
A Blueprint for Building Better Maternity Care Payment Systems
In the United States, too many of our mothers are dying during and after childbirth. Costs of childbirth care are high for everyone—for health plans, for taxpayers, and for families. We are moving in the wrong direction, and it is well past time to change course.
In the United States,
Experts and stakeholders who care about maternal health have come together to publish the
The
When I was a graduate student in health policy, I read a seminal book by one of my mentors, renowned health economist
The Blueprint directly engages some of the specific challenges that fee-for-service (FFS) payment models present for childbirth care. Frankly, normal birth is a process that sometimes takes a lot of patience, reassurance, waiting, and encouragement—elements of care that are not well compensated in FFS care. Paying for clinicians to “do things” works well when patients are sick and require specific services, but most pregnant people are not sick. They are healthy, pregnant people who need monitoring and support as they go through pregnancy, give birth to their babies, recover physically and emotionally, and parent their new child. We need payment models that compensate teams (including physicians, midwives, nurses, doulas, community health workers, lactation support providers, etc, as needed) for providing risk-appropriate and evidence-based services during pregnancy, childbirth, and the postpartum period. The Blueprint provides guidance on potential steps that could be taken to improve financing of maternity care.
Even under newer payment models that evolved in response to the known challenges of FFS care, the mode of delivery (cesarean vs vaginal) drives reimbursement for childbirth, financially nudging facilities and clinical practices toward greater use of a cesarean section. Indeed, data from 2010 births show that the
It is both possible and necessary to better organize the billions of dollars spent annually on healthcare services related to pregnancy and childbirth. The Blueprint offers multiple recommendations for improving maternity care payment systems, including the following:
- Greater use of episode-based payment, which has shown promise in states like Arkansas and healthcare systems like Geisinger.
- Better incorporates concepts like the maternity care home into practice by integrated financing of services, following examples set by North Carolina, Texas, Wisconsin, and the Center for Medicare & Medicaid Innovation’s Strong Start program.
- Pay for high performing elements of maternity care, such as access to care from midwives, care in freestanding birth centers, and support from doulas.
- Implement quality improvement processes that support access to physiologic birth and high accountability for maternal support before, during, and after childbirth, including adoption of metrics based on scientific evidence such as the recent ACOG [American College of Obstetrics and Gynecology] guidelines supporting low-intervention birth and more comprehensive postpartum care.
Other aspects of the Blueprint address crucial factors, without which improvement in maternity care is not possible, including directly and respectfully
But payment matters. Organizing the financing of healthcare delivery to support improvements in maternal and infant health is possible and urgently necessary.
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