Bringing the Tools of Accountable Care to Maternity Care is a Great Idea – But This Sure Ain’t It
By VICTORIA ADEWALE & J.D. KLEINKE
How desperate are we to find some kind of good news about the sorry state of maternity care in America? To find out, look no further than the current cover of no less venerable a health policy journal than Health Affairs.
With the headline “Medicaid ACO Improves Maternity Care” jumping off the cover of its September issue, we were expecting great things from the article “Massachusetts Medicaid ACO Program May Have Improved Care Quality for Pregnant and Postpartum Enrollees” (Megan B. Cole, et al.). The headline certainly promises some rare good news for all of us working to fix the national embarrassment that is maternity care in the US in general, and the maternal mortality crisis in particular.
But alas, the article itself is one more reminder that process improvements are not outcomes improvements. It is also a classic case of earnest researchers’ tendency to torture retrospective data — because it happens to be available for study — into something that might be useful. While it would be easy to dismiss out of hand the listless findings of this study of data-convenience, the danger here is they may well provide yet more ammunition for skeptical payers not to pay for more care that numerous studies have shown patients desperately need.
The authors make a valiant effort with an elegant study design to glean what they can from the “natural experiment” of analyzing pre- and post-natal care delivered to pregnant patients before and after the implementation of Accountable Care Organizations in Massachusetts. But as another old saw goes: when you have a hammer, everything looks like a nail; and patient enrollment in a primary care ACO, as with this dataset, hardly counts as an independent variable with much power to predict the care utilization and outcomes of maternity care for covered enrollees.
It is well established in the literature – not to mention an accepted truism among providers and patients – that when most women become pregnant, the bulk of their care shifts from the primary care setting to obstetrician/gynecologists (OB/GYNs) and certified nurse-midwives (CNMs). Many researchers and clinicians believe that much of this shift occurs even before a confirmed pregnancy, as a consequence of fertility challenges and pregnancy planning.
The authors did find that pregnant patients newly enrolled in ACOs had a small increase in the number of pre- and post-natal visits.
On its face, this a good thing, given how few visits maternity care patients get in the US compared to the rest of the developed world. But for that bump in visits, the study shows no meaningful improvements in maternal or fetal outcomes. The authors also found a mere 3 percentage point reduction in the “chance” of a c-section; but this is not a 3 percent rate reduction, and is thus statistically meaningless, even in this large a study population. And compared to most of the rest of the world, where surgical interventions by fee-for-service OB/GYNs and hospitals are not rewarded with more revenue, patients in the US need a rate reduction of 10 to 15 points, not three. The potential overall cost savings and improvement in post-natal outcomes associated with such a reduction are well-documented and would be staggering. This is the clarion call for “accountable care” laser-focused on maternity care, not the fragments of process improvement related to a primary care system mostly irrelevant to this patient population.
Additionally, we would be remiss not to acknowledge that moderate and high-risk pregnancies in particular are managed by obstetricians or maternal fetal medicine specialists. Though this study attempts to exclude patients with complex conditions, it identifies and excludes only multiple gestations. There is a spectrum of hypertension, diabetes, and various other conditions that would have prompted co-management or transfer of care within these populations. The idea that adequate management of maternity care can be added to the already overbooked and over-burdened primary care physician is dismissive of women’s health and borderline negligent. Primary care physicians for Medicaid patients have more than enough to manage, especially when undergoing their own professional conversion to accountable care.
If the authors want to measure the real impact of accountable care strategies on pregnancy care and outcomes, they should be studying any of the dozens of real-world experiments in progress for Medicaid and commercial populations all around the country. True transformation of maternity care will come not from studying the experience of women in primary care systems that are not involved in the delivery of their babies; rather, it requires a focused and concerted effort — with meaningful changes to reimbursement — on an antiquated, intervention-driven maternity care system that does care for them before, during, and immediately after those deliveries. The components of this transformation include a much greater use of CNMs for normal pregnancies, who provide far more pre- and post-natal care, and who have demonstrable effects on early inductions of labor, c-section rates, and downstream rates of NICU admissions.
The core tools of accountable care in general are central to this, in particular bundled payments for risk-stratified patients, and pay-for-performance rewards and penalties for good or bad outcomes. But all of these tools need to be highly specific to the needs of pregnant women, not as a happenstance to how their primary care providers are paid for the entire population of which they happen to be members. Other accountable care strategies unique to maternity care also include a long overdue movement toward a team-based, medical home model that will benefit from multiple, specially-trained clinical roles, including OB/GYNs, CNMs and doulas. Failure to acknowledge the complexity of these challenges is one of the many reasons maternity care remains an antiquated field of medicine still plagued with major maternal mortality and morbidity.
This is not a picayune academic point. The dispiriting results of this study of data convenience will serve only to arm the bean-counters in commercial and Medicaid managed care plans who are all too ready to pounce on any increase in visits with no correlated improvement as a waste of money.
This study not only does not show what the cover headline promised, but the exact opposite — and thus sets all of us back on the difficult path to meaningful maternity care modernization.
Victoria Adewale, MD, MS, MBA, is an OB/GYN, Medical Service Corps Officer in the US Army Reserve, and Fellow in Maternal-Fetal Medicine at Women & Infants Hospital in Providence, Rhode Island. J.D. Kleinke is a medical economist, health care information industry pioneer, and the author of “Catching Babies”, a novel about the training of OB/GYNs currently in development as a TV series.