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Kathryn Thompson on Quality of Care for Pregnant Black Medicaid Enrollees

  • Kathryn Thompson
  • December 18 2024
  • PC148-2024

Kathryn Thompson
Kathryn Thompson

There are many ways to assess the quality of care that pregnant people receive pre- and post-partum, as well as during delivery itself. Dr. Kathryn Thompson shares her findings on how the care that pregnant Black Medicaid enrollees receive compares to their more affluent white peers, and the policy and practice opportunities for addressing the social determinants of health that are involved. 

Kathryn Thompson is an Assistant Professor at Boston University’s School of Public Health in the departments of Community Health Sciences and Health Law, Policy, and Management. She is also an IRP 2024–2025 Visiting Poverty Scholar. 

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Siers-Poisson [00:00:06] Hello and thanks for joining us for the Poverty Research & Policy podcast from the Institute for Research on Poverty at the University of Wisconsin–Madison. I’m Judith Siers-Poisson. For this episode, we’re going to be talking with Dr. Kathryn Thompson about her research on how to close the existing quality gap and improve outcomes for pregnant Black Medicaid enrollees. Kathryn Thompson is an assistant professor in the departments of Community Health Services and Health Law, Policy, and Management at Boston University. She’s also a 2024 IRP Visiting Poverty Scholar. Kathryn, thanks for joining us today.

Thompson [00:00:42] Thank you for having me.

Siers-Poisson [00:00:44] I’d like to start with just a brief look at maternal health care in the United States as it compares to other countries. Where do we stand?

Thompson [00:00:52] Well, compared to other developed nations… so, if you think of a developed nation such as France or Japan, the US is really kind of falling behind, especially when it comes to the maternal mortality rates, if you’re thinking about that specifically. Especially when you think about typical demographic factors that should protect individuals like income or education, it’s seeming to not help when it comes to like that disparity gap or insurance coverage. Things that we hope to improve outcomes are actually not contributing at all. And we’re kind of like falling behind when compared to our counterparts.

Siers-Poisson [00:01:27] And what about when you factor in race here in the United States? You said the maternal mortality rate was already below what you would expect for a developed country like ours. What happens when you factor in race?

Thompson [00:01:40] So I know many people think about the statistic they hear on the news or that they’ve heard countless times that Black women are 3 to 4 times more likely to die from pregnancy related complications, especially when you compare them to their white counterparts. And that is actually the stark reality. It’s not a disparity that’s new. It is a disparity that has actually gotten more attention, I would say, within the past couple of years. But it is actually a trend that has been happening for decades. And especially when you look at something like severe maternal morbidity very close to mortality, it is a percentage that has actually risen since the 1990s.

Siers-Poisson [00:02:12] Do we know why?

Thompson [00:02:14] It’s a very multifaceted and complex answer, especially when you start looking at it compared by states location than the individual behaviors of a particular person, what they have access to, what they don’t. Of course, a lot of people will say, yes, it’s a lot of systemic factors and you can even kind of like nail it down to, you know, things that are happening within the U.S. that are specific to the US. Things that come to mind like structural, systemic racism or things that stem from that, like redlining and segregation, etc.

Siers-Poisson [00:02:48] We’re going to definitely talk more about access a little later in our conversation. Right now, I’d like to have you explain the concept of birth equity and what it means for your work and also for the policy and practice implications of your research.

Thompson [00:03:02] So birth equity means ensuring that all birthing people, regardless of their race, income, location, have the resources and most importantly, the care they need in order to achieve their optimal birth outcomes. For my work, it means kind of challenging those systemic barriers. So I look at it especially within an institution, so hospitals and then especially challenging state and Medicaid policies. The implications can be pretty vast when you start thinking about it. Policies need to focus on, you know, improving access to high quality care, addressing things like social determinants of health. You know, even when it comes to like clinical practices and racial biases within health care itself.

Siers-Poisson [00:03:41] That concept of birth equity is very personal for you and your motivation for your work on this issue. Can you share a little bit about that?

Thompson [00:03:49] Of course. So this is a story that I have shared before I did a couple of talks on and how I start a lot of my kind of research talks. So back in 2006, I lost my aunt at a very young age. She was 34 and pregnant. She had an asthmatic attack and just was not able to make it to a high-quality institution in order to receive timely care. And it was one of those deaths that was preventable. You know, she had an asthmatic attack and she just happened to be too far away from an adequate health care facility in a rural area in order to receive care in a timely manner. It was a death, like I said, that was preventable. She could have been saved. And it was one of those things, especially when I embarked on my educational journey, it kind of sat in the back of my mind is how do I improve care for communities, not only that I’m deeply rooted in, but also communities in which I care about. And I instantly think of my family that’s back in rural Mississippi and how can I improve access and care for individuals, whether it’s, you know, improving quality, providing access for them to, you know, become better educated about what’s available to them within their own insurance or their state or their health care program. And how can I provide some type of beneficial impact to my community so that we can kind of decrease this disparity gap that we see between racial ethnic groups.

Siers-Poisson [00:05:13] Kathryn, let’s dig into your work on pregnant Medicaid enrollees. First, just so we’re all starting from the same place, can you give us a brief overview of what Medicaid is and who’s eligible for coverage?

Thompson [00:05:26] Medicaid provides coverage to low-income individuals and families, including children, the elderly, pregnant persons, those with Supplemental Security or SSI, and also supports individuals with end stage renal disease.

Siers-Poisson [00:05:40] So for pregnant people on Medicaid, what do we know about overall outcomes without breaking it down right now by race or other factors?

Thompson [00:05:49] So first of all, Medicaid finances nearly 50% of births within the United States. So Medicaid touches nearly half of the births. So it has the opportunity to kind of like affect these outcomes in a very positive way. Pregnant persons on Medicaid usually have worse adverse outcomes when compared to private insurance or other individuals outside of the Medicaid program. So you’re going to see higher rates of, when I say adverse pregnancy outcomes like stillbirth and pre-term birth, you’re going to see higher rates of maternal mortality and also higher rates of severe maternal morbidity.

Siers-Poisson [00:06:22] So as we’ve already touched on, you really can’t ignore racial differences within those populations because there are such stark differences in outcomes. So what do we know when we look at race and the population of pregnant people who are on Medicaid? And it’s not just Black and White, but there are, of course, Hispanic and other groups as well.

Thompson [00:06:43] Yes, of course. So like I mentioned before, Black women on Medicaid are 3 to 4 times more likely than their white counterparts to die from pregnancy related complications. Their rates of severe maternal morbidity are just exponentially higher. And when you talk about the leading causes of maternal mortality, it adversely affects Black pregnant persons at higher rates. So when you’re talking about complications like preeclampsia, hemorrhage, cardiovascular disease, but you also need to start thinking about things like delays in care or misdiagnosis or lack of access to high quality care.

Siers-Poisson [00:07:19] So are Black pregnant people at the highest risk for all of those? How does it compare to other racial or ethnic groups?

Thompson [00:07:28] They are amongst the highest, yes. And so you would see higher rates among Black pregnant persons, that’s mainly what I study, especially when you’re comparing them to their White counterparts. But they also see higher rates and in Hispanic populations as well.

Siers-Poisson [00:07:43] I’d like to take a moment to discuss the impacts of racism and the different ways it might be expressed that could come into play in the pre- and post -natal care and also delivery.

Thompson [00:07:54] Oh yes, of course. So racism plays a very large role, especially when you start talking about different types of racism and how they may manifest in health care settings. So first you can talk about certain biases or discriminatory actions, and those can come in the way of when you’re talking about health care providers, whether they’re unconsciously or consciously engaging in kind of like those biased or discriminatory practices. Another way is kind of structural ways, so structural ways in ways of policy so that policies that limit access to certain institutions or resources for communities of color. And then, of course, how does an individual kind of take the stereotypes and internalize them and start to believe a lot of these beliefs about themselves or about their own race and how they interact with health care systems or health care providers themselves?

Siers-Poisson [00:08:46] Well, in this case, there’s racism and then there is also misogyny. And so the lessons that many of us get about being a woman and there are many examples of where women would talk about things that they were experiencing with their bodies. And they were dismissed by a predominantly male, predominantly white medical establishment.

Thompson [00:09:07] Yes, they were dismissed. They’re not believed. You know, there’s a whole body of literature that talks about, you know, like race based science and things like that and how individuals, whether it was women or whether it was Black women, you know, they feel less pain or they’re able to take on more pain or they don’t they don’t need an epidural or they don’t need X, Y and Z. And so it’s just like, how do we combat a long history of not listening to, not believing women and really providing the best optimal care for them in the prenatal and the postpartum and then outside of pregnancy as well.

Siers-Poisson [00:09:47] With that in mind, let’s go back to the data on birth outcomes. I’d like to start with stillbirths, which is such a tragic outcome. First, what is considered a stillbirth?

Thompson [00:09:59] So stillbirth is the subsequent delivery of an infant before a certain period of time. Usually the cutoff is around 20 weeks. Stillbirth is a very rare occurrence. It usually happens within only like 1% of total deliveries compared to preterm birth, where I believe the average is around 10%.

Siers-Poisson [00:10:19] So what happens when we look at the rate of stillbirths and we break it down by race?

Thompson [00:10:24] So stillbirth and preterm births are significantly higher for Black birthing persons compared to white birthing persons. So nationally, Black persons experience stillbirth and around ten stillbirths per 1,000 births. And that’s usually around half or 50% when you compare them to white counterparts. So about five out of every 1,000 births for white women. Similarly, preterm births are around 10 to 14% for Black pregnant persons versus a little bit less than 10%, around 9% for white birthing persons.

Siers-Poisson [00:10:57] So we just talked about the difference by race for stillbirths and preterm births. What about by socioeconomic status or in your work, especially, being enrolled in Medicaid?

Thompson [00:11:09] Yes. So this gap still persists when it comes to socioeconomic status and then also for Medicaid coverage. So, for example, Black women on Medicaid are still experiencing preterm birth rates at higher percentages. So depending on the state, depending on the location, usually between 10 and 14% on Medicaid. And for white birthing persons, usually it hovers around like 9 to 10%. So it still follows that national average just because Medicaid is so highly indicative of what’s happening around the nation. So usually we’ll see these statistics be kind of mirroring each other.

Siers-Poisson [00:11:42] I think one of the most interesting aspects of your work is your focus on quality of care and how that element contributes or could possibly alleviate some of these disparities. First, how do you measure the quality of a particular hospital and what are kind of the levels of quality that you see?

Thompson [00:12:01] So there are many different hospital quality metrics. I actually created my own quality hospital metric, and I did this for a variety of reasons, mainly because a lot of the quality metrics that exist out there, especially when it comes to obstetrics, include certain obstetric outcomes within the quality measure itself. So particularly for me, when I’m measuring preterm birth or stillbirth or maternal mortality, it’s kind of like a good rule of thumb not to use a quality metric that uses an indicator such as preterm or stillbirth to kind of come up with that final number or like, you know, the final quintile. So I kind of created my own. I was a very ambitious PhD student, and I decided to create my own that have like the standard measure across all hospitals, especially being really cognizant of hospital closures, obstetric center closures, hospital mergers and acquisitions, where one year in my data I would see one hospital that does exist. I can find the information for it, address, NPI number, things like that. But, within the next year it disappears essentially. So how do I find or create a metric of which all hospitals have? And we kind of settled on a couple of different things like severe maternal morbidity. We looked at the percent of Black patients served. We looked up staffing ratios, so nurse to patient ratios, bed count, these types of metrics. So we pulled from the American Hospital Association, MAX provider characteristics that CMS provides, and also from Hospital Compare, which is a survey for Medicare. And amongst all of these different data sets, we were able to come up with our own hospital quality metric that used lag Z scores of these metrics from the year prior in order to predict a hospital quality measure for the next year.

Siers-Poisson [00:13:49] So thinking about hospital quality in a very real and concrete sense for, say, a pregnant person who is receiving care before delivery and then delivering their baby there, what does say a low-quality hospital experience versus a higher-quality hospital experience look like?

Thompson [00:14:10] So higher-quality hospitals, when you think about it, typically have better maternal outcomes when you’re thinking about it in the context of maternal and child health, have better maternal outcomes, lower rates of complications. And then if you’re looking at it from like a survey perspective, higher patient satisfaction scores or just higher survey satisfaction scores overall, just depending on how you’re looking at it. Lower quality, usually these institutions are lower resourced. The payer mix isn’t quite as diverse. Often times they are within certain neighborhoods. They serve a specific demographic or a larger portion of a demographic, whether that’s individuals that are on Medicaid, and especially when you compare them to higher-quality institutions. And so high quality, low quality has many different definitions, but I kind of like to lean on those.

Siers-Poisson [00:15:04] I’m interested in the aspect of where the higher-quality hospitals might be located and who has access to them. Is that something that you can measure?

Thompson [00:15:14] Yes. And so prior literature kind of shows that higher quality hospitals are predominantly located in wealthier, urban, largely areas that are predominantly white. There’s a lot of studies that are coming out. Elizabeth Howell does a lot of this work in kind of like New York and also in her UPenn system. And she found that Black women were 60% more likely to give birth in hospitals with worse maternal outcomes compared to white women. However, the hospitals in lower-income areas and those serving more Medicaid patients tend to have lower quality scores. Like I said before, due to those lower resources and then also higher patient loads. And so you start to see those differences there.

Siers-Poisson [00:15:53] And do you see a difference in public or private hospitals?

Thompson [00:15:58] Yes. So public hospitals, which often serve more Medicaid patients and they also serve like more lower-income patients, tend to have higher rates of adverse outcomes compared to those who’d identify as private hospitals.

Siers-Poisson [00:16:12] Are all hospitals required to take Medicaid patients, or do they have some discretion in who they are serving?

Thompson [00:16:20] I think they’re highly encouraged to take a diverse array of patients, especially if a patient presents at an ED or a patient presents at a hospital,l to provide care for that individual. But you start to see stark differences. I think I kind of put this in, I guess you would say more in reality, where are individuals giving birth, where are individuals receiving care? Are they receiving that within their own neighborhoods? Are they traveling farther distances in order to receive that care? Are they bypassing other institutions of different quality in order to receive care at a certain place? And there’s a lot of factors that play into it. It’s choice. It’s location, it’s neighborhood and where you are. But if you think about this from the context, especially for me as a Black woman, where am I comfortable? Where am I comfortable giving birth? You know, I speak to family members and I speak to friends and very strategic about where they would like to receive care, you know, where they feel like they will receive better or more optimal care from physicians or nurses that look like them, or where they feel like they will be respected, or where they feel like they won’t face bias or discrimination within that setting. And so I think a lot of factors go into where a person delivers and it’s personal choice, ambulance patterns. And then also in emergency moments, you know, a lot of things can be up in the air in emergency moments.

Siers-Poisson [00:17:50] So are you able to see advantages of giving birth in a high-quality hospital setting equally across race and Medicaid status?

Thompson [00:17:59] So not equally. So the advantages of delivering in a high-quality hospital are not evenly distributed one across race or across actual status of Medicaid coverage. So like while giving birth in a high-quality hospital generally improves outcomes, Black woman even when delivering at the same hospitals as their white counterparts often experience, you know, still a disparity in their outcomes. And that could be systematic barriers and biases. It can also be like things like differential treatment.

Siers-Poisson [00:18:28] So, Kathryn, we’ve covered a lot. What do you see as the policy and practice implications of this research?

Thompson [00:18:35] That’s such a multifaceted question. And I’m actually going to spend a little bit more time on this one, especially when you’re talking about closing that Black/white disparity gap, which is a big interest of mine. Policy changes must prioritize expanding access for individuals on Medicaid, on private insurance, just to all individuals, especially when it comes to accessing higher-quality institutions for marginalized communities. And I think that Medicaid, especially Medicaid itself, with the leverage that it has in providing so much care for pregnant and postpartum persons, can really be used as a tool. And it is really an underutilized tool. There’s just so much potential within one insurance program to not only provide care in the prenatal period, but also care in the postpartum period. And then when a person presents to an institution as well so while they’re receiving care during their pregnancy. So by designing Medicaid programs that target racial and ethnic disparities and they can offer advanced prenatal care, home visitation programs, culturally competent care. States have the flexibility to better address the populations in which they serve. Medicaid also has the potential to incentivize providers to improve care in underserved areas. And you can do that through like value-based payment programs, etc. But beyond access, we need to confront things like racism that’s embedded in the health care systems, and that can be happening through institutional reforms going beyond like anti-bias training providers, but really thinking about how, one, we’re like training providers to care for different communities differently. We can also have robust data collection and also accountability systems that monitor key metrics that we’re talking about. So how can we better collect data on maternal mortality and severe maternal morbidity and even race? Because that is becoming a metric that is getting a little muddier as time goes on, especially within large datasets like Medicaid or like T-MSIS data. And then the really big part, especially when you’re talking about policies, is ensuring that that policy has interventions or programs that are initiatives that are relevant to the communities in which they’re serving. So how you can make them flexible enough? How can you tailor a specific policy or provide flexibility within a policy, whether that’s state or Medicaid level, that can provide the resources, the care for that individual community within a certain state? Because the state of Massachusetts, for instance, is going to look very different from the state of Wisconsin. So how are we being really intentional when it comes to the types of policies and practices and initiatives through programs like Medicaid or even outside of Medicaid that can take care of or provide benefits or expand eligibility or provide resources or address social determinants of health for the communities which we care about and the communities in which we study. I’m a really big proponent of recognizing individuals as people rather than a number. And so how can we take policies and how can we kind of like move the research forward that we bridge what’s happening at this higher level, what’s happening, you know, within a spreadsheet or an observation or whatever it may be. And how do we connect that with the experiences and the perspectives of the individuals that these policies are supposed to influence?

Siers-Poisson [00:22:09] That’s a perfect segway into my question of how do you see the experiences and voices of Black individuals and communities being valued and incorporated into practice approaches?

Thompson [00:22:22] This is something that in the research world we can do a better job of. I believe that there is so much value and rich information in speaking with the individuals which the policies that we impose affect. And so how do we know that the policies and is doing what it intended to do? How do we know that if an individual has an unmet health care need that it is supposed to be, you know, provided by specific benefits or a program or a policy that was implemented X, Y, Z time ago, that they’re actually benefiting from that. Are they being connected to these resources? Are they being told about these resources? Are individuals seeing the benefit of these resources within themselves and their daily living? And when it comes to the quality of their health care, but also when it comes to the quality of their health outcomes? And so it is something that is valuable. And that’s why I am a very large proponent, as a quantitatively trained researcher, I am a big proponent of one: mixed methods. And then also qualitative research, because I believe that the qualitative plus the quantitative makes for a great body of research.

Siers-Poisson [00:23:37] And as we wrap up, what further research would you like to do or see done on this topic?

Thompson [00:23:43] So much. There’s a couple of things. One, I’m very interested in a state’s Medicaid program, investment in social determinants of health or policies that improve social determinants of health. So when we’re talking about employment, when we’re talking about support for housing or, you know, just providing support for the unhoused. How do we connect individuals with healthy, safe nutritional foods? You know, how do we combat food insecurity within our communities, which is so prevalent? How do we provide access to quality health care services, whether that’s in ways of transportation, things like that? How do we support individuals finding jobs and kind of like reducing that unemployment rate? And so I believe there’s a lot of I guess you would say there’s a lot of opportunity by investing in social determinants of health, especially for Medicaid programs, in order to see this disparity gap, as we say, decrease amongst racial ethnic groups, amongst different communities, the variation that we see across states. And so we already know the social determinants of health are a key indicator of a lot of these different outcomes. So why as programs or why as Medicaid programs, can we not make that investment on the back end in order to see improvements on the front end and then also study the effectiveness of like culturally-tailored, community-driven care models? So I’m also a big proponent of using midwives and doulas. I also believe that every child does not need to be born in an actual hospital. So what about birthing centers or community care centers that extend kind of like these obstetric services into communities without someone having to go to a big private or public hospital? And I think it’s really imperative that we kind of make these investments in these things in order to do impactful, timely, and significant longitudinal research so we can kind of like assess these long-term impacts.

Siers-Poisson [00:25:54] Kathryn, thank you so much for taking the time to discuss your research with us. It’s really fascinating, and you’ve really given us a lot to think about.

Thompson [00:26:02] Thank you for having me. This was really fun!

Siers-Poisson [00:26:06] Thanks so much to Dr. Kathryn Thompson for talking with us about her research on the disparities faced by Black pregnant Medicaid enrollees and the policy and practice innovations that could lessen barriers to quality care. The production of this podcast was supported in part by funding from the U.S. Department of Health and Human Services Office of the Assistant Secretary for Planning and Evaluation. But views expressed by your speakers don’t necessarily represent the opinions or policies of that office or of any other sponsor, including the University of Wisconsin–Madison. Music for the episode is by Poi Dog Pondering. Thanks for listening.

Categories

Child Development & Well-Being, Children, Economic Support, Family & Partnering, Gender Inequality, Health, Health Care, Inequality & Mobility, Means-Tested Programs, Neighborhood Effects, Parenting, Place, Racial/Ethnic Inequality, Social Determinants of Health

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