The need for a comprehensive payment approach that supports the entire maternity care experience from prenatal, labor, and delivery, to postnatal care, is critical for both maternal and child health outcomes. Aligning payment to reward better birth outcomes is becoming more widespread. A handful of states are experimenting with bundled payments to advance value-based payment strategies that improve the quality of maternity care. However, much of this experimentation is built on volume-driven service infrastructure.
The Current State
Fundamentally, the current scope of services for maternity care is built on a fee-for-service system, and this can limit the type of coverage for services that effectively improve the value of maternity care. Medicaid, for example, is the largest single-payer for pregnancy-related services, financing 43% of all U.S. births. Medicaid is required to cover pregnancy, delivery, and post-partum services to low-income women. However, there is no formal definition of what services states must include for women beyond inpatient and outpatient hospital care. This means that there is great variation in what services can be provided, and there is little incentive to encourage payers or provider systems to offer what may be considered more high-value services to improve the quality of care. In 2016, the Health Care Payment Learning & Action Network recommended comprehensive services (shown in Table 1) to improve the pregnancy, delivery, postpartum, and birth-outcomes for mothers. Under current law, coverage for such services such as education classes or doula assistance may not be provided as part of a comprehensive set of services across states. Further, there may not be enough incentive to invest in such services when the performance protocol is more focused on the number of services as opposed to quality.
Table 1: Recommended Services for Maternity Care
| Phase | Services Covered |
| Prenatal | Prenatal visits |
| Blood testing | |
| Diabetes testing | |
| Doula services | |
| Childbirth education | |
| Preventing screenings | |
| Delivery | Labor & birth |
| Postpartum | Breastfeeding support |
| Depression screening | |
| Contraception planning | |
| Linkage to pediatric care | |
| Primary care | |
| Psychological services |
Enter Bundled Payment
A bundled arrangement for maternity care could offer and incentivize a more comprehensive approach to the maternity care experience. In such an arrangement, the payment design can encourage payers and providers to provide a continuum of services that rewards quality and yields cost-savings. When providers are accountable for the quality and outcomes of the care, there is an impetus to invest in strategies and services that demonstrate improvement. However, this impetus can attenuate under prospective or retrospective reconciliation and various payment and contracting arrangements between payers and providers. Some insurers might only bundle payments for the medical practices and cut a separate deal for hospital costs. Ideally, a prospective payment strategy is a step away from fee-for-service towards more coordinated, integrated, and value-based care. How a provider organization that is accountable for maternal health outcomes responds to prospective payment is a function of how well they can manage and coordinate the care under the bundled price [pdf]. Though commercial and state insurers are taking strides towards testing these payment models, a lot of them are still built on a fee-for-service infrastructure with retrospective reconciliation. Operational, financial, and regulatory considerations make it much harder to implement an approach that may not fit within the confines of the current payment environment.
Considerations
In most bundled payment initiatives, the accountable entity takes responsibility for coordinating and improving the quality of care. If the providers are accountable, they receive a lump sum payment and assume financial risk for the total cost of care. In other words, if expenses are above the projected amount, then the provider or accountable entity incurs financial penalties.
For organizations that are fully integrated or are part of ACOs, accountability may be easier to implement due to existing payment and data sharing infrastructure. Distributing financial risk when multiple providers are involved in the provision of care for the bundled payment program adds more regulatory and operational complexity. Also, determining the actual price of the bundle adjusting for patient-specific severity factors (such as high-risk pregnancies) and other regional and geographic factors are other important areas of concern.
The feasibility of a comprehensive approach is critical to the achievement of successful outcomes. This means that there is no one- size- fits- all solution, the pricing and service design of the bundle should encourage and reward efficiency and flexibility to include services that are high-value and under-reimbursed. In a previous blog post, I mentioned how principles of Value-Based-Insurance-Design could increase access to quality health care services. A similar approach can be adopted with maternity care models. Examples could include non-payment for early elective deliveries, and improved reimbursement and coverage for certified nurse midwives, perinatal support services such as doulas, and other effective interventions to improve maternal and birth health outcomes.
Conclusion
Bundled payments for maternal health care offers an opportunity to change a volume-driven financing system to a more accountable one. This system, when supported by a prospective payment strategy, can encourage greater innovation and coordination in episode payment. Further, the present fee structure does little to promote high-value service delivery, accountability, or improved outcomes. While pricing, risk adjustment, service provision, and episode definition are essential considerations to the feasibility and implementation of a maternity care bundle, a comprehensive, value-driven strategy may not be meaningfully furthered if it is built on the current payment infrastructure.
Nicole Pereira