Workforce Serving Pregnant and Postpartum Medicaid Enrollees at Community Health Centers, 2016 to 2021

Abstract

Introduction:

Community Health Centers (CHCs) care for nearly a third of all pregnant Medicaid enrollees. Given that Medicaid covers 41% of childbirths, CHCs play a critical role in ensuring pregnant enrollees’ access to perinatal services. Despite their importance, little is known about the CHC workforce serving these patients. This study uses multi-state Medicaid claims data to analyze the providers caring for pregnant Medicaid enrollees at CHCs.

Methods:

Our primary data source was the Transformed Medicaid Statistical Information System (T-MSIS) Analytical File (TAF), 2016 to 2021. We identified all pregnant and postpartum Medicaid enrollees that received care at CHCs and examined the workforce serving this population from the following specialties: Obstetricians and Gynecologists (OBGYNs), Nurse Practitioners (NPs), Family Physicians (FPs), and Physician Associates (PAs). We summarized the annual number of providers from each specialty and total number of pregnant and postpartum enrollees served per year. Since the study period overlapped with the COVID-19 pandemic, we also examined the provision of telehealth by this workforce.

Results:

The workforce serving pregnant Medicaid enrollees at CHCs each year grew 23% during the study period (22 027-28 668 providers), and that serving postpartum enrollees increased by 20% (25 655-32 026). Total annual number of NPs experienced faster growth than FPs for both pregnant (31% vs 17%) and postpartum enrollee care (27% vs 17%). OBGYN and PA counts remained relatively stable during the study period. The number of providers that served pregnant and postpartum Medicaid enrollees via telehealth peaked in April 2020. Each year, OBGYNs served about 140 pregnant enrollees per provider, compared to 30 for FPs, 20 for NPs, and 10 for PAs. Similarly, the average number of postpartum enrollees served was steady during the study period: OBGYNs served around 70, FPs 20, and both NPs and PAs approximately 10 postpartum enrollees each year.

Discussion:

This unique analysis of data from Medicaid claims showed growth in the CHC perinatal workforce and highlighted the role played by providers from certain specialties and professions in caring for pregnant Medicaid enrollees. Policymakers could leverage these findings to design targeted investments for high-impact provider groups within the CHC perinatal workforce.

Introduction

Community Health Centers (CHCs) are a vital component of the U.S. healthcare system. They serve nearly 1 in 6 Medicaid enrollees and provide perinatal care to roughly 560 000 individuals. ¹ Given that Medicaid covers 41% of all childbirths nationally, CHCs play a critical role in ensuring access to prenatal and postpartum services, particularly for disadvantaged populations. ² However, despite their significance, the workforce serving pregnant Medicaid enrollees at CHCs remains largely understudied. This lack of understanding becomes increasingly important, since CHCs are projected to significantly increase the patient population they currently serve and the workforce they employ. A recent study by Putnam et al ³ highlighted that about 41% of CHCs provide prenatal care, typically larger centers with multidisciplinary teams, serving higher proportions of non-white or non-English-speaking patients. This underscores the role of CHCs as crucial access points for underserved communities, especially pregnant people. However, Putnam’s et al’s data was drawn from a limited set of CHCs (408), did not provide workforce trends, and did not specifically focus on those covered by Medicaid.

This study addresses a knowledge gap by exploring the characteristics and dynamics of the workforce serving pregnant Medicaid enrollees at CHCs using multi-year, multi-state Medicaid claims data. By shedding light on this essential aspect of healthcare delivery, we hope to inform strategies for improving maternal and infant health outcomes within this critical setting.

Methods

Data

This study utilized 2016 to 2021 data from the Transformed Medicaid Statistical Information System (T-MSIS) Analytical File (TAF) and the National Plan and Provider Enumeration System (NPPES) for the years 2016 to 2021.^1,4,5 TAF was the main data source, providing comprehensive information on pregnant Medicaid enrollees’ service utilization. We focused on key files, including Annual Demographic and Eligibility (DE), Inpatient claims, Annual Provider, and the Other services (OT) claims. To complement and focus our analysis on the workforce at CHCs, we leveraged a data set which identified National Provider Identifiers (NPIs) associated with CHCs (see Appendix C for details). The NPPES also provided standardized information such as specialty taxonomy codes of healthcare providers serving Medicaid enrollees.

Sample

The study sample included all providers who were listed as service providers on claims for pregnant Medicaid enrollees at CHCs in 28 states and DC. Since an accurate estimation of pregnant enrollees is required to identify providers who served them, we excluded 14 states that did not have reliable estimates of the number of enrollees who had delivered according to prior CMS reports. ⁶ Next, we excluded 4 states that had low-quality TAF data during the study period; data quality assessments were adopted from methods described in prior studies.^{7 -9} Finally, since we focused on monthly workforce trends, 4 states that did not have any CHC provider serving Medicaid enrollees during any month of the study period were excluded. See Appendix A for the list of states that were excluded under each condition. The final analytical sample included data from around 1,280 CHCs each year.

Analysis

We began by identifying all pregnant Medicaid enrollees and assigning a date of delivery to each enrollee, using a 5-step algorithm published by CMS which identifies enrollees that had a delivery (see Appendix B). ¹⁰ Next, we identified all professional (OT) claims associated with pregnant enrollees 296 days prior to the delivery event (prenatal period) and 365 days post the delivery event (postpartum period). We limited prenatal and postpartum period claims data based upon whether the billing NPI on a claim was associated with a CHC. For this step of the analysis, we used a proprietary database to identify all organizational billing NPIs that CHCs use for claims billing (Appendix C). We then calculated, at the individual provider-level NPI, the number of pregnant enrollees rendered any service (including telehealth) during each year and month of the study period (Appendix D). We focused on telehealth services since the study period included the early years of the COVID-19 pandemic. We used NPPES data to obtain the specialty and profession of each provider in the sample. Due to their documented role in perinatal care, we focused on the following specialties and professions: Obstetricians and Gynecologists (OBGYNs), Nurse Practitioners (NPs), Family Physicians (FPs), and Physician Associates (PAs).

Notably, we did not have complete information about whether an enrollee was in their prenatal period during the year 2021, since some of them delivered during the year 2022, which was not part of the study period. Consequently, the study period for all analyses of the workforce serving pregnant Medicaid enrollees is restricted to the years 2016 to 2020. Similarly, we did not have complete information about whether an enrollee was in their postpartum period during the year 2016, since some of these enrollees had a delivery in the year 2015, which was not part of the study period. As a result, the study period for all analyses of the workforce serving postpartum Medicaid enrollees is restricted to the years 2017 to 2021.

Measures

We summarized the annual numbers of providers who cared for pregnant and postpartum enrollees during the study period. Having data across multiple years allowed us to capture perinatal service provision more accurately. In additional analyses, we also examined monthly patterns in the number of providers to identify shifts in care delivery that may have resulted from disruptions related to the COVID-19 pandemic. We also measured the mean number of pregnant and postpartum enrollees served by providers from select specialties and professions. Stata 18 was used for all analyses. ¹¹

Results

In our sample, the total number of providers serving pregnant Medicaid enrollees at CHCs each year grew 23% from 2016 to 2020 (22 027-28 668 providers), while the annual number of providers serving postpartum enrollees at CHCs increased 20% from 2017 to 2021 (25 655-32 026; Table 1). Trends in the workforce somewhat mirrored the changes in the number of pregnant and postpartum Medicaid enrollees that received care at CHCs (Appendices E and F). The annual number of pregnant enrollees that received care at CHCs was around 430 000; while a slightly lower number of enrollees received care during their postpartum period (390 000).

Table 1.

Annual CHC Workforce.

Year	Total number of providers serving pregnant Medicaid enrollees	Total number of providers serving postpartum Medicaid enrollees
2016	22 027	N/A
2017	23 905	25 655
2018	26 914	28 444
2019	28 964	30 609
2020	28 668	30 554
2021	N/A	32 026

While the total number of NPs and FPs providing care to pregnant Medicaid enrollees increased from 2016 to 2020, the number of OBGYNs and PAs caring for pregnant and postpartum enrollees remained stable (Figure 1). Similar trends were also observed in the workforce caring for postpartum Medicaid enrollees (Figure 2). Interestingly, the growth in the annual number of NPs providing care to pregnant and postpartum Medicaid enrollees outpaced that of FPs. The total number of NPs serving pregnant enrollees grew by 31%, while the same figure was 17% for Family Physicians. The total number of NPs serving postpartum enrollees grew by 21%, while that of FPs grew by 17%. Additional analysis showed that the number of dentists, social workers, and counselors who served pregnant Medicaid enrollees also increased during the study period (Appendix G).

Figure 1.

Annual CHC workforce from select specialties and professions serving pregnant Medicaid enrollees, 2016 to 2020.

Figure 2.

Annual CHC workforce from select specialties and professions serving postpartum Medicaid enrollees, 2017 to 2021.

The monthly number of providers that served pregnant Medicaid enrollees via telehealth peaked at around 5200 in April 2020, during the early period of the COVID-19 pandemic (Figure 3). This was followed by a drop in this number during the latter part of 2020 and an increase to 5000 in December 2020, which was during the winter surge of 2020. Similarly, as many as 6500 providers served postpartum Medicaid enrollees in April 2020: a level seen again in December 2020, followed by stabilization around 5000 during the year 2021 (Figure 4).

Figure 3.

Monthly CHC workforce providing telehealth to pregnant Medicaid enrollees, 2019 to 2021.

Findings restricted to December 2019 to April 2021, as the analysis did not include complete data for enrollees who had a delivery in 2022.

Figure 4.

Monthly CHC workforce providing telehealth to postpartum Medicaid enrollees, 2019 to 2020.

Finally, analysis of the average annual patient volume showed that the mean number of pregnant enrollees served remained largely stable from 2016 to 2020. Over the study period, on average, OBGYNs served approximately 140 enrollees, FPs 30, NPs 20, and PAs served the lowest number of pregnant enrollees at about 10. (Appendix H). Similarly, the average number of postpartum enrollees served remained stable from 2017 to 2021 (Appendix I) with OBGYNs serving approximately 70 enrollees on average, followed by FPs (20). NPs and PAs both saw around 10 postpartum enrollees on average.

Discussion

This unique analysis of Medicaid claims data from TAF showed that the CHC workforce providing care to pregnant and postpartum Medicaid enrollees significantly increased from 2016 to 2021. Our finding that NPs and FPs progressively assumed a larger role in caring for pregnant and postpartum Medicaid enrollees from 2016 to 2021, possibly reflects the staffing patterns at CHCs. Findings on the lack of significant growth in the number of OBGYNs serving pregnant Medicaid enrollees at CHCs are worrying. Evidence shows that losing access to OBGYNs due to various reasons such as closures of obstetric units in rural areas is associated with poor maternal health outcomes.^12,13 Workforce projections from HRSA indicate that significant shortages in the number of OBGYNs may occur by 2030. ¹⁴ Concurrently, significant growth in the number of NPs is also projected under these estimates. While this analysis focused only on the CHC workforce, our findings are largely consistent with the projections.

Growth in the number of providers that are not typically involved in the care of pregnant individuals (dentists, social workers, and counselors) confirms prior reports that CHCs offer a comprehensive and integrated approach to prenatal care, addressing the multifaceted needs of expectant mothers. ¹⁵ The role of other specialties and professions in perinatal care provision at CHCs, such as the dentists and behavioral health specialists we identified, should be explored by future research.

Additionally, findings suggest that providers across different specialties and professions consistently engaged with a similar number of enrollees on average, without any 1 group significantly increasing their service levels.

Results about the provision of care to pregnant and postpartum Medicaid enrollees via telehealth modalities are consistent with prior work examining trends in telehealth provision for commercially insured pregnant individuals. ⁹ Similar to our results, prior reports showed a surge in telehealth provision to pregnant individuals covered by commercial insurance during the early part of the pandemic, followed by a drop-off in mid-2020 and then another surge during winter 2020. While additional years of Medicaid data will be needed to track telehealth provision beyond the public health emergency, it is promising to find that telehealth continues to remain a healthcare delivery modality for prenatal and postpartum care for Medicaid enrollees. Our findings provide a baseline to assess the impact of telehealth, particularly in the post-partum period in delivering services such as behavioral health care that can be critical to maintaining the health of mothers and their children.

Several upcoming policy developments are likely to impact the workforce that cares for pregnant and postpartum Medicaid enrollees, both at CHCs and at other locations. First, nearly all states have extended Medicaid coverage up to 12 months after delivery, which is likely to increase demand for services from postpartum enrollees. ¹⁶ For CHCs, this may mean continued engagement with the enrollees they care for during pregnancy and will merit the adoption of appropriate workforce arrangements. In parallel, 15 states will implement the CMS TMaH model over the next decade. ¹⁷ TMaH aims to increase the role of doulas and midwives in pregnancy care. Several states are planning to create pathways for doulas and midwives to receive Medicaid reimbursement. CHCs participating in the model will be encouraged to include these professions in their perinatal care workforce in the future. There is also a growing need for CHCs in rural and remote areas to add to the workforce and form partnerships to provide a full range of maternity services needed by pregnant enrollees.

Despite these findings, our analysis has several limitations. First, we did not restrict the underlying patient populations based on their comorbidities, pregnancy outcomes, or risk profile. We also did not restrict or specify the type of service provided. It is possible that high-risk pregnancies and those that did not result in a live birth require a different workforce to manage them. Future research should analyze how CHCs alter their workforce composition to address complex pregnancies. Second, findings are generalizable only to the states and territories included in the analysis, and to the CHCs operating within them. Additionally, we may have missed providers who were not listed as service providers on Medicaid claims. Next, while our analysis summarizes overall trends, individual CHCs may have adopted unique staffing approaches during the study period to care for the pregnant patients they serve. Finally, TAF data has known quality issues and may have had an impact on study findings.

Conclusion

CHCs are indispensable providers of perinatal care for Medicaid enrollees, serving hundreds of thousands of pregnant and postpartum individuals annually. This study offers the first comprehensive, multi-year analysis of the CHC workforce delivering such care, revealing important trends and implications for policy and practice. Growth in NP and FP numbers reflects a growing reliance on non-OBGYN providers to meet needs of pregnant Medicaid enrollees, especially in underserved areas. However, OBGYN numbers remained stagnant, raising concerns given their critical role in managing complex pregnancies and the projected national shortage of these specialists. Including behavioral health and dental providers in perinatal care highlights CHCs’ integrated, team-based approach to addressing the multifaceted needs of expectant mothers. Sustained use of telehealth throughout the pandemic underscores its value as a delivery modality for prenatal and postpartum care, particularly in rural and underserved communities.

As nearly all states have extended Medicaid postpartum coverage to 12 months, demand for services is expected to rise. At the same time, any potential Medicaid funding cuts could strain CHC resources, threatening their ability to maintain or expand their perinatal workforce. Policymakers must consider these pressures and invest strategically in CHCs to ensure continued access to comprehensive, high-quality care for pregnant and postpartum Medicaid enrollees.

Appendices

Appendix A.

Selecting states for analysis.

Appendix B.

Identifying pregnant Medicaid enrollees and assigning a date of delivery.

Step	Relevant TAF File	Logic and purpose
1. Identify enrollees in the enrollment file who qualify for inclusion in the analysis	DE file	To identify enrollees in the population of interest: those who are ever enrolled in Medicaid or CHIP in the calendar year, are female, and are ages 8 to 64 years.
2. Merge claims and enrollment data to create annual IP and OT files for enrollees in the population of interest	IP, OT, and DE files	Only retain those claims matching a beneficiary who qualifies for inclusion in the analytic population.
3. Join header and line-level files	IP and OT files	Each monthly IP and OT TAF RIF consists of 2 files: the header-level file and the line-level file. Certain line- level data elements are required to identify claims or encounters for pregnant and postpartum enrollees, including revenue code (on facility claims only), and CPT or HCPCS procedure codes. Additional header- level data elements are also required to identify pregnant and postpartum enrollees, including diagnosis code and ICD procedure code (on inpatient facility claims only). As a result, each header-level record must be linked with its associated line-level records to evaluate whether the claim qualifies as the delivery of a pregnancy or postpartum service.
4. Identify claims for live birth, stillbirth, or L&D.	IP and OT files	Identify and create a claim-level flag for live birth, stillbirth, and L&D by using diagnosis codes, procedure codes, and revenue center codes (see Identifying Beneficiaries with Severe Maternal Mortality (SMM))
5. Determine estimated date of delivery for each live birth, stillbirth, or L&D event	IP and OT files	In the population of interest, the algorithm identifies enrollees with claims related to live birth, stillbirth, or L&D and then creates an estimated date of delivery. This date is based on the date of admission for inpatient services with claims related to live birth, stillbirth, or L&D. If there is no admission date, then the estimated date of delivery is the earliest date of service from claims in the IP file related to live birth, stillbirth, or L&D.

Appendix C: Creating a Database of Billing NPIs Associated With CHCs

CHCs often have multiple practice locations that can each have their own unique NPI numbers. But prior to the development of this database, they were not all uniquely available in one location or linked with the respective CHC grantee organization, limiting the ability to identify all services provided by CHCs in Medicaid claims data. To address this gap, we linked multiple data sources to create a complete list of CHC NPIs. We used a combination of Uniform Data System (UDS) to identify all CHC “grantees” by year, and combined them with the following data: IRS Form 990 non-profit tax returns, the National Plan and Provider Enumeration System (NPPES), the Medicare Provider Enrollment, Chain, and Ownership System (PECOS), and the AHRQ Compendium of Health Systems. This allowed us to create a richer source of CHC identifiers beyond those found in the UDS and better track organizational relationships, including affiliations with specific health systems. A rigorous and thorough multi-pronged approach was used to collate all CHC site identifiers which included CHC identifiers such as National Provider Identifiers (NPIs), Tax Identification Numbers (TINs), and business names and then linking each identifier with the appropriate NPI. As part of this process, data was deduplicated and cleaned via advanced matching algorithms to associate CHCs with their respective NPIs, TINs, and manually verifying the results. By cross-referencing these identifiers with hospital-related data, we also identified CHCs that were with specific health systems using various sources, including local news and health center websites.

Appendix D: Creating Provider Summary Files

The graphic below summarizes how we calculated the annual number of pregnant or postpartum enrollees served by each provider. We also used a similar method to calculate the monthly number of enrollees by each provider.

Appendix E.

Trends in the Monthly Number of Pregnant Medicaid Enrollees Served at CHCs in their Prenatal Period.

Note: The total number of pregnant enrollees appears to drop during the latter part of 2021, as the analysis did not include complete data for enrollees who had a delivery in 2022.

Appendix F.

Trends in the Monthly Number of Pregnant Medicaid Enrollees Served at CHCs in their Postpartum Period.

Note: The total number of postpartum enrollees appears to be lower during early 2016, as the analysis did not include complete data for enrollees who had a delivery in 2015.

Appendix G.

Changes in select workforce serving pregnant Medicaid enrollees.

Appendix H.

Mean number of pregnant Medicaid enrollees served per year by providers from select specialties and professions, 2016 to 2020.

Appendix I.

Mean number of postpartum Medicaid enrollees served per year by providers from select specialties and professions, 2017 to 2021.