Despite being one of the wealthiest countries in the world, the United States faces a dire maternal health crisis. The Centers for Disease Control and Prevention (CDC) recently reported that the overall maternal mortality rate increased from 2019 to 2020 in the United States, from 754 to 861 deaths per 100,000 live births. Alarmingly, the maternal mortality rate for Black women increased 26 percent during that time, from 44 deaths per 100,000 live births to over 55 in 2020. This worsening statistic is evidence of a failing health care system that does not cater to the unique needs of women and birthing people.
The United States has a health care system that rewards quantity of services over quality, and this ethos is embedded in how the system handles payment and delivery. To improve outcomes—particularly in maternal health—the United States must adopt a health care payment system that accounts for the actual value of care provided. This commentary will describe current models of health care payment and their respective effects on health outcomes within maternity care. The available evidence demonstrates that current health care payment systems must be reformed and expanded in order for maternal health outcomes to be improved.
Unlike fee-for-service, value-based care programs consider the quality of care and only provide reimbursements if quality and patient experience measures are met.
Currently, fee-for-service is the primary payment method in the United States health care system. At its inception, it seemed like the perfect solution for how to bill patients, because health care providers would be reimbursed for each service provided. However, patients’ needs have become more complex, emphasizing a corresponding need for preventive care and coordinated treatment. Value-based programs were created as an alternative to the fee-for-service model, with the goal of providing patients with quality care while reducing the per-capita cost of health care. Unlike fee-for-service, value-based care programs consider the quality of care and only provide reimbursements if quality and patient experience measures are met. However, only a few value-based programs have achieved their goal of improving the quality of care, leaving much room for improvement. As we look to reform these payment models and ultimately phase out fee-for-service altogether, we must examine where we can address disparities and how we can be inclusive of maternity care in these solutions.
How Is Fee-for-Service Inadequate?
Fee-for-service is formally known as the “traditional payment model of health care.” Under a fee-for-service model, doctors and other health care providers are paid a fee for each particular service rendered, which ultimately rewards providers for the volume and quantity of services. This has resulted in a health care system that values quantity over quality, with substandard care and inflated prices as a result.
Unsurprisingly, many issues have arisen with this payment model, including issues with inefficiencies and lack of accountability. For instance, providers are rewarded for medical overuse, which is the unnecessary delivery of tests and services. This trend does not come out of an overabundance of caution, but rather out of a profit motive; the services do not always align with what is best for the patient, resulting in excessive procedures that further put the patient at risk. For example, hospitals are currently being paid $9,000 more for cesarean sections than vaginal births. There are also disparities in who undergoes cesarean sections: Black women are more than 4 percent more likely than white women to have a cesarean section (even for low-risk births), putting them at higher risk for complications like hemorrhage and infection. However, physicians and hospital systems are still rewarded for performing this high-risk procedure. Cesarean sections are a primary example of how financial incentives do not align with effective maternity care and why reforming fee-for-service must be a priority.
The Strengths of Value-Based Programs
Due to the model’s perverse incentives, health care policy analysts have advocated phasing out fee-for-service and adopting new payment methods that are inclusive of quality and value. Value-based care, which was first introduced in 2006 as an alternative reimbursement program, rewards health care providers for the quality of care they give to patients.
There are a number of different models of value-based care. Several of the most common payment models are described briefly below.
Accountable Care Organizations (ACOs): Accountable care organizations consist of groups of doctors, hospitals, and other health care providers who come together to give coordinated, high-quality care to patients. ACOs originally existed as a public option under Medicare but have since grown in the commercial payer market as well. This model aims to deliver better-quality care to patients while decreasing health care costs.
Patient-Centered Medical Homes (PCMH): A patient-centered medical home is a care delivery model that coordinates patient care through a primary-care physician. Medical homes were designed to increase the amount of personalized care patients receive from their physicians, and better care and an improved patient experience have been the result. Through PCMHs, states like Colorado and Maryland have been able to improve their quality scores and increase their savings by “reducing hospital and emergency department visits, mitigating health disparities, and improving patient outcomes.”
Bundled payments: Bundled payments are payment structures in which different health care providers who are treating a patient for the same or related conditions are paid an overall sum rather than being paid for each individual treatment, test, or procedure. The voluntary Bundled Payments for Care Improvement (BPCI) program was first implemented under Medicare in 2011, and has evolved to now include private insurers as well. Currently, bundled payments include a team of health care providers from different specialties and care settings to ensure that every aspect of a patient’s condition is cared for. If the team can successfully prove that they have met quality measures and decreased the cost of services, they can benefit financially from the savings.
From accountable care organizations to bundled payments, each program or model aims to recenter the patient’s needs and improve the quality of care. Unlike fee-for-service, value-based care programs are backed by research that supports coordinated and effective care, which will improve health outcomes. By reforming payment methods and expanding the programs mentioned above, we have an opportunity to decrease readmissions, improve safety, and lower costs in the field of maternity care as well.
How Are States Implementing Value-Based Programs?
As more public and private payers begin exploring value-based care, individual states have also made an effort to launch alternative payment methods. For example, Arkansas launched the Arkansas Health Care Payment Improvement Initiative (AHCPII) in 2012. The Arkansas Payment Improvement Initiative (APII) is a “multi-payer model combining patient-centered medical homes (PCMHs) with episodic payments for certain acute and chronic conditions.” It was designed with the intent to transition Arkansas to a more patient-centered health system. AHCPII aims to recenter the patient’s needs while simultaneously improving quality of care, increasing access to health care, and eliminating unnecessary costs.
Through the program, Arkansas established several episodes of care in areas such as pregnancy, elective orthopedic surgery, tonsillectomy, colonoscopy, acute asthma care, and attention deficit disorder. An episode of care is a collection of care services provided to treat a particular condition for a given length of time. Arkansas has made improvements in maternal health by way of their perinatal episode of care model. The perinatal episode is a type of value-based payment, and holds providers accountable through gainsharing and risk-sharing payments based on costs and quality. AHCPII adapted the perinatal episode of care model, aiming to “encourage patient-centered care throughout pregnancy, reduce variation in the cost and quality of pregnancy care, and increase provider accountability for improving the quality and efficiency of perinatal care.” From 2012 to 2019, they saw a decline in cesarean deliveries and emergency department visits. Overall, the model successfully promoted patient-centered care throughout pregnancy by creating incentives for providers to keep costs to a minimum. Arkansas ended use of the model in 2021 as all episodes of care were phased out.
Similar to Arkansas, New York implemented a Section 1115 Medicaid waiver entitled the Delivery System Reform Incentive Payment in 2014. Through the waiver, they have made several efforts to improve outcomes, specifically in maternal health. New York ultimately decided to bundle maternity care, meaning that all of the costs associated with pregnancy are grouped. The maternity bundled payment includes all care from the onset of pregnancy (i.e., prenatal care, delivery, post-delivery, and the first month of the newborn’s care). As a result, hospitals have shifted their focus towards improving health education; increasing the uptake of prenatal care and pre-and interconception counseling; lowering C-section rates; improving resource utilization; and increasing the use of screening for postpartum depression. Each of these efforts aligns with practices known to lower one’s risk and improve their chances of a successful pregnancy.
How Can We Include Maternity Care in the Value-Based Model’s Expansion?
By 2030, the Centers for Medicare and Medicaid Services (CMS) expects all Medicare payments to go through value-based models. However, some of the nation’s current implementations of the value-based model have continued to fall short or have lacked adequate maternity care. For this reason, as we reform and expand these programs, it is crucial to look at how we can effectively include maternity care into existing and new value-based programs. There are several ways we could better address maternal health outcomes through value-based care.
A study published in 2008 in the American Journal of Obstetrics and Gynecology found that maternal mortality is 2.2 per 100,000 live births for cesarean sections and 0.2 per 100,000 for vaginal births. Cesarean sections result in poorer health outcomes for birthing people, yet hospitals are paid more for cesarean sections when compared to vaginal births. Payment models should incentivize lowering the rate of cesarean sections. This will ultimately encourage providers to perform vaginal births instead of resorting to a high-risk procedure that could further lead to maternal mortality.
Bundling care is a standard model used in value-based programs and was implemented in order to lower care costs by covering the entire cycle of care for a particular condition. Payment methods should continue to establish maternity bundles that include all aspects of childbirth from pregnancy to birth and postpartum. In doing so, no gaps remain to leave new mothers at risk during any part of their pregnancy.
Support from doulas and midwives during pregnancy, birthing, and postpartum is known to improve health outcomes related to maternal health. Payment models should include doula and midwifery services as part of ACOs, which will provide patients with personalized care and improve their overall birthing experience.
Fee-for-service payment models stand in the way of improving health outcomes. By phasing out these models we have an opportunity to address and improve health disparities—particularly in maternal health. We can recenter the patient’s needs and improve the overall quality of care patients receive by implementing value-based care models. As policymakers look to reform current payment methods, we must look at disparities like those in maternal mortality and analyze how we can align payment incentives with efforts known to improve maternal health.