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A Blueprint for Building Better Maternity Care Payment Systems

Katy B. Kozhimannil, PHD, MPA, is an associate professor in the Division of Health Policy and Management at the University of Minnesota School of Public Health and Director of Research at the University of Minnesota Rural Health Research Center. Her research applies health policy and health services research to the field of women's health, with a focus on maternal and child health. Dr Kozhimannil conducts research to inform the development, implementation, and evaluation of health policy that impacts reproductive-age women and their families. Twitter @katybkoz. E-mail kbk@umn.edu
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.

Experts and stakeholders who care about maternal health have come together to publish the Blueprint for Advancing High-Value Maternity Care Through Physiologic Childbearing (hereafter called the Blueprint). Published on June 28, 2018, the Blueprint centers on access to healthy physiologic care around the time of childbirth. To do so, it lays out ideas for broad health systems changes to incent higher-value maternity care, with an eye toward improving health outcomes and experiences with wiser spending.

The Blueprint focuses on 6 improvement strategies and makes priority recommendations for each. The first improvement strategy is: Improve maternity care through innovative care delivery and payment systems and quality improvement initiatives. While this is not a novel idea, the time for it is now. 

When I was a graduate student in health policy, I read a seminal book by one of my mentors, renowned health economist Joe Newhouse. The book, entitled Pricing the Priceless, engaged the challenges of healthcare financing along multiple dimensions. Both the title of and the concepts within that seminal text are germane here. How do we put a price on caring for people during pregnancy and childbirth in a way that financially supports the use of evidence-based practice; the safest, healthiest outcomes; and the best possible birth experiences?

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 total payments for a cesarean birth (prenatal, labor and delivery, postpartum, and newborn care) were substantially higher than payments for vaginal birth, in both private health plans ($27,866 for a cesarean birth vs $18,329 for a vaginal birth) and Medicaid programs ($13,590 vs $9131 for cesarean and vaginal births, respectively).  Clearly, the goal of such reimbursement is to compensate facilities and clinicians for the higher acuity of services that are needed to support a surgical birth when it is needed. To be clear, no clinician I’ve ever met is recommending a cesarean to a patient based solely on potential reimbursement. However, clinicians work in healthcare systems run by administrators who have to pay attention to the bottom line to keep the doors open and the books in the black, and the choices that clinicians and their patients have during labor and delivery is shaped by administrative rules, guidelines, and decisions. So, how can payment systems be changed to align incentives of health care system administrators, clinicians, patients, and families?

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:
  1. Greater use of episode-based payment, which has shown promise in states like Arkansas and healthcare systems like Geisinger.
  2. 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.
  3. Pay for high performing elements of maternity care, such as access to care from midwives, care in freestanding birth centers, and support from doulas.
  4. 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 engaging mothers in this work and addressing racial and geographic inequities that haunt maternal and infant health. 

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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