If you own or operate your practice, or even just work for a maternity provider, you have likely heard something about new payment models for maternity care. If you are like most of us, learning about new models is a bit ironic when we hardly understand the the models we currently have. In fact, making billing practices more consumer-friendly (ie. based on common sense) is part of the goal of new system design.
Here at Maternity Neighborhood, we’ve made it our business to “go to school” for understanding the new payment structures coming your way and with this article, intend to translate some of the jargon and put things in perspective that will hopefully help you and your practice get in position to take advantage of some of the opportunities these reforms may bring.
Clinical Episode Payment: What is it?
Clinical episode payment models are different from traditional fee-for-service (FFS) health care payment models. In FFS, providers are paid separately for each service they deliver. This is one of many drivers of overuse of procedures in maternity care as providers are rewarded for doing more. In clinical episode payment (CEP) models, consideration is given for quality, costs and outcomes over a set period of time and across multiple settings. This course of care is known as the clinical episode. The goal of shifting from FFS to CEP models is, not surprisingly, increased coordination of care, enhanced quality of care and less fragmentation in the medical system. Sounds great, right?
So why aren’t we there yet?
Well, it turns out that despite the benefits CEP offers, it’s hard to design and implement these models without overcoming financial, technological, cultural, logistical and informational obstacles. It is these obstacles that are systematically being addressed by a recently published whitepaper from the federally-funded Health Care Payment Learning and Action Network (LAN). The convened a CEP Work Group and the Work Group developed a White Paper: “Accelerating and Aligning Clinical Episode Payment Models”. This landmark document will likely serve as a roadmap for maternity episode design. As a data infrastructure and engagement tool that is highlighted in the paper itself, Maternity Neighborhood stands ready to help our customers succeed in this evolving health care ecosystem.
Three themes to new payment models
If we could wave a magic wand and make the maternity episode of care “perfectly patient-centered”, how would we imagine it? The LAN outlines three themes that need to be incorporated along with the rainbows and unicorns of our dreams:
- Engagement of patients and their families. Not a hard one for midwives to agree on, in fact this is something we have been saying (and doing) for a long time. What we don’t do very well is document and measure that engagement. This is why Maternity Neighborhood has decided to make our Care Guide an integrated component to our basic EHR package. We recognize that we are all in a catch-22 when it comes to getting paid for traditionally “non-covered services” such as engagement and education. Now that CEP gives us an opportunity to incorporate these critical services into a payment pathway, it is even more important that ALL of our customers learn how to use the MN Care Guide to track and measure the delivery and impact of engagement throughout the entire episode of pregnancy through post-partum care.
- Taking responsibility/accountability is a challenging component for episodes that rely on numerous care teams. We all recognize that the gaps in care women experience are most acute when collaboration is not seamless. All providers who contribute to a maternity episode have the potential to work together in a manner that shares risk and responsibility. Getting this right, or wrong, is a critical factor in achieving success.
- Following the rules is easy — until the rules change. Because payment reform is driven via a not so gentle regulatory nudge (aka: the Affordable Care Act), it’s hard to know what we “should” do vs what we “must” do. The current rules allow for choices in how Medicaid sets up contracts within each state, while Medicare has already moved to mandatory CEP for both joint replacement and cardiac care. State rules are always subject to change, but it’s fair to assume that as incentives line up in favor of CEP models at the federal level, the states will likely follow suit. In order words, you can choose to explore these new ideas as opportunities now, or as mandates later. Either way, it’s good to know what it’s all about.
How can Maternity Neighborhood help?
We want to start by being a real resource to our customers. Through our vast array of advisors and consultants with many layers of expertise, we can answer your questions on payment reform and how it will impact you.
Next, we want to make our tools more readily available to our customers who are price-restricted out of some of our features due to your current practice size or model. We are now offering the Care Guide, Billing and Scheduling tools for FREE for practices that would like to take advantage of our engagement tools but have been priced out of using these valuable resources. If your practice is ready to start documenting your engagement and education, we want you on our Care Guide today. Give us a call to get started!
Stay tuned! More articles and information to come on Episode Design, Contracting and more from the CEP white paper.
Midwife, CEO and Founder of Maternity Neighborhood