A Scoping Review of Alternative Payment Models in Maternity Care: Insights in Key Design Elements and Effects on Health and Spending

Designing economic evaluations alongside clinical trials in maternal health care: A guide for clinical trial design

BACKGROUND

Economic evaluations are being conducted with increasing frequency in the maternity care setting, with more randomized controlled trials containing a health economic component. Key emerging criticisms of economic evaluation in maternity care are lack of robust data collection and measurement, inconsistencies in methodology, and lack of adherence to reporting guidelines.

METHODS

This article provides a guide to the design of economic evaluations alongside clinical trials in maternal health. We include economic concepts and considerations for the maternity setting and provide examples from the UK and Australia.

RESULTS

There are many important considerations for the design of economic evaluations alongside clinical trials. To be effective, researchers must select types of economic evaluation, which align with their study objectives; choose an appropriate evaluation perspective, time horizon, and discount rate; and identify accurate ways to measure and evaluate health outcomes and costs.

DISCUSSION

This guide is written for noneconomists and can be used for designing economic evaluations to be conducted as a part of clinical trials. We seek to improve the quality, consistency, and transparency of economic evaluations in maternal health.

Impact of reimbursement systems on patient care - a systematic review of systematic reviews

BACKGROUND

There is not yet sufficient scientific evidence to answer the question of the extent to which different reimbursement systems influence patient care and treatment quality. Due to the asymmetry of information between physicians, health insurers and patients, market-based mechanisms are necessary to ensure the best possible patient care. The aim of this study is to investigate how reimbursement systems influence multiple areas of patient care in form of structure, process and outcome indicators.

METHODS

For this purpose, a systematic literature review of systematic reviews is conducted in the databases PubMed, Web of Science and the Cochrane Library. The reimbursement systems of salary, bundled payment, fee-for-service and value-based reimbursement are examined. Patient care is divided according to the three dimensions of structure, process, and outcome and evaluated in eight subcategories.

RESULTS

A total of 34 reviews of 971 underlying primary studies are included in this article. International studies identified the greatest effects in categories resource utilization and quality/health outcomes. Pay-for-performance and bundled payments were the most commonly studied models. Among the systems examined, fee-for-service and value-based reimbursement systems have the most positive impact on patient care.

CONCLUSION

Patient care can be influenced by the choice of reimbursement system. The factors for successful implementation need to be further explored in future research.

Society for Maternal-Fetal Medicine Special Statement: Clinical quality measures in obstetrics

This article provides an updated overview and critique of clinical quality measures relevant to obstetrical care. The history of the quality movement in the United States and the proliferation of quality metrics over the past quarter-century are reviewed. Common uses of quality measures are summarized: payment programs, accreditation, public reporting, and quality improvement projects. We present listings of metrics that are reported by physicians or hospitals, either voluntarily or by mandate, to government agencies, payers, "watchdog" ratings organizations, and other entities. The costs and other burdens of extracting data and reporting metrics are summarized. The potential for unintended adverse consequences of the use of quality metrics is discussed along with approaches to mitigating adverse consequences. Finally, some recent attempts to develop simplified core measure sets are presented, with the promise that the complex and burdensome quality-metric enterprise may improve in the near future.

Stakeholder perspectives on payment reform in maternity care in the Netherlands: A Q-methodology study

Based on theoretical notions, there is consensus that alternative payment models to the common fee-for-service model have the potential to improve healthcare quality through increased collaboration and reduced under- and overuse. This is particularly relevant for maternity care in the Netherlands because perinatal mortality rates are relatively high in comparison to other Western countries. Therefore, an experiment with bundled payments for maternity care was initiated in 2017. However, the uptake of this alternative payment model remains low, as also seen in other countries, and fee-for-service models prevail. A deeper understanding of stakeholders' perspectives on payment reform in maternity care is necessary to inform policy makers about the obstacles to implementing alternative payment models and potential ways forward. We conducted a Q-methodology study to explore perspectives of stakeholders (postpartum care managers, midwives, gynecologists, managers, health insurers) in maternity care in the Netherlands on payment reform. Participants were asked to rank a set of statements relevant to payment reform in maternity care and explain their ranking during an interview. Factor analysis was used to identify patterns in the rankings of statements. We identified three distinct perspectives on payment reform in maternity care. One general perspective, broadly supported within the sector, focusing mainly on outcomes, and two complementary perspectives, one focusing more on equality and one focusing more on collaboration. This study shows there is consensus among stakeholders in maternity care in the Netherlands that payment reform is required. However, stakeholders have different views on the purpose and desired design of the payment reform and set different conditions. Working towards payment reform in co-creation with all involved parties may improve the general attitude towards payment reform, may enhance the level of trust among stakeholders, and may contribute to a higher uptake in practice.

Maternal and neonatal risk-appropriate care: gaps, strategies, and areas for further research

Risk-appropriate care is a strategy to improve perinatal health outcomes by providing care to pregnant persons and infants in facilities with the personnel and services capable of meeting their health needs. The Association of State and Territorial Health Officials hosted discussions among state health officials, health agency staff, and clinicians to advance risk-appropriate care. The discussions focused on neonatal levels of care, levels of maternal care, ancillary services utilized for care of both populations including transport and telemedicine, and issues affecting provision of care such as standardization of state policies or approaches, reimbursement for services, gaps in risk-appropriate care, and equity. State-identified implementation strategies for improvement were presented. In this Perspective, we summarize current studies describing provision of risk-appropriate care in the United States, identify gaps in research, and highlight ongoing and proposed activities to address research gaps and support state health officials and clinicians.

Summary of neonatal and maternal transport and reimbursement policies-a 5-year update

OBJECTIVE

To examine the number of states with neonatal and maternal transport and reimbursement policies in 2019, compared with 2014.

STUDY DESIGN

We conducted a systematic review of web-based, publicly available information on neonatal and maternal transport policies for each state in 2019. Information was abstracted from rules, codes, licensure regulations, and planning and program documents, then summarized within two categories: transport and reimbursement policies.

RESULT

In 2019, 42 states had a policy for neonatal transport and 37 states had a policy for maternal transport, increasing by 8 and 7 states respectively. Further, 31 states had a reimbursement policy for neonatal transport and 11 states for maternal transport, increases of 1 state per category. Overall, the number of states with policies increased from 2014 to 2019.

CONCLUSION

The number of state neonatal and maternal transport policies increased; these policies may support provision of care at the most risk-appropriate facilities.

Comparison of Estimated Incentives for Preventing Postpartum Depression in Value-Based Payment Models Using the Net Present Value of Care vs Total Cost of Care

IMPORTANCE

Strong financial incentives are critical to promoting widespread implementation of interventions that prevent postpartum depression. Value-based payment (VBP) approaches could be adapted to capture longer-term value and offer stronger incentives for postpartum depression prevention by sharing the expected future health care savings estimated by reduced postpartum depression incidence with clinicians.

OBJECTIVE

To evaluate whether sharing 5-year expected savings estimated by reduced postpartum depression incidence offers stronger incentives for prevention than traditional VBP under a variety of circumstances.

DESIGN, SETTING, AND PARTICIPANTS

This decision analytic model used a simulated cohort of 1000 Medicaid-enrolled pregnant individuals. Health care costs for individuals receiving postpartum depression preventive intervention or not, over 1 or 5 years post partum, in a variety of scenarios, including varying rates of Medicaid churn (ie, transitions to a new Medicaid managed care plan, commercial insurance plan, or loss of coverage) were estimated for the period 2020 to 2025. The model was developed between March 5 and July 30, 2021.

EXPOSURE

Sharing 100% of 1-year actual health care cost saving vs 50% of 5-year estimated health care cost savings associated with reduced postpartum depression incidence.

MAIN OUTCOMES AND MEASURES

The main outcome was the amount of clinician incentive shared in a VBP model from providing preventive interventions. The likelihood of the health care payer realizing a positive return on investment if it shared 50% of 5-year expected savings with a clinician up front was also measured.

RESULTS

The simulated cohort was designed to be reflective of the demographics characteristics of pregnant individuals receiving Medicaid; however, no specific demographic features were simulated. Providing preventive interventions for postpartum depression resulted in an estimated 5-year savings of $734.12 (95% credible interval [CrI], $217.21-$1235.67) per person. Without health insurance churn, sharing 50% of 5-year expected savings could offer more than double the financial incentives for clinicians to prevent postpartum depression compared with traditional VBP ($367.06 [95% CrI, $108.61-$617.83] vs $177.74 [95% CrI, $52.66-$296.60], respectively), with a high likelihood of positive return for the health care payer (91%). As health insurance churn increased, clinician incentives from sharing estimated savings decreased (73% reduction with 50% annual churn).

CONCLUSIONS AND RELEVANCE

In this decision analytic model of VBP approaches to incentivizing postpartum depression prevention, VBP based on 5-year expected savings offered stronger incentives when churn was low. Policy should support health care payers and clinicians to share estimated savings and overcome health insurance churn issues to promote wide-scale implementation of interventions to prevent perinatal mental health conditions.

Models of Risk Selection in Maternal and Newborn Care: Exploring the Organization of Tasks and Responsibilities of Primary Care Midwives and Obstetricians in Risk Selection across The Netherlands

An effective system of risk selection is a global necessity to ensure women and children receive appropriate care at the right time and at the right place. To gain more insight into the existing models of risk selection (MRS), we explored the distribution of different MRS across regions in The Netherlands, and examined the relation between MRS and primary care midwives’ and obstetricians’ satisfaction with different MRS. We conducted a nationwide survey amongst all primary midwifery care practices and obstetrics departments. The questionnaire was completed by 312 (55%) primary midwifery care practices and 53 (72%) obstetrics departments. We identified three MRS, which were distributed differently across regions: (1) primary care midwives assess risk and initiate a consultation or transfer of care without discussing this first with the obstetrician, (2) primary care midwives assess risk and make decisions about consultation or transfer of care collaboratively with obstetricians, and (3) models with other characteristics. Across these MRS, variations exist in several aspects, including the routine involvement of the obstetrician in the care of healthy pregnant women. We found no significant difference between MRS and professionals’ level of satisfaction. An evidence- and value-based approach is recommended in the pursuit of the optimal organization of risk selection. This requires further research into associations between MRS and maternal and perinatal outcomes, professional payment methods, resource allocation, and the experiences of women and care professionals.