Building on the ACA: Administrative Actions to Improve Maternal Health
Create innovative care models that pay for quality and promote the equitable delivery of care:
The ACA authorized the creation of the Center for Medicare and Medicaid Innovation (CMMI) within HHS to design and implement innovative health care payment models. The office has previously operated models focused on maternal health, including those aimed at reducing early deliveries, improving prenatal care, and caring for mothers with substance use disorders. There have also been state-based payment and delivery models aimed at improving maternal health. For example, state Medicaid programs have enacted maternity care homes, whereby patients are assigned a provider who coordinates their various medical needs, and the provider may receive payment incentives for delivering certain services or meeting specific quality metrics. In North Carolina, 70 percent of the pregnant people participating in the state’s pregnancy medical home received prenatal care starting in the first trimester. The Momnibus also includes bills that call on HHS to develop new care models: The Tech to Save Moms Act, introduced by Rep. Eddie Bernice Johnson (D-TX) and Sen. Bob Menendez (D-NJ), encourages the CMMI to consider developing a model that integrates telehealth services in the screening, monitoring, and management of pregnancy-related care. The Impact to Save Moms Act, introduced by Rep. Jan Schakowsky (D-IL) and Sen. Bob Casey (D-PA), would also create a new perinatal care alternative payment model. Additionally, the Data to Save Moms Act, introduced by Rep. Sharice Davids (D-KS) and Sen. Tina Smith (D-MN), would establish a Task Force on Maternal Health Data and Quality Measures. It would also require a review of existing quality measures, including a review of their effectiveness and the barriers preventing providers from implementing them, among other factors. The Momnibus would provide funding to enact these models, but HHS also has the authority to develop the models through administrative actions.
The CMMI should exercise this authority to design a demonstration project that is focused on addressing maternal health inequities, particularly for Black and Indigenous pregnant people. These models should incorporate maternal health quality measures, such as the National Quality Forum-endorsed measures on C-sections or early elective deliveries (i.e., induced pregnancies and C-sections before 39 weeks) to discourage these procedures when not medically necessary. Additionally, these models should incorporate reproductive health measures such as the patient-centered contraceptive counseling measure, which asks patients about whether they received the contraceptive care and counseling of their choosing. The CMMI should also include quality family planning guidelines, which provide evidence-based recommendations to help people decide when and whether to become pregnant and which are associated with improved maternal health outcomes. Such measures can also be incorporated into other insurance coverage requirements to ensure public and private plans are only paying for quality care.
It is also important that participating providers be racially and ethnically diverse and representative of the communities that they serve. Ensuring that providers receive cultural competency training has also been found to yield positive outcomes. A meta-analysis of 19 studies found that when providers received training in cultural competency, patients had improved health care access and utilization. Providers who predominantly serve communities of color have also been frequently excluded from participating in innovative models; it is important that the agency provide increased funding and technical assistance to allow these providers an equal opportunity to participate in the demonstration project. Specifically, demonstration projects should include safety-net providers such as family planning providers, rural providers, and other providers who have been historically underfunded. Additionally, nonphysician providers and birthing support such as midwives and doulas should be included given the known positive effect they have on maternal health outcomes. Within these models, participating providers, as well as other health care workers involved, should be required to receive implicit bias and anti-racism trainings.
Throughout and after the demonstration project, the participating entities should report patients’ disaggregated data based on race, ethnicity, sex, gender, gender identity, sexual orientation, disability status, immigration status, English proficiency, income, and geographic location. This information should be considered when evaluating the effectiveness of the innovation model. Additionally, the evaluation should conduct a proper risk adjustment to account for social and environmental factors that are outside of the providers’ control to ensure the quality of care delivered is properly assessed. Some experts have rightly raised a concern that without proper risk adjustment, an unintended consequence of a value-based payment model could be the unfair penalization of providers who serve communities that have historically been disadvantaged in the health care system and thus came into the demonstration with poorer health.
Overall, however, there are substantial cost savings associated with care coordination and value-based payment models. This approach has been taken up in the maternity care context: A 2015 study in North Carolina showed that when women who were covered by Medicaid for at least part of their pregnancy were enrolled in the state’s Baby Love Maternity Care Coordination program—a home visiting program that coordinated prenatal visits, mental health counseling, and childbirth education, among other services—they experienced a decline in preterm birth risk compared with a control group. In regards to alternative payment models, Tennessee implemented a perinatal episode-of-care payment model that saved the state more than $4.7 million between 2014 and 2015 and led its C-section rate to drop from 31.4 percent in 2014 to 29.2 percent in 2015.