Imagine a pregnancy episode is a pizza (apologies to vegans). Consumers in the U.S. have been getting frozen grocery store pizza as a standard, and you want to be able to offer a special pie with some fancy toppings. Women who can pay more can now get extras loaded on top and it turns out that these women seem to be having better outcomes. In fact, there starts to be some concern that the frozen pizza might actually be harmful if consumed. What do we do? Do the special ingredients people start to make a basic pizza with the elements of a specialty pizza that we think are the most important? Or do the special ingredients people start to collaborate with the frozen pizza makers to make a better, more comprehensive and high-quality pizza?
This is exactly what many of you are doing today with your birth services. Some birth centers and home birth midwives are trying to make a better pizza through a boutique model that covers the entire pie, from corn meal crust to gourmet olives. At the same time, other birth centers and hospital-based OBs and midwives, doulas, lactation specialists, care navigators, counselors/social workers and childbirth educators are offering their services to the frozen pizza makers to try to make a better version that can be mass-produced. Which model works best remains to be seen, and the success of any kind of replication model for good pizza (birth) practices is going to hinge greatly on who takes responsibility for making sure that we not only make a really good pie, but that it’s a pie that consumers actually want and enjoy eating.
The concept of accountability can be applied to many aspects of healthcare delivery. In terms of payment and reimbursement models, however, the concept applies to a larger framework than simply providing high-quality care. While quality care is internalized in a well-designed Clinical Episodic Payment (CEP) model, the issue of accountability refers to population-level responsibility for success. In the case of the maternity episode, success means that outcomes are good, costs are reasonable/lower and patients are engaged and satisfied. The concept of assuming financial risk for this success is central to the determination of readiness for any provider to participate in a contract that involves bundling services. In other words, who is actually making (and selling) the pizza?
According to the HCP-LAN white paper titled Accelerating and Aligning Clinical Episode Payment Models, the ideal scenario is where all of the providers involved in the episode share some of the financial risk. This helps align the incentives for success and creates an environment where the culture of collaboration and coordination is adopted by everyone on the care team, whether they actually work in the same practice or not.
Though accountability should not be confused with liability, there are some details to be worked out if we are going to includes services like birth center and home birth in a CEP bundle. The good news is that there are models out there already in which agreements are made that clarify responsibility, liability and management roles in a multisite/multiorganization sharing of a pregnancy episode. Even more importantly, this payment model opens the door for previously “noncovered” services that have proven to be valuable to be covered under insurance. So, what would be considered an “extra topping” on the pizza would become essential, like every mom having access to a doula.
As all of this seeps into my consciousness, I find myself asking , “Why is accountability such a new concept in maternity care? How long it is going to take to get these models piloted, implemented, matured and scaled?” I believe that the sooner we can make the shift, the better off we’ll all be — providers, systems, payers and, most especially, families.
Maternity Neighborhood is taking steps to enable our platform and services to better leverage the opportunity to shift to CEP models. We are designing demonstration projects and implementing more expansions in our billing, reporting and integration systems that are designed to optimize the level of care coordination, interorganizational patient engagement and cost accounting needed to ensure that we won’t lose this opportunity to incorporate the best possible ingredients for quality care delivery and experience for the families we all serve. We look forward to sharing the journey (and the great pizza!) with you.
Midwife, CEO and Founder of Maternity Neighborhood
American Association of Birth Centers – Birth Institute
September 22-26, 2016
Midwives Alliance of North America
October 13-18, 2016