Medicaid Reimbursement for Maternal Depression Screening and Care for Postpartum Depression

Sarah H Gordon; Sobin Lee; Nigel Deen; Megan B Cole; Emily Feinberg; Alison Galbraith

doi:10.1001/jamapediatrics.2025.1790

. 2025 Jun 30;179(9):1009–1016. doi: 10.1001/jamapediatrics.2025.1790

Medicaid Reimbursement for Maternal Depression Screening and Care for Postpartum Depression

Sarah H Gordon ^1,^✉, Sobin Lee ², Nigel Deen ¹, Megan B Cole ¹, Emily Feinberg ³, Alison Galbraith ⁴

¹Department of Health Law, Policy, and Management, Boston University School of Public Health, Boston, Massachusetts

²Department of Economics, Boston University, Boston, Massachusetts

³Hassenfeld Child Health Innovation Institute, Brown University School of Public Health, Providence, Rhode Island

⁴Department of Pediatrics, Boston Medical Center and Boston University Chobanian & Avedisian School of Medicine, Boston, Massachusetts

Accepted for Publication: April 15, 2025.

Published Online: June 30, 2025. doi:10.1001/jamapediatrics.2025.1790

^✉

Corresponding Author: Sarah H. Gordon, PhD, MS, Department of Health Law, Policy, and Management, Boston University School of Public Health, 715 Albany St, Boston, MA 02118 (gordonsh@bu.edu).

Author Contributions: Dr Gordon and Ms Lee had full access to all of the data in the study and take responsibility for the integrity of the data and the accuracy of the data analysis.

Concept and design: Gordon, Deen, Feinberg.

Acquisition, analysis, or interpretation of data: Gordon, Lee, Cole, Feinberg, Galbraith.

Drafting of the manuscript: Gordon, Deen.

Critical review of the manuscript for important intellectual content: All authors.

Statistical analysis: Lee.

Obtained funding: Gordon.

Administrative, technical, or material support: Gordon.

Supervision: Gordon.

Conflict of Interest Disclosures: Dr Gordon reported receiving grants from the National Institute of Mental Health during the conduct of the study and receiving grants from the National Institute of Child Health and Human Development, the National Institute of Minority Health and Health Disparities, the National Institute of Dental and Craniofacial Research, and the Abdul Latif Jameel Poverty Action Lab and personal fees from the Commonwealth Fund and the Robert Wood Johnson Foundation outside the submitted work. No other disclosures were reported.

Funding/Support: This work was funded by grant K01MH127253 from the National Institute of Mental Health.

Role of the Funder/Sponsor: The funder had no role in the design and conduct of the study; collection, management, analysis, and interpretation of the data; preparation, review, or approval of the manuscript; and decision to submit the manuscript for publication.

Data Sharing Statement: See Supplement 2.

^✉

Corresponding author.

PMCID: PMC12210141 NIHMSID: NIHMS2093984 PMID: 40587153

Key Points

Question

What is the association between Medicaid reimbursement for maternal depression screening during well-child visits and rates of billed screens during the postpartum year?

Findings

In this cohort study including 137 867 births in Colorado, Medicaid reimbursement for postpartum depression (PPD) screening for mothers during well-child visits was associated with a 9.6–percentage point increase in the probability of having a billed screen for maternal depression.

Meaning

These findings suggest that Medicaid reimbursement for PPD screening during well-child visits may increase rates of detection of PPD among mothers during the first year post partum.

This cohort study of 137 867 births in Colorado assesses whether Medicaid coverage for postpartum depression screening among mothers during well-child visits was associated with increased rates of screening, diagnoses of mood or anxiety disorders, and rates of mental health treatment.

Abstract

Importance

Clinical guidelines recommend routine screening for postpartum depression (PPD) during well-child visits. All but 5 US states provide Medicaid reimbursement to pediatric practitioners for screening mothers for PPD during well-child visits, but little is known about how reimbursement affects screening, diagnosis, and treatment.

Objective

To evaluate the association between Medicaid reimbursement for PPD screening during well-child visits and screening, diagnosis, and treatment for mood or anxiety disorders in the postpartum year.

Design, Setting, and Participants

This cohort study used a difference-in-differences study design to analyze claims data and birth records obtained from the Colorado All Payer Claims Database for the period January 1, 2013, to December 31, 2019, for Medicaid-insured and commercially insured births that occurred between 2012 and 2018. Data were analyzed between February 16, 2024, and March 21, 2025.

Exposure

Colorado Medicaid reimbursement for PPD screenings during well-child visits.

Main Outcomes and Measures

The primary outcome was billed depression screens during well-child visits. Secondary outcomes were diagnoses of a postpartum mood or anxiety disorder and outpatient mental health care or prescription medication use during the postpartum year. We defined an indicator variable for before (2013) vs after (2014-2019) the Colorado Medicaid program began reimbursing for maternal depression screening during well-child visits on January 1, 2014.

Results

This study included 137 867 births, 104 085 of which were paid by Medicaid and 33 782 of which were paid by commercial insurance. The mean (SD) age of mothers in the Medicaid-insured group during the 2013 prepolicy period was 25.6 (5.7) years compared with 31.7 (4.7) years among mothers in the commercially insured group; during the postpolicy period, the mean (SD) ages were 26.5 (5.7) years and 32.1 (4.4) years, respectively. During the prepolicy period, for births insured by Medicaid vs commercial insurance, the mothers were more likely to have been born outside the US (14.2% vs 10.3%; P = .01), reside in a more rural area (14.5% vs 8.1%; P < .001), have not completed high school or college (24.8% vs 1.1%; P < .001), and have a lower income (80.3% vs 8.2%; P < .001). In adjusted difference-in-differences models, reimbursement for maternal depression screening during well-child visits among Medicaid-insured mothers was associated with a 9.60–percentage point (ppt) (95% CI, 9.10-10.00 ppt) increase in the probability of billed depression screens during well-child visits (P < .001), 0.18 (95% CI, 0.17-0.19) additional billed well-child visit depression screens per birth (ie, 18 additional screens per 100 births), a 2.5-ppt (95% CI, 1.40-3.50 ppt) increase in the probability of being diagnosed with a postpartum mood or anxiety disorder, a 3.3-ppt (95% CI, −4.60 to 2.00 ppt) decrease in prescription medication (P < .001), and a 3.3-ppt (95% CI, 2.50-4.10 ppt) increase in any outpatient mental health treatment (P < .001) compared with mothers who had commercial insurance.

Conclusions and Relevance

The findings of this cohort study suggest that Medicaid reimbursement for PPD screening during well-child visits may increase rates of detection, postpartum mood or anxiety disorder diagnoses, and outpatient treatment among mothers in the postpartum year. Insurance reimbursement for PPD screenings during well-child visits appears to be a promising policy strategy; however, additional interventions may be needed to address barriers to conducting screenings and referrals in pediatric settings and accessing postpartum mental health treatment.

Introduction

Postpartum depression (PPD) is the most common complication of childbirth and is associated with adverse effects on mothers and infants.^1,2,3,4 The overall incidence of PPD is estimated at 13%, though prevalence is higher among people whose childbirth is paid for by Medicaid (17%) versus commercial insurance (10.1%).⁵ Among mothers, PPD is associated with lower levels of self-esteem, positive affect, anger control, functional status, quality of life, and higher levels of anxiety, substance use, and suicidality.^{6,7,8,9,10,11} Infants of mothers with PPD exhibit worse social-emotional, cognitive, language, motor, and behavioral development compared with infants of mothers without PPD, and these associations extend into middle childhood and adolescence.¹² PPD also incurs high societal costs; the 5-year cost of untreated perinatal mood disorders has been estimated at $31 800 per affected mother-infant dyad; PPD has also been associated with increased emergency department use among mothers and infants.^13,14,15,16

The American Academy of Pediatrics (AAP) has recommended universal screening for PPD in well-child visits at months 1, 2, 4, and 6.¹⁷ Well-child visits occur more frequently during the year after childbirth compared with postpartum or primary care visits and are often better attended, offering more frequent opportunities for detection.^18,19 Additionally, in 2016, the US Preventive Services Task Force (USPTF) recommended universal depression screening as an evidence-based preventive service, including for pregnant and postpartum individuals,⁵ which under the 2010 Affordable Care Act meant that commercial insurers were required to cover screening with no cost-sharing. However, this recommendation did not focus specifically on screening during pediatric visits. To date, all but 5 state Medicaid programs reimburse pediatric practitioners for maternal depression screening during well-child visits; however, to our knowledge, no studies have evaluated the effectiveness of this reimbursement on postpartum screening or treatment rates among Medicaid beneficiaries.²⁰ Studies have demonstrated that screening for PPD during well-child visits has been perceived as feasible by practitioners and acceptable to patients,^21,22,23 but the most recent data available from the AAP indicate that only just over half of pediatric practitioners report routinely conducting such screenings.²⁴

The objective of this study was to assess whether Medicaid coverage for PPD screening in well-child visits may be associated with increased rates of screening in well-child visits, diagnoses of mood or anxiety disorders, and rates of mental health treatment among postpartum Medicaid beneficiaries. We used all payer claims and birth records from Colorado from 2013 to 2019 and a difference-in-differences study design to evaluate Colorado’s 2014 Medicaid reimbursement for PPD screening in well-child visits as a fee-for-service payment among Medicaid-insured patients compared with a commercially insured group.

Methods

This cohort study was approved by the Boston University Institutional Review Board; the requirement of informed consent was waived owing to the use of retrospective, publicly available data. We followed the Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) reporting guideline.

Data Collection and Study Sample

We used data from the Colorado All-Payer Claims Databases (APCD) linked with birth certificates from January 1, 2013, to December 31, 2019, for Medicaid-insured and commercially insured births that occurred between 2012 and 2018. Birth records were obtained from and linked by the Colorado Department of Public Health and Environment. To measure maternal depression screenings billed under the infant’s Medicaid ID, we linked mothers and infants within the APCD using a unique birth identification variable that was common to both the mother and infant’s birth record (eMethods 1 in Supplement 1). Our sample comprised Medicaid and commercially insured inpatient hospitalizations for the delivery of a liveborn infant identified using International Classification of Diseases, Ninth Edition (ICD-9); International Statistical Classification of Diseases, Tenth Edition (ICD-10); and Current Procedural Terminology (CPT) codes. We excluded births that occurred in 2019 to observe a 12-month postpartum follow-up period for all births. We restricted our sample to individuals who had continuous insurance coverage, with a maximum coverage gap of 1 month, from 9 months before birth through 12 months after birth.

Measures

Because the reimbursement policy was specific to Medicaid, the treatment group was defined by whether a birth was followed by 12 months of continuous enrollment in Medicaid or commercial insurance, with a default of Medicaid if the mother had coverage in both. We defined an indicator variable for before (2013) vs after (2014-2019) the Colorado Medicaid program began reimbursing for PPD screening during well-child visits on January 1, 2014.

Our primary outcome variable was the rate of at least 1 screening for maternal depression during well-child visits per birth. Screening was assessed using codes provided directly from the Colorado Department of Health Care Policy and Financing, which oversees the Health First Colorado (the Colorado Medicaid program), which we also corroborated with publicly released provider bulletins (eMethods 2 in Supplement 1).²⁵ We counted screenings that co-occurred on a claim for a well-child visit in the first year of an infant’s life that were billed under either the mother or the infant’s Medicaid ID. We also calculated the average number of screens that occurred in well-child visits per birth during the postpartum year.

As secondary outcomes, we examined rates of diagnoses for postpartum mood or anxiety disorders and receipt of outpatient therapy or medication treatment billed through the mother’s insurance. While the reimbursement policy targeted screening for depression specifically, following prior work, we measured diagnoses for both postpartum mood or anxiety disorders because the 2 conditions are often overlapping and co-occurring, commonly used screening instruments may identify symptoms of both, and misclassification may occur in claims.²⁶ We used ICD-9 and ICD-10 diagnosis codes for any claim indicating a mental health diagnosis during the postpartum year, regardless of care setting and whether the diagnosis was preexisting or de novo.

We assessed mental health treatment following the methods of Gordon et al²⁷ using the following outcomes: (1) receipt of any outpatient mental health care, including individual or group outpatient psychotherapy or behavioral therapy identified using CPT codes; (2) a prescription fill for a medication for mood or anxiety disorders based on national drug codes from the National Committee for Quality Assurance Healthcare Effectiveness Data and Information Set measures²⁸; and (3) receipt of either treatment type. We included prescription medication for both mood and anxiety disorders as many of the same medications are used to treat both conditions.²⁹ We did not limit treatment assessment to patients with a mental health diagnosis because previous studies with claims data have found that patients may start antidepressants post partum without a recorded diagnosis.³⁰

Covariates included age, race (including Asian, Black, White, and other race [including American Indian or Alaska Native, Native Hawaiian or Other Pacific Islander, and unknown race]), Hispanic ethnicity, country of birth, educational level, marital status, rurality, income, the number of prenatal visits, first trimester prenatal care initiation, existing chronic conditions prior to pregnancy, preterm birth, a composite measure of pregnancy and delivery complications, cesarean delivery, and a prior diagnosis of a mood or anxiety disorder during the 12 months prior to delivery (eMethods 3 in Supplement 1). Race and ethnicity data were collected to adjust for documented differences in attendance at well-child and postpartum visits and rates of postpartum depression by race and ethnicity.^31,32,33

Statistical Analysis

The unit of analysis was the delivery quarter. We computed means and standard deviations among the Medicaid-insured vs commercially insured groups before (quarters 1-4 of 2013) and after (quarters 1-4 of 2014-2019) Colorado began reimbursing pediatric practitioners for conducting PPD screening during well-child visits. We plotted unadjusted quarterly rates of each outcome among the Medicaid-insured vs commercially insured groups over the study period. We also computed unadjusted mean outcome rates in the Medicaid-insured vs commercially insured groups and percentage point (ppt) changes before and after the reimbursement policy was implemented.

We estimated adjusted difference-in-differences linear probability regression models for each outcome. The primary independent variable was an interaction term between a binary prepolicy vs postpolicy indicator and a binary variable classifying individuals as predominantly enrolled in Medicaid vs commercial insurance in the 12 months post partum. All models controlled for the aforementioned covariates. We calculated heteroskedasticity-robust standard errors clustered at the level of the mother to account for multiple deliveries by the same mother.

To assess the internal validity of the difference-in-differences framework, we conducted event studies estimating separate coefficients for the association between enrollment in Medicaid vs commercial insurance and each prepolicy and postpolicy quarter relative to quarter 4 of 2013, the quarter before the policy was implemented (eMethods 4 in Supplement 1). We conducted F-tests of the joint significance of each of the interaction terms between the Medicaid vs commercial insurance enrollment indicator variable and each prepolicy quarter to assess whether the trends prior to the policy change were statistically different in the 2 groups over time. To assess how the slopes changed over time in each group, we also estimated an interrupted time series analysis. To further assess changes in the composition of the sample over time, we plotted mean rates of each covariate across the study period for Medicaid vs commercial insurance. We also estimated a sensitivity analysis controlling for the total number of well-child visits per birth in the postpartum year.

Data were analyzed between February 16, 2024, and March 21, 2025, using Stata, version 16.1 (StataCorp LLC). Two-sided P < .05 was considered statistically significant.

Results

Table 1. Characteristics of Births by Insurance Type Before vs After Colorado Medicaid Reimbursement for Postpartum Depression Screening During Well-Child Visits^a.

Characteristic	Prepolicy period			Postpolicy period
Characteristic	Medicaid (n = 13 094)	Commercial insurance (n = 4084)	P value	Medicaid (n = 90 991)	Commercial insurance (n = 29 698)	P value
Age, mean (SD), y	25.6 (5.7)	31.7 (4.7)	<.001	26.5 (5.7)	32.1 (4.4)	<.001
Race
Asian	332 (2.5)	171 (4.2)	<.001	2734 (3.0)	1319 (4.4)	<.001
Black	1378 (10.5)	125 (3.1)		9703 (10.7)	659 (2.2)
White	10 100 (77.1)	3651 (89.4)		67 656 (74.4)	26 108 (87.9)
Other^b	1284 (9.8)	137 (3.4)		10 898 (12.0)	1612 (5.4)
Ethnicity
Hispanic	5833 (44.6)	579 (14.2)	<.001	38 696 (42.5)	4349 (14.6)	<.001
Born outside the US	1859 (14.2)	422 (10.3)	.01	13 395 (14.7)	3042 (10.2)	<.001
Rural residence	1895 (14.5)	331 (8.1)	<.001	13 053 (14.3)	2702 (9.1)	<.001
Educational level
High school	9846 (75.2)	4039 (98.9)	<.001	72 058 (79.2)	29 427 (99.1)	<.001
College	1831 (14.0)	3230 (79.1)	<.001	15 884 (17.5)	24 017 (80.9)	<.001
Annual income, $
0-24 999	9164 (70.0)	168 (4.1)	<.001	54 947 (60.4)	1061 (3.6)	<.001
25 000-34 999	1343 (10.3)	167 (4.1)		11 814 (13.0)	902 (3.0)
35 000-49 999	787 (6.0)	376 (9.2)		7835 (8.6)	2116 (7.1)
50 000-74 999	330 (2.5)	847 (20.7)		4316 (4.7)	5508 (18.5)
≥75 000	72 (0.6)	2155 (52.8)		1340 (1.5)	18 170 (61.2)
Unknown	1398 (10.7)	371 (9.1)	.04	10 739 (11.8)	1941 (6.5)	<.001
Marital status
Married	6770 (51.7)	3718 (91.0)	<.001	48 475 (53.3)	27 202 (91.6)	<.001
Unmarried or unknown	6324 48.3)	366 (9.0)	<.001	42 516 (46.7)	2469 (8.4)	<.001
No. of prenatal care visits, mean (SD)	10.4 (4.0)	10.7 (3.3)	<.001	10.5 (4.1)	10.6 (3.21)	<.001
First-trimester prenatal care initiation	9694 (74.0)	3755 (91.9)	<.001	68 125 (74.9)	26 829 (90.3)	<.001
Prior diagnosis of depression or anxiety	1181 (9.0)	317 (7.8)	<.001	15 905 (17.5)	3526 (11.9)	<.001
Chronic conditions	3670 (28.0)	687 (16.8)	<.001	25 939 (28.5)	5354 (18.0)	<.001
Maternal complications	1195 (9.1)	486 (11.9)	<.001	10 710 (11.8)	4079 (13.7)	<.001
Preterm birth	1070 (8.2)	251 (6.2)	<.001	8067 (8.9)	2008 (6.8)	<.001
Cesarean delivery	2858 (21.8)	1201 (29.4)	<.001	21 011 (23.1)	8589 (28.9)	<.001

Open in a new tab

^{^a}

Data are presented as No. (%) unless indicated otherwise. Percentages may not sum to 100% owing to rounding. The prepolicy period comprised 2013 quarter 1 to 2013 quarter 4 (January 1 to December 31, 2013); the postpolicy period comprised 2014 quarter 1 to 2018 quarter 4 (January 1, 2014, to December 31, 2018).

^{^b}

Includes American Indian or Alaska Native, Native Hawaiian or Other Pacific Islander, and unknown race.

Figure 1, Figure 2, and Figure 3 show unadjusted plots of rates of billed PPD screens during well-child visits, postpartum mood or anxiety disorder diagnoses, and prescription drug and outpatient mental health treatment in the postpartum year in the Medicaid-insured and commercially insured groups. Billed PPD screens during well-child visits and diagnoses for postpartum mood and anxiety disorders among Medicaid-insured and commercially insured patients increased during the postpolicy period, with larger increases among Medicaid-insured patients. In 2019, the last year of our study period, billed PPD screens during well-child visits occurred following 32.3% of Medicaid-insured births.

Figure 3. — The graphs show the unadjusted quarterly proportions of births for which the mother had at least 1 outpatient mental health visit (A) and at least 1 fill for a prescription medication for a mood or anxiety disorder (B) among mothers in the postpartum year. The dashed vertical line indicates when Colorado began reimbursing for depression screening during well-child visits in January 2014. Q indicates quarter.

Table 2 shows unadjusted outcome rates before and after Colorado began reimbursing for PPD screening during well-child visits as well as adjusted difference-in-differences estimates. In adjusted difference-in-differences models, reimbursement for PPD screening during well-child visits was associated with a 9.60-ppt (95% CI, 9.10-10.00 ppt) increase in billed maternal depression screening during well-child visits (P < .001) and 0.18 (95% CI, 0.17-0.19) additional billed screens per birth during the postpartum year (P < .001)—or 18 additional screens per 100 births—in the Medicaid-insured group compared with the commercially insured group (Table 2). The policy was also associated with a 2.50-ppt (95% CI, 1.40-3.50 ppt) increase in any diagnosis for a postpartum mood or anxiety disorder in the postpartum year (P < .001). We found that the policy was associated with a 3.30-ppt (95% CI, −4.60 to 2.00 ppt) decrease in prescription medication (P < .001) but a 3.30-ppt (95% CI, 2.50-4.10 ppt) increase in any outpatient mental health treatment (P < .001) in the Medicaid-insured vs commercially insured groups.

Table 2. Changes in Postpartum Screening, Diagnosis, and Treatment Outcomes by Insurance Type Before and After Colorado Began Reimbursement for Postpartum Depression Screenings During Well-Child Visits^a.

Outcome during postpartum year	Medicaid			Commercial insurance			Adjusted difference-in-differences estimate, ppt (95% CI)	P value
Outcome during postpartum year	Prepolicy period	Postpolicy period	Change from prepolicy period to postpolicy period, ppt (95% CI)	Prepolicy period	Postpolicy period	Change from prepolicy period to postpolicy period, ppt (95% CI)	Adjusted difference-in-differences estimate, ppt (95% CI)	P value
Screening during well-child visit, %	0.11	18.22	18.11 (17.45 to 18.77)	0^b	8.31	8.31 (7.26 to 8.95)	9.60 (9.17 to 10.08)	<.001
No. of screenings occurring during well-child visits per 100 births	0.001	0.33	0.33 (0.31 to 0.34)	0.001	0.14	0.14 (0.12 to 0.16)	0.18 (0.17 to 0.19)	<.001
Any PMAD diagnosis, %	11.15	22.05	10.91 (10.17 to 11.65)	9.28	15.78	6.50 (5.30 to 7.60)	2.50 (1.40 to 3.50)	<.001
Any prescription fill for depression or anxiety medication, %	20.00	18.97	−1.02 (−1.71 to −0.30)	13.91	14.57	0.70 (−0.40 to 1.90)	−3.30 (−4.60 to −2.00)	<.001
Any outpatient mental health treatment, %	3.05	7.81	4.76 (4.29 to 5.23)	4.90	5.85	0.95 (0.19 to 1.70)	3.30 (2.50 to 4.10)	<.001

Open in a new tab

Abbreviations: PMAD, postpartum mood or anxiety disorder; ppt, percentage point.

^{^a}

The prepolicy period comprised 2013 quarters 1 to 4 (January 1 to December 31, 2013); the postpolicy period comprised 2014 quarter 1 to 2018 quarter 4 (January 1, 2014, to December 31, 2018).

^{^b}

Value was rounded to 0 due to small sample sizes (n < 10).

Event study plots are shown in eFigures 1 to 5 in Supplement 1. Results of F-tests of the null hypothesis that the prepolicy interaction terms were equal to zero were nonsignificant for all outcomes (eTable 1 in Supplement 1). Trends in covariates were also relatively stable over time in both the Medicaid-insured group and the commercially insured group (eFigures 6-15 in Supplement 1). Interrupted time series analyses and event study plots indicated an attenuation of differences in outcomes associated with the policy between the Medicaid-insured group and the commercially insured group in the postpolicy period as outcome rates increased among commercially insured patients (eFigure 16 and eTable 2 in Supplement 1). The results did not change substantively when controlling for the total number of well-child visits (eTable 3 in Supplement 1).

Discussion

In this difference-in-differences analysis, we found that Colorado’s 2014 Medicaid reimbursement of PPD screenings during well-child visits was associated with an increase in the rate and number of depression screens practitioners billed for during well-child visits among Medicaid-insured patients compared with patients in a commercially insured group. We also found that reimbursement was associated with significant increases in the rates of mood and anxiety disorder diagnoses and outpatient mental health treatment but decreases in rates of prescription fills for medications for mood or anxiety disorders. These findings suggest that paying pediatric practitioners to screen for PPD during well-child visits may increase screening and detection rates, with more modest effects on treatment.

Despite significant increases associated with Medicaid reimbursement, rates of billed screens for PPD during well-child visits reached a maximum of approximately one-third of Medicaid-insured births by the end of the study period. Take-up among pediatric practitioners may remain constrained if financial incentives are not large enough to change behavior, though relative to the 45 other states that currently reimburse for PPD screenings during well-child visits, Colorado provides the most generous reimbursement in the country ($31.59 for a positive screen and $11.38 for a negative screen).²⁰ Other barriers faced by pediatricians may include lack of time, lack of training and referral support, or a perception that maternal depression screening is outside the purview of pediatric care.³⁴ Pediatric practitioners may also conduct screenings that they do not bill for, particularly in Federally Qualified Health Centers and Rural Health Clinics, which are often paid via lump sum rather than fee-for-service. The Colorado Department of Health Care Policy and Financing, which oversees the state Medicaid program, acknowledges challenges with billing for maternal depression screening that may affect screening rates obtained from administrative claims data.³⁵ However, in Colorado, health centers are required to submit line-level procedure codes on claims, and provider bulletins from the state Medicaid agency provide specific instructions for how to bill for screening.²⁵

The benefits of screening interventions are maximized when screening is combined with referral, follow-up, and treatment, if appropriate.^5,36 Our findings suggest that policies that only target screening may not translate into large gains in treatment.^29,35 This could be for several potential reasons. The increase in the proportion of enrollees screened during well-child visits may not be large enough to result in observable increases in population-level treatment rates. Those who were screened in well-child visits after the reimbursement policy went into effect may have also been screened in other settings, resulting in duplicative detection that did not result in increased rates of treatment. It is also possible that despite an increase in screening, referrals to treatment originating from pediatric settings pose unique challenges, including lack of referral resources and/or comfort making referrals among pediatric practitioners who may be less familiar with mental health care options for adults or who may practice in separate networks.^22,37,38

However, the magnitude of the associations we observed are notable in light of several factors that have the potential to attenuate differences in outcomes between the Medicaid-insured and commercially insured groups in the postpolicy period. First, the Affordable Care Act required that all commercial insurers cover USPTF-recommended preventive services with no patient cost-sharing starting in 2010, and in 2016, the USPTF recommended an annual depression screening for adults, including postpartum women. This policy likely contributed to the increases in screening, diagnosis, and treatment rates among the commercially insured group, particularly after 2016. Relatedly, while commercial adoption of reimbursement for PPD screening during well-child visits lagged behind Medicaid’s adoption of this benefit nationally and in Colorado, an increasing number of plans began including this benefit during the study period. However, exact information on which plans did so, and when, is not publicly available. This may partly explain why we observed some convergence in screening and diagnosis rates over time, with an uptick around 2016 as more plans began reimbursing for this service, potentially in response to the USPTF recommendation.

Underreporting of screening in health centers, which disproportionately serve Medicaid patients, may have resulted in greater levels of underdetection of screening in the Medicaid group. Additionally, because decisions regarding universal screening are likely made at the practice-level based on a payer mix and financial factors, there may be spillover from a reimbursement policy targeting Medicaid patients to commercially-insured patients. Collectively, these factors bias our findings toward the null, yet we still detected significant positive associations for screening, diagnosis, and outpatient treatment, suggesting that policy effects may be larger than indicated by our findings. Of note, clinical guidelines, including the Centers for Medicare & Medicaid Services informational bulletin,²⁰ the USPTF recommendation,⁵ and the AAP policy statement,¹⁷ may have affected clinical practice broadly and therefore enrollees in both Medicaid and commercial insurance during the study period. This may account for some of the increases in diagnosis rates observed among both groups; however, in the context of a difference-in-differences study, this would not explain differential results observed among Medicaid-insured vs commercially insured groups.

This study has a number of implications for clinical practice and policy. Our findings suggest that financial incentives are not sufficient to achieve universal PPD screening in well-child visits when measured by billed claims, and pediatric practitioners may need additional supports, such as training and referral guidance, in order to fully adopt this evidence-based practice. While all but 5 US states reimburse for PPD screening in well-child visits in Medicaid, policy design varies in terms of screening tools, number of screens covered, reimbursement amount, and referral guidance.²⁰ Some states also cover PPD screenings as part of a well-child care bundled payment, in which case the payment is not fee-for-service and may not provide a strong financial incentive for adoption. Additionally, only about 10% of Colorado Medicaid beneficiaries are enrolled in Medicaid-managed care plans—a much lower proportion relative to other states, which may affect how fee-for-service based reimbursement incentives affect pediatric practitioners in Colorado relative to states with higher rates of Medicaid managed care plan reliance.³⁹ Growing use of multidimensional screening tools in recent years, such as the Survey of Well-Being Young Children,⁴⁰ which includes a maternal depression screening tool in the 2-, 4-, and 6-month screening, may have since enhanced maternal depression screening adoption.

Our findings also suggest that reimbursement was associated with a modest increase in rates of outpatient treatment but a decrease in rates of prescription medication. Promising strategies to increase referral and treatment rates after a positive screen in pediatric settings have been identified in the literature and include practitioner training, referral tracking and follow-up, psychiatric access programs, colocated adult and pediatric care, integrated physical and behavioral health care, and the presence of community-based care managers or social workers.⁴¹ While shown to be effective, these interventions can be time-intensive and are generally not reimbursable under current care delivery models. Moreover, these interventions may not be able to overcome wide-scale shortages of mental health professionals or primary care practitioners who accept Medicaid insurance who can provide mental health counseling or medication management.

Limitations

This study has several limitations. First, our outcomes relied on administrative claims data and therefore did not capture rates of screening and diagnosis that are not billed for or other interventions that were free or paid for out-of-pocket, such as community mental health programs or support groups. Second, Colorado expanded Medicaid to low-income adults with incomes below 138% of the federal poverty level in January 2014, which increased the duration of Medicaid coverage for some postpartum individuals.⁴² To address this, we restricted our analysis to those with 12 months of continuous postpartum enrollment and examined the composition of both groups over time. Third, we were unable to examine outcomes only among those who were screened during well-child visits due to small sample sizes. Future research should evaluate the effects of reimbursement policies on treatment outcomes specifically among those who were screened in pediatric settings.

Conclusions

The findings of this cohort study suggest that Medicaid reimbursement for maternal depression screening during well-child visits may increase rates of detection, postpartum mood or anxiety disorder diagnoses, and outpatient mental health treatment among mothers in the postpartum year. Since 2021, nearly all US states, including Colorado, have extended Medicaid coverage for all pregnant individuals from 60 days to 1 year post partum under an option provided in the American Rescue Plan Act, which may increase access to mental health treatment in the year after birth.²⁷ Other interventions to address high rates of postpartum maternal mental health conditions among Medicaid enrollees should target the continuum of mental health care for maternal depression rather than screening only, including barriers to screening adoption among pediatric practitioners and expanding access to community mental health resources.

Supplement 1.

eMethods 1. Description of Data and Sample Size by Year and Treatment

eMethods 2. Definitions of Outcomes Measures

eMethods 3. Definition of Covariates

eMethods 4. Event Study Specification

eFigure 1. Event Study Plot for Rate of Any Maternal Depression Screening During a Well-Child Visit in the Postpartum Year

eFigure 2. Event Study Plot for Number of Maternal Depression Screenings During a Well-Child Visit Per Birth in the Postpartum Year

eFigure 3. Event Study Plot for Rate of Any Diagnosis for a Postpartum Mood or Anxiety Disorder in the Postpartum Year

eFigure 4. Event Study Plot for Rate of Any Outpatient Mental Health Treatment in the Postpartum Year

eFigure 5. Event Study Plot for Rate of Any Prescription Treatment for Depression or Anxiety in the Postpartum Year Prescription Treatment

eTable 1. F-Test of Joint Significance of Prepolicy Period Event Study Coefficients

eFigure 6. Average Maternal Age Trend by Treatment

eFigure 7. Proportion of Births to Black, Hispanic, White, or Other Racial or Ethnic Minority Group Mothers in Commercial vs Medicaid Insurance, 2013-2019

eFigure 8. Proportion of Births Outside the US in Commercial vs Medicaid Insurance, 2013-2019

eFigure 9. Proportion of Births With Mother Graduating From High School or College in Commercial vs Medicaid Insurance, 2013-2019

eFigure 10. Proportion of Births With Mother Married in Commercial vs Medicaid Insurance, 2013-2019

eFigure 11. Prenatal Care Initiation in First Trimester in Commercial vs Medicaid Insurance, 2013-2019

eFigure 12. Adverse Health and Birth Outcomes in Medicaid vs Commercial Insurance, 2013-2019

eFigure 13. Proportion of Births by Income in Commercial vs Medicaid Insurance, 2013-2019

eFigure 14. Proportion of Births in Rural Regions in Commercial vs Medicaid Insurance, 2013-2019

eFigure 15. Proportion of Births With Prior Mood and Anxiety Disorder Diagnosis

eFigure 16. Interrupted Time Series Analysis of Medicaid Reimbursement for Maternal Depression Screening in Colorado after Medicaid vs Commercially Insured Births

eTable 2. Slope Changes from Interrupted Time Series Analysis of Medicaid Reimbursement for Maternal Depression Screening in Colorado After Medicaid vs Commercially Insured Births

eTable 3. Changes in Postpartum Screening, Diagnosis, and Treatment Outcomes Before vs After Colorado Began Reimbursement for Postpartum Depression Screenings in Well-Child Visits in January 2014, Adjusting for Total Well-Child Visits

jamapediatr-e251790-s001.pdf^{(1.3MB, pdf)}

Supplement 2.

Data Sharing Statement

jamapediatr-e251790-s002.pdf^{(14.3KB, pdf)}

References

1.Farías-Antúnez S, Xavier MO, Santos IS. Effect of maternal postpartum depression on offspring’s growth. J Affect Disord. 2018;228:143-152. doi: 10.1016/j.jad.2017.12.013 [DOI] [PubMed] [Google Scholar]
2.Dean DC III, Planalp EM, Wooten W, et al. Association of prenatal maternal depression and anxiety symptoms with infant white matter microstructure. JAMA Pediatr. 2018;172(10):973-981. doi: 10.1001/jamapediatrics.2018.2132 [DOI] [PMC free article] [PubMed] [Google Scholar]
3.Slomian J, Honvo G, Emonts P, Reginster JY, Bruyère O. Consequences of maternal postpartum depression: A systematic review of maternal and infant outcomes. Womens Health (Lond). 2019;15:1745506519844044. doi: 10.1177/1745506519844044 [DOI] [PMC free article] [PubMed] [Google Scholar]
4.Liu Y, Kaaya S, Chai J, et al. Maternal depressive symptoms and early childhood cognitive development: a meta-analysis. Psychol Med. 2017;47(4):680-689. doi: 10.1017/S003329171600283X [DOI] [PubMed] [Google Scholar]
5.Siu AL, Bibbins-Domingo K, Grossman DC, et al. ; US Preventive Services Task Force . Screening for depression in adults: US Preventive Services Task Force recommendation statement. JAMA. 2016;315(4):380-387. doi: 10.1001/jama.2015.18392 [DOI] [PubMed] [Google Scholar]
6.Posmontier B. Functional status outcomes in mothers with and without postpartum depression. J Midwifery Womens Health. 2008;53(4):310-318. doi: 10.1016/j.jmwh.2008.02.016 [DOI] [PMC free article] [PubMed] [Google Scholar]
7.Vliegen N, Casalin S, Luyten P, et al. Hospitalization-based treatment for postpartum depressed mothers and their babies: rationale, principles, and preliminary follow-up data. Psychiatry. 2013;76(2):150-168. doi: 10.1521/psyc.2013.76.2.150 [DOI] [PubMed] [Google Scholar]
8.Wang SY, Chen CH, Chin CC, Lee SL. Impact of postpartum depression on the mother-infant couple. Birth. 2005;32(1):39-44. doi: 10.1111/j.0730-7659.2005.00335.x [DOI] [PubMed] [Google Scholar]
9.Darcy JM, Grzywacz JG, Stephens RL, Leng I, Clinch CR, Arcury TA. Maternal depressive symptomatology: 16-month follow-up of infant and maternal health-related quality of life. J Am Board Fam Med. 2011;24(3):249-257. doi: 10.3122/jabfm.2011.03.100201 [DOI] [PMC free article] [PubMed] [Google Scholar]
10.Rankin L, Mendoza NS, Grisham L. Unpacking perinatal experiences with opioid use disorder: relapse risk implications. Clin Soc Work J. 2023;51(1):34-45. doi: 10.1007/s10615-022-00847-x [DOI] [PMC free article] [PubMed] [Google Scholar]
11.Pope CJ, Xie B, Sharma V, Campbell MK. A prospective study of thoughts of self-harm and suicidal ideation during the postpartum period in women with mood disorders. Arch Womens Ment Health. 2013;16(6):483-488. doi: 10.1007/s00737-013-0370-y [DOI] [PubMed] [Google Scholar]
12.Rogers A, Obst S, Teague SJ, et al. Association between maternal perinatal depression and anxiety and child and adolescent development: a meta-analysis. JAMA Pediatr. 2020;174(11):1082-1092. doi: 10.1001/jamapediatrics.2020.2910 [DOI] [PMC free article] [PubMed] [Google Scholar]
13.Pollack LM, Chen J, Cox S, et al. Healthcare utilization and costs associated with perinatal depression among Medicaid enrollees. Am J Prev Med. 2022;62(6):e333-e341. doi: 10.1016/j.amepre.2021.12.008 [DOI] [PMC free article] [PubMed] [Google Scholar]
14.Luca DL, Margiotta C, Staatz C, Garlow E, Christensen A, Zivin K. Financial toll of untreated perinatal mood and anxiety disorders among 2017 births in the United States. Am J Public Health. 2020;110(6):888-896. doi: 10.2105/AJPH.2020.305619 [DOI] [PMC free article] [PubMed] [Google Scholar]
15.Rokicki S. Perinatal depression associated with increased pediatric emergency department use and charges in the first year of life. Health Aff (Millwood). 2024;43(4):477-485. doi: 10.1377/hlthaff.2023.01443 [DOI] [PubMed] [Google Scholar]
16.Pluym ID, Holliman K, Afshar Y, et al. Emergency department use among postpartum women with mental health disorders. Am J Obstet Gynecol MFM. 2021;3(1):100269. doi: 10.1016/j.ajogmf.2020.100269 [DOI] [PMC free article] [PubMed] [Google Scholar]
17.Earls MF, Yogman MW, Mattson G, Rafferty J; Committee on Psychosocial Aspects of Child and Family Health . Incorporating recognition and management of perinatal depression into pediatric practice. Pediatrics. 2019;143(1):e20183259. doi: 10.1542/peds.2018-3259 [DOI] [PubMed] [Google Scholar]
18.State of health care quality report. National Committee for Quality Assurance . 2013. Accessed November 6, 2024. https://www.ncqa.org/report-cards/health-plans/state-of-health-care-quality-report/
19.Leiferman JA, Dauber SE, Scott K, Heisler K, Paulson JF. Predictors of maternal depression management among primary care physicians. Depress Res Treat. 2010;2010:671279. doi: 10.1155/2010/671279 [DOI] [PMC free article] [PubMed] [Google Scholar]
20.Maternal depression screening and treatment: a critical role for Medicaid in the care of mothers and children. Centers for Medicare & Medicaid Services . May 11, 2016. Accessed November 6, 2024. https://www.medicaid.gov/federal-policy-guidance/downloads/cib051116.pdf
21.Freeman MP, Wright R, Watchman M, et al. Postpartum depression assessments at well-baby visits: screening feasibility, prevalence, and risk factors. J Womens Health (Larchmt). 2005;14(10):929-935. doi: 10.1089/jwh.2005.14.929 [DOI] [PubMed] [Google Scholar]
22.Guevara JP, Gerdes M, Rothman B, et al. Screening for parental depression in urban primary care practices: a mixed methods study. J Health Care Poor Underserved. 2016;27(4):1858-1871. doi: 10.1353/hpu.2016.0167 [DOI] [PubMed] [Google Scholar]
23.Byatt N, Biebel K, Friedman L, Debordes-Jackson G, Ziedonis D. Women’s perspectives on postpartum depression screening in pediatric settings: a preliminary study. Arch Womens Ment Health. 2013;16(5):429-432. doi: 10.1007/s00737-013-0369-4 [DOI] [PubMed] [Google Scholar]
24.Kornfeind K, Bauer N, Garner A, et al. Primary care pediatricians’ current screening practices for developmental delay, maternal depression, and social determinants of health. American Academy of Pediatrics . Updated May 20, 2020. Accessed April 24, 2024. https://www.aap.org/en/research/pas-abstracts/primary-care-pediatricians-current-screening-practices-for-developmental-delay-maternal-depression/
25.Provider bulletins. Colorado Dept of Health Care Policy and Financing . Accessed November 6, 2024. https://hcpf.colorado.gov/bulletins
26.Nakić Radoš S, Tadinac M, Herman R. Anxiety during pregnancy and postpartum: course, predictors and comorbidity with postpartum depression. Acta Clin Croat. 2018;57(1):39-51. doi: 10.20471/acc.2018.57.01.05 [DOI] [PMC free article] [PubMed] [Google Scholar]
27.Gordon SH, Lee S, Steenland MW, Deen N, Feinberg E. Extended postpartum Medicaid in Colorado associated with increased treatment for perinatal mood and anxiety disorders. Health Aff (Millwood). 2024;43(4):523-531. doi: 10.1377/hlthaff.2023.01441 [DOI] [PMC free article] [PubMed] [Google Scholar]
28.HEDIS and performance measurement. National Committee for Quality Assurance . Accessed March 3, 2024. https://www.ncqa.org/hedis/
29.Ballenger JC. Anxiety and depression: optimizing treatments. Prim Care Companion J Clin Psychiatry. 2000;2(3):71-79. [DOI] [PMC free article] [PubMed] [Google Scholar]
30.Geier ML, Hills N, Gonzales M, Tum K, Finley PR. Detection and treatment rates for perinatal depression in a state Medicaid population. CNS Spectr. 2015;20(1):11-19. doi: 10.1017/S1092852914000510 [DOI] [PubMed] [Google Scholar]
31.Attanasio LB, Ranchoff BL, Cooper MI, Geissler KH. Postpartum visit attendance in the United States: a systematic review. Womens Health Issues. 2022;32(4):369-375. doi: 10.1016/j.whi.2022.02.002 [DOI] [PMC free article] [PubMed] [Google Scholar]
32.Abdus S, Selden TM. Well-child visit adherence. JAMA Pediatr. 2022;176(11):1143-1145. doi: 10.1001/jamapediatrics.2022.2954 [DOI] [PMC free article] [PubMed] [Google Scholar]
33.Kozhimannil KB, Trinacty CM, Busch AB, Huskamp HA, Adams AS. Racial and ethnic disparities in postpartum depression care among low-income women. Psychiatr Serv. 2011;62(6):619-625. doi: 10.1176/ps.62.6.pss6206_0619 [DOI] [PMC free article] [PubMed] [Google Scholar]
34.Yu M, Sampson M. Pediatrician attitudes and practices regarding postpartum depression screening: training and interprofessional collaboration needed. J Interprof Educ Pract. 2019;15:1-4. doi: 10.1016/j.xjep.2018.12.005 [DOI] [Google Scholar]
35.Health First Colorado Maternity Report: an analysis of 2019 births. Colorado Dept of Health Care Policy and Financing . September 2021. Accessed November 6, 2024. https://hcpf.colorado.gov/sites/hcpf/files/Maternity%20Report%20-%20Sept2021.pdf
36.ACOG Committee opinion No. 757: screening for perinatal depression. Obstet Gynecol. 2018;132(5):e208-e212. doi: 10.1097/AOG.0000000000002927 [DOI] [PubMed] [Google Scholar]
37.Heneghan AM, Chaudron LH, Storfer-Isser A, et al. Factors associated with identification and management of maternal depression by pediatricians. Pediatrics. 2007;119(3):444-454. doi: 10.1542/peds.2006-0765 [DOI] [PubMed] [Google Scholar]
38.Kerker BD, Storfer-Isser A, Stein REK, et al. Identifying maternal depression in pediatric primary care: changes over a decade. J Dev Behav Pediatr. 2016;37(2):113-120. doi: 10.1097/DBP.0000000000000255 [DOI] [PMC free article] [PubMed] [Google Scholar]
39.Managing Medicaid in Colorado. Colorado Health Institute . March 10, 2023. Accessed November 6, 2024. https://www.coloradohealthinstitute.org/research/managing-medicaid-colorado
40.Survey of Well-Being of Young Children. TEAM UP Scaling and Sustainability Center . Accessed December 4, 2024. https://www.tuftsmedicine.org/medical-professionals-trainees/academic-departments/department-pediatrics/survey-well-being-young-children
41.Olin SS, McCord M, Stein REK, et al. Beyond screening: a stepped care pathway for managing postpartum depression in pediatric settings. J Womens Health (Larchmt). 2017;26(9):966-975. doi: 10.1089/jwh.2016.6089 [DOI] [PMC free article] [PubMed] [Google Scholar]
42.Gordon SH, Sommers BD, Wilson IB, Trivedi AN. Effects of medicaid expansion on postpartum coverage and outpatient utilization. Health Aff (Millwood). 2020;39(1):77-84. doi: 10.1377/hlthaff.2019.00547 [DOI] [PMC free article] [PubMed] [Google Scholar]

Associated Data

This section collects any data citations, data availability statements, or supplementary materials included in this article.

Supplementary Materials