BOX 7-1
Costs, Values, and Reimbursement Issues Associated with
Various Birth Settings
Key Points Made by Individual Speakers

  • Medicaid is a major payer for births in the United States, paying for approximately 40 percent of all births nationwide. Medicaid also pays for many poor birth outcomes. To sustain itself, Medicaid is seeking ways to reduce costs. William Shrank discussed the wide range of new payment models being tested by the Center for Medicare and Medicaid Innovation (CMMI), also known as “the Innovation Center.” Many of these models impact perinatal care.
  • After a decades-long history of state laws, regulations, and policies enacted or implemented to foster collaboration between midwives and physicians, Laurie Cawthon suggested that Washington State serves as a model for varied birth settings. She presented results from an unpublished study based on Medicaid claim and U.S. birth certificate data comparing expenditures between hospital, home, and birth center births. Expenditures for out-of-hospital births are consistently lower than for hospital births.
  • While Medicaid interest in perinatal care is high, involving Medicaid in perinatal research is challenging. Kathleen Nolan identified several key challenges: data collection; state-level variation in Medicaid coverage; and the unknown impact of the shifting Medicaid landscape on pregnancy coverage.

in cost. The U.S. Department of Health and Human Services secretary has the authority to expand successful models through rule making, not legislation, leading to rapid implementation.

William Shrank described programs announced by CMMI to date (as of the time of the workshop). He stated that the Center was still in its infancy, having been established just 2 years ago, but that already it has announced a large agenda of new programs. He noted at the outset that he would describe each program’s relevancy to childbirth care but emphasized that the goal is to think more broadly about “the changing incentives, the changing environment, the changing platform and what that means for all of us as we strive to improve the quality and reduce the cost of care for the patients that we serve.”

The programs announced thus far by CMMI are grouped into several categories:


•   Coordinated Care

images   Coordinated care is a central theme of the Affordable Care Act and was written directly into the CMMI statute, that is, that CMMI should emphasize new programs that attempt to im-

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