Well-Child Visits After Adoption of an Equity-Focused Payment Incentive in Medicaid

ABSTRACT

Objectives: Well-child visits are a key source of preventive care, yet Black infants receive them less often than infants of other racial groups. Our objective was to evaluate a Medicaid health equity payment program that incentivized Medicaid managed care plans to improve well-child visit utilization among Black families.

Study Design: Interrupted time-series analysis with a nonequivalent comparison group.

Methods: Using Pennsylvania Medicaid administrative health care data for 119,326 birthing parent–child dyads, we examined trends in receipt of the recommended number of well-child visits by 15 months of age before and after the equity payment program took effect in January 2020, comparing Black infants with infants of other race groups. We used Poisson regression to estimate incidence rate ratios (IRRs) for receipt of the recommended well-child visits after vs before the program.

Results: Black infants made up 26% of the study sample. After implementation of the equity incentive program, the receipt of the recommended number of well-child visits did not change significantly among Black infants (IRR, 0.97; 95% CI, 0.85-1.11) but declined among infants of other racial groups (IRR, 0.94; 95% CI, 0.88-1.00). Among Black infants, well-child visit rates appeared to rise in the Southwest region of the state and to decline in the Southeast region.

Conclusions: Well-child visit rates among Black infants did not change significantly overall after the equity incentive program took effect, although rates differed by region. Longer follow-up is needed to determine whether such incentives can reduce racial disparities in well-child visits.

Am J Manag Care. 2026;32(11):622-629

doi:10.37765/ajmc.2026.90041

Takeaway Points

Little is known about whether Medicaid payment incentives can reduce racial disparities in infants’ preventive care.

• Pennsylvania Medicaid added a racial health equity component to its managed care pay-for-performance program, rewarding plans for raising well-child visit rates among Black infants.
• After the incentives took effect, we found that well-child visit rates among Black infants did not change significantly overall and that trends differed by region.
• Plans’ readiness to implement equity incentives varies and may influence how well such incentives work.
• States considering similar incentives should allow for longer follow-up because early results may not reflect mature programs.

Well-child visits in infancy are an important opportunity for preventive care, including monitoring of infants’ growth and development, screenings, vaccinations, and referrals to subspecialty care or social services.^1,2 Well-child visit attendance is associated with a decreased risk of emergency department visits³ and hospitalizations for ambulatory care sensitive conditions.^3,4

The American Academy of Pediatrics recommends 6 to 9 well-child visits in the first 15 months of life.¹ Nationally representative data show that 61% of infants and children aged 0 to 3 years have the recommended number of well-child visits.⁵ One concerning, yet persistent, trend shows that Black infants tend to receive fewer well-child visits compared with other racial groups, even when controlling for socioeconomic status.⁶ A total of 53% of Black infants had recommended well-child visits,⁵ and fewer Black families, relative to White families, reported having a usual source of care.⁷

State Medicaid programs represent a major source of health care for children in the US, providing coverage for 38% of children overall and 57% of Black children.^8,9 To address racial gaps in access to well-child visits, Pennsylvania Medicaid adopted a structural intervention by adding a racial health equity component to an existing pay-for-performance program. Pennsylvania Medicaid requires nearly all beneficiaries to enroll in a managed care plan.¹⁰ It has historically operated a pay-for-performance program under which a proportion of payments to the plans is adjusted based on a set of health care quality metrics, including the receipt of well-child visits from birth to 15 months.¹⁰ Starting in 2020, an equity incentive payment program was created to assess managed care plans’ overall performance and performance stratified by race. Plans that improve well-child visit rates among Black infants receive additional performance payments; plans with lower rates among all infants must improve more to earn the full payment.¹⁰ We hypothesized that after adoption of the program, rates of receipt of the recommended number of well-child visits in the first 15 months of life would show an increasing trend among Black infants but no change in trend among non-Black infants.

METHODS

Study Data and Cohort

The study was approved by the University of Pittsburgh Institutional Review Board. We accessed Pennsylvania Medicaid administrative health care data, which include a census of Medicaid enrollment records (with demographic data and managed care plan enrollment data) and inpatient, outpatient, and pharmacy records. We first identified all women aged 15 to 50 years with a Medicaid-covered live birth delivery from 2018 to 2022 who were enrolled for 15 or more days per month for at least 12 months postpartum, following our prior work.^11,12 We used a unique household identifier in the data set to exactly match records of women with records of their infants, based on the woman’s date of delivery and the infant’s date of birth,¹³ resulting in a match rate of 98%. We restricted the data to dyads in which infants remained enrolled in Medicaid during the first 15 months of life and had information on managed care plan enrollment. For infants whose managed care plan information was missing from their enrollment record, we imputed managed care plan enrollment based on health care utilization or parental records. Our final analytic data set included 119,326 infants born between 2018 and 2021, with linked data related to their birthing parents. See eAppendix Figure 1 (eAppendix available at ajmc.com) for a flow chart of the study cohort creation.

Intervention: Equity Incentive Payment Program

In January 2020, Pennsylvania Medicaid implemented the equity incentive payment program for Medicaid managed care plans. Nearly all Medicaid beneficiaries in Pennsylvania are enrolled in Medicaid managed care plans, which are subject to pay-for-performance requirements for health care quality measures.¹⁰ A detailed description of the program has been published elsewhere.¹⁰

Briefly, under the new equity incentive payments, $26 million in Medicaid plan payments are withheld from total payments and made available to plans that achieve annual improvements in access to timely prenatal care and well-child visits among Black beneficiaries. First, Medicaid plans are assessed on overall performance for well-child visit attendance in the first 15 months for all infants under the standard pay-for-performance program (ie, the proportion of enrolled infants who have 6 or more well-child visits). Next, Medicaid plans are assessed on the annual improvement of the measure among Black infants. Plans in the top 50% of performance against national benchmarks on the first step (well-child visits among all infants) can earn the full incentive payment if well-child visit rates among Black infants improve by 3 or more percentage points in the second step. In contrast, plans in the lower 50% of performance on the first step must improve well-child visit rates among Black infants by 5 or more percentage points to earn the full incentive payment; the payment decreases more steeply at lower levels of improvement.¹⁰

The Pennsylvania Medicaid program asks people to report their race and ethnicity according to the Office of Management and Budget categories at the time of enrollment.¹⁴ In our data set, we examined the following available race categories separately on the Medicaid enrollment records of both the birthing parent and infant: American Indian or Alaska Native, Asian, Black or African American, Native Hawaiian or Pacific Islander, White, some other race, or missing.

We then defined exposure to the intervention based on each infant’s race category and date of birth. Black infants born between January 2020 and September 2021 who were 15 months of age by December 2022 were in the intervention group, and Black infants born between January 2018 and September 2018 who were 15 months of age before January 2020 were in the comparison group. Infants born between October 2018 and December 2019 were excluded because they were not exposed to the intervention for their entire first 15 months. Infants of other racial groups and those with missing data on race, who were never exposed to the intervention, served as a comparison group; we modeled the same time trend among them before and after the equity incentive payment program took effect.

Outcome

The study outcome was a binary measure indicating whether a child had received 6 or more well-child visits by 15 months of age. We defined well-child visits as outpatient office visits with a primary care clinician, per the administrative specification for the Medicaid core quality metrics.¹⁵

Covariates

We defined confounders likely to be associated with both the structural intervention (as defined by child race and date of birth) and with having the recommended number of well-child visits (eAppendix Table 1). These included child sex, Hispanic/Latine ethnicity, residence in a rural county, an indicator of which managed care plan the infant was enrolled, a time indicator for when COVID-19 vaccines were available, low birth weight (< 2500 grams), whether the child was ever placed in foster care, and whether the child or parent was ever hospitalized with COVID-19.Because race is a social construct and the race of family members may affect experiences of health care, we also included indicators of whether the birthing parent’s race and ethnicity matched the infant’s. In eAppendix Table 2, we present the concordance between the parent’s andinfant’s reported race and ethnicity categories.

Statistical Analysis

We first calculated descriptive statistics for infants in our study population, overall and stratified by race group and by cohort (preintervention vs post intervention). We also calculated descriptive statistics examining the concordance between race and ethnicity of the infant and the birthing parent.

We conducted an interrupted time series (ITS) analysis to test whether the level of well-child visit use increased among Black infants and infants of other racial groups after adoption of the equity payment program.¹⁶ To implement ITS models, we transformed our individual-level data set into monthly observations within each of the 5 Medicaid regions (Lehigh/Capital, Northeast, Northwest, Southeast, and Southwest) in Pennsylvania. The Medicaid regions correspond to the managed care plans available to Medicaid beneficiaries. The unit of analysis was the monthly rate of well-child visits (ie, the number of infants turning 15 months of age in that month with 6 or more well-child visits relative to the total number of infants turning 15 months of age in that month). We used Poisson regression models, stratified by child race (Black vs other racial groups), to test for changes in well-child visit rate trends after program adoption.¹⁷ The dependent variable was the monthly count of infants receiving the recommended number of well-child visits, with the number of infants at risk included as an offset term. Models also included a time indicator and other covariates, and SEs were clustered by Medicaid region. To examine potential regional differences in the intervention effects, we also estimated race group–specific rates separately for each of the 5 Pennsylvania Medicaid regions.

We chose an ITS design for our primary analysis because we were interested in examining time trends in utilization, rather than an average postprogram effect, due to the onset of the COVID-19 pandemic during our study period. However, as a secondary analysis, we replicated our model using a difference-in-differences framework to estimate the program’s average treatment effect. For this model, we created a binary dependent variable measuring whether an infant received at least 6 well-child visits by 15 months of age. We then used a linear probability model that included indicators for Black infant race and the postpolicy period, their interaction (Black infant race indicator × postpolicy indicator), and other covariates, with SEs clustered at the Medicaid region level. We then derived average marginal effects from the regression model using marginal standardization.¹⁸ Full regression results, including all covariates, are shown in eAppendix Table 3.

RESULTS

The final analytic cohort included 119,326 infants: 30,606 Black infants (9508 preintervention and 21,098 post intervention) and 88,720 infants of other racial groups (25,534 preintervention and 63,186 post intervention). Descriptive characteristics of our study population, overall and stratified by race and intervention status, are shown in Table 1. Overall, approximately half of the study cohort was male, 26% were Black, 19% were Hispanic/Latine, and 11% resided in rural areas. Generally, within race categories, characteristics of the study sample were comparable before and after the equity payment program took effect. The rate of low birth weight was approximately 4 percentage points higher among Black infants than among infants of other racial groups. We observed similar rates of COVID-19 hospitalizations and foster care placement across all racial groups.

Results from ITS specifications are graphed in Figure 1. Among Black infants, trends in receipt of the recommended number of well-child visits for those turning 15 months of age declined from the preintervention period to the early postintervention period. However, the rates appeared to rebound, and by the end of the follow-up period, they were comparable to preintervention levels. Our models estimated that among Black infants, the rates of well-child visit utilization were not statistically changed post intervention, relative to preintervention (IRR, 0.970; 95% CI, 0.846-1.111). Among non-Black infants (our comparison group), the trend was somewhat different, with rates of well-child visits among those turning 15 months of age declining post COVID-19 and not rebounding to the pretrend level; we estimated an approximate 6% decline in well-child visit utilization (IRR, 0.936; 95% CI, 0.879-0.997). Although many covariates did not predict well-child visit rates, we found that vaccine availability was associated with an 8% higher rate of well-child visits among Black infants (IRR, 1.081; 95% CI, 1.015-1.152) but not among non-Black infants (IRR, 1.018; 95% CI, 0.954-1.086).

Regional heterogeneity in these time trends among Black infants is shown in Figure 2, with comparable trends among non-Black infants shown in Figure 3. Among Black infants, rates of well-child visits post intervention appeared to increase in the Southwest region but decrease in the Southeast region. Among non-Black infants, trends were flatter in both regions over time.

In the difference-in-differences model, we found that the pre-post policy change in receipt of recommended well-child visits in Black infants relative to non-Black infants was 2.9 percentage points (95% CI, -0.4 to 6.2). As shown in Table 2, post program, we observed a small increase in the proportion of infants receiving recommended well-child visits by 15 months among Black infants, from an average predicted probability of 58.3% (95% CI, 52.1-64.5) to 59.4% (95% CI, 57.0-61.7). Among non-Black infants, the average predicted probability of receiving the recommended well-child visits by 15 months decreased from 63.0% (95% CI, 61.3-64.8) to 61.2% (95% CI, 58.3-64.2). The predicted difference in the probabilities of receipt of recommended well-child visits between Black infants and non-Black infants was –4.7 (95% CI, –10.7 to 1.3) preprogram and –1.8 (95% CI, –6.5 to 2.8) post program.

DISCUSSION

After adoption of the equity payment program that modified a Medicaid managed care pay-for-performance program to incentivize higher well-child visit rates among Black infants, trends in the recommended number of well-child visits did not worsen for Black infants but did worsen slightly for non-Black infants. These trends are in contrast to national data showing that racial disparities in access to well-child visits widened during the COVID-19 pandemic in 2020 and 2021.¹⁹ Our study suggests that the equity payment program may have helped prevent declines in well-child visits among Black infants and increased access to care in certain regions of the state.

Our findings reflect the early phase of program implementation. In a prior qualitative study of managed care plan leaders’ perspectives about this program, plans varied in their readiness to implement interventions to reduce racial inequities in access to well-child visits.²⁰ These findings are consistent with the geographic variation in receipt of well-child visits that we observed in the present study. Additionally, the program effects may change in the future as managed care plans and health care providers adopt new practices, as has been observed with the study of other value-based payment models.²¹ 

These findings add new evidence about the role of financial incentives to advance racial health equity in public insurance programs. First, we focused on infant health, which has been less commonly targeted by pay-for-performance programs. For example, there has only been one evaluation of a pediatric pay-for-performance program in the Medicaid managed care context.²² Second, we studied a program that explicitly focuses on health care outcomes among Black families, whereas most prior financial incentive programs have been universal.²³ Prior literature has posited that universal financial incentive programs could improve racial health equity: If racial minority patients had disproportionately worse outcomes on health care quality metrics, the programs would spur health care providers to improve those metrics among these groups.²⁴ Generally, universal pay-for-performance programs may have had a small but positive effect on racial health equity, but low-resource institutions that treat communities of color often face financial penalties under these programs.^24,25 An evaluation of a Massachusetts program in which hospitals were eligible for incentive payments based on racial and ethnic health disparities found no effect on racial or ethnic disparities, and Massachusetts discontinued the program after only 4 years.²⁶ The Massachusetts program was distinct from the Pennsylvania program in that it focused only on hospital-level performance and combined 5 clinical quality metrics into a single score, focusing on the gap between White and other racial and ethnic groups.²⁶

Despite our promising findings that well-child visit utilization improved in certain regions after policy implementation, it is notable that the overall proportion of Black infants receiving the recommended number of well-child visits remained at 56% in 2022, well below the ideal of universal utilization of well visits. In prior studies, Black families with infants enrolled in Medicaid have identified structural barriers to accessing well-child visits, such as lack of transportation and disrespectful experiences in health care settings.^27,28 Other research has suggested that changes to care experiences, including continuity of care and easier access to care, are important factors for parents.²⁹ As Medicaid managed care plans focus on activities to address health equity,³⁰ these barriers could be addressed via specific interventions.

Limitations

Our study had limitations. First, the timing of program adoption—January 2020—coincided with the start of a major global pandemic. In the US context, a wealth of data has shown that Black communities were disproportionately negatively affected by the COVID-19 pandemic, including in measures of access to care.^19,31-33 As such, our results could be biased due to pandemic-related factors. Our analyses controlled for COVID-19–related hospitalizations (indicating severe disease) in both infants and their parents. Additionally, we used a monthly time-series design to assess changing trends after the program was implemented and during the pandemic. Second, our health care administrative data lack mediating variables on the causal pathway between the Medicaid program and well-child visit use, such as specific interventions to increase access to visits. However, our qualitative study suggested substantial variation in managed care plan approaches, which is consistent with the observed regional heterogeneity. Third, our study data are unable to measure spillover effects of managed care plan interventions on infants not enrolled in the plan. For example, if a managed care plan implemented an effective intervention to improve well-child visits but served only limited regions of the state, infants in other regions of the state would not benefit. Conversely, an effective intervention could also have spillover effects to infants enrolled in commercial insurance plans, if the intervention changed provider behavior. Because our study data are not all payer, we are unable to measure this potential effect. Fourth, results here reflect early data on the program’s effects. As managed care plans’ interventions evolve, a longer follow-up time of the program’s effects is warranted. Fifth, we considered those infants with missing race to be not identified as Black. If missing race is systematically different among infants of different race groups, which is not knowable in our data, this could introduce bias into our assessment of non-Black infants.

CONCLUSIONS

In an evaluation of an equity-centered pay-for-performance program in a large state Medicaid program, we found that overall rates of well-child visit utilization did not change among Black infants, relative to other race groups, but did increase among Black infants post intervention in certain regions of the state. Findings support the feasibility of modifying pay-for-performance programs in Medicaid to specific subgroups, and merit long-term study to assess impact on racial disparities experienced by Black families.

Author Affiliations: Department of Health Policy and Management, University of Pittsburgh School of Public Health (MJ, JB, EC, JE), Pittsburgh, PA; CONVERGE@Pitt, University of Pittsburgh School of Medicine (MJ, JE), Pittsburgh, PA; Department of Biostatistics and Health Data Science, University of Pittsburgh School of Public Health (JMB), Pittsburgh, PA; Department of Epidemiology, University of Pittsburgh School of Public Health (AC, DM), Pittsburgh, PA; Department of Community Health and Prevention, Drexel University Dornsife School of Public Health (IH), Philadelphia, PA.

Source of Funding: This research was supported by funding from the Robert Wood Johnson Foundation and the Pennsylvania Department of Human Services. The content is solely the responsibility of the authors and does not represent the official views of the Robert Wood Johnson Foundation or the Pennsylvania Department of Human Services. The funders had no role in the design and conduct of the study. The Pennsylvania Department of Human Services provided access to Medicaid health care records for the study.

Author Disclosures: The authors report no relationship or financial interest with any entity that would pose a conflict of interest with the subject matter of this article.

Authorship Information: Concept and design (JB); acquisition of data (EC); analysis and interpretation of data (JB, JMB, AC, EC, JE, IH); drafting of the manuscript (JB, EC, IH); critical revision of the manuscript for important intellectual content (JB, JMB, AC, JE, IH); statistical analysis (JB, JMB, AC, JE); provision of patients or study materials (MJ, DM); obtaining funding (MJ, DM); administrative, technical, or logistic support (JB, EC); and supervision (MJ).

Address Correspondence to: Marian Jarlenski, PhD, MPH, University of Pittsburgh School of Public Health, 130 DeSoto St, A619, Pittsburgh, PA 15261. Email: marian.jarlenski@pitt.edu.

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