Researchers: Dutch Maternity Care Bundled Payment Changed Clinician Behavior

Even as the implementation of a variety of bundled-payment alternative payment models (APMs) is becoming increasingly common in the U.S. healthcare system, a case study from the Netherlands points to some interesting parallels, and offers findings worth exploring.

Writing in the September issue of Health Affairs, a group of Dutch and American healthcare researchers writes in “Integrating Maternity Care Through Bundled Payments In the Netherlands: Early Results And Policy Lessons,” that some gains, primarily financial and process, have been found in a Dutch initiative around bundled payments for maternity care.

The researchers—Zoe T. M. Scheefhals, Jeroen N. Struijs, Albert Wong, Mattijs E. Numans, Zirui Song, and Eline F. de Vries, write that “Bundled payments are increasingly used globally to move healthcare delivery in a value-based direction. However, evidence remains scant in key clinical areas. We evaluated bundled payments for maternity care in the Netherlands during the period 2016-18. We used a quasi-experimental difference-in-differences design to measure the association between the bundled payment model and changes in key clinical and economic outcomes. Bundled payments were associated with an increase in outpatient, midwife-led births and a reduction in in-hospital, obstetrician-led births, along with changes in the use of labor inductions and planned versus emergency cesarean deliveries.”

Further, the researchers write, “Total spending on maternity care decreased by US $328 (5 percent) per pregnancy. No changes in maternal or neonatal health outcomes were observed. Several policy lessons emerged,” they state. “First, bundled payments appeared to help affect providers’ behavior in the maternity care setting. Second bundled payments seemed to exert heterogeneous effects across participating maternity care networks, as the same financial incentive translated into different changes in clinical practices and outcomes. Third, alternative payment models should be designed with clear goals and definitions of success to guide evaluation and implementation.”

The authors note that, “In this first quasi-experimental evaluation of maternity care bundled payments in the Netherlands with a two-year follow-up period, participation in the intervention was associated with small changes in maternity care use and slower spending, with no observed changes in maternal and neonatal health outcomes at this point.”

Ultimately, the researchers conclude, “[B]undled payments appeared to be capable of affecting providers’ behavior in the maternity care setting. Second, bundled payment incentives played out different in different contexts; more insight is needed into the mechanisms behind this treatment effect heterogeneity. Third, explicitly formulating reform goals and defining success before payment reform is helpful for determining whether the reform is successful, which in turn is key for policy decisions.”