Since the U.S. Government Accountability Office (GAO) recently released a report titled “Maternal Health: Outcomes Worsened and Disparities Persisted During the Pandemic,” I thought this would be a good opportunity to write the promised follow-up to my first blog post about maternal mortality and population health. After doing further research since I first published that post, in retrospect a more accurate title for the series would’ve been “Maternal, Infant, and Population Health” since maternal health and newborn health are often closely linked, and maternal mortality only tells part of a larger story.
But what’s done is done, so let’s proceed.
In my first post I largely focused on strategies for improving maternal health before, during, and after giving birth, mostly zeroing in on the utilization of midwives. Contrary to the post’s title, however, I didn’t introduce much of a population health perspective. So let’s take this a step further and look at how population-level care strategies might optimize maternal and newborn health.
A Broken System
Since I delved pretty far into how the U.S. stacks up against other peer countries in terms of our healthcare system (spoiler alert: we rate significantly worse in almost every category, including maternal health), I won’t cover the same ground here. To help orient us, though, I do want to offer a snapshot of where we are now that the COVID-19 pandemic is (hopefully) receding, and the GAO report helps us do that.
The authors of the report analyzed CDC data through much of the pandemic and compared it to the same data sets collected in pre-pandemic years. They found some interesting things, all of which point to the fact that, as the report’s title suggests, maternal health declined during the pandemic. Here are their top-line findings:
- Maternal deaths increased during the pandemic compared to 2018 and 2019
- COVID-19 contributed to 25% of maternal deaths in 2020 and 2021
- The maternal death rate for Black or African-American women was disproportionally higher compared to White and Hispanic or Latina women
Access to care was flagged as a major contributing factor to these outcomes. And key to any discussion of population health, negative social determinants of health (SDOH) played a central role:
“Stakeholders and Department of Health and Human Services (HHS) officials told GAO that the pandemic exacerbated the effects of social determinants of health—factors such as access to care, transportation, or technology; living environment; and employment—on maternal health disparities.”
Given that the U.S. healthcare system was not well-positioned to intervene in social drivers of maternal health problems before the pandemic, lockdowns and other measures meant to protect people’s health ironically led to a worsening of the situation. So that we don’t drop the ball again and allow pregnant women to go untreated until it’s too late, how can we learn from our failures over the past few years? I believe that a population health approach holds many of the answers.
Incentivizing Maternal and Infant Care
One doesn’t have to look farther than the annual measurement efforts done by the Health Care Payment Learning & Action Network (HCPLAN) to see that among other insurers, Medicare and Medicaid are pushing medicine toward two-sided risk alternative payment models (APMs), where both insurers and providers bear a portion of the financial risk for treating patients, with special emphasis on so-called Population-Based Payment Models, or PBPMs (which I discussed in a previous blog post).
Between 2019 and 2020, U.S. healthcare payments flowed through two-sided risk APMs at rates that increased from 16.5% to 17.9% of payments. Yes, PBPMs only made up a small fraction of these payments, but it’s clear CMS is pushing in this direction. As promising as two-sided risk APMs are to improving care of all kinds, including maternal care, in their current form they only go so far, often focusing on process measures instead of more holistic care that targets access-to-care issues.
One possible solution to this issue would entail combining something called “bundled payments” with a PBPM such as an accountable care organization (ACO). This idea, which is being championed by the folks at the Duke Margolis Center for Health Policy, involves some outside-the-box thinking as it entails aligning disparate stakeholders to ensure a continuity of care of both mother and child over a much longer time horizon that often currently exists.
The Importance of Bundling Care
HealthCare.gov defines bundled payments like this: “A payment structure in which different health care providers who are treating you for the same or related conditions are paid an overall sum for taking care of your condition rather than being paid for each individual treatment, test, or procedure. In doing so, providers are rewarded for coordinating care, preventing complications and errors, and reducing unnecessary or duplicative tests and treatments.”
This coordination of care is key to improving maternal and infant health – in the form of physical care and, for the mother, behavioral health services – before, during, and after pregnancy. including coverage for whole-person care where midwives and doulas play a critical role (I discussed the central importance of midwives to maternal and infant health in my previous post on the topic).
On the payer side, continuity of care is very important to shoring up healthcare disparities, considering that so-called “Medicaid enrollment churn” can lead to disruptions in care; for example, one study found that 55 percent of women enrolled in Medicaid or the Children’s Health Insurance Program (CHIP) between 2005 and 2013 experienced a coverage gap in the six months prior to giving birth. And since Medicaid covers 42 percent of all births, CMS can exert significant influence in improving longitudinal health outcomes and reducing healthcare disparities, since many of those covered by Medicaid for pregnancy-related services are in minority or rural populations.
As things stand, relatively few perinatal bundles of care focus on intervening in social drivers of health. Indeed, as the Duke report makes clear, “most existing evaluations of perinatal bundles focus on performance measures such as spending, care processes, and limited pregnancy outcome measures (such as rates of early elective delivery, vaginal delivery and cesarean delivery), but not on patient experience or broader maternal health outcomes like morbidity and mortality.”
Returning to the idea of combining bundled payments with PBPMs, the authors of a 2021 JAMA study found that “compared with inclusion in bundled payments alone, simultaneous inclusion in both ACOs and bundled payment programs was associated with lower institutional postacute care spending and readmissions for medical episodes and lower readmissions but not spending for surgical episodes.” In other words, maternal and infant patients who receive care simultaneously under ACOs like a PBPM and bundled payments can experience optimal outcomes. This approach seems to hold great potential to shore up gulfs in coverage and longitudinal care, and it’ll be interesting to watch how it progresses.