Improving Maternal and Child Health Through Value-based Care
By Taylor Darlene Pomeranz, MPH Candidate 2022, University of Arizona and Cleyonia Tolliver, MPH Candidate 2022, University of Arizona
The quality of healthcare for expecting mothers has become a major concern within public health. Approximately 700 women die in the United States (U.S.) each year as a result of pregnancy or its complications (Pham et al., 2020). “A pregnancy-related death is defined as the death of a woman while pregnant or within 1 year of the end of a pregnancy –regardless of the outcome, duration or site of the pregnancy–from any cause related to or aggravated by the pregnancy or its management, but not from accidental or incidental causes'' (Pregnancy Mortality Surveillance System | Maternal and Infant Health | CDC, 2020). The occurrence of pregnancy-related deaths is steadily increasing with limited efforts put forth to decrease the chances of complications, especially for women of color. Recent data show that U.S. maternal mortality rates are rising, and Black, American Indian, and Alaska Native people giving birth are two to four times more likely to die from pregnancy-related complications than their white counterparts (Khanal, 2021). Many women are not receiving quality pre or postnatal care due to the lack of health insurance and quality of care. “Nearly 1 in 7 US women of childbearing age remain uninsured'' (Lu, 2018). More than half of deliveries in the US are covered by Medicare, but Medicare stops paying for pregnancy care after 6 weeks postpartum, potentially leading to women skipping their 6- week postpartum visit. During this visit oftentimes things such as depression and other potential life threatening issues are diagnosed (Slomski, 2019). Through value-based care, healthcare providers and medical practices will be able to help effectively improve health outcomes for women’s health.
Although there are many gaps when it comes to access of care, such as rural communities not having informed health care professionals, lack of transportation and more, there are multiple ways to improve access to care. There are many challenges to address when it comes to maternal mortality, but a collaborative team response between hospitals, healthcare systems, professional organizations and public health agencies allows a dynamic workforce to overcome the barriers. This allows the best care to be given to childbearing women to reduce the public health crisis of maternal mortality. Communication is key in the healthcare field and in order to address barriers, effective communication strategies must be a top priority in the continuum of care. Quality improvement programs can be an effective and cost-effective way to improve patient safety and quality of care. By applying these programs, the hospital can discover needs and assess them accordingly to promote better quality for both the patients and healthcare providers. The implementation of teach back moments in order to assure the patient understands what the provider is stating, allowing for questions to be answered, reducing the risk of future complications. Providers talk to the patient with terms they understand, provide them with a copy of all necessary information and additional resources available.
One way to improve access to care is to increase Medicaid coverage and eligibility for childbearing women. Also, having a specialist visit rural communities on a monthly basis and specific programs tailored to individuals who do not have insurance, so everyone is receiving care. Lastly, rural communities provide access to telemedicine (Maternal Mortality Action Plan, 2019). AIM Maternity Safety Bundles (sets of evidence-based practices), which include obstetric hemorrhage, safe reduction of primary cesarean births, postpartum care, obstetric care for women who use drugs and reducing racial/ethnic disparities (Maternal and Child Health Bureau, 2016).
Value-based care looks at healthcare from many angles in which patients receive healthcare and the overall goal is to improve the quality and outcomes for patients. Value-based care can seem like a simple concept, but proactive in the sense of improving overall care for patients who need it. As the global maternal mortality rate fell 44 percent between 1990 and 2015, maternal mortality and pregnancy-related deaths in the US have gone in the opposite direction, increasing 139 percent since 1987 (Pierce-Wrobel & Green, 2019). By measuring the quality of healthcare and incorporating value-based strategies, more women will be able to experience a healthier pregnancy and postpartum care. Best practices, preventative screenings and wellness are some ways the goal of value-based care can be reached. For example, incorporating annual well women exams, nutrition, pre and postnatal care and mental health resources can all improve the quality of care.
Bundled payments is an example of how value-based payments generate great outcomes. A bundled payment is a single payment for an episode of care or to treat a specific condition for a set period of time, incentivizing providers to coordinate care and focus on the patient’s individual needs rather than one particular service (Waldrop, 2019). The organization of bundled payments can come in different forms. These payments can be prospective, where payment is made prior to service delivery, or retrospective, in which costs are tracked against a predetermined rate and payments are adjusted based on adherence to this rate and quality measurement (Waldrop, 2019). CMS found that bundled payment arrangements have consistently increased in recent years—from around 23 percent of all payments in 2015, 29 percent in 2016, to 34 percent of payments in 2017 (Waldrop, 2019).
Value-based payment strategies is a method in which value-based care can be effective. This concept has not been fully embraced yet. With the right design, a value-based model for maternity care involving bundled payment can help address these issues by: reducing the rate of C-sections and other birthing interventions while encouraging support for vaginal and vaginal birth after cesarean deliveries; improving outcomes for patients by lowering risk of infections and shortening recovery time; expanding the use of lower-cost resources, such as midwives and advanced practice providers for prenatal visits and improving patient satisfaction through better care coordination and outcomes (Kerby et al., 2020). Payment strategies encourage care coordination for medically high-risk patients, increasing access to preventive care and mental health care throughout pregnancy (Waldrop, 2019).
Measuring the quality of health care can be viewed in three forms: structural, process, and outcome. Out of these three forms, process and outcomes can measure the effectiveness of payment reforms. Process measures are those that indicate what a provider does to maintain or improve health (Waldrop, 2019). These measures are important for efforts such as care coordination of chronic conditions, as these conditions typically require ongoing treatment (Waldrop, 2019). Outcome measures are those that reflect the impact of the health care service or intervention on the health status of patients (Waldrop, 2019). Determining the appropriate quality measures for a given condition or episode of care is a fundamental aspect of using these delivery system reforms to improve care and evaluating their effectiveness in reducing costs without sacrificing quality (Waldrop, 2019).
Improving maternal health through value-based care can provide the healthcare industry many opportunities. By working with organizations involved in quality improvement and reporting, safety and overall quality of care can improve for mothers. The level of need is significant, and the health care system must work to reduce health disparities. Structural, long-lasting change must continue to be advocated for to help reduce this public health crisis. With a collaborative effort, maternal health can greatly improve within the United States.
1. Pham, O., Artiga, S., Orgera, K., & Ranji, U. (2020, November 10). Racial disparities in maternal and infant health: An overview. KFF. Retrieved from https://www.kff.org/report-section/racial-disparities-in-maternal-and-infant-health-an-overview-issue-brief/.
2. Pregnancy Mortality Surveillance System | Maternal and Infant Health | CDC. (2020, February) www.cdc.gov. https://www.cdc.gov/reproductivehealth/maternal-mortality/pregnancymortality-surveillance-system.htm#how
3. Khanal, P. (2021, August 8). Improving maternal health outcomes: State policy actions and opportunities. Center for Health Care Strategies. Retrieved from https://www.chcs.org/resource/improving-maternal-health-outcomes-state-policy-actions-and-opportunities/.
4. Lu, M. C. (2018). Reducing Maternal Mortality in the United States. JAMA, 320(12), 1237. https://doi.org/10.1001/jama.2018.11652
5. Slomski, A. (2019). Why Do Hundreds of US Women Die Annually in Childbirth? JAMA, 321(13), 1239. https://doi.org/10.1001/jama.2019.0714
6. MATERNAL MORTALITY ACTION PLAN. (2019). https://azdhs.gov/documents/operations/managingexcellence/breakthrough-plans/maternal-mortality-breakthrough-plan.pdf
7. Programs & Initiatives | Maternal and Child Health Bureau. (2016, May 21). Hrsa.Gov. https://mchb.hrsa.gov/maternal-child-health-initiatives/mchb-programs
8. Pierce-Wrobel C, Green K. To Help Fix The Maternal Health Crisis, Look To Value-Based Payment. Health Affairs. https://www.healthaffairs.org/do/10.1377/hblog20190711.816632/full/. Published July 16, 2019
9. Waldrop, T. (2019, June 28). Improving women's health outcomes through payment and delivery system reform. Center for American Progress. Retrieved from https://www.americanprogress.org/issues/healthcare/reports/2019/06/28/471445/improving-womens-health-outcomes-payment-delivery-system-reform/.
10. Kerby, T., Bidgood, R., & Le, D. (2020, October 22). Why Effective Maternity Care requires an innovative, value-based strategy. hfma. Retrieved from https://www.hfma.org/topics/financial-sustainability/article/why-effective-maternity-care-requires-an-innovative--value-based.html.