It's an incredible thought to carry the instruments for accountable care to maternity care, but it surely's definitely not

By VICTORIA ADEWALE & JD KLEINKE

How determined are we to search out some form of excellent news in regards to the unhappy state of maternity care in America? To search out out, look no additional than the present cowl of a no much less venerable well being coverage journal than Well being Affairs.

With the pinnacle “Medicaid ACO improves maternity care” Once we jumped off the quilt of the September challenge, we anticipated nice issues from the article “Massachusetts Medicaid ACO Program Could Have Improved Care High quality for Pregnant and Postpartum Enrollees” (Megan B. Cole, and all.). The headline definitely guarantees excellent news for all of us working to unravel the nationwide disgrace of U.S. maternity care generally, and the maternal mortality disaster specifically.

However sadly the article itself is one other reminder that course of enhancements not enhancements in outcomes. It’s additionally a basic case of the tendency of great researchers to torture retrospective knowledge — as a result of they occur to be out there for analysis — into one thing that could be helpful. Whereas it will be simple to dismiss the lackluster findings of this data-ease research out of hand, the hazard right here is that they might present but extra ammunition for skeptical payers not to pay for extra care, which quite a few research have proven sufferers desperately want.

The authors make a valiant try with a chic research design to glean what they will from the “pure experiment” of analyzing pre- and postnatal care offered to pregnant sufferers earlier than and after the implementation of Accountable Care Organizations in Massachusetts. However as one other previous saying goes, if in case you have a hammer, every thing appears to be like like a nail; and the enrollment of sufferers in a main care ACO, like this dataset, hardly counts as an impartial variable with a lot energy to affect healthcare use and outcomes. maternity care for insured individuals.

It’s properly established within the literature – and an accepted fact amongst well being care suppliers and sufferers – that when most ladies develop into pregnant, the vast majority of their care shifts from main care to obstetricians and authorized nurse-midwives. Many researchers and clinicians consider that a lot of this shift happens even earlier than a confirmed being pregnant, resulting from fertility points and being pregnant planning.

The authors did discover that pregnant sufferers newly enrolled in ACOs had a small enhance within the variety of pre- and postnatal visits.

On the floor, it is a good factor, contemplating how few visits maternity care sufferers get within the U.S. in comparison with the remainder of the developed world. However for that enhance in visits, the research exhibits No significant enhancements in maternal or fetal outcomes. The authors additionally discovered a discount of solely 3 proportion factors within the “odds” of cesarean part; however this isn’t 3 % price discount, and thus statistically meaningless, even on this massive research inhabitants. And in comparison with the remainder of the world, the place surgical procedures by gynecologists and fee-for-service hospitals will not be rewarded with elevated income, sufferers within the U.S. want a 10- to 15-point price discount, not three. The potential total price financial savings and improved postpartum outcomes that may include such a discount are properly documented and can be staggering. That is the clear name for “accountable care” laser-focused on maternity care, not the fragments of course of enchancment associated to a main care system that’s largely irrelevant to this affected person inhabitants.

Moreover, we might be remiss if we didn’t acknowledge that reasonable and excessive danger pregnancies are primarily managed by obstetricians or maternal fetal drugs specialists. Whereas this research makes an attempt to exclude sufferers with complicated circumstances, it solely identifies and excludes a number of pregnancies. There’s a spectrum of hypertension, diabetes, and several other different circumstances that may have warranted co-management or switch of care inside these populations. The concept that satisfactory administration of maternity care will be added to an already overburdened and overburdened main care doctor detracts from ladies’s well being and is borderline negligent. Major care physicians serving Medicaid sufferers have greater than sufficient to handle, particularly when they’re present process their very own skilled conversion to accountable care.

If the authors need to measure the true influence of accountable care methods on being pregnant care and outcomes, they need to research one of many dozens of real-world experiments at present underway for Medicaid and industrial populations throughout the nation. Actual transformation of maternity care is not going to come from finding out the experiences of ladies in main care techniques that not concerned within the start of their infants; somewhat, it requires a targeted and concerted effort—with significant adjustments in reimbursement—in an outdated, intervention-based maternity care system that do look after them earlier than, throughout, and instantly after these deliveries. The parts of this transformation embody a lot higher use of CNMs for regular pregnancies, offering rather more pre- and postnatal care, and having demonstrable results on early inductions of labor, cesarean part charges, and downstream charges of NICU admissions.

The important thing instruments of accountable care generally are crucial right here, notably bundled funds for risk-stratified sufferers, and rewards and penalties for good or unhealthy outcomes based mostly on efficiency. However all of those instruments have to be extremely particular to the wants of pregnant ladies, not an unintentional match of how their main care suppliers are paid for all the inhabitants of which they occur to be a component. Different accountable care methods distinctive to maternity care additionally embody a long-overdue motion towards a team-based, medical house mannequin that can leverage a number of, specifically skilled scientific roles, together with OB/GYNs, CNMs, and doulas. Failure to acknowledge the complexity of those challenges is likely one of the many causes maternity care stays an antiquated medical discipline that continues to be suffering from excessive charges of maternal mortality and morbidity.

This isn’t a petty tutorial level. The discouraging outcomes of this knowledge comfort research serve solely to arm the accountants in industrial and Medicaid managed care plans, who’re all too blissful to contemplate any enhance in visits and not using a correlated enchancment as a waste of cash.

This research not solely not present what the front-page headline promised, however the reverse — thus setting us all again on the troublesome path to significant modernization of maternity care.

Victoria Adewale, MD, MS, MBA, is an OB/GYN, Medical Service Corps Officer within the U.S. Military Reserve, and Fellow in Maternal-Fetal Medication at Ladies & Infants Hospital in Windfall, Rhode Island. J.D. Kleinke is a medical economist, a pioneer within the well being care info business, and the writer of Catching Infants, a novel about OB/GYN coaching that’s at present in improvement as a tv sequence.