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Connecticut and Pennsylvania’s Approaches to Maternity-Focused Value-Based Payment Models

Medicaid covers more than 40 percent of births nationally. Given the critical role that Medicaid plays in maternal health, there is a longstanding interest in the role of Medicaid service delivery systems to improve perinatal health outcomes. A growing number of states are implementing maternity-focused payment models, including value-based payment models. This case study highlights Connecticut and Pennsylvania’s respective approaches to designing maternity-focused value-based payment models as one approach to improve maternal health outcomes.

The Intersection of Maternal Outcomes and Value-Based Payment

Maternal mortality rates are often considered a basic measure of a country’s overall health. Despite the U.S. having one of the most advanced health care systems in the world, U.S. maternal mortality rates are among the highest of all industrialized countries.[1] Maternal mortality has steadily increased in the U.S. over the past decade, with significant racial, ethnic, and socioeconomic disparities persisting.[2] Non-Hispanic Black women have the highest rates of poor birth outcomes in the U.S., substantially higher than rates for non-Hispanic White or Hispanic women.[3] Most maternal deaths are considered preventable, with the majority due to cardiovascular conditions, infection or sepsis, hemorrhage, and suicide or overdose. The timing of maternal deaths is spread equally across the perinatal period. [4]

With more than 40 percent of all births in the U.S. paid for by Medicaid, there is growing interest in exploring how Medicaid service delivery systems can be adapted to help improve maternal health outcomes.[5] States are increasingly designing and implementing value-based payment (VBP) models as one potential solution by holding providers more accountable for both the quality and cost of the care they are providing.[6]

VBPs, or alternative payment models, focus on reimbursement based on the quality of care provided as well as rewarding lower cost. They are not designed to alter how care is delivered; rather, they are meant to incentivize targeted quality improvements, reduce cost of care, and decrease disparities in care. There are a variety of arrangements within VBP models (see text box). VBP models are dynamic and exist at every level of health care, including hospitals or health care systems, health plans and individual clinicians. Relatedly, VPB models can be general or targeted to a specific health care need (e.g., maternity care).[7]

Some states are designing and implementing specific maternity-focused value-based payment models, including perinatal episodes of care, pay-for-performance, and pregnancy medical homes. This case study explores how Connecticut and Pennsylvania are using VBP to improve maternal health outcomes.

Common Approaches to Maternity-Focused Value-Based Payment Models

Pay-for-Performance: Pay-for-performance (P4P) models are one approach to VBP in which providers receive financial incentives to meet certain predefined quality metrics. Some P4P programs may include financial penalties if metrics are not met. Select performance measures associated with maternity-specific P4P models include completion of health risk assessments or depression screening and reported rates of primary Cesarean deliveries or elective early deliveries.[8]

Episodes of Care or Bundled Payment: Episodes of care or bundled payment models offer payment incentives to manage quality and cost across a set or bundle of services (e.g., perinatal episode). This model encourages all providers to reduce cost to a level that the state deems acceptable by penalizing providers with high costs and rewarding providers with low costs. Most of these models apply only to low- to moderate-risk pregnancies but not higher-risk pregnancies to help control for unpredictability.[9]

Pregnancy Medical Homes: Pregnancy medical homes aim to improve outcomes by addressing clinical, behavioral, and social aspects of care. They focus on population health and use both community and patient engagement. Payments are tied to providing services such as risk assessments or ensuring postpartum visit access.[10]

Connecticut’s Maternity Pay-for-Performance

Connecticut uses a pay-for-performance (P4P) model, the Obstetrical Pay for Performance, that was established in 2013 for obstetric care.[11] Provider participation in the P4P is voluntary. Participating providers must be enrolled in Connecticut’s Medicaid program and be a clinician providing obstetric care to Medicaid-enrolled patients. All participating providers are eligible for bonus payments if certain quality metrics are met; there are no penalties if metrics are not met. Cost of care does not factor into bonus payments. Bonus payments are based on the total amount of funding available in the bonus pool, spread out over all providers. Payments are calculated retrospectively and paid annually. Participating providers must fill out a prenatal online notification form to connect the patient with the provider. All Medicaid beneficiaries served by the practice are included.

The Obstetrical Pay for Performance model includes services provided starting between 12 to 28 weeks’ gestation through 22–84 days postpartum and aims to include all pregnant women enrolled in Medicaid.[12] Eight quality measures are used to measure provider performance, with each measure worth a certain number of points.[13] These quality measures include receipt of a comprehensive postpartum visit; completion of the prenatal online notification form; first prenatal visit and risk identification; low-dose aspirin prophylaxis for certain patients; self-measured blood pressure; full-term vaginal, spontaneous delivery; completion of a postpartum online forms; and at least one postpartum visit. Most metrics are tied to specific time frames and are weighted based on a point system. Bonus payments are based on total number of points earned, and thus the more enrolled patients a provider has, the greater the opportunity to earn points.

While there has been no formal evaluation yet to assess the effectiveness of this P4P model on maternal health outcomes or obstetric care after four cycles, some performance measures have been reported by Connecticut Medicaid up through cycle three. One performance measure, completion of the online notification form within 14 days of the first prenatal visit, was essentially unchanged over three cycles (averaging slightly above 50 percent), whereas another performance measure tracking full-term vaginal deliveries after spontaneous labor increased by nearly 15 percent over three cycles. While improvement on the attributed performance measures cannot necessarily be fully attributed to the Connecticut’s P4P, the results offer opportunities for additional exploration.[14]

Connecticut’s Medicaid program is currently transitioning to a Maternity Payment Bundle with weighted quality measures, social risk adjustment, and one quality measure that is clinically risk adjusted. Additionally, the new bundle includes funding for doulas and lactation supports. The obstetric P4P will sunset when the maternity payment bundle launches.

The Pennsylvania Model

In 2021, the Pennsylvania Department of Health and the Pennsylvania Department of Human Services (DHS) undertook several health care reforms, called Whole Person Health, with a goal of improving health outcomes in the state. The initiative focuses on addressing both the value of health care and strengthening access to social determinants of health and health equity, with the goal of creating a health care system that meets the holistic needs of each person.[15] Maternity care is one of several focus areas included in the initiative. There are significant inequities in maternal and infant mortality in Pennsylvania, with Black women three times more likely to experience a death than White women.[16] Because Medicaid accounts for approximately 34 percent of all deliveries, DHS chose to enact a new value-based payment model to address these poor outcomes.

The Maternity Care Bundle[17] is a form of bundled payment (see text box) that includes all services rendered during pregnancy, including prenatal visits, labor and delivery, and routine postpartum care. Participating providers receive bonus payments that are determined by performance on specific quality metrics, as well as associated decreases in cost of care. Quality measures include social determinants of health, postpartum depression screenings, substance use disorder treatment, timeliness of prenatal care, postpartum care, postpartum depression screening and follow-up, immunization status, and well-child visits. Additionally, participating providers that meet these metrics for Medicaid-enrolled Black patients are eligible to receive an additional incentive. Prenatal and newborn care are linked in this model as a payment dyad because newborn outcomes such as preterm birth and low birth weight are closely tied to early initiation into prenatal care and quality maternal care. A single bundled payment is made to the entire maternity care team, including the newborn team, and is not dependent on meeting any quality metrics. Incentivized payments are also made to the entire maternity/newborn care team based on achievement of quality metrics. The providers are then responsible for allocating the payments to each provider within the care team. The Maternity Care bundle includes community-based organizations to address social determinants of health.

DHS has several tools to monitor the effectiveness of these new payment models. The Pennsylvania Health Equity Analysis toolkit is a public online mapping tool that allows for analysis of health equity data. It includes three years of health outcomes from various sources aligned with census information and zip codes, providing information on ethnic and racial demographics. The PA Navigate system will be an interactive platform serving as a care coordination system for providers. It will also provide access to Pennsylvanians to search for information on social services needed to obtain optimal health.

Weighing the Use of Maternity-Focused Value-Based Payments

Many states are considering value-based payment models as one strategy to improve maternity care and address the rising maternal mortality in the U.S. While the full impact of alternative payment models is not yet fully known, value-based payment models have the potential to address the maternal health crisis in various ways, including strengthening access and quality of perinatal care and reducing costs.

Endnotes

  1. World Bank Open Data. “World Bank Open Data,” https://data.worldbank.org/indicator/SH.STA.MMRT
  2. “Pregnancy Mortality Surveillance System, Maternal and Infant Health, Centers for Disease Control and Prevention,” www.cdc.gov/reproductivehealth/maternal-mortality/pregnancy-mortality-surveillance-system.htm
  3. National Center for Environmental Health. “Picture of America Reproductive Outcomes.” Centers for Disease Control and Prevention,” 2014. www.cdc.gov/pictureofamerica/pdfs/picture_of_america_reproductive_outcomes.pdf
  4. Creanga. Pregnancy-Related Mortality in the United States. Obstet Gynecol 2017
  5. “Medicaid’s Role in Maternal Health,” Medicaid and CHIP Payment Access Commission, June 2020. Accessed May 1, 2023. www.macpac.gov/wp-content/uploads/2020/06/Chapter-5-Medicaid%E2%80%99s-Role-in-Maternal-Health.pdf
  6. Jacobs, Douglas, Elizabeth Fowler, Lee Fleisher, and Meena Seshamani. “The Medicare Value-Based Care Strategy: Alignment, Growth, and Equity …” Health Affairs, July 21, 2022. www.healthaffairs.org/content/forefront/medicare-value-based-care-strategy-alignment-growth-and-equity
  7. Value-Based Payment for Maternity Care in Medicaid: Findings from Five States. Medicaid and CHIP Payment and Access Commission, 2021. www.macpac.gov/wp-content/uploads/2021/09/Value-Based-Payment-for-Maternity-Care-in-Medicaid-Findings-from-Five-States.pdf
  8. Value-Based Payment for Maternity Care in Medicaid: Findings from Five States. Medicaid and CHIP Payment and Access Commission, 2021.
  9. Value-Based Payment for Maternity Care in Medicaid: Findings from Five States. Medicaid and CHIP Payment and Access Commission, 2021.
  10. Value-Based Payment for Maternity Care in Medicaid: Findings from Five States. Medicaid and CHIP Payment and Access Commission, 2021.
  11. Medical Assistance Program Oversight Council, Women and Children’s Health Committee. “Connecticut Department of Social Services Obstetrical Pay for Performance.” www.cga.ct.gov/ph/med/related/20190101_Women%20&%20Childrens%20Health%20Committee/20191209/OBP4P_December_9_2019%20presentation.pdf
  12. Medical Assistance Program Oversight Council, Women and Children’s Health Committee. “Connecticut Department of Social Services Obstetrical Pay for Performance.”
  13. Medical Assistance Program Oversight Council, Women and Children’s Health Committee. “Connecticut Department of Social Services Obstetrical Pay for Performance.”
  14. Medical Assistance Program Oversight Council, Women and Children’s Health Committee. “Connecticut Department of Social Services Obstetrical Pay for Performance.”
  15. “Medicaid’s Role in Maternal Health,” Medicaid and CHIP Payment Access Commission, June 2020. Accessed May 1, 2023. www.macpac.gov/wp-content/uploads/2020/06/Chapter-5-Medicaid%E2%80%99s-Role-in-Maternal-Health.pdf
  16. Review of The State of Health Equity in Pennsylvania, Pennsylvania Department of Health, 2019. www.health.pa.gov/topics/Documents/Health%20Equity/The%20State%20of%20Health%20Equity%20in%20PA%20Report%20FINAL.pdf
  17. Pennsylvania Department of Human Services. “Roadmap to Whole Person Health,” 2021. Accessed April 27, 2023. www.dhs.pa.gov/HealthInnovation/Documents/WholePersonCareReport_Final.pdf

Acknowledgements

This blog was written by Amy Nelson who is a practicing OB-GYN. Nelson is an intern with NASHP as part of her graduate studies and supports the organization’s maternal health portfolio.

This case study is a publication of the National Academy for State Health Policy (NASHP). This project is supported by the Health Resources and Services Administration (HRSA) of the U.S. Department of Health and Human Services (HHS) under the Supporting Maternal and Child Health Innovation in States Grant No. U1XMC31658; $398,953. This information, content, and conclusions are those of the authors and should not be construed as the official position or policy of, nor should any endorsements be inferred by HRSA, HHS, or the U.S. government.

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