title: The effect of Medicaid managed care on prenatal care: the case of Puerto Rico.
abstract: OBJECTIVE
  From 1994 to the year 2000 the government of Puerto Rico implemented a health care reform which included the mandatory enrollment of the entire Medicaid eligible population under Medicaid managed care (MMC) plans. This study assessed the effect of MMC on the use, initiation, utilization, and adequacy of prenatal care services over the reform period.
  
  
  METHODS
  Using the vital records of all infants born alive in Puerto Rico from the year 1995-2000, a series of bivariate and multivariate analyses were conducted to assess the effect of insurance status (traditional Medicaid, MMC, private insurance and uninsured) on prenatal care utilization patterns. In order to assess the potential influence of selection bias in generating the health insurance assignments, propensity scores (PS) were estimated and entered into the multivariate regressions.
  
  
  RESULTS
  MMC had a generally positive effect on the frequency and adequacy of prenatal care when compared with the experience of women covered by traditional Medicaid. However, the PS analyses suggested that self-selection may have generated part of the observed beneficial effects. Also, MMC reduced but did not eliminate the gap in the amount and adequacy of prenatal care received by pregnant women covered by Medicaid when compared to their counterparts covered by private insurance.
  
  
  CONCLUSIONS
  The Puerto Rico Health Reform to implement MMC for pregnant women was associated with a general improvement in prenatal care utilization. However, continued progress will be necessary for women covered by Medicaid to reach prenatal care utilization levels experienced by privately insured women.
authors.affiliation: Puerto Rico Health Services Research Institute, Graduate School of Public Health, University of Puerto Rico, San Juan, Puerto Rico. hmarin@rcm.upr.edu.
authors.forename: Heriberto A
authors.initials: HA
authors.lastname: Marín
authors.forename: Roberto
authors.initials: R
authors.lastname: Ramírez
authors.forename: Paul H
authors.initials: PH
authors.lastname: Wise
authors.forename: Marisol
authors.initials: M
authors.lastname: Peña
authors.forename: Yelitza
authors.initials: Y
authors.lastname: Sánchez
authors.forename: Roberto
authors.initials: R
authors.lastname: Torres
mesh_terms: D000293:Adolescent; D000328:Adult; D005260:Female; D018166:Health Care Reform; D006801:Humans; D008329:Managed Care Programs / Q000458:organization & administration*; D008484:Medicaid / Q000458:organization & administration*; D011247:Pregnancy; D011295:Prenatal Care / Q000592:standards / Q000706:statistics & numerical data*; D011647:Puerto Rico; D014481:United States; D055815:Young Adult