The Payers’ Playbook

Employer Groups Pushing For Improving Maternal Health

But health plans and hospitals are resisting efforts to do more to limit complications during pregnancy and childbirth.

Given the startling statistic that the rate of women dying of pregnancy- and childbirth-related complications in the United States is increasing, it seems logical that the U.S. health system would focus on improving outcomes in this area of care. Even more startling are these facts: The rate of women dying of these complications is declining elsewhere in the world, and 60% of such deaths in the U.S. are preventable, according to a report last year from NPR and ProPublica.

Maternal mortality rate for selected countries, 1990–2015

Per 100,000 live births

Source: Kassebaum NJ et al., Lancet, Jan. 5, 2017

But not all health plans address this disparity in health care delivery—and some even resist efforts to make improvements, says Cheryl Larson, president and CEO of the Midwest Business Group on Health, a Chicago-based coalition of employers.

For eight years, MBGH has sought better care for mothers and newborns. In 2010, it led an initiative to address the high rate of early elective deliveries in Illinois by partnering with the state hospital association, physician societies, local health departments, the March of Dimes, and others. Over three years, this effort helped drop the rate of early-elective deliveries in Illinois from 18% to 2% of all births, according to data from the Leapfrog Group, Larson says.

Last year, several MBGH employers wanted to develop a bundled-payment program with hospitals and physicians and yet found health insurers were uninterested, Larson says. “They said it was not enough of a priority for them,” she adds. Physicians and hospitals were generally uninterested as well, saying bundled payment would be too difficult administratively and financially, she says.

“Underlying this resistance is that hospitals don’t want to upset the ob-gyns who bring a lot of money into the system,” Larson explains. “And on the health plan side, they say they can’t commoditize this effort. Plus, if they haven’t come up with it as part of their own innovations, they don’t want to invest the time or resources to create something either.”

“Across the United States, the rate of C-sections is much higher than it should be,” says Cheryl Larson, CEO of the Midwest Business Group on Health.

Employers pay for more than half all health care in the United States, so it’s significant that they want to limit the number of Caesarean sections, epidural injections, and episiotomies whenever possible, Larson says. Complications during childbirth drive up costs and can be a reflection of poor overall quality of care.

“Across the United States, the rate of C-­sections is much higher than it should be,” comments Larson. Epidural injections and episiotomies during childbirth also increase risks for mothers and, in some cases, for children.

“There’s also a cost issue involved and, obviously, employers and none of us want to pay for procedures that are not medically necessary,” she says.

For all these reasons, MBGH and other employer coalitions are seeking to hold the health system accountable for poor results.

Florida focus on babies

Based on a review of cost and quality data, the Florida Health Care Coalition, which represents such employers as Walt Disney Company and Universal Florida, among other companies, started a program last year to get health plans and hospitals more involved in improving maternal health. Last fall, during a coalition-sponsored event with the March of Dimes called, “Babies, Business and the Bottom Line,” the employers made recommendations to reduce high rates of early elective deliveries and medically unnecessary C-sections, for example, says Karen van Caulil, PhD, the coalition’s president and CEO.

Some Florida health plans will put those recommendations into their plan offerings for next year, van Caulil adds.

The Florida Health Care Coalition wants insurers to educate their pregnant plan members about the benefits of progesterone, says Karen van Caulil, the coalition’s CEO.

Armed with claims data and ratings from the Leapfrog Group, an organization of employers started in 2000 to rate hospitals on quality and patient safety, the coalition aims to redesign benefit programs by developing bundled payment for maternity services and to steer workers and family members to the best providers.

The coalition also is working with the March of Dimes, the Orange County Healthy Start Coalition, and the state Department of Health to promote the use of injections of the hormone progesterone to reduce and prevent premature births, van Caulil says. The March of Dimes says such injections can help a woman’s uterus grow during pregnancy, prevent it from having contractions, and may reduce the risk of premature birth in some women, such as those who have a short cervix or who have had a spontaneous premature birth in the past.

This year, the coalition has been educating employers about the use of progesterone and asking health plans to educate their pregnant plan members about it, van Caulil adds. Also, the coalition encourages employers to waive the requirement that workers take time off to get these injections, to consider administering them in on-site health centers (if available), and to cover the expense of having home-health nurses administer these injections at home whenever possible.

As the employers in Florida are doing, the Northeast Business Group on Health, which represents employers in New York and surrounding states, introduced an effort in June to educate expectant mothers and fathers in New York City and Long Island about the risks that C-sections, induced births, and episiotomies pose to mothers and babies. A new website, ExpectNY, helps expectant mothers and fathers compare hospitals based on the rates of these procedures and other factors. “Employers are fairly unanimous that maternity is one of the areas in which high-quality procedures and outcomes are most pressing,” said Marco Diaz, a senior vice president at News Corp. and vice chair of NEBGH’s Board of Directors.

NEBGH CEO Candice Sherman agrees, saying employers need to hold health plans and the delivery system accountable for higher quality, lower-cost maternity care. Employers may feel as if they’re swimming against the current if hospitals, physicians, and health insurers are reluctant to address this pressing issue. But they’re not alone. In June, the National Partnership for Women & Families called for the health system to implement what it called six well-tested, evidence-informed strategies to address the country’s abysmal record on maternal and infant care and health outcomes.

As part of this strategy, the partnership released its “Blueprint for Advancing High-Value Maternity Care Through Physiologic Childbearing,” which calls for rewarding health care providers and systems that deliver quality, woman-centered maternity care; measuring and reporting on the quality of such care; and doing more to engage women and families in maternity care. We need all of these and other efforts. Without them, this country will continue to spend more on health care than any other nation while ranking near the bottom when it comes to the health of mothers and their newborns.

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