One of the Last Frontiers? Value-Based Care Concepts Come to Maternal and Child Health

July 26, 2019
The Health Care Transformation Task Force’s report on maternal and child healthcare lifts a veil on some of the more perplexing challenges in a key area of healthcare delivery—with sharp suggestions for changes to incentives

Could value-based care concepts be applied through federal, state, and private payment, in ways that might reshape maternal and child healthcare? Until recently, the maternal and child health area has been one that has remained possibly less scrutinized than some other areas, with regard to forcing change around cost-effectiveness and clinical outcomes.

Sure, there has been some focus on examining why some hospitals have higher cesarean section (c-section) rates than others; and some researchers have looked at areas such as low birth weight and poor prenatal care. But broad interventions have tended to elude this area of care delivery.

But earlier this month, two leaders of a group called the Health Care Transformation Task Force published an analysis in the Health Affairs Blog that asserts absolutely that healthcare policy leaders should start thinking seriously about making changes in public and private reimbursement in order to improve outcomes in maternal and child health.

Writing on July 16, 2019, Clare Pierce-Wrobel, senior director, and Katie Green, a senior associate, in the Health Care Transformation Task Force, state that “A simmering US health crisis has bubbled to the surface. As the global maternal mortality rate fell 44 percent between 1990 and 2015, maternal mortality and pregnancy-related deaths in the US have gone in the opposite direction, increasing 139 percent since 1987. The stark disparities by race have persisted for the past six decades, with black women still three to four times more likely to die pregnancy-related deaths in the US as the rates continue to climb. This is a serious problem without a simple solution,” Pierce-Wrobel and Green write, “but one finally getting the attention it deserves from policy makers and the general public. Significantly reversing the trend will require honest introspection about the health care system’s role in contributing to the increasingly poor outcomes and high costs of maternity care.”

Indeed, Pierce-Wrobel and Green assert, per their just-released report, entitled “Expanding Access to Outcomes-Driven Maternity Care through Value-Based Payment,” that the current reimbursement system around maternity and child health is “flawed in three primary ways: it does not adequately cover high-value services; it does not hold providers accountable for overall cost and outcomes; and it does not encourage coordination between providers for the health of the mom and baby.”

Pierce-Wrobel and Green state that there are essentially three approaches that offer real potential to change the dynamics in this key area of healthcare delivery and payment. There are, they write, “perinatal fee schedule changes that pay differently for high-value versus low-value care”; “value-based maternity payments that link reimbursement to maternal outcomes and total cost to address variability of high-risk interventions and outcomes”; and “comprehensive payments for mother and newborn that link reimbursement for both maternal and infant quality outcomes and total cost.”

With regard to the second option, they note that “Examples include bundled payments and blended case rates, which mitigate the financial incentive to perform cesarean sections (c-sections) for low-risk births without medical indication. C-sections now account for almost one-third of all births, contributing to rising costs and associated risks of surgery; the Agency for Healthcare Research and Quality estimates that 35 percent of all c-sections were low-risk births.” Meanwhile, per the third option, they emphasize that “Comprehensive payments for mother and newborn that link reimbursement for both maternal and infant quality outcomes and total cost. Few payment policies have effectively implemented comprehensive payments for the mother/newborn dyad because most insurance plans cover and reimburse for their care separately, even though effective and appropriate perinatal care for the mother directly correlates to newborn outcomes and care needs.”

What’s new or at least newer here is the idea of using payment systems to change or modify clinician behaviors in the maternal and child health area. Excessive c-section rates have been studied quite extensively, and the obstetrician leaders in individual hospitals and health systems have tried to force clinician behaviors, in order both to improve outcomes and save money. But those efforts have nearly all been “one-off” efforts, to date. What if labor and delivery charges really were shifted to bundled payments, or whatever they might be called? Could such financial incentives convince obstetricians to work closely with their fellow physicians and nurses to modify their approaches to delivery? To be successful, they would need to make changes at the point of care, which in obstetrics is particularly challenging, given obstetricians’ call schedules, the complexity of the labor and delivery clinical environment, and the nuances involved in physician-patient communications and interactions. But it’s hard to argue that it wouldn’t be worth a try to change payment incentives.

And how about “comprehensive payments” for the care of mothers and infants? One enormous possibility would be to apply the broad principles that these researchers are suggesting, in the Medicaid managed care arena, where a strong set of incentives already exists to look more systemically at processes and incentives. Of course, the Medicaid environment is also an extremely challenging one, given the poverty, instability of living conditions, and educational issues involved in managing the care of Medicaid populations.

Still, someone clearly be doing something in that area. The Health Care Transformation Task Force’s report notes that c-sections went from being 20.7 percent of infant deliveries in 1996, to comprising nearly one-third of all births in 2017. That’s a staggering statistic, and one that implicitly calls out for some kind of action.

Will change in this area be difficult? Certainly. But the opportunity to create changes that will benefit patients and families, while at the same time bending the overall cost curve in U.S. healthcare, are clearly plentiful.

“Much of the active payment reform efforts for maternity care have tweaked around the edges of the existing fee structure, but this crisis demands much more than a band-aid approach,” Pierce-Wrobel and Green note in their analysis in the Health Affairs Blog. “We need more coordinated efforts across the public and private sector to upend misaligned financial incentives for maternity care. Childbirth is the most common reason for hospitalization, and cesarean section is the most common surgery in the US; refining the underlying financial model and rebalancing the care model and site of service will not come easily. As described in the Task Force report, there are several ways that private industry purchasers, payers, and providers can join forces and use aligned market power to advance outcomes-driven maternity care models. Yet, policy maker action is also needed to realize more widespread and transformational change away from the status quo.”

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