The thrill of delivering newborns helped pull Dr. Jack Feltz into the sphere of obstetrics and gynecology.
More than 30 years later, he nonetheless enjoys treating sufferers, he mentioned. But now, Feltz can also be working to alter the best way medical doctors are paid for maternity care.
Feltz’s New Jersey-based apply, Lifeline Medical Associates, just lately partnered with the insurer UnitedHealthcare to check a brand new cost mannequin. The insurer units a finances with the apply to pay medical doctors one lump sum for prenatal providers, supply and 60 days of care afterward. If the prices are available in under that quantity, the medical apply will get to maintain a number of the financial savings. (Hospitals aren’t part of this contract; the insurer pays them individually for his or her providers.)
“We’ve always been taught to take care of patients as if they were our mothers and our daughters,” mentioned Feltz, who additionally leads a coalition of obstetricians known as the U.S. Women’s Health Alliance that advocates for high-quality, inexpensive care. “But now we have to take care of our patients as if they were our mothers and our daughters, and as if it was our money.”
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This new program, introduced in May, is a primary step by the insurer to bundle doctor funds for maternity care right into a single flat payment that covers all care and procedures. A handful of insurers and state Medicaid packages are experimenting with related fashions, generally incorporating hospitals and different well being suppliers as effectively.
By shifting from paying for maternity care in a piecemeal technique to counting on bundled funds, insurers and medical doctors say they hope to chop prices and enhance the standard of take care of pregnant girls. The lump sums are additionally seen by medical doctors and insurers as a potential manner to enhance outcomes, together with driving down the variety of cesarean sections within the United States.
About one-third of all deliveries within the U.S. happen by C-sections, although the World Health Organization estimates they’re medically required in solely 10% to 15% of births. The rate varies dramatically amongst particular person hospitals.
These surgical procedures can enhance the danger of infections or different medical issues for the mom and child. And they’re dearer than a vaginal supply.
“The way we’ve been doing things is just not justifiable,” mentioned David Lansky, a senior adviser on the Pacific Business Group on Health, a San Francisco-based coalition of personal and public organizations that collectively buy well being take care of 10 million Americans. “The shift we’re talking about is to say someone is accountable for all the care that needs to be provided to support a family through this experience.”
The skilled affiliation that represents obstetricians, nevertheless, is approaching the brand new cost technique with warning as a result of it might expose medical doctors to monetary dangers.
And even followers of such a mannequin acknowledge there are nonetheless important obstacles to be labored out earlier than this type of flat-fee system could possibly be applied broadly.
The bundled-payment mannequin is comparatively new in maternity care, and its construction can differ by insurer. Some insurers might pay a single quantity to at least one physician, who makes use of that to cowl the hospital care. Other plans can choose to barter a separate contract with the hospital. Insurers can select to pay medical doctors earlier than or after sufferers obtain providers. The size of care, eligibility and providers included within the bundle may range.
Patients typically will not be even conscious their care is being dealt with below a bundled cost.
In conventional protection, insurance coverage funds for some girls are delivered as bundled funds for parts of their prenatal care, mentioned Suzanne Delbanco, govt director of Catalyst for Payment Reform, a corporation that helps advise employers and different organizations that purchase well being protection. However, the newest model is completely different as a result of insurers are including high quality measures that enhance accountability and extra providers, resembling supply prices, to the bundle.
UnitedHealthcare started testing the choice with Feltz’s apply and one other in Texas. The insurer mentioned it hopes to increase to as many as 20 practices by the top of the yr. Cigna and Humana are additionally piloting bundled maternity care packages. A couple of Medicaid packages, together with these in Arkansas, Ohio and Tennessee, have experimented with it.
Expanding the hardly ever used mannequin to incorporate maternity care might signify a significant shift in well being care finance. Births had been the most typical explanation for hospitalizations amongst sufferers discharged in 2016, in response to authorities information.
“Maternity care is kind of the sleeper of health care services,” mentioned Dr. Neel Shah, an assistant professor of obstetrics, gynecology and reproductive biology at Harvard Medical School.
The pivot in funds is being made as the standard of maternity care within the United States comes below renewed scrutiny. An estimated 700 women in the U.S. die annually due to pregnancy-related problems, the federal Centers for Disease Control and Prevention reported. The fee of deaths within the U.S. is worse than that of many different prosperous international locations, NPR and ProPublica reported in 2017.
And C-sections price extra. In the Denver space, for example, the typical vaginal supply prices $7,716 whereas the typical C-section prices $14,274, in response to 2019 information from the Health Care Cost Institute. On common, business and Medicaid insurers pay 50% extra for C-sections than for vaginal deliveries, in response to a 2013 report by Truven Health Analytics, a well being business consulting group.
Lansky’s group examined bundled funds for births in 2014 in Southern California. According to their report, the speed of C-sections in first-time, low-risk pregnancies dropped by almost 20% in lower than one yr among the many first three collaborating hospitals.
However, a number of the bundled-payment fashions fall wanting aspirations. Tennessee saved cash in 2017 after adopting the cost mannequin for Medicaid beneficiaries. But the speed of C-sections remained unchanged, in response to a report by the Medicaid and CHIP Payment and Access Commission (MACPAC), a nonpartisan advisory group for Congress.
In Ohio, the place the Medicaid program coated sophisticated pregnancies in addition to people who had been low-risk, bundling funds right into a lump sum for OB-GYNs price the state greater than anticipated, the advisory group discovered.
Bundling raises different considerations, too. Because some bundled-payment packages assign the whole price of care to a single doctor, the monetary burden falls on that doctor. Dr. Lisa Hollier, the fast previous president of the American College of Obstetricians and Gynecologists, is worried that these fashions might discourage team-based care.
If the doctor offering prenatal care overlooks an issue completely different physician should deal with throughout supply, for instance, it wouldn’t be truthful for the OB-GYN delivering the newborn to bear the monetary burden, Hollier mentioned.
How payers outline a low-risk being pregnant can also be unclear, she mentioned. If the goal value for the suite of providers within the mannequin isn’t risk-adjusted for the price of treating situations like gestational diabetes, she mentioned, medical doctors could possibly be penalized for treating these sufferers.
Gestational diabetes happens in as much as 10% of pregnancies within the U.S. yearly, according to the CDC, and sufferers with the situation want further checks, checkups and insulin.
Julianne Pantaleone, nationwide director of bundled funds and technique at UnitedHealthcare, mentioned the insurer, as it really works by its pilot program, won’t penalize physicians for offering care past the preliminary finances.
The lack of strong information programs constructed for bundled funds additionally poses a possible barrier to efficiently adopting the mannequin, mentioned Blair Barrett Dudley, a senior supervisor on the Pacific Business Group on Health.
Insurers and medical doctors want real-time information to make sure they’re assembly the mannequin’s high quality measures. However, these info banks are costly to construct, Dudley mentioned, and most of the present ones aren’t structured for this cost construction.
Feltz agreed that getting such information can be crucial to a profitable bundled cost program. Without the data, he mentioned, “it’s like launching a ship and not knowing where it’s going to go.”
Carmen Heredia Rodriguez: CarmenH@kff.org”>CarmenH@kff.org, @ByCHRodriguez