A Bundle of Joy? Bundled Payments for Maternity Care

The rising costs of healthcare generally, and the high costs of childbirth in the United States, are forcing innovation in payment models for maternity care alongside the ongoing efforts in other clinical areas. As a time-limited condition, maternity care may be uniquely well-suited for bundled payment models, which associate 1 global fee with provision of a set of services. Indeed, a range of different stakeholders—from health plans (like Horizon Blue Cross and Blue Shield of New Jersey) to self-insured employers (like General Electric) to freestanding birth centers (like the Minnesota Birth Center)—are all piloting bundled payment models for maternity care. These experiments highlight the appetite for value in maternity care and the interest in bundled payments by both public and private payers. The innovators in maternity care bundled payments vary widely in their approaches, and our field will learn from their experiences as adoption of this strategy continues to accelerate.

The recent draft White Paper, “Accelerating and Aligning Clinical Episode Payment Models: Maternity Care” written by the Clinical Episode Payment Work Group of the Healthcare Payment Learning & Action Network aims to propose a framework for clinical episode payment for maternity services that effectively advances the goals of the Triple Aim. The group’s recommendations offer helpful guidance to payers, providers, and healthcare delivery systems that seek to improve maternity care through payment reform. They designated 3 operational considerations: stakeholder perspectives, data infrastructure, and regulatory environment, and highlighted 10 design elements for a maternity care payment bundle: quality metrics, episode definition, episode timing, patient population, services, patient engagement, accountable entity, payment flow, episode price, and type and level of risk. The White Paper highlights research findings relevant to each of these and provides specific recommendations for all 10 design elements, in the context of maternity care bundled payments.

The recommendations are in draft form, and the integration of comments from the perspectives of diverse stakeholders will further enhance the usefulness of the framework for episode-based payment of maternity care. There are a few key areas where additional discussion and attention may be warranted:

1. Enhancing the role of patient-reported outcomes in determining quality metrics. For example, the domains identified in the “Good Birth” project (agency, personal security, connectedness, respect, and knowledge) may help to define specific measures of the quality of the birth experience from the patient perspective. Such metrics may be a valuable complement to currently-recommended outcomes.
2. Consider whether quality metrics could also include compliance with Alliance for Innovation on Maternal Health (AIM) bundles, and measurement of both levels and variability across provider groups or facilities. Maternal morbidity may be another measure to consider, and there are validated algorithms that could be used for identification of these outcomes.
3. Data are needed regarding maternity costs for midwife-led management of prenatal care for low-risk women (regardless of the eventual birth setting/delivery mode) in order to helpfully inform episode pricing.
4. Adding discussion of transition out of the episode (“discharge planning”) for postpartum women to ensure continuity with primary care. This is particularly important in the context of “churning” for many of the 48% of women whose births are covered by Medicaid, but whose eligibility may end 60 days after delivery.
5. Defining the low-risk patient population based on more clinically-nuanced criteria endorsed by the Society for Maternal Fetal Medicine (SMFM). If a more fine-tuned definition of low risk is not feasible, the conditions defined as high risk by maternal-fetal medicine specialists should be considered in the context of risk adjustment.
6. Specifically including doula care during pregnancy, labor and delivery, and postpartum within the list of services provided under a maternity care bundle. Doing so is consistent with recommendations from the American College of Obstetricians and Gynecologists and SMFM.
7. Specifically including perinatal depression screening within the list of services provided in the bundle, as recommended by the US Preventive Services Task Force in their most recently-updated guidelines.
8. When evaluating the regulatory environment for clinical episode payment for maternity care, consider how state scope of practice regulations for midwives may influence provider networks and patient access.

Bundling for maternity care payments holds promise not only for health plans and healthcare delivery systems, but also for frustrated patients who struggle to get information on the costs of maternity care. Bundled payments may allow for greater flexibility, improved rewards for high performance, and higher value for each dollar spent, and the successes and challenges of today’s innovators will inform future endeavors in maternity care payment reform.