An Update on Research Issues in the Assessment of Birth Settings Workshop Summary (2013) / Chapter Skim
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7 Costs, Values, and Reimbursement Issues Associated with Various Birth Settings
7 Costs, Values, and Reimbursement Issues Associated with Various Birth Settings
Pages 115-132
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From page 115... ...
, also known as "the Innovation Center," was mandated by the Affordable Care Act and appropriated $10 billion for testing new payment models. Its purpose is to find new ways to leverage different approaches to paying for care through providers, health systems, hospitals, and states, with the ultimate goal of improving quality, improving outcomes, and reducing total cost of care.
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From page 116... ...
, also known as "the Innovation Center." Many of these models impact perinatal care. • fter a decades-long history of state laws, regulations, and policies enacted or A implemented to foster collaboration between midwives and physicians, Laurie Cawthon suggested that Washington State serves as a model for varied birth settings.
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From page 117... ...
• Preventive Care o reventive care models include the Million Hearts Campaign P and Strong Start. Coordinated Care Pioneer ACO Model Shrank described several of the Coordinated Care models, beginning with the Pioneer ACO Model, which he observed has received significant media coverage.
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From page 118... ...
CPCi is a multipayer initiative, with all payers investing in comprehensive primary care and with Medicare paying approximately $20 per beneficiary per month to improve care coordination. On the front end, Shrank explained, the initiative helps physicians invest in delivering higher-quality and more efficient primary care, for example by hiring a nurse practitioner to help people with diabetes better manage their blood sugars or by hiring a pharmacist to help patients better adhere to their medications or understand drug side effects.
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From page 119... ...
. The Bundled Payments for Care Improvement model is based on bundling for the entire care episode, so not just for the inpatient phase of care but also for the post-acute care period.
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From page 120... ...
From 2004 to 2011, the number of home births nearly doubled, with the proportion of home births increasing from 1.1 to 1.9 percent of total births. From 2000 to 2011, the number of births in free 2 his T section summarizes information presented by Laurie Cawthon, M.D., M.P.H., Washington State Department of Social and Health Services, Olympia, Washington.
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From page 121... ...
Not until 2001 did the state Medicaid agency begin reimbursing for planned home births. Vaginal births after Cesarean deliveries, multiple gestation, and breech births that occurred in home settings were excluded from Medicaid reimbursement.
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From page 122... ...
Cawthon noted that, in 2011, there were 1,674 home births and 1,006 birthing center births in Washington State. The researchers identified prenatal care providers using Medicaid claim codes and assigned the women who they cared for into one of six categories: perinatologists (N = 3,544)
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From page 123... ...
Births Out of Hospital C-Section N = 14,259 N = 102 N = 82 N = 184 N = 2,558 Prenatal Care $2,892 $1,842 $1,545 $1,709 $3,011 Delivery $2,086 $961 $1,441 $1,175 $3,127 Postpartum $625 $282 $490 $ 375 $ 719 TOTAL $5,603 $3,085 $3,476 $3,259 $6,858 FIGURE 7-1 Average Medicaid expenditures for achieved birth place type in Washington State, 2010-2012, with only low-risk births included. Figure 7-1 SOURCE: Cawthon, 2013.
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From page 124... ...
The Cesarean delivery rate for home births was 9.4 percent; for birthing center births, 11.4 percent; for mixed providers, 12.2 percent; for all out-of-hospital births, 11.6 percent; for hospital CNM, 20.2 percent; and for hospital births with no CNM prenatal care, 29.4 percent. Cawthon remarked on the noteworthiness of the reduction in Cesarean delivery rates among hospital births to women who received prenatal care from a CNM compared to women who did not receive CNM prenatal care.
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From page 125... ...
Births Out of Hospital C-Section N = 26,061 N = 162 N = 112 N = 274 N = 10,343 Prenatal Care $3,036 $1,836 $1,645 $1,758 $3,424 Delivery $2,077 $1,335 $1,392 $1,358 $2,835 Postpartum $653 $363 $420 $386 $787 TOTAL $5,767 $3,533 $3,457 $3,502 $7,046 FIGURE 7-2 Average Medicaid expenditures for achieved birth place type in Washington State, 2010-2012, with all births included. 125 SOURCE: Cawthon, 2013.
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From page 126... ...
Births Out of Hospital Other N = 2,323 N = 101 N = 70 N = 93 N = 264 N = 14,261 Prenatal Care $2,899 $2,262 $1,773 $1,766 $1,958 $2,873 Delivery $1,898 $1,276 $1,424 $1,428 $1,369 $2,279 Postpartum $615 $335 $444 $497 $421 $640 TOTAL $5,412 $3,873 $3,641 $3,691 $3,748 $5,792 FIGURE 7-3 Average Medicaid expenditures for intent-to-treat births in Washington State, 2010-2012, with only low-risk births included. SOURCE: Cawthon, 2013.
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From page 127... ...
Births Out of Hospital Other N = 4,785 N = 182 N = 101 N = 159 N = 442 N = 30,571 Prenatal Care $3,170 $2,549 $1,988 $2,499 $2,403 $3,067 Delivery $1,985 $2,012 $1,499 $1,519 $1,717 $2,288 Postpartum $682 $453 $387 $457 $440 $685 TOTAL $5,837 $5,014 $3,874 $4,475 $4,560 $6,039 FIGURE 7-4 Average Medicaid expenditures for intent-to-treat births in Washington State, 2010-2012, with all births included. SOURCE: Cawthon, 2013.
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From page 128... ...
Finally, to gain a broader perspective on cost of care, Cawthon suggested examining, in addition to expenditure data, costs of birth outcomes that are not recorded in immediate and direct Medicaid expenditures. COST, VALUE, AND REIMBURSEMENT ISSUES: THE MEDICAID PERSPECTIVE3 Kathleen Nolan was invited to share her thoughts on issues raised by William Shrank and Laurie Cawthon.
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From page 129... ...
Such substantial state-level variation makes establishing a national agenda for a perinatal care delivery system and payment reform very difficult. In summary, Nolan reiterated three key challenges: (1)
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From page 130... ...
health care system, the challenge of decreasing costs in a for-profit system, the challenge of measuring actual cost of care, payment reform and perinatal care, "supervision" language used by Medicaid, and Medicaid reimbursement for midwives. Improving Outcomes in Hospital Settings A member of the audience observed that the focus of the workshop discussion should be on improving the quality of all birth settings, not just home birth settings.
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From page 131... ...
She asked the panelists to comment on the use of bundled payments in perinatal care. Cross-Barnet replied that some prenatal care is already being bundled, with a set fee for prenatal care plus birth delivery; but that it is unclear how the bundling is impacting quality of care.
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From page 132... ...
. Medicaid Reimbursement for Midwives A member of the audience clarified that there is a federal mandate that all state Medicaid programs reimburse nurse-midwives, regardless of where those births occur (at home, in a birth center, or in a hospital)
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