Analytical Piece

Received: 25 January 2022 - Revised: 20 April 2022 - Accepted: 20 April 2022

DOI: 10.1002/pd.6155

R E S E A RCH NOT E

Insurance and geographic variations in non‐invasive prenatal testing

Jacqueline Ellison1 | Catharine Wang2 | Christina Yarrington3 | Philip Connors3 |

Amresh Hanchate4

1Department of Health Services, Policy, and Practice, Brown University School of Public Health, Providence, Rhode Island, USA

2Department of Community Health Sciences, Boston University School of Public Health, Boston, Massachusetts, USA

3Department of Obstetrics and Gynecology, Boston Medical Center, Boston, Massachusetts, USA

4Department of Social Sciences and Health Policy, Wake Forest School of Medicine, Boston, Massachusetts, USA

Correspondence

Jacqueline Ellison, Department of Health

Services, Policy, and Practice, Brown

University School of Public Health, 121 South

Main St, Providence, RI 02912, USA.

Email: [email protected]

Funding information

National Human Genome Research Institute,

Grant/Award Number: R21 HG009567;

Healthcare Research and Quality National

Research Service Award, Grant/Award

Number: 5T32 HS000011

Key points

What is already known about this topic?

� Single‐site studies suggest racial, ethnic, and insurance disparities in use of Non‐invasive

prenatal testing (NIPT).

� Population‐level research from outside the U.S. highlights significant geographic variations

in NIPT uptake.

What does this study add?

� Enrollees living in zip‐codes with a higher proportion of Black and Hispanic/Latino residents

were significantly less likely to receive NIPT.

� Enrollees living in zip‐codes with a higher proportion of people living below the federal

poverty level (FPL) were significantly less likely to receive NIPT.

� Birthing people with Medicaid were five times less likely to receive NIPT than those with

commercial coverage.

Non‐invasive prenatal testing (NIPT) during pregnancy is a highly

sensitive and specific screening tool for chromosomal aneuploidy.

This screening has the highest detection rate for Down syndrome,

and unlike invasive methods, carries no risk for miscarriage or other

pregnancy complications.1,2 In 2012, the American College of

Obstetrician‐Gynecologists (ACOG) recommended that pregnant

people at increased risk for aneuploidy, including those aged 35 and

older, be offered NIPT.3 Because this relatively new technology has

advantages over both traditional serum marker screening and inva-

sive diagnostics with improved detection rate and lower obstetric

risk respectively, quantifying disparities in uptake is particularly

important.

As with other prenatal services in the U.S., inequities in invasive

prenatal testing are well‐established.4,5 Single‐site studies have also

demonstrated disparities in NIPT based on insurance type, race, and

ethnicity, however findings on the role of insurance are

inconclusive.6,7 While important, single‐site studies may not be

generalizable. Given pervasive inequities in access to prenatal care in

the U.S., understanding geographic and insurance coverage dispar-

ities in NIPT use at the population‐level is critical.

Massachusetts (MA) has one of the highest insurance coverage

rates in the country and, by 2015, NIPT was reimbursed by both

public and commercial payers for pregnant residents aged 35 and

older. The state is therefore a ‘best case scenario’ context from

which to understand variations in NIPT uptake. Our objective was to

estimate the population‐level rate of NIPT uptake in Massachusetts

and identify disparities based on insurance type and patient zip‐ code.

We used the 2015 Massachusetts All‐Payer Claims Database,

which represents nearly all healthcare utilization records of Massa-

chusetts residents under the age of 65.8 These data capture service

use, patient age, insurance type, and 5‐digit zip‐code at the time of

1004 - Prenatal Diagnosis. 2022;42:1004–1007. wileyonlinelibrary.com/journal/pd © 2022 John Wiley & Sons Ltd.

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billing. We used 2015 data as this was the first year a specific NIPT

billing code (CPT 81420) was adopted. Using ICD‐9 codes for de-

livery, we identified pregnant patients aged 35 years or older at their

delivery between 7/1/2015 to 12/31/2015 who were eligible for

NIPT use per ACOG guidelines.

Our outcome, NIPT uptake, was defined as the number of

patients who received NIPT per 1000 eligible (i.e., pregnant people

aged 35 and older). We estimated NIPT rates by insurance type,

admission to a teaching hospital, and at the zip‐code level, the

proportion of residents living below 100% of the federal poverty

level (FPL), and the proportion of Black or Hispanic residents.

Focusing on delivery hospital allowed us to capture potential dif-

ferences in practice patterns between affiliates of teaching and

non‐teaching hospitals. Because of documented racial/ethnic and

income disparities in invasive diagnostic testing, and in the absence

of individual sociodemographic information, we used census data

to characterize patient zip‐codes by the proportion of Black/His-

panic and low‐income residents (high vs. low). Our goal was to

assess the role of area‐level sociodemographic characteristics

and NIPT uptake. To distinguish between the high and low cate-

gories, we ranked all zip‐codes in Massachusetts by the overall

proportion of Black/Hispanic and low‐income residents, and

defined zip‐codes in the top 25% of each category as a "high" zip‐ code. We initially examined the proportion of Black and Hispanic

residents separately, however because there was substantial

overlap between the two, we chose to combine these groups.

Finally, we estimated adjusted odds of NIPT using logistic regres-

sion, accounting for insurance type, delivery at a teaching hospital,

and zip‐code sociodemographic composition, and including hospital

random effects and clustered standard errors at the hospital‐level.

Individuals with missing data were dropped from the analysis

(n = 403).

There were 4506 non‐invasive prenatal tests performed on

22,393 pregnant patients aged 35+ (201.2 per 1000) in 2015 (Ta-

ble 1). We observed considerable geographic variation. Patients living

in zip‐codes within and surrounding the Boston metropolitan area

were more likely to receive NIPT, as were those living in Eastern MA

(Figure 1). The observed NIPT rate (per 1000 pregnant individuals

aged 35+) was 48.7 for Medicaid enrollees and 272.1 for commercial

enrollees; 123.0 and 223.2 for patients living in a zip‐code with a high

versus low proportion of Black/Hispanic residents; and 107.7 and

218.4 for those in a zip‐code with a high versus low proportion of

low‐income residents. In adjusted models, pregnant people living in a

zip‐code with a high Black/Hispanic population were significantly less

likely to receive NIPT (aOR:0.80; 95% CI: 0.59–0.95) then people

living outside these zip‐codes, as were those living in low‐income zip‐ codes (aOR:0.80; 95% CI: 0.70–0.93). Medicaid enrollees were less

likely than commercial enrollees to receive NIPT (aOR:0.18; 95% CI:

0.16–0.20).

In this population‐level analysis of NIPT uptake in Massachu-

setts, we found that birthing people covered by Medicaid were over

five times less likely to receive NIPT than their counterparts with

commercial coverage. Lower NIPT rates in zip‐codes with a high

proportion of low‐income or Black/Hispanic residents also suggests

that geographic variations in uptake may reflect racial/ethnic and

income disparities independent of insurance coverage. We found

no significant association between NIPT uptake and delivery at a

teaching hospital.

Our findings on geographic variation are consistent with research

from Australia and the Netherlands which found that people living in

socioeconomically disadvantaged neighborhoods were less likely to

receive NIPT.9,10 The finding that people with Medicaid coverage

were less likely to receive NIPT is inconsistent with a single‐site study

in Wisconsin which found that pregnant people with Medicaid were

more likely to receive NIPT than those with commercial coverage.6

This discrepancy is likely due to the fact that commercial payers in

Wisconsin were not required to reimburse for NIPT. As with the

present study, a single‐site study in Massachusetts also found lower

NIPT uptake among Medicaid enrollees.7 A study performed in Col-

orado which evaluated all prenatal genetic testing found no differ-

ence in uptake between Medicaid and commercial enrollees.11

Inconsistent findings on variation by insurance status highlight the

fundamental role of payer coverage on financial barriers to NIPT, and

how these may drive regional variations in use. In addition to within‐ state variation identified in the present study, there is likely

substantial between‐state variation due to differences in state pol-

icies governing commercial payers and Medicaid programs.

Research is needed to understand reasons for lower NIPT uptake

by Medicaid enrollees in the state, despite coverage of this screening

by the Massachusetts Medicaid program. It is possible that the fa-

cilities where patients with Medicaid receive prenatal care are less

likely to offer NIPT. For example, federally qualified health centers

which serve low‐income populations may not have a lab on site or a

relationship with an NIPT company, both of which are necessary to

offer testing. It is also possible that pregnant Medicaid patients do

not know about, prefer not to undergo, or are not offered NIPT.

Interpersonal racism via clinician discrimination and bias perpetuates

inequities in perinatal service delivery and outcomes.12,13 Structural

racism includes policies governing the distribution of healthcare re-

sources and is another fundamental cause of perinatal health in-

equities.14 Medicaid typically reimburses services at lower rates than

commercial payers, and clinical implementation of NIPT was pre-

dominantly led by industry.15 Consequently, profit‐driven decisions

in the early diffusion of this technology likely prioritized higher‐ income populations.16 Because Black, Hispanic, and low‐income

birthing people are more likely to be covered by Medicaid, discrep-

ancies in NIPT uptake among Medicaid enrollees disproportionately

affect these populations.

This study has limitations. First, we were unable to capture

patient‐level sociodemographic characteristics with insurance claims

data. Zip‐code level proxies are crude measures of patient charac-

teristics and should be interpreted as such. We were also unable to

capture NIPT use by enrollees with coverage through the Veterans

Administration, Tricare, or Medicare, which may offer less generous

coverage for pregnancy‐related services. Given established varia-

tions in state Medicaid programs, our findings may not generalize

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outside of Massachusetts. This study also used data from the early

days of NIPT, and increased awareness of the technology may have

improved uptake since then. Finally, because we could not observe

patient preferences for NIPT, we were unable to determine whether

disparities are a consequence of patient preferences or access bar-

riers. Black patients and those presenting for prenatal care at a later

gestational age are less likely to receive genetic counseling, sug-

gesting that discrepancies in NIPT may be due to provider counseling,

not patient choice.11 It is also important to note that people who did

not receive NIPT may have received other serum screening tests,

such as first trimester or quad screens, or undergone invasive pro-

cedures such as amniocentesis or chorionic villus sampling.

Our findings highlight substantial disparities in NIPT uptake

based on insurance and zip‐code of residence. These disparities likely

reflect established inequities in prenatal care. Research is needed to

identify barriers and facilitators to uptake and to evaluate

TAB L E 1 Rates (per 1000 eligible patients) and adjusted odds of Non‐invasive prenatal testing (NIPT) use

Cohort NIPT rate Adjusted OR (95% CI) P

Total patients (n = 22,393) 201.2

Insurance

Medicaid (n = 7106) 48.7 0.18 (0.16–0.20) <0.001

Commercial (n = 15,287) 272.1 Ref

Teaching hospital

Yes (n = 5025) 182.1 1.15 (0.80–1.67) 0.453

No (n = 17,368) 206.8 Ref

Zip‐code sociodemographicsa

Proportion of Black/Hispanic residents

High (n = 4886) 123.0 0.80 (0.70–0.90) <0.001

Low (n = 14,586) 223.2 Ref

Proportion living below the FPL

High (n = 3584) 107.7 0.80 (0.70–0.93) 0.003

Low (n = 15,886) 218.4 Ref

Note: The model included hospital random effects and clustered standard errors at the hospital level.

Abbreviations: CI, confidence interval; NIPT, non‐invasive prenatal testing; OR, odds ratio; Ref, referent.

The model included hospital random effects and clustered standard errors at the hospital level. aZip‐code sociodemographic indicators were derived from the Census Bureau's American Community Survey and defined based on patient zip‐code at

time of delivery and the population proportion of Black/Hispanic residents or residents living below 100% the FPL within each zip‐code.

F I GUR E 1 Zip‐code variation in Non‐invasive prenatal testing (NIPT) rates (per 1000 eligible patients) [Colour figure can be viewed at wileyonlinelibrary.com]

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interventions to address inequities in NIPT use. Specifically, survey

research to determine which patients are and are not offered NIPT

versus traditional serum screening will be critical moving forward.

Ultimately, our findings suggest that the benefits of NIPT availability

have not been realized in a substantial portion of the population‐ particularly among pregnant people who disproportionately experi-

ence barriers to care.

ACKNOWLEDGMENT

Funding for this study was provided to Amresh Hanchate and

Catharine Wang by the National Institute of Health Human Genome

Research Institute (R21 HG009567). Jacqueline Ellison was sup-

ported by the Agency for Healthcare Research and Quality National

Research Service Award (5T32 HS000011).

CONFLICT OF INTEREST

The authors declare no conflict of interest.

DATA AVAILABILITY STATEMENT

The data that support the findings of this study are available from the

Massachusetts Center for Health Information Analysis. Restrictions

apply to the availability of these data, which were used under license

for this study.

ORCID

Jacqueline Ellison https://orcid.org/0000-0003-1346-0965

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How to cite this article: Ellison J, Wang C, Yarrington C,

Connors P, Hanchate A. Insurance and geographic variations

in non‐invasive prenatal testing. Prenat Diagn.

2022;42(8):1004‐1007. https://doi.org/10.1002/pd.6155

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nloaded from https://obgyn.onlinelibrary.w

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strava, W iley O

nline L ibrary on [06/03/2023]. See the T

erm s and C

onditions (https://onlinelibrary.w iley.com

/term s-and-conditions) on W

iley O nline L

ibrary for rules of use; O A

articles are governed by the applicable C reative C

om m

ons L icense