Presentation (CTI)

OBJECTIVES: Timeliness of Prenatal Care (TOPC) and Postpartum Care (PPC) are critical HEDIS quality metrics that significantly influence health plan financial performance. These measures determine reimbursement rates and Pay-for-Performance bonuses, while missing benchmarks risks NCQA accreditation. This study evaluated the impact of a virtual maternity strategy centered on proprietary early identification and targeted quality gap closure.
METHODS: This retrospective cohort analysis used medical claims from Medicaid- and commercially-insured patients across seven US states (N=9,573). The primary exposure was participation in a virtual maternity program driven by a proprietary identification engine utilizing diverse data sources (e.g., claims, labs, healthcare information exchanges, patient-reported outcomes) to detect pregnancy early in gestation, often upstream of standard payer notifications. This data-driven early capture creates the necessary lead time for proactive, provider-led outreach and 24/7 virtual clinical support specifically designed to convert identified gaps into completed, HEDIS-qualifying TOPC and PPC visits. Baseline differences in demographics and risk were adjusted using Inverse Probability Weighting (IPW). Double-robust logistic regressions estimated the percentage change in odds of visit completion.
RESULTS: The proprietary identification and outreach model was associated with significant increases in both metrics (p < 0.00001). Program execution yielded an 82.3% increase in the odds of TOPC (4.1 percentage point adjusted difference) and a 46.7% increase for PPC (8.4 percentage point adjusted difference). IPW successfully balanced baseline risks. When applied to the Texas Medicaid Pay for Quality Program, these compliance gains would secure between $2M and $6M in capitation withhold returns for a single mid-sized plan.
CONCLUSIONS: A maternity strategy that leverages multi-source data for early-gestation identification combined with provider-led gap closure is associated with significantly higher rates of timely prenatal and postpartum care. This creates a scalable capability for health plans to optimize quality-based reimbursement and accreditation by successfully converting early engagement into verifiable clinical outcomes.