Quell elective, early deliveries with reimbursement changes
RECENT RESEARCH has shown that pregnancies lasting at least 39 weeks have better outcomes than elective induction or caesarian section occurring earlier in the pregnancy. The challenge for payers is to translate this research into provider information to help them reduce the number of elective deliveries before that 39-week mark.
For example, infants face an increased risk of admission to a neonatal intensive care unit (NICU) in such cases, and elective induced labor can increase the risk of caesarian birth. For health plans, this evidence not only points to potentially poorer outcomes for patients but also higher costs.
"The Joint Commission has begun using elective early deliveries as a core measure for maternity care as part of the accreditation process for hospitals," says Amy Romano, CNM, MSN, associate director of programs for Childbirth Connection, an advocacy group in New York. "The Leapfrog Group also adopted this metric as its primary measure of quality for maternity care services."
As a result, a growing number of hospitals are taking steps to significantly reduce or eliminate elective deliveries before 39 weeks, putting in place protocols that forbid obstetricians from scheduling an elective induction any earlier.
"And that represents a real groundswell," says Chris Stanley, MD, senior medical director of UnitedHealthcare for the Rocky Mountain region in Denver. "Hospitals and doctors are not saying that elective deliveries should be banned, but they are making the case for using evidence-based best medicine to show why elective deliveries should not be scheduled prior to 39 weeks."
For their part, health plans also have a significant role to play in these efforts. Health plans can change—and some are changing—reimbursements to discourage elective early deliveries. Health plans also are well positioned to educate and inform their pregnant subscribers of the risks involved with early elective delivery prior to 39 weeks.
Medical directors recognize the risks associated with an early delivery. Likewise, the cost of care in a NICU with significant complications can reach the millions. Add in the potential cost of long-term chronic conditions throughout the lives of the infants, and the potential costs are even greater. Taking steps to avoid even one catastrophic case can be financially worthwhile.
"To change clinical behavior, you have to change economic rewards," says J.D. Kleinke, chief executive officer of Mount Tabor Online Services in Portland, Ore., and MHE editorial advisor. "Money does change everything, and health plans have always known that."
However, health plans need to tread carefully lest they be seen as interfering with patient care. Using money to influence and incentivize providers' medical practice as opposed to dictating it with clinical mandates is the better approach, says Kleinke.
"Nobody likes the rules approach, and it never works anyway," he says. "The best medicine for the patient is also the best economics both for the health plan and for the provider."
SHIFTING COSTS TO PROVIDERS
Michigan-based Priority Health, a health plan covering 8,000 employer groups, recently changed its reimbursement approach by providing the same level of reimbursement for elective c-sections as it does for a vaginal delivery.
Dr. Fox says the change reflects evidence-based care and avoiding wasteful and unnecessary spending. There is no evidence that outcomes improve with a c-section, but there is evidence that it can actually cause long-term problems, he says.
"We are not willing to pay more for an elective c-section for a woman who doesn't have any medical indications," says John Fox, MD, the plan's associate vice president for medical affairs.
Priority Health implemented the change in reimbursement in July and will track early delivery rates. However, the plan analyzed data for the prior year and found that if the new reimbursement level had been in place, 10% of the cases involving elective c-sections would have been reimbursed at the same level as a vaginal delivery. Dr. Fox is optimistic that change in physician reimbursement will have an impact.
"I cannot see physicians and hospitals providing elective c-sections knowing they won't be paid for it," he says.