negative difference indicates lower costs among the care coordination
group


care between 2-28 days within each time period), and are
similar to the $8,821 (converted to 2008 dollars [8]) pre-
viously estimated among Florida Medicaid enrollees [31].
This comparison suggests consistency, despite methodo-
logical differences and slightly different populations
(e.g., we restricted to births from women with screen scores
of >4).
There are four important limitations to this study. First,
despite adjusting our analysis for several covariates, con-
founding by unmeasured covariates (e.g., social support)
remains a possibility because a temporal comparison group
was not available. Second, our results may not generalize
to Florida Medicaid non-MCO enrollees, Healthy Start
participants, or Medicaid MCO enrollees because of
missing data, and our prioritizing internal over external
validity. Our results represent singleton births to women
who were: (1) at increased risk of poor birth outcomes
(Healthy Start screen score of >4); (2) enrolled in Florida
Medicaid non-MCO programs (not due to medical need);
(3) had linkable Healthy Start, birth, and Medicaid data;
and (4) received care coordination or were not contacted
for participation in the Healthy Start program. Third, we
were unable to assess potential long-term medical cost
benefits to the mother or the child from the additional
services provided to care coordination participants. For
example, women receiving smoking cessation counseling
may reduce their child's long-term risk of asthma. Fourth,
implementation of the Florida Healthy Start program likely
differs across the state because several community-based
coalitions coordinate the program. By combining the


coalitions into a statewide program, we may have masked
positive effects of extraordinary programs.
There were three important strengths of this study. First,
the large statewide study population (n = 65,349) allowed
us to adjust the analysis for tweleve important covariates.
Second, recall bias for perinatal expenditures was reduced
because we used Medicaid paid claims that are reported
independently of Healthy Start program. Third, expendi-
tures and covariates were available for 3 years prior to the
Medicaid waiver and 6 years after the waiver, enabling us
to evaluate short- and long-term waiver effects.
Our study supports the potential cost benefit of care
coordination programs like Florida Healthy Start by
showing reduced delivery costs following program
expansion. The increased costs of prenatal and infant care,
however, suggest additional research is needed to isolate
specific services or exemplary program sites responsible
for the reduced delivery costs. Increased understanding of
the factors driving the observed delivery cost savings may
allow development of more effective and efficient prenatal
care programs.

Acknowledgments The research was supported in part by funding
from the Florida Agency for Health Care Administration. The authors
wish to thank Cheryl L. Clark, DrPH, RHIA and Marie Melton from
the Florida Department of Health for useful conversations regarding
Healthy Start operations. We also thank Charmy Chhichhia, J. Roger
Clemmons, and Briony Tatem, MS from the Institute for Child Health
Policy for data management and technical assistance. Publication of
this article was funded in part by the University of Florida Open-
Access Publishing Fund.


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Matern Child Health J


Open Access This article is distributed under the terms of the
Creative Commons Attribution Noncommercial License which per-
mits any noncommercial use, distribution, and reproduction in any
medium, provided the original authors) and source are credited.




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