Clinical Episode Payment for Maternity Care: Opportunities and Challenges

April 26, 20161:00pm – 2:15pm

Roadshow Slide Library

2WELCOME

Cara Osborne, CNFChief Operating Officer

Baby+Company

3SESSION OBJECTIVES

Learn about the work of the CEP Work Group and its recommendations for maternity care episode payment design.

Describe current innovations in paying for the delivery of high quality maternity care

Provide insight into strategies for engaging patients and their families in the design of high quality care delivery

Offer opportunity for audience questions and facilitated discussion

4AGENDATime (ET) Topic & Speaker

1:00 – 1:20 CEP Work Group Overview and Maternity Episode Payment RecommendationsCara Osborne

1:20 – 1:35 Maternity and Newborn Care Bundled Payment Pilot Karen Love

1:35 – 1:50 Implications of Episode Payment on Women and FamiliesMaureen Corry

1:50 – 2:05 Panel Discussion

2:05 – 2:15 Facilitated Audience Q&A

5

Key Activities Identifying the elements for elective

joint replacement, maternity, and cardiac care episode payments

Identifying best practices for implementing clinical episode payment models

The group will identify the most important elements of clinical episode payment models for

which alignment across public and private payers could accelerate the adoption of these models

nationally. The emphasis will be on identification of best practices to provide guidance to

organizations implementing clinical episode payment models.

Lewis Sandy Senior Vice President, Clinical Advancement, UnitedHealth Group

Chair

18 MembersClinical Episode Payment (CEP)CEP Work Group

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Cara Osborne MSN, CNM, ScD Chief Clinical Officer, Baby+Co.

Dale Paton Reisner, MDMaternal Fetal Medicine SpecialistSwedish Medical Center

Carol Sakala, PhD, MSPH Director of Childbirth Connection ProgramsNational Partnership for Women & Families

Richard Shonk, MD, PhDChief Medical Officer, the Health Collaborative

Steve SpauldingSenior Vice President, Enterprise NetworksArkansas BlueCross BlueShield

Barbara WachsmanChair, Pacific Business Group on Health

Jason Wasfy, MDDirector, Mass General Heart Center

Brooks Daverman, MPPDirector of the Strategic Planning and Innovation Group, Tennessee Division of Health Care Finance and Administration

François de Brantes, MS, MBAExecutive Director, Health Care Incentives Improvement Institute, Inc.

Mark Froimson, MD, MBAExecutive Vice President and Chief Clinical Officer Trinity Health, Inc.

Rob Lazerow Practice Manager, Research and InsightsThe Advisory Board Company

Catherine MacLean, MD, PhDChief Value Medical Officer, Hospital for Special Surgery

Jennifer Malin, MD, PhDStaff Vice President, Clinical Strategy, Anthem, Inc.

Amy Bassano, MPPDirector, Patient Care Models Group, Centers for Medicare and Medicaid Services

Edward Bassin, PhDChief Analytics Officer, Archway Health

John Bertko, FSA, MAAAChief Actuary, Covered California

Kevin Bozic, MDChair of Surgery and Perioperative Care, Dell Medical School at the University of Texas at Austin

Alexandra Clyde, MS Corporate Vice President of Global Health Policy, Reimbursement and Health Economics, Medtronic, Inc

Lewis Sandy, MD, MBA Executive Vice President, Clinical Advancement, UnitedHealth Group

Member RosterCEP MEMBERS

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Final ReleaseJune 24, 2016

ReviseMay-June 2016

Public CommentApril – May 2016

Draft ReleaseApril 22, 2016

DevelopmentFebruary – April 2016

for CEP modelsMATERNITY

The draft white paper titled Accelerating and Aligning Clinical Episode Payment Models: Maternity Care, describes design recommendations for using bundled payment to pay for patient-centered prenatal, birth, and postpartum care as one comprehensive episode. The white paper reviews existing maternity care episode payment efforts in order to develop a set of recommendations that can potentially pave the way for broad adoption of bundled payment in a way that has not yet occurred.

Key Components • Design Elements• Recommendations • Operational Issues

8WORK GROUP CHARGEPromote Alignment:

Design ApproachAlignment Approach

Find a Balance Between:Alignment/consistency and flexibility/innovationShort-term realism and long-term aspiration

Provide a Directional Roadmap to:

Providers Health Plans Consumers Purchasers States

9PURPOSE OF EPISODE PAYMENTEpisode Payments Reflect How Patients Experience Care:

A person develops symptoms or has health concernsHe or she seeks medical careProviders treat the conditionThe patient receives care for his or her illness or condition

Episode Payment Can:Create incentives to break down existing siloes of carePromote communication and coordination among care providersImprove care transitions Respond to data and feedback on the entire course of illness or treatment

Goal: The treatments the patients receive along the way reflect their wishes and cultural values.

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Unexplained Variation

Conditions & procedures for which there is high variation in the care that patients receive, despite the existence evidenced based “best” practices.

High Volume, High Cost

Conditions & procedures for which high cost is due to non-clinical factors such as inappropriate service utilization and poor care coordination that correlate with avoidable complications, hospital readmissions and poor patient outcomes.

Care Trajectory

Conditions & procedures for which there is a well-established care trajectory, which would facilitate defining the episode start, length and bundle of services to be included.

Availability of Quality Measures

Conditions & procedures with availability of performance measures that providers must meet in order to share savings which will eliminate the potential to incentivize reductions in appropriate levels of care.

$ Empowering Consumers

Conditions & procedures with opportunities to engage patients and family caregivers’ through the use of decision aids support for shared decision-making; goal setting and support for identifying high-value providers.

EPISODE SELECTION CRITERIA

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$Regulatory

Environment

Stakeholder Perspectives

Data Infrastructure

Stakeholder Perspectives:Ensure that the voices of all stakeholders – consumers, patients, providers, payers, states and purchasers – are heard in the design and operation of episode payments

Data Infrastructure: Understand and develop the systems that are needed to successfully operationalize episode payments

Regulatory Environment: Recognize and understand relevant state and/or federal regulations, and understand how they support or potentially impede episode payment implementation

Episode Design and Operational ConsiderationsEPISODE PARAMETERS

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for CEP modelsMaternity

MATERNITY EPISODEGoal: Improve the value of maternity care by improving outcomes and experience of care, and reducing costs, for the woman and her baby by: Increasing the percentage of births that are done vaginally; decrease C-

sections;

Increasing the percentage of births that are full-term; decrease preterm and early elective births;

Decreasing complications and mortality, including readmissions, higher levels of NICU use

Engaging women and families in their maternity care

Improving coordination across the providers, settings, and phases of maternity care

Reliably providing woman- and family-centered care

13MATERNITY - TIMELINEEpisode Timeline for Prenatal through Postpartum Care

Track Quality Measures

Stopping Point~ 60 days post-birth

~ 60 days

Postpartum

~ 3-10 days

Labor & Birth

~ 37-40 weeks

DeliveryPost 37 weeks for Nulliparous Term

Singleton Vertex (NTSV) – lowest risk pregnancy

Prenatal

Starting Point~ 40 weeks prior or pregnancy

Epis

ode

Dur

atio

n

• Depression Screening

• Contraception Planning

• Ensuring Link from Birth to Pediatric Care Provider Occurs

Reimbursable Services

• Labor and Delivery

Serv

ices

GOALSIncrease:• % of full-term births• % of vaginal births

Decrease:• % of pre-term and early elective

births• % of unnecessary C-sections• Complications and mortality (inc.

readmission & levels of NICU use)

Use of evidenced-based care to achieve Woman- and family-

centered care

Improving coordination across providers, settings and maternity

care

Goals

Directly Related Not Typically Reimbursed NOT Directly Related• Monthly prenatal visits• Routine ultrasound• Blood testing• Diabetes testing• Genetic testing

• Doulas• Care navigators• Group education

meetings

• Preventive screenings (chlamydia, cervical cancer)

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Design Elements1. Episode Definition 2. Episode Timing 3. Patient Population 4. Services 5. Patient Engagement

Episode includes prenatal care, labor and birth, and postpartum care for all

low-risk women and babies

Episode begins 40 weeks pre-birth and ends at 30 days post birth for the

baby, 60 days postpartum for the

woman

Women whose pregnancies are

considered to be low-risk and their babies

All services provided during pregnancy, labor

and birth, and post-partum for the woman.

Pediatric services are not included

Patient engagement must be supported at all stages,

including provider selection, shared care

planning, and prenatal and parenting education.

6. Accountable Entity 7. Payment Flow 8. Episode Price 9. Type and Level of Risk 10. Quality Metrics

Provider best able to engineer change in the way

care is delivered to the patient, and able to accept risk. The clinician (not the hospital) may best fit this

description.

Payment flow – either upfront FFS or

prospective payment –depends on the unique characteristics of the

model’s players.

Balance single and multiple providers and

regional utilization history. Reflect the cost of services needed to

achieve the goals of the episode payment model.

Upside and/or downside risk, depending on the

model.

Clinical and Patient-Reported Outcome

Measures of both the woman and the baby

DRAFT FOR PUBLIC COMMENTEpisode Design Parameters for Maternity and Prenatal CareMATERNITY – DESIGN ELEMENTS

Baby+Company

February 5, 2016

Overview & Payment Structure

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Women are increasingly interested in out of hospital birth

25% of women said that they would prefer a birth center birth if one were available; another 39% would consider it

30% increase in out of hospital birth since 2010

Lowering the Cesarean Section rate in the US is a high priority and maternity centers can play a role

National average rate of 33% versus 6% average in birth centers in the US.

W.H.O recommends rates of between 5% and 10%.

ACOG has made lowering the rate a top strategic priority and suggested that expanding access to birth centers could play an important role in improving outcomes

Source: Agency for Healthcare Research and Policy; Childbirth Connection: Listening to Mothers III: Pregnancy and Birth, 2013; American Association of Birth Centers Press Kit; American College of Obstetricians and Gynecologists (ACOG) and Society for Maternal-Fetal Medicine (SMFM), “Obstetric Care Consensus Statement #2-, Levels of Maternity Care.”, Obstetrics & Gynecology, Feb 2015.

Consumer demand and cost trends are driving interest in ‘out of hospital birth’

U.S. maternity care is high cost

One of the largest contributors to health bill ($100bn/year)

Among the top 5 hospital costs to payers

1

2

3

1) Lower cost 2) Improve customer satisfaction3) Improve clinical outcomes for

low-risk moms and babies

Increasing access to safe, out of hospital birthing options can:

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Outcomes that are as good or better than hospital based care

Source: (1) Stapleton et al.: "Outcomes of care in birth centers: demonstration of a durable model," JMWH, 2013; Begley et al., 2011; Janssen et al., 2012; (2) National Vital Statistics Reports, Vol. 63, No. 6, November 5, 2014 “Trends in low-risk Cesarean Delivery in the United States 2009-2013

1. Lower cesarean rates– C-section rates of 6%1 vs. 26.9% for women with low-risk pregnancies in the United

States2

2. Outcomes that are as good or better1

– Morbidity or mortality rates that are as good or better than hospital based care– Higher breastfeeding rates – Lower NICU Admissions rates

3. Wellness benefits that extend beyond the maternal episode

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Source: Truven Health Analytics, The Cost of Having a Baby in the United States, 2013; National Center For Health Statistics; Vital Statistics Report: Volume 63, No 6, November 4, 2015

Significant savings

Regular Cesarean

HOSPITAL

50% reduction

Regular

Cost

per

Bir

th

$0

$5,000

$10,000

$15,000

$20,000

$25,000

$30,000

$18k

$28k

$9k

Savings come both from a reduction in the number of cesarean sections and a reduction in the cost of vaginal birth.

United States Average(low-risk pregnancies) Baby+Co. Average

Cesarean Rate 26.9% 6%

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Prenatal Care

Individual Visit

Care Planning

Visit

Group Visit

Care Planning

Visit

Individual Visit

Group Visit

Care Planning

Visit

Individual Visits

}up to 12 wks 16-18wks

22-24wks

26-28wks

30-32wks

34-36wks

by 37wks

39+wks

TouchCare/Phone Consultations PRN

Individual Visits PRN

Group Visit

Classes, Workshops, and Support Groups

Interactive EHR with curated content library & Client Handbook

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Labor + Birth Care

Continuous Midwifery Presence

Additional Skilled Support

Preparation for Early Discharge

Early Labor Active Labor Birth + Postpartum/

Newborn Recovery

Until 4-12 hrs. Postpartum

TouchCare/Phone Consultations

Range of Comfort Measures- Self-directed movement; nitrous oxide; water birth

Fetal Monitoring- intermittent auscultation of fetal heart tones using dopplers

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Postpartum and Newborn Care

TouchCare/Phone Visit

Individual Visit

Individual Visit (Mom + Baby)Home Visit Individual Well

Woman Visit

24 hrs 1 week 4 - 6 weeks48 - 72 hrs 4 - 6 months

New Mom’s Group

TouchCare/Phone Consultation PRN

Lactation Counseling

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Summary of Work With Payers

1. We are working with payers to set pricing based on the outcomes we deliver (healthy mom and baby) rather than the inputs we are using

1. With most payers we are establishing a single episodic case rate for our birth clients that covers both the facility and professional fees (and a set of other services). With this structure, we are incentivized to deliver a healthy mom and baby and a happy family at the lowest possible cost.

2. With some of our partners we earn an incremental percentage at the end of the year if we hit certain quality markers

3. Our pricing structure has limitations in that it is set up for birth center care and if a patient transfers to the hospital, payers will pay an incremental cost to the receiving providers.

4. However, our current rate structure sets a price benchmark for the episodic cost of low-risk uncomplicated birth as it demonstrates that it is possible to deliver high outcomes and a high touch service at a low cost.

5. We are currently working with our health system and physician partners to more closely integrate our services and could ultimately negotiate a single birth price for any patient that initiates care at the birth center (even those that ultimately transfers), thereby adding a true risk sharing element to our pricing structure.

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Mo. 1 2 3 4 5 6 7 8 9 Labor & delivery

6 weeks postpartum

We have set episodic case rates for birth and transfer clients

Timeline

Key touchpoints

Bundled rate for all prenatal services at birth center and labor support for patients who transfer during labor

Labor & deliveryPost-partum

care & lactation support

Complete episode

IP transfersepisode

AP transfersepisode

Bundled rate for all birth center services as part of the complete pregnancy episode (including follow up at 6wks postpartum)

Bundled rate of patients who transfer out prior to labor

Initial OB visit / orientation to care, routine prenatal visits,tele-med visits & other forms of remote communication w/ CNMs,

childbirth classes, breastfeeding & nutritional counseling

1

2

3

Ongoing well woman care: annual exams, birth control counseling, contraceptive provision, fertility counselingWell woman

care

4

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Baby +Company as a Purchaser

~100 employees

Interest in offering maternity care for our employees that is in keeping with the care that we offer the families that we serve

As a small company we have limited leverage in plan design

The plan that was the best fit for our employees broadly isn’t contracted with us as a provider

25PANEL SPEAKERS

Karen LoveExecutive Vice President and

Chief Operating OfficerCommunity Health Choice

Maureen CorrySenior Advisor

Childbirth Connection Programs

National Partnership for Women & Families

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Karen LoveExecutive Vice President and Chief Operating OfficerCommunity Health Choice

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Maureen CorrySenior AdvisorChildbirth Connection ProgramsNational Partnership for Women & Families

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https://hcp-lan.org/groups/cep/maternity-care/

Access the white paper: