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Care Management Reduced Infant Mortality for Medicaid Managed Care Enrollees in Ohio
Alex J. Hollingsworth, PhD; Ashley M. Kranz, PhD; and Deborah Freund, PhD
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Care Management Reduced Infant Mortality for Medicaid Managed Care Enrollees in Ohio

Alex J. Hollingsworth, PhD; Ashley M. Kranz, PhD; and Deborah Freund, PhD
Care management was effective at reducing infant mortality among the most vulnerable infants enrolled in an Ohio Medicaid managed care organization.

Objectives: In 2012, the Ohio Department of Medicaid introduced requirements for enhanced care management to be delivered by Medicaid managed care organizations (MCOs). This study evaluated the impact of care management on reducing infant mortality in the largest Medicaid MCO in Ohio.

Study Design: Observational study using infant and maternal individual-level enrollment and claims data (2009-2015), which used a quasi-experimental research design built on a sibling-comparison approach that controls for within-family confounders.

Methods: Using individual-level data from the largest MCO in Ohio, we estimated linear probability models to examine the effect of infant engagement in care management on infant mortality. We used a within-family fixed-effects research design to determine if care management reduced infant mortality and estimated models separately for healthy infants and nonhealthy infants.

Results: Infant engagement in care management was associated with a reduction of 7.4 percentage points (95% CI, –10.7 to –4.1; P <.001) in infant mortality among the most vulnerable infants, those identified as not well at birth. This effect was larger in recent years and likely driven by new statewide enhanced care management requirements. Infant mortality was unchanged for healthy infants engaged in care management (coefficient = 0.03; 95% CI, –0.01 to 0.08).

Conclusions: This study provides evidence that care management can be effective in reducing infant mortality among Medicaid MCO enrollees, a population at high risk of mortality. Few infants were engaged in care management, suggesting to policy makers that there is room for many additional infants to benefit from this intervention.

Am J Manag Care. 2020;26(3):127-131.
Takeaway Points
  • Nearly half of US births are covered by Medicaid, and these infants are at increased risk of dying during the first year of life.
  • Our study found that infant engagement in care management significantly reduced infant mortality among the sickest infants enrolled in the largest Medicaid managed care organization in Ohio.
  • Care management programs that focus on the most vulnerable, least healthy infants have the potential to reduce infant mortality, particularly among populations already at high risk of infant mortality.
Despite a 15% decline in the US infant mortality rate (IMR)—from 6.86 deaths per 1000 live births in 2004 to 5.82 in 2014—rates remain high for many vulnerable subpopulations.1 One particularly vulnerable group is the Medicaid population, whose IMR is twice that of the non-Medicaid population. One study reported that the IMR of Indiana newborns enrolled in Medicaid was 7.16 per 1000 live births compared with 4.19 in the non-Medicaid population.2 Elevated IMR among Medicaid enrollees is of particular importance because more than 40% of births in the United States in 2016 were covered by Medicaid.3 Moreover, nationally, 70% of Medicaid participants are enrollees in managed care organizations (MCOs),4 an alternative payment model in which there are financial incentives to reduce costs. Thus, any successful intervention focused on Medicaid MCO enrollees has the potential to avoid a large number of infant deaths and serve as a model for both the fee-for-service and non-Medicaid populations.5

Many state Medicaid programs have implemented care management requirements for MCOs or designed care management interventions to improve birth outcomes. Although care management has no strict definition, it is loosely described as a patient-centered, team-based approach to coordinating medical care with an emphasis on chronic conditions.6 Prior studies suggest that care management for pregnant women may lead to fewer preterm births,7 fewer low-birth-weight births,8,9 and reduced infant mortality.10 In 2012, the Ohio Department of Medicaid introduced requirements for enhanced care management to be delivered by Medicaid MCOs, including a minimum staff/member ratio, quarterly face-to-face contact with members, and multidisciplinary teams to care for high-risk members.11 For high-risk infants in the intensive care unit (ICU), the teams included nurses and social workers and were designed to manage unique infant needs (eg, connection to specialists). Although care management guidelines were not specific to infants, these changes provide a unique opportunity to conduct a case study examining the potential for care management to reduce infant mortality. As such, we conducted a quasi-experimental study to determine if enhanced care management reduced infant mortality among Medicaid managed care enrollees in an Ohio MCO.


We obtained individual-level enrollment and claims data from CareSource, a large Ohio Medicaid MCO that covers 60% of Ohio Medicaid enrollees. We combined these data with county characteristics from the Area Health Resources File from 2009 to 2015. In our preferred model, we studied 61,560 infants born from 2009 to 2015, enrolled in CareSource at birth, who had at least 1 sibling enrolled since birth in the MCO. Infant mortality within the first year of life was measured as a dichotomous variable. Infants were linked to mothers and siblings using a maternal identifier. Care management was offered to infants predicted to be high cost using a proprietary algorithm or who were identified as born from high-risk pregnancies. Infant engagement in care management was defined as a dichotomous variable indicating any engagement beginning in the first month of life.

We used linear probability models to examine the relationship between infant engagement in care management and infant mortality. We first used a cross-sectional approach, estimating models controlling for infant, maternal, and community characteristics reported in the Table [part A and part B], including infant sex, race/ethnicity, maternal age at birth, a multiple birth indicator, number of primary care providers in the county, and unemployment rate. Indicators of maternal health conditions were constructed from claims data using Expanded Diagnosis Clusters to identify mothers who ever had a substance use disorder or serious mental health issue. These models also controlled for time-invariant county-level characteristics (eg, rural/urban county status) and birth-year-cohort invariant characteristics (eg, recessions) through the inclusion of county and birth-year fixed effects.

We also used a within-family approach, which adds controls for family-invariant characteristics (eg, genetic predisposition or parental education) through the addition of maternal fixed effects. The within-family model is our preferred design because it minimizes the potential for selection bias to have an impact on our treatment effect estimates. The simple difference between the mortality rate of those infants engaged in care management and those not engaged cannot be considered the true effect of care management because engagement was not randomly assigned. To overcome concerns related to nonrandom assignment, we used a quasi-experimental sibling-comparison research design and examined the subpopulation of maternal siblings who have the same health status at birth. For a detailed explanation of the sibling-comparison research design, see the work of D’Onofrio et al, who used this approach to remove confounding factors when estimating the effect of preterm birth on infant mortality and morbidity.12 Importantly, the sibling-comparison approach removes confounding variables and risk factors common to siblings, such as the material genetic environment and any time-invariant maternal characteristics.

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