Pain Points and Solutions to Reduce Cost Variation in Maternal Care

The healthcare industry, patients, patient advocates, and lawmakers are coming together to drive improvements for expecting and new mothers and newborns. With the mounting scrutiny and public pressure, providers will need to accurately document, report and demonstrate concrete progress in their maternal outcomes. To do so, they’ll need to internalize and overcome the variation in the cost and care for this population, which has been affected by multiple factors, including incongruent regulations, fee-for-service payments and socioeconomic inequalities.

Differing regulations at the state level obfuscate the industry’s ability to assemble and analyze information about maternal disparities.

For years, with a lack of federal regulations or reporting requirements for perinatal healthcare, states have been able to decide which maternal health services they cover beyond hospital care, the data they collect on expectant mothers, and how they choose to respond to the outcomes. Medicaid finances nearly 45 percent of births and Medicaid coverage continues to vary state by state, resulting in major gaps in publicly available maternal healthcare information. While some states collect patient demographics such as race, ethnicity, income and health insurance, others do not.

The lack of federal standards has also resulted in inconsistencies in the way states record and investigate maternal deaths, meaning the U.S. has not recognized an official annual count of pregnancy-related fatalities or an official maternal mortality rate for more than a decade.

The fee-for-service reimbursement model does not incent wellness care for mother and baby.

Under current regulations, payment systems prevent providers from assuming accountability for overall cost and outcomes or coordinating with their peers for the health of the mother and baby. As part of a patient’s hospital stay, payers will often bill mothers separately for the facility fee, the provider’s fee, and sometimes a global maternity fee that incorporates prenatal and postpartum care. This division of payments does not incent providers to code the stay, or bill the payer, with a focus on the mother’s or baby’s overall outcomes. This can lead to perinatal variability, uncoordinated care, unnecessary interventions and higher costs. By reimbursing providers once a complication has developed, providers are incentivized to allocate more dollars and resources toward treating mothers and babies who are sick as opposed to preventing the negative outcomes in the first place.

National organizations, including the American College of Obstetricians and Gynecologists, are pushing for redesigned postpartum care that incents ongoing wellbeing for women postpartum, particularly to screen and treat depression and anxiety.

Social disparities remain a top reason for variation in maternal healthcare.

Access to, and compliance with, comprehensive prenatal care helps women manage conditions and reduce the likelihood of complications. Yet, women who are socioeconomically disadvantaged or of racial minorities are shown to receive less prenatal and postpartum care, and therefore they have documented worse outcomes. Barriers to care for them include cost, access, geographical constraints, education level and other social determinants of health.

These long-held norms are beginning to shift at the federal level, as public pressure pushes lawmakers toward more standardized reporting, definitions and coverage for maternal healthcare.

Payers are experimenting with maternity care bundled payment programs to encourage better care coordination across the entire episode of maternity care, while legislators, trade associations and watchdog groups are advocating for greater transparency. A few examples:

• In December 2018, the federal government signed the Preventing Maternal Deaths Act, which mandates that states investigate the deaths of women who die within a year of being pregnant.
• Legislation in process aims to better standardize maternal care, enabling providers to prevent and respond to complications arising from childbirth and help reduce maternal deaths.
• Starting in July 2020, The Joint Commission will begin publicly reporting hospitals that have a consistently high cesarean birth rates using hospital-reported data from 2018 and 2019.

Hospitals and health systems will play an important role in helping abate the rising costs related to maternal healthcare.

In 2019, Premier announced a Perinatal Collaborative that now has more than 10 leading hospitals working to reduce risk and reach zero preventable maternal and neonatal harm and deaths. Participants focus on preventing adverse events, ensuring patients are treated in the correct and most appropriate setting, and increasing the delivery of evidence-based care to help reduce variation and control cost. The results of the collaborative are being collected and will be shared publicly.

Armed with meaningful insights, optimal technology and an eye toward models that drive coordinated and reliable care, providers are helping steer the treatment environment toward high-value, cost-efficient care for pregnant women and new mothers.

Premier members are improving maternal health in five key ways:

1. Business intelligence analytics and insights: Leaders require access to comprehensive clinical data that aggregates risk factors, volumes, outcomes and complications for their maternal population. A perinatal dashboard is a highly valued tool to accomplish this work. With the right business intelligence capabilities, providers collect data, identify patients at higher risk for adverse outcomes and plan interventions, helping circumvent costly complications. The analytics leveraged should be able to assimilate elements from all nationally recognized maternal safety care bundles and incorporate the 80-plus measures that target identified indicators related to harm and death. This is critical to standardize the care that mothers receive and reduce variation in cost irrespective of age, race or payer.
2. Highly reliable care: Armed with business intelligence and the knowledge of which patients need additional support, hospitals can standardize and customize their perinatal care by developing evidence-based practices, including interventions to address scenarios for high-risk patients as they work toward zero harm. Highly reliable concepts are fully aligned with the nationally endorsed guidelines and strategies. Providers should craft standard care guidelines to incorporate not just the national maternal safety bundles, but also operational and quality measures, including length of stay, readmissions, cost and efficiency, as well as medical indicators for risk factors and other clinical conditions such as preeclampsia and behavioral health protocols.
3. Technology to enable adherence: As staff and clinicians create and adopt standardized care models and train around them, leaders need to evaluate adherence to evidence-based guidelines – or barriers that are preventing it. Embedding a data-enabled clinical decision support (CDS) solution into the workflow can help support clinicians in delivering real-time, patient-specific best practices that are based directly on the organization’s standardized care guidelines. CDS analytics can also show how clinicians respond to the organization’s point-of-order alerts, demonstrating to leaders the effectiveness of a hospital’s standardized care guidelines. This ensures the right care is provided at the right time, helps improve adherence to evidence-based guidelines and prevents variation that may result in harm and additional costs.
4. Risk-stratification to support at-risk patients. It’s critical that organizations collect socioeconomic information from patients such as social determinants of health, whether through screening tools or other methods, to help women who may lack the resources to properly care for themselves and growing babies. Using results from risk-stratification, providers should identify and modify care for pregnant women who exhibit risk factors for maternal mortality or morbidity, including obesity; substance or opioid use disorders; heart disease; hypertension; and chronic disease such as diabetes. These conditions can often exacerbate pregnancy-related complications, and left untreated, these conditions can worsen post-pregnancy, resulting in additional care, cost and emotional stress.
5. Payment models that incent whole-person, value-based care. Because of barriers to healthcare access, women of color, lower socioeconomic status and those living in rural areas are more likely to exhibit risk factors for adverse maternal outcomes, and thereby higher costs for care. As payers introduce financial models that incent providers to coordinate care as efficiently and cost-effectively as possible, risk-stratification will identify women who need more hands-on guidance. Care models that are tailored to specific groups of women based on risk assessments could de-emphasize overmedicalization, such as Cesarean deliveries for low-risk women, and guide more resources toward women who are higher-risk. Progressive organizations are also exploring high-value alternatives, such as direct-to-employer payment models, in which providers strategically coordinate quality care and are less likely to recommend unnecessary and costly interventions.

Learn more about what Premier is doing to advance maternal healthcare as part of its Bundle of Joy campaign.