As the global rate of maternal mortality has declined significantly, the rate of pregnancy-related mortality has more than doubled in the United States in the past three decades. Researchers with the Maternal Health Hub have recommended four actions policymakers can take to address maternal health, including developing new value-based payment and care delivery models.
The Maternal Health Hub is operated by the Health Care Transformation Task Force, a nonprofit industry consortium that brings together patients, payers, providers and purchasers to align public- and private-sector efforts in value. The project is supported by The Commonwealth Fund.
Besides U.S. maternal health outcomes moving in the wrong direction, they also have signaled systemic inequities for pregnant and birthing persons of color, with Black and Indigenous people two to three times more likely to die in childbirth than white people, the report noted.
Below are summaries of the four recommendations the report makes to policymakers.
1. Extend postpartum coverage. The report notes that in states that have not expanded Medicaid to low-income adults, birthing persons that become eligible for and enroll in Medicaid during their pregnancies can lose coverage after 60 days postpartum. Extending Medicaid coverage for low-income pregnant people to a full year postpartum has the potential to help at least 200,000 people per year gain coverage during a critical window for new moms and babies, as more than half of deaths occur after birth and in the postpartum period, the report notes.
States could individually take this action through waivers or financing extended Medicaid coverage on their own, or Congress could take up legislation to update federal statute.
2. Implement pay parity. Nurse midwifery care provided in birth centers and perinatal support services such as doulas, childbirth educators and peer supports can reduce disparities and improve health outcomes. Yet they are inadequately reimbursed – if at all, the report stresses.
Community-based doula programs are uniquely positioned to bridge the health system and community support system for low-income women and women of color to reduce health disparities. Currently, only five states cover doula services. Furthermore, while the Affordable Care Act required Medicare to pay midwives the same amount in physicians’ fees as they would pay clinicians at a hospital, this impacts a small percentage of births and has not been uniformly implemented for other payers. State Medicaid programs and private payers can take immediate steps to improve reimbursement rates for midwifery care and birth center facilities to improve outcomes for birthing persons.
3. Utilize value-based payment and care delivery models. The fee-for-service model of reimbursement creates misaligned incentives based on volume and acuity of services, the report notes. The Center for Medicare and Medicaid Innovation can design and test a holistic alternative payment model that explicitly incorporates improvements in health equity as an objective. But reforming the underlying fee schedule can be a first step to paying for high-value care, especially during this public health emergency. Expanding coverage and pay parity for birth workers is also a way for Medicaid programs to support healthy pregnancies during theCOVID pandemic and beyond by adequately covering telehealth for an expanded set of services such as behavioral health, remote patient monitoring, and group prenatal care. This can mitigate barriers that existed pre-pandemic – such as access to childcare and transportation necessary to attend in-person appointments – while updating arcane clinical protocols to better reflect the quality rather than frequency of prenatal and postpartum visits.”
The report also notes that a bill introduced in Congress in 2020, the IMPACT to Save Moms Act, would direct CMS to establish a Perinatal Care Alternative Payment Model Demonstration Project to allow states to test payment models for maternity care, including postpartum care, under Medicaid and CHIP.
4. Advance health equity. Unrooting systemic racism and economic inequalities thatcontinue to drive racial disparities in maternal health outcomes in the U.S. requires an all-of-government approach, the Maternal Health Hub report suggests. States including Michigan, NewJersey, and California have moved to implement policies to require that healthcare providers undergo implicit bias training, and others have taken steps to advance health equity in Medicaid by targeting health disparities when measuring and incentivizing quality performance.
The federal and state governments can improve data collection to include race and ethnicity information upon Medicaid enrollment, and standardize birth and death certificate data to better identify racial health inequities. The Maternal Health Pandemic Response Act of 2020, if enacted, would require the CDC to coordinate, collect, and publicly post data related to COVID-19 and pregnancy disaggregated by race, ethnicity, and state.