There are multiple health care crises facing Americans. Drug pricing, opioid addiction, the list goes on. Maternity care should also be on this list.
Childbirth is the most common cause of U.S. hospitalizations among most employee populations and the cost of delivery ranges from $9,000 to $28,000 depending on type of delivery and the state in which the baby is delivered. And over the last five years, this price has increased an average of $2,000, or 15 percent.
But there are other reasons why maternity care deserves to be in the spotlight. Beyond the risks that nature brings, the health care system intervenes too much in the process of birth, leading both to higher expenditures and worse outcomes for mothers and babies. The quality of maternity care varies wildly as many providers stray from the clinical guidelines, and maternal mortality is on the rise.
The odds of a woman having a cesarean delivery are too often impacted by where she lives or which hospital she chooses rather than a woman’s or baby’s risk factors. Interventions are appropriate and even lifesaving when pregnancies are high-risk. But for low-risk pregnancies, maternity care is one of the few areas of health care where doing less usually means better care.
The most egregious example is early elective deliveries when women have their babies before they are full-term without a medical reason for doing so either through cesarean delivery or the induction of labor.
Babies born early are more likely to have respiratory problems and need intensive care. A decade ago, these had risen to 28 percent of births in the U.S. Increased public scrutiny has reduced this number, but 8 percent of hospitals still have rates of over 5 percent when it should be zero.
Not long ago, employers were hesitant to “interfere” with maternity care, viewing it as a highly personal area of health care. But as more employers have become aware of shortcomings in this area, they have realized a lack of interference verges on neglect. If you’re an employer, here’s what you can do.
Educate your own population about clinical guidelines and support informed decision-making by expectant mothers. National Partnership for Women and Families’ “Listening to Mothers” survey findings shed light on the experiences women are having with childbirth and you can turn to the March of Dimes for great, free, educational materials for employees.
Look at Your Own Data
Determine the rate of cesarean deliveries in your population and identify whether any of the health care providers responsible for sizable portions of births in your population have cesarean delivery rates higher than the Healthy People 2020 goal, or even just higher than the national average. Then, act. For example, Dow Chemical spoke with a hospital responsible for a sizable portion of the births in the company’s population and together they agreed, along with the insurance carrier, to work toward reducing cesarean deliveries.
Ask Tough Questions of Your Partners
Find out what your health insurance plan, consultant or broker are doing to improve the quality of maternity care. Quality measurement and reporting can highlight adherence to guidelines and outcomes and support quality improvement. Also, how we pay providers for maternity care can create incentives for them to adhere to clinical guidelines, improve quality and efficiency and reduce unnecessary spending.
Learn how provider payment influences incentives
Looking at our current payment practices, it’s notable that today we pay 50 percent more for cesarean deliveries than for spontaneous vaginal deliveries. We also mostly pay “fee-for-service,” meaning more care and more expensive care enhances provider revenue. The wrong incentives lead to excessive intervention, especially in labor and delivery, and especially on the hospital side where the revenue gain is greater than it is for physicians. The right incentives could encourage adherence to guidelines but are underutilized.
A variety of alternative payment methods could improve maternity care. Pay for performance rewards providers who adhere to guidelines or meet target rates of cesarean deliveries. Paying relatively more for vaginal births than cesareans could change practice patterns quickly. Even a single blended payment amount removing the financial advantage for a cesarean can work. In Southern California, this approach decreased cesarean deliveries by 20 percent.
A single package price for prenatal care, labor and delivery services and postpartum care – a bundled payment — could encourage providers to collaborate on producing the best outcomes for their patients. It reduced cesarean deliveries at Geisinger by 26 percent. This payment method could gain traction, and
Humana recently launched maternity care bundled payment models with several practices.
A refusal to pay for medically unnecessary cesareans, such as early elective deliveries, seems like a no brainer. Nonpayment (and quality improvement efforts) for early elective deliveries in South Carolina decreased these deliveries from 10 percent to 3 percent between 2011 and 2015.
Go Back to the Basics
Altering benefit designs and provider networks can support good choices by pregnant women. Health plans could also expand provider networks to include certified nurse midwives, hospitals with laborists on staff, free-standing birth centers and even doulas. Consider centers of excellence for maternity services or narrow networks that select providers, in part, on their adherence to maternity care guidelines.
The bad news is that it has been very difficult to get health plans and providers to see the larger trends and take individual responsibility for their roles in driving them. The good news is that there are many underutilized levers at the disposal of employers that could lead to better outcomes for women and babies. It’s going to take many employers pressing for these changes to make a difference addressing this health crisis. Let’s get started.
Suzanne Delbanco is the executive director of the Catalyst for Payment Reform. Comment below or email firstname.lastname@example.org.