Should healthcare policy leaders start thinking seriously about making changes in public and private reimbursement in order to improve outcomes in maternal and child health? Absolutely yes, according to an analysis of payment mechanisms in that key area, published in the Health Affairs Blog.
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 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.”
As the authors note, “The Health Care Transformation Task Force (HCTTF)—a coalition of payers and providers committed to embracing value-based payment models—today released a report, Expanding Access to Outcomes-Driven Maternity Care through Value-Based Payment, which examines how the maternal health crisis has been exacerbated by the predominant fee-for-service payment system. The report comprehensively details the current state of value-based payment adoption for maternity care in the US, showing that despite clear evidence about what works, efforts to transform maternity care payments have remained sluggish. We reviewed promising ‘outcomes-driven maternity payment models’ that address the shortcomings of the current fee structure and categorized them into three levels,” they write.
Essentially, three promising options, the authors say, are “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.”
The Health Care Transformation Task Force’s report notes, among other things, that “The rate of pregnancy-related deaths in the U.S. has more than doubled in the past 20 years, and that rate is 3 to 4 times higher for black women than white women. The growing attention to the issue indicates significant public interest and opportunity for policy action,” the report notes.
And, among its findings, the report says that “Myriad complex and intertwining factors contribute to growing disparities and poor maternal health outcomes for women in the U.S., including:
> Large variations in labor and delivery unit practice management;
> Surgical complications from cesarean deliveries (i.e., C-section) without indication;
> The rising rate of delivery by C-section, from 20.7% in 1996 to almost one-third of all births by 2017;
> Increasing prevalence of pre-existing chronic diseases among pregnant woman such as cardiovascular and heart disease which together account for over a quarter of pregnancy-related deaths;
> The dramatic increase in the number of pregnant women with opioid use disorder, which quadrupled between 1999-2014;
> Ongoing lack of access to prenatal care and increases in patient cost-sharing that adversely impact care plan adherence, more so for low-income patients; and
> Underutilization and lack of access to postpartum care, with approximately 10% of women not attending a postpartum visit and lower attendance rates among socially and economically vulnerable women.”
“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.”
