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An influential group of healthcare
leaders puts it bluntly: The resources spent on maternity care services are not
leading to the highest value.
Instead, there are too many Cesarean
deliveries, too many preterm births, and too many early elective inductions,
all of which increase the need for neonatal intensive care services. The infant
mortality rate in the United States is higher than in 38 other countries. The maternal
mortality rate has doubled in the last 30 years.
The Health Care Payment and Learning
Action Network (HCPLAN), a collaborative group of private and public
stakeholders convened by the Department of Health and Human Services to advance
the use of alternative payment models, thinks the current payment system is
partly to blame for the nation’s poor track record of maternity and newborn
care. In a white paper issued recently, HCPLAN recommends
the use of episode-of-care (i.e., bundled) payments to incentivize the use of
HCPLAN’s work group includes top
executives from many major health plans, although payers thus far have been
slow to push for maternity care payment reform. Devising a new way to pay for
an episode that may last 10 months or more, involves a wide range of providers,
and starts with one patient and ends with two is a daunting task.
But now that HCPLAN has published
recommendations on how to get started, purchasers intend to jump on them. “We
want to capitalize on the momentum,” says Brynn Rubinstein, senior manager for
the Transform Maternity Care initiative at Pacific Business Group on Health
That group, representing Walmart,
Boeing, and many of the nation’s other largest healthcare purchasers, hopes
regional and national pilots to test episode payment for maternity care will start
soon, because its members are not satisfied with the value they are getting. Combined
maternal and newborn stays account for more than 20 percent of hospital stays—and
the wide variation in costs does not correlate with outcomes.
“PBGH feels it’s the role of the
purchaser and the employer to kind of pound the table and let plans know that
the time is now,” Rubinstein says. “While there are many obstacles to navigate,
they are all challenges that can be overcome.”
Since 2008, Geisinger Health
Plan, based in Danville, Pa., has been proving that the theory behind bundled
payments for maternity care holds up in practice. The plan uses bundled
payments for maternity care delivered at Geisinger Health System, where
standardized care processes have reduced the total cost of care.
“If you decrease your
early elective delivery rate and your C-section rate, you end up decreasing
your NICU days and the other high-end costs that tend to happen to babies born
too early,” says John Bulger, DO, chief medical officer of Geisinger Health
Plan and CMO for population health for the health system.
That said, perinatal bundles
are among the most complex in Geisinger’s suite of ProvenCare episode-of-care
packages. The design team identified 103 unique best-practice measures that are
tracked for every patient; if a mother begins her care with Geisinger in the
first trimester, there are as many as 300 opportunities to deliver those
measures to each patient. By comparison, Geisinger tracks 19 best-practice
measures—and 40 opportunities to deliver them—for patients who receive coronary
artery bypass grafts.
hallmark of care transformation—does work for maternity care, Bulger says. “It
changed the culture in the obstetrics department to focus more on quality and
focus more on processes of care—more on what they needed to do versus what they
did not need to do,” he says. “Our early elective delivery rate has been
essentially zero for six-plus years, and we saw our C-section rate go down
fairly quickly as well.”
Like most maternity care leaders,
Sean C. Blackwell, MD, chair and professor in the Department of Obstetrics,
Gynecology and Reproductive Sciences at McGovern Medical School at UTHealth in
Houston, thinks physicians must be the “accountable entity,” responsible for
designing and directing maternity care and for dividing the payment among
providers in the bundle.
That’s why his
department—roughly 80 OB/GYNs who belong to a large independent physician
practice—is in a two-year pilot with a Medicaid managed care plan that covers
roughly half of all births in the Houston area. Finding the right mix of
quality measures, payment incentives, and care protocols to succeed in a
bundled payment contract is going to take time, and Blackwell, who also serves
as chief of service for obstetrics and gynecology at Children’s Memorial
Hermann Hospital, wants to figure it out.
Through the pilot,
Blackwell (pictured at right) gained access to data about the actual cost of care for a given
pregnancy. The data made clear to him that a truly cost-effective maternity
bundle must also include ancillary costs such as laboratory testing, medication
use, and fetal imaging, all of which have potentially high costs.
Another lesson learned:
The actual spend on physician services may need to increase for avoidable—and
expensive—hospital admissions and readmissions to decrease.
“Even though OB/GYN
physician services may only represent 10 percent of the total cost of maternity
care, the physicians are the captains of the ship who are making not only
clinical care decisions that affect maternal and newborn outcomes but also
decisions regarding utilization of services within the hospital,” Blackwell
says. “Reducing the frequency and/or severity of preterm birth is by far the
number one opportunity to decrease costs of maternity care and improve
Reducing unnecessary Cesarean
deliveries is the second-biggest opportunity for improving health and reducing
“Strategies such as
adopting clinical pathways and managing lengths of stay all require physician
partnership,” Blackwell says. “It is unrealistic to believe hospital leadership
can do this unilaterally. If hospitals are going to successfully decrease the
cost of their care, they must be aligned with their physicians and have shared
incentives related to cost and quality.”
Beyond that challenge,
the data disconnect between payers and providers will take some effort to
resolve. For example, health plans tend to use quality measures that are relevant
to their own reporting requirements but that may be unrelated to physician care
or outside the control of the OB/GYN physician. Thus, physicians and payers
must come to agreement on what constitutes high-quality obstetrical care and
what measures are important. Both sides must compromise, Blackwell says.
of the measures that are feasible to use will be imperfect or suboptimal, and
measures that are more ideal may not be easily obtainable or laborious to
assess and track,” he says.
During the first year of
the two-year pilot, Blackwell’s group did not make substantial changes to care
processes or focus on reducing costs of care. Rather, the year was devoted to
gathering baseline data for quality measures and analyzing the payers’ data to
understand the overall costs associated with maternity and newborn care so that
a better care model could be designed.
“When you think of all
the good things that doctors and midwives and nutritionists and diabetes
educators and lactation consultants can do to improve outcomes, we have got to
redesign the care and the payment model so those things are appropriately
valued and people can invest in them,” he says.
Blackwell is committed to
working through the many challenges associated with maternity bundles because
he believes a bundled-payment approach will be widely adopted. But he doesn’t
think it will be easy.
“The learning curve is
just going to be tremendous here,” he says.
Providence Health &
Services, one of the largest not-for-profit health systems in the country, does
not yet have a bundled-payment contract for maternity care, but it has spent
the past four years getting ready for such an arrangement.
is a very challenging aspect of moving toward bundled payment,” says Laurel
Durham, regional director of perinatal services, Providence Women and
Children’s Services. “We’ve been focused on the clinical pathway as a first
step in addressing payment reform.”
Based in Renton, Wash.,
Providence serves five western states. Midwifery care is offered throughout the
system, but a unique midwifery model has been developed in the Portland area.
Starting in 2012, the Portland midwife clinic began using its product
development methodology to bring the Triple Aim goals to maternity care.
“We found that we could
incorporate group appointments and add doulas and social workers,” says Durham (pictured at right).
“And we could have a team-based model of care that allows everyone to work at
the top of their license. By focusing on the patient experience, we increased
patient satisfaction while reducing cost.”
In 2013, Providence
piloted its “pregnancy care package” in a single clinic in Portland. The
package is designed to coordinate care from prenatal services through labor and
delivery to the postpartum and post-discharge phases. The care team, which is
anchored by certified nurse midwives, includes nurses, doulas, patient
navigators, a consulting OB/GYN physician, and social workers. The pregnancy
care package operates within Providence’s larger footprint in Oregon, giving
patients easy access to the system’s services and resources.
During the pilot year,
women served in the pregnancy care package model had a Cesarean rate of just
over 20 percent, compared to a national average of 32 percent. In its first
year, the pregnancy care package, which gives women options for pain management
during labor, resulted in an epidural rate that was 23 percent below the
national average, and just 1 percent of women had early elective deliveries.
Durham believes the lower
epidural rate can be attributed to two factors. “Rates were lower in part
because these pregnancies were lower-risk and among women who wanted to have
low-intervention births,” she said. “Additionally, the pregnancy care package
provides the support these women need to achieve their birth experience goals.”
The cost of services provided through the pregnancy care package was 15 percent
less than in the traditional care model, while patient satisfaction scores were
in the 98th percentile.
Since then, the pregnancy
care package model has expanded to three women’s clinic locations and two
hospital delivery sites, making it a convenient option for any woman living in
or near Portland. Delivery volume has grown dramatically, and Providence
continues to innovate to make the package attractive. For example, workgroups
defined the scope of practice for doulas to support patients throughout the
continuum of their birth experience, including a Cesarean section when
necessary and postpartum.
Even as they optimize
their care delivery model, Providence leaders see the barriers facing payment
reform. For example, doulas provide support to women who want nonmedicated
births, allowing them to avoid epidurals. Although doula services are bundled
into the pregnancy care package model, some health plans do not cover doula
services outside of this bundled approach.
“We need to find a way to
determine the value of navigators, doulas, and the integration of behavioral
health services in maternity care,” Durham says. “Those are really important
parts of pregnancy care, and it will be challenging for this to spread rapidly
without addressing the value they provide, and subsequently, payment.”
Although the HCPLAN workgroup and others recommend designating OB providers as
the “accountable entity” that accepts a bundled payment for maternity care,
Durham thinks that function can be handled by a health system, with OB
providers leading the process.
“A health system can help
provide the infrastructure many providers would need to manage a bundled
payment model,” she says. “If they are paid and then have to allocate payment
to others who were involved in the care, it becomes really complicated from a logistical
Butcher writes about healthcare business and policy topics for several HFMA
Interviewed for this article: Brynn Rubinstein, senior
manager for Transform Maternity Care, Pacific Business Group on Health, San
Francisco; John B. Bulger, DO, MBA, chief medical officer, Geisinger Health
Plan, and chief medical officer-population health, Geisinger Health System,
Danville, Pa.; Sean Blackwell, chair
and professor in the Department of Obstetrics, Gynecology and Reproductive
Sciences at McGovern Medical School at UTHealth, and chief of service for obstetrics
and gynecology, Children’s Memorial Hermann Hospital, Houston; Laurel Durham, regional
director perinatal services, Providence Women and Children’s Services, Providence
Health & Services, Portland.
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