Bringing the Instruments of Accountable Care to Maternity Care is a Nice Thought – However This Certain Ain’t It
By VICTORIA ADEWALE & J.D. KLEINKE
How determined are we to search out some form of excellent news in regards to 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 concern, 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 definitely guarantees some uncommon excellent news for all of us working to repair the nationwide embarrassment that’s maternity care within the US generally, and the maternal mortality disaster specifically.
However alas, the article itself is yet one more reminder that course of enhancements are not outcomes enhancements. Additionally it is a traditional case of earnest researchers’ tendency to torture retrospective knowledge — as a result of it occurs to be obtainable for research — into one thing that may be helpful. Whereas it could be simple to dismiss out of hand the listless findings of this research of data-convenience, the hazard right here is they could nicely 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 chic research design to glean what they will 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 previous noticed goes: when you’ve a hammer, the whole lot appears to be like like a nail; and affected person enrollment in a main care ACO, as with this dataset, hardly counts as an unbiased variable with a lot energy to foretell the care utilization and outcomes of maternity care for coated enrollees.
It’s nicely established within the literature – to not point out an accepted truism amongst suppliers and sufferers – that when most ladies turn into pregnant, the majority of their care shifts from the first care setting to obstetrician/gynecologists (OB/GYNs) and licensed 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 improve within the variety of pre- and post-natal visits.
On its face, this a very good 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 research reveals no significant enhancements in maternal or fetal outcomes. The authors additionally discovered a mere 3 share level discount within the “probability” of a c-section; however this isn’t a 3 p.c fee discount, and is thus statistically meaningless, even on this giant a research 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 aren’t rewarded with extra income, sufferers within the US want a fee discount of 10 to fifteen factors, not three. The potential general value financial savings and enchancment in post-natal outcomes related to such a discount are well-documented and can 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 main care system largely irrelevant to this affected person inhabitants.
Moreover, we’d be remiss to not acknowledge that reasonable and high-risk pregnancies specifically are managed by obstetricians or maternal fetal medication specialists. Although this research makes an attempt to exclude sufferers with advanced situations, it identifies and excludes solely a number of gestations. There’s a spectrum of hypertension, diabetes, and varied different situations that will have prompted co-management or switch of care inside these populations. The concept satisfactory administration of maternity care might be added to the already overbooked and over-burdened main care doctor is dismissive of ladies’s well being and borderline negligent. Main 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 impression of accountable care methods on being pregnant care and outcomes, they need to be finding out any of the handfuls of real-world experiments in progress for Medicaid and business populations throughout the nation. True transformation of maternity care will come not from finding out the expertise of ladies in main care programs which can be not concerned within the supply of their infants; relatively, it requires a centered and concerted effort — with significant modifications to reimbursement — on an antiquated, intervention-driven maternity care system that does take care of them earlier than, throughout, and instantly after these deliveries. The elements of this transformation embody a a lot higher use of CNMs for regular pregnancies, who present much 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 generally are central to this, specifically bundled funds for risk-stratified sufferers, and pay-for-performance rewards and penalties for good or unhealthy outcomes. However all of those instruments must be extremely particular to the wants of pregnant ladies, not as a happenstance to how their main care suppliers are paid for your entire inhabitants of which they occur to be members. Different accountable care methods distinctive to maternity care additionally embody an extended overdue motion towards a team-based, medical house 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 without doubt one of the many causes maternity care stays an antiquated area of drugs nonetheless plagued with main maternal mortality and morbidity.
This isn’t a picayune tutorial level. The dispiriting outcomes of this research of knowledge comfort will serve solely to arm the bean-counters in business and Medicaid managed care plans who’re all too able to pounce on any improve in visits with no correlated enchancment as a waste of cash.
This research not solely does not present what the duvet headline promised, however the precise reverse — and thus units all of us again on the troublesome 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 info trade pioneer, and the creator of “Catching Infants”, a novel in regards to the coaching of OB/GYNs at present in improvement as a TV sequence.
