Maternity Deserts an Alarming Trend in the U.S.
May 1st, 2023
Maternity units across the country continue to close at increasing rates, leaving women at a heightened risk of maternal mortality. In fact, 47% of rural community hospitals report having no obstetric services in 2020. According to a report by the March of Dimes, more than 2.2 million women of childbearing age live in maternity care deserts, affecting nearly 150,000 babies.
Maternity care deserts are counties in which access to maternity health care services is limited or absent, either through lack of services or barriers to a woman’s ability to access that care. Living in a maternity care desert contributes significantly to a woman’s risk of maternal mortality. Studies show that this risk is even higher for women in rural areas, who have fewer options for prenatal care and fewer health care providers available to deliver their babies. This creates longer wait times and longer travel times to seek care.
The reasons behind these closures are complex, but many hospitals with obstetrics units are closing due to financial pressures, such as low reimbursement rates and high malpractice insurance costs. Additionally, the aging population of health care providers, particularly among obstetricians and midwives, creates additional challenges for rural communities. This results in fewer obstetricians and midwives available to provide prenatal care and deliver babies.
What’s the Solution?
Intervention from policymakers, including legislation, may be necessary to address the underlying causes of maternity deserts. Policy efforts should focus on ensuring all women have access to quality prenatal care and a safe environment for delivering their babies. Federal and state governments can invest in programs to recruit and retain physicians and midwives in rural areas, and the root causes of these closures can be addressed by offering financial incentives, such as loan forgiveness and tax incentives, to hospitals that offer obstetric services.
Several state Medicaid programs and major health systems in New Mexico, Missouri and Utah are leveraging telemedicine and remote monitoring and developing hub and spoke models of care in which obstetricians or maternal fetal medicine specialists in urban areas provide education and support to rural providers, who are more likely to be family medicine physicians and nurse practitioners than obstetricians.
Since obstetric unit closures in rural hospitals are often due to inadequate payments from private insurers, it’s time to rethink the way we pay for maternity care in these settings. The Center for Healthcare Quality and Payment Reform has proposed a new strategy which could create sweeping change – paying rural hospitals a monthly fee for each insured woman of childbearing age in the community, in addition to paying service-based fees directly related to pregnancy, delivery and postpartum.
Employers also have a critical role to play and know that improving maternal health outcomes in the U.S. and reducing disparities will require changes to the existing system of care to make it more patient-centered.
Here’s what employers can do to mitigate the trend of increased maternity deserts:
- Benefit design: Ensure employees have access to and coverage for community models of perinatal care, including midwives and birth centers. Evidence shows freestanding birth centers in rural communities offer a safe and local alternative for high-quality maternity care, rather than pregnant women having to drive long distances for labor and birth. For example, employers can cover out-of-network midwives and birth centers at in-network rates to improve access to community providers.
- Payment models: Paying for maternity care in one bundled payment encourages high-value maternity care by utilizing midwives, reducing unnecessary interventions such as C-sections and increasing maternal mental health screening in the prenatal period. When all providers, including the facility, are operating under a single budget, they are incentivized to coordinate care, increase efficiency and choose care delivery options that offer the best outcome for the patient’s health and experience. Purchasers can also consider paying rural hospitals a standby capacity payment in addition to service-based fees.
- Contracting standards and accountability: Employers can work in coordination to develop common standards, measures and purchasing principles. This set of tools could be used in contracting with health plans and providers to ensure high-quality, affordable and equitable maternity care. The PBGH Comprehensive Maternity Care Workgroup has begun this work. Employers and public purchasers interested in joining this effort can reach out to Blair Dudley.
Read more about employer strategies to promote high-value maternity care.
Supporting Non-Hospital Birthing Options: Employer Strategies to Improve Quality
May 23rd, 2022
Maternal infant health outcomes in the U.S. remain the worst among high-income countries, and Black women in the U.S. are nearly three times more likely to die from pregnancy-related complications than white women are. Additionally, U.S. women of reproductive age are significantly more likely to have problems paying their medical bills or to skip or delay needed care because of costs.
To underscore the high costs disproportionate to the poor maternal health outcomes, the cost of maternity care represents American employers’ second-highest annual health care expenditure – $1 in every $5. Faced with unacceptable results, employers are looking for pathways to improve maternal health care quality, affordability and the overall patient experience.
Improving Quality and Lowering Costs
Consumer surveys have shown that more patients are seeking non-hospital, community-based childbirth options, such as midwives, doulas and birth centers. This is particularly true for birth participants of color who are looking for alternatives to the hospital-physician childbirth experience.
Recent CDC 2020 vital statistics data mirror what we have seen from consumer surveys. Although overall births declined, in 2020 the number of births in birth centers nearly doubled. This is a significant indication that more women want choice in their maternity care team and care location and that more families, when given a choice, are seeking a non-hospital childbirth option.
Non-hospital maternity care options can help to address the problem of high-cost, low-quality care. Evidence shows the use of midwives improves overall maternal and infant health and decreases the cost of maternity care. In fact, research shows that collaborative care led by certified nurse midwives can result in 22% fewer primary C-sections. It also helps address a growing shortage of perinatal health providers. Despite these benefits, however, certified nurse-midwives are vastly underutilized, delivering only 9% of babies nationally.
A birth center is a midwife-led childbirth facility that offers individuals and families a more natural, lower intervention and less medicalized childbirth experience. Birth centers are freestanding facilities and separate from acute obstetric or newborn care where care is provided in the midwifery and wellness model of care. Birth centers typically have relationships with other community health providers and arrangements with other facilities, such as hospitals, for transfers to other levels of care when needed.
The CMS Strong Start program demonstrated that women who received prenatal care in birth centers had better outcomes and lower costs. This included lower rates of:
- Preterm births
- Low birth weight
Additionally, costs were more than $2,000 lower per mother-infant pair during birth and the following year for women who received prenatal care in birth centers.
How Purchasers Can Support Non-Hospital Options
Employers know that improving maternal health outcomes in the U.S. and reducing disparities will require changes to the existing system of care to make it more patient centered. Here are three ways employers can influence the health system and health plan leaders’ perspectives to address the barriers preventing birth center expansion, collaboration between hospitals and birth centers and access to midwives:
- Benefit design: Benefits programs can be designed to expand access to midwives and birth centers. For example, eBay has started covering out-of-network midwives at in-network rates to improve access to community providers.
- Payment and contracting: By paying for care differently and moving towards value-based payment rather than fee-for-service models, employers can greatly improve access to high-value facilities such as birth centers. A simple birth center bundled payment model would allow all prenatal, labor and delivery and postpartum care provided by the birth center to be captured under one claim/invoice. A bundled payment project with Qualcomm produced valuable lessons learned that could benefit other employers pursuing a bundled payment option.
- Quality improvement: In the event of a transfer from a birth center to a hospital, the transfer process is smooth and respectful for the patient and their family. PBGH is leading a project in California to establish a model to inform procedures regarding transfers.
In response to the lack of comprehensive, coordinated care and the overmedicalization of childbirth PBGH has developed several strategies to help employers impact their maternity marketplace.
Telehealth Providing Critical Pregnancy Support During Pandemic
April 20th, 2020
Telehealth has emerged as a vital tool for helping expecting mothers and clinicians manage pregnancy in the time of COVID-19.
That was the overarching take away from a recent webinar on maternity issues and the COVID-19 pandemic held by Pacific Business Group on Health and co-hosted by the Washington Health Care Authority and Washington Health Alliance. Participants included employers who help cover the costs of about 70% of all births in Washington state.
Telehealth’s ability to regularly connect pregnant women and their doctors has become essential in the face of the need to practice social distancing, which keeps expectant moms at home, employers said. An audio-visual link becomes particularly useful as mothers approach their due date or face the questions and concerns that inevitably follow birth.
According to employers, a growing number of health plans are making changes in telehealth coverage due to the pandemic, including waiving costs for patients who access care this way.
Ensuring that both payers and providers continue to support and expand telehealth services after the pandemic eases will be important, they added. On April 14, the Federal Communications Commission (FCC) announced a $200 million program to help non-profit providers establish telehealth services to better connect with patients.
Adjusting to the New Normal
Beyond increased use of telehealth, employers said the epidemic has resulted in a small percentage of pregnant women (5-10%) requesting transfers to birthing centers to avoid the risks of COVID-19 infection by delivering at a hospital. While most women will still deliver in a hospital setting, the current crisis has underscored the need to leverage all available maternity assets in our communities.
Developing a better understanding of how health benefit designs can create incentives for giving birth in settings outside the hospital, when appropriate, will be important for the future, employers said. Some webinar participants suggested that designating specific medical centers or alternative care sites as maternity centers could reduce risk of infection.
Employers also indicated that innovative solutions are needed to provide socially isolated expectant moms and new parents with venues for learning and reestablishing a sense of community. Possible options could include weekly education and Q&A sessions via Facebook Live or regular forums for discussing pregnancy-related issues that could be established through an employer’s human resources department. Group prenatal classes not only engage patients in their care and improve quality, these types of resources provide expectant mothers with necessary support from both peers and providers during this vulnerable time.
Looking Ahead: New Payment Models
Virtually all webinar participants agreed that the current fee-for-service payment structure constrains the way providers can deliver care, and that alternate ways of paying clinicians who provide maternity care are long overdue. New models are needed to support high-quality care that puts the patient’s needs first. Instead of having to ask themselves “can I bill for this,” providers could focus on simply delivering care in the most effective and patient-centered way possible.
Webinar participants echo what PBGH has been consistently hearing from patients and employers: the COVID-19 epidemic is creating an important catalyst for changes across health care and barriers to adopting telehealth more broadly may finally be coming down.