Bringing the Instruments of Accountable Care to Maternity Care is a Nice Concept – However This Positive Ain’t It
By VICTORIA ADEWALE & J.D. KLEINKE
How determined are we to seek out some type of excellent news concerning the sorry state of maternity care in America? To search out out, look no additional than the present cowl of no much less venerable a well being coverage journal than Well being Affairs.
With the headline “Medicaid ACO Improves Maternity Care” leaping off the duvet of its September difficulty, we had been anticipating nice issues from the article “Massachusetts Medicaid ACO Program May Have Improved Care Quality for Pregnant and Postpartum Enrollees” (Megan B. Cole, et al.). The headline actually guarantees some uncommon excellent news for all of us working to repair the nationwide embarrassment that’s maternity care within the US usually, and the maternal mortality disaster particularly.
However alas, the article itself is yet another reminder that course of enhancements are not outcomes enhancements. It’s also a traditional case of earnest researchers’ tendency to torture retrospective information — as a result of it occurs to be accessible for examine — into one thing that is perhaps helpful. Whereas it could be simple to dismiss out of hand the listless findings of this examine of data-convenience, the hazard right here is they could properly present but extra ammunition for skeptical payers not to pay for extra care that quite a few research have proven sufferers desperately want.
The authors make a valiant effort with a sublime examine design to glean what they’ll from the “pure experiment” of analyzing pre- and post-natal care delivered to pregnant sufferers earlier than and after the implementation of Accountable Care Organizations in Massachusetts. However as one other outdated noticed goes: when you might have a hammer, the whole lot seems like a nail; and affected person enrollment in a major care ACO, as with this dataset, hardly counts as an impartial variable with a lot energy to foretell the care utilization and outcomes of maternity care for lined enrollees.
It’s properly established within the literature – to not point out an accepted truism amongst suppliers and sufferers – that when most girls grow to be pregnant, the majority of their care shifts from the first care setting to obstetrician/gynecologists (OB/GYNs) and authorized nurse-midwives (CNMs). Many researchers and clinicians imagine that a lot of this shift happens even earlier than a confirmed being pregnant, as a consequence of fertility challenges and being pregnant planning.
The authors did discover that pregnant sufferers newly enrolled in ACOs had a small enhance within the variety of pre- and post-natal visits.
On its face, this an excellent factor, given how few visits maternity care sufferers get within the US in comparison with the remainder of the developed world. However for that bump in visits, the examine reveals no significant enhancements in maternal or fetal outcomes. The authors additionally discovered a mere 3 proportion level discount within the “likelihood” of a c-section; however this isn’t a 3 % charge discount, and is thus statistically meaningless, even on this giant a examine inhabitants. And in comparison with a lot of the remainder of the world, the place surgical interventions by fee-for-service OB/GYNs and hospitals usually are not rewarded with extra income, sufferers within the US want a charge discount of 10 to fifteen factors, not three. The potential total value financial savings and enchancment in post-natal outcomes related to such a discount are well-documented and could be staggering. That is the clarion name for “accountable care” laser-focused on maternity care, not the fragments of course of enchancment associated to a major care system largely irrelevant to this affected person inhabitants.
Moreover, we’d be remiss to not acknowledge that average and high-risk pregnancies particularly are managed by obstetricians or maternal fetal drugs specialists. Although this examine makes an attempt to exclude sufferers with complicated circumstances, it identifies and excludes solely a number of gestations. There’s a spectrum of hypertension, diabetes, and numerous different circumstances that may have prompted co-management or switch of care inside these populations. The concept that satisfactory administration of maternity care might be added to the already overbooked and over-burdened major care doctor is dismissive of girls’s well being and borderline negligent. Major care physicians for Medicaid sufferers have greater than sufficient to handle, particularly when present process their very own skilled conversion to accountable care.
If the authors need to measure the actual influence of accountable care methods on being pregnant care and outcomes, they need to be learning any of the handfuls of real-world experiments in progress for Medicaid and industrial populations throughout the nation. True transformation of maternity care will come not from learning the expertise of girls in major care programs which might be not concerned within the supply of their infants; moderately, it requires a centered and concerted effort — with significant modifications to reimbursement — on an antiquated, intervention-driven maternity care system that does look after them earlier than, throughout, and instantly after these deliveries. The parts of this transformation embrace a a lot higher use of CNMs for regular pregnancies, who present way more pre- and post-natal care, and who’ve demonstrable results on early inductions of labor, c-section charges, and downstream charges of NICU admissions.
The core instruments of accountable care usually are central to this, particularly bundled funds for risk-stratified sufferers, and pay-for-performance rewards and penalties for good or dangerous outcomes. However all of those instruments should be extremely particular to the wants of pregnant girls, not as a happenstance to how their major care suppliers are paid for all the inhabitants of which they occur to be members. Different accountable care methods distinctive to maternity care additionally embrace an extended overdue motion towards a team-based, medical dwelling mannequin that can profit from a number of, specially-trained scientific roles, together with OB/GYNs, CNMs and doulas. Failure to acknowledge the complexity of those challenges is likely one of the many causes maternity care stays an antiquated subject of medication nonetheless plagued with main maternal mortality and morbidity.
This isn’t a picayune tutorial level. The dispiriting outcomes of this examine of information comfort will serve solely to arm the bean-counters in industrial and Medicaid managed care plans who’re all too able to pounce on any enhance in visits with no correlated enchancment as a waste of cash.
This examine not solely does not present what the duvet headline promised, however the precise reverse — and thus units all of us again on the tough path to significant maternity care modernization.
Victoria Adewale, MD, MS, MBA, is an OB/GYN, Medical Service Corps Officer within the US Military Reserve, and Fellow in Maternal-Fetal Medication at Girls & Infants Hospital in Windfall, Rhode Island. J.D. Kleinke is a medical economist, well being care data trade pioneer, and the creator of “Catching Infants”, a novel concerning the coaching of OB/GYNs presently in improvement as a TV sequence.
