For many employers, discussions with employees about pregnancy focus on one topic: maternity leave.
Yet, it is important to remember that length of maternity leave is only one of several important decisions made by an employee preparing for childbirth.
Expecting parents are highly engaged in selecting a provider and developing a birth plan — choices that will ultimately influence the cost and quality of care a mother and her child will receive. For younger employees, a pregnancy, whether their own or their spouse’s, may be the first significant contact he or she has had with the healthcare system, thus underscoring the weight attributed to each decision.
Maternity care is also an important issue for employers, as obstetric admissions are typically the single most common admission in commercial populations. Verisk Health’s normative database shows that on average, a maternity admission costs an employer upwards of $9,000, and pre-natal and post-natal care typically contribute another 20-30% of spend. When you consider that 6% of women between the ages of 19 and 44 have a child each year, the costs add up fast.
Given the importance of maternity care to both employees and employers, the question is how to optimize the value of the care your employees receive.
Understanding the value equation
High risk pregnancies and outlier cases aside, maternity care is a relatively homogenous condition category. However, there is substantial variability in cost. We have observed as high as 50% variation within costs in a single market for vaginal deliveries without complications.
Variations in utilization rates of certain procedures can also increase costs substantially without necessarily improving outcomes.
For example, here in Massachusetts, the Health Policy Commission found 50% variation in Cesarean section (C-section) rates among the top 10 hospitals (by number of discharges). This compounds the issue with hospital pricing, since C-sections can cost as much as 50% more than a vaginal delivery.
In addition to increasing costs, C-section overutilization can also lead to poorer outcomes. According to the American College of Obstetricians and Gynecology, C-sections put the mother at greater risk of infection, heavy blood loss, and surgical complications while simultaneously increasing the newborn’s risk of infection, respiratory issues, and lower APGAR scores.
Elective deliveries and episiotomies are also areas of potential overuse, and their incidence rates can be tracked to gauge the quality of care delivered.
“In addition to increasing costs, C-section overutilization can also lead to poorer outcomes.”
While the American College of Obstetricians and Gynecologists requires 39 weeks of gestation prior to elective delivery, research shows that more than one-third of elective repeat C-sections are not performed in accordance with this guideline. When these guidelines are not followed, newborns are more susceptible to respiratory distress syndrome, temperature regulation issues, high levels of bilirubin, and hearing, vision, and learning defects.
In addition to restricting elective pre-term deliveries, ACOG also recommends restricted use of episiotomies due to the increased risk of muscle tear, bleeding, and infection. However, data indicates that episiotomies are an often used routine obstetrical practice.
Other maternity quality measures reinforce evidence-based standards of care. To reduce a mother’s risk of pulmonary embolism after C-section, ACOG recommends the use of pneumatic compression devices or venous thrombus embolus (VTE) prophylaxis. Likewise, all newborns should be screened for early onset hyperbilirubinemia prior to discharge from the hospital.
Driving greater value: The agenda for employers
Maternity care presents an ideal starting point for value-based purchasing initiatives because it is high volume, clinically homogenous, and exhibits wide variety in cost and quality. While decisions in maternity care will always be driven by patient preferences, here are a few ways employers can help improve the value of care their employees receive:
1. Know the numbers. Analyze your claims data to identify the top hospitals that your employees use, the amount you spend at each facility, and differences in costs between the hospitals. Use the quality measures published in the Leapfrog Hospital Survey to benchmark performance against nationally recognized standards.
2. Spark dialogue with providers. Once you’ve assessed which hospitals provide the best value for maternity care, share your analysis with the most significant facilities. In our experience, several larger employers are using their data to enable more transparent, collaborative conversations. If your presence is smaller, work with a local purchasing group to make your voice heard.
3. Raise awareness among expectant parents. In parallel with sharing data with providers, develop a communication plan to educate your employees about their options. Developing a birth plan is one of the most actively researched healthcare decisions, especially for first time parents. However, the research can often be more focused on the amenities of the facility than quality and outcomes. Since patient engagement is so high for maternity care, it may be easier to drive behavioral change among expectant parents than it is for other health issues often targeted by employers (e.g., weight loss).
4. Champion payment reform. Several state Medicaid programs have adopted innovative episode-based payment systems to reward high-value maternity care. Forward-thinking employers can use model contract language from Catalyst for Payment Reform to help incorporate these types of strategies into their agreements with health plans. According to CPR, payment strategies such as bundled payment and blended payment (a single rate for any type of delivery) can help address the issues associated with overutilization in maternity care.
5. Consider reference pricing and incentives. Long term, employers may consider changing plan incentives to encourage high-value maternity care. For example, an employee might shoulder a greater share of the cost burden for an elective C-section if it is not medically necessary or physician advised. Since personal preference is such a factor in maternity care delivery, this concept will need to be handled with sensitivity.
In many ways, maternity care is a microcosm of the challenges in our healthcare system. We routinely perform “medical miracles,” particularly for neonatal care, and yet there is substantial room for improvement in routine care. By advancing value-based purchasing initiatives, employers can play a key role in helping improve the cost and quality of maternity care.
