How to Improve Care for Women Through Pregnancy and Beyond
If one of the barometers of health system performance is how well women are supported during pregnancy, childbirth, and after delivery, something is terribly amiss in the U.S. The strongest indicator is the maternal mortality rate. While it has been falling in much of the world, deaths during pregnancy and the year after among U.S. women have been rising: from 7.2 deaths per 100,000 live births in 1987 to 17.2 deaths per 100,000 births in 2015. Maternal mortality rates have increased for both white and black women, but there are persistent racial disparities: black women are three times more likely to die of pregnancy-related causes than white women. While many explanations have been put forth to explain these trends — better reporting, a rise in the prevalence of chronic conditions, and the impact of structural racism and poverty — experts agree the majority of maternal deaths are preventable.Off partial
Rising maternal mortality highlights problems in our nation’s approach to maternal health, including lack of medical oversight and social support during the postpartum period and inadequate coordination among obstetric and primary care providers. Interruptions in coverage also place women at risk. This problem is acute in the Medicaid program, which covers more than 40 percent of childbirths. In states that have not expanded eligibility for the program to low-income, non-childbearing adults, many women find themselves without coverage just 60 days after giving birth.
In this issue of Transforming Care, we examine efforts to redress these shortcomings by wrapping more supportive services around women who are at heightened risk due to their social or medical needs, and by stepping up support for months or even years after childbirth. We do not focus on efforts to reduce complications during childbirth itself, though the Alliance for Innovation in Maternal Health and the American College of Obstetricians and Gynecologists are leading important work to promote safer deliveries through “bundles” of best practices. Instead, we explore what happens before and after childbirth.
Using Pregnancy as Opportunity to Intervene
While childbirth is often a normal and even empowering experience, for a subset of women it’s a stress test on the body and spirit that puts them and their babies at risk. Many of those working to improve maternal health see pregnancy as on opportunity to engage women in regular care, particularly those who haven’t visited a doctor since they were children or have put their jobs, families, or others ahead of their own health. Frequent prenatal visits serve as an opportunity to identify and address what may be undiagnosed chronic conditions, including hypertension and diabetes, or behavioral health issues that may be exacerbated by pregnancy.
Group Prenatal Care and the Women-Inspired Neighborhood Network
One of the most successful models for supporting women during the prenatal period is CenteringPregnancy, a program organized around group prenatal visits that include between six and 12 women at similar stages of pregnancy. The visits, which can last up to two hours and are typically facilitated by obstetric physicians, midwives, or other clinicians, offer health education, anticipatory guidance about common postpartum challenges, and links to community supports. Each woman also has a private exam with her obstetrics provider.
The groups create opportunities for women to trade ideas for coping with the stresses of pregnancy and parenting, and this bonding helps keep women engaged, says Erin Conklin, M.P.A., CenteringPregnancy’s state program manager in Michigan. “If a patient misses an appointment, other members of the group will check in, saying, ‘We missed you. Are you coming? Do you need a ride?’”
Now in nearly 600 sites across the U.S., including many federally qualified health centers and other clinics serving low-income women, CenteringPregnancy has been linked to improved patient and provider satisfaction and reduced racial disparities in infant and maternal outcomes. (For examples of other group prenatal classes and their results, see this opinion from the American College of Obstetricians and Gynecologists.)
In 2016, the Women-Inspired Neighborhood Network: Detroit (WIN Network), founded by four of Detroit’s major health systems in an effort to reduce infant mortality rates, began offering CenteringPregnancy classes. In a first among Centering programs, community health workers (CHWs) help lead the group classes (along with certified nurse midwives from Henry Ford Health System), facilitating discussions on healthy lifestyles and nutrition, how to navigate the health care system, and other topics.
Most of the women who take part are African American and nearly all are Medicaid beneficiaries. While they tend to be relatively healthy (those with medically complex pregnancies are referred to traditional prenatal care), many have financial problems and lack resources to cover basics like diapers and strollers; some live in shelters or boarding houses. “Housing is the biggest need,” says Jaye Clement, M.P.H., M.P.P., director of community health, programs, and strategies at Henry Ford Health System, one of the four founders. “We see 10 people living in two-bedroom apartments.” The CHWs make multiple home visits, as many as 12 for those deemed at highest risk, to assess women’s needs and help them tap into sources of stable housing, childcare, transportation, or other support.
The CHWs work with women during their pregnancies and through their babies’ first year. “We are all about empowerment,” says Nada Dickinson, a CHW team leader. “A lot of women in low-income communities, especially African-American women, feel judged, not just by medical professionals. They don’t think they have value. We tell them they are intelligent and know their bodies. We encourage them to challenge things if they feel something isn’t right.”
Across Detroit’s Wayne County, 14 percent of black babies are born at low birthweight and nearly 12 percent of all babies are premature. In contrast, only 7 percent of the 172 babies born to women who’ve participated in WIN Network’s CenteringPregnancy since 2016 had babies with low birthweight or born prematurely.Off partial Off
New Jersey’s Healthy Women Healthy Families Initiative
New Jersey, which has the fifth highest maternal mortality rate in the country, is working to expand access to the CenteringPregnancy model and other maternal health programs — using a centralized referral system to identify the most vulnerable women and then surrounding them with extra support through their pregnancies and their baby’s first three years. Funded by federal and state maternal and child health block grants ($4.7 million annually) and philanthropic support ($2 million), Healthy Women Healthy Families, launched last year and focuses primarily on African-American women living in eight New Jersey cities with the highest black infant mortality rates. Health care providers and community health workers screen women to identify those who may be at risk. Cities are also enlisting churches, schools, libraries, and soup kitchens to identify women who may need help. An intake specialist then reviews women’s medical and social needs and connects them to CenteringPregnancy groups, nurse home visits, food pantries, job/employment services, benefit programs, or others.
The program was informed by the New Jersey Department of Health’s survey and focus group research, which found that pregnant black women are twice as likely as pregnant white women to report stress, and they point to different sources: white women most often mention the illness or death of a loved one, while black women mention more frequent arguments with their partners, moving, and problems paying bills. When asked the root causes of New Jersey’s high infant and maternal mortality rates, community health workers and other staff who work directly with low-income women pointed to the lack of culturally competent maternal health care providers and difficulty accessing care in a timely way. They also cited insufficient access to housing, childcare, and transportation.Off partial
In addition to community health workers, some cities are fielding doulas to support women through childbirth and help them with breastfeeding and other infant care. Program leaders hope that doulas and CHWs will stay in regular contact with women so they can help identify any red flags after delivery. “Doulas and CHWs will see women earlier after delivery than the doctors may see them and may communicate with them more often,” says Lisa Asare, M.P.H., assistant commissioner in the Division of Family Health Services at the New Jersey Department of Health. “They can teach women how to recognize danger signs … and act upon them.”Off
Engaging Women in Substance Use Disorder Treatment
Clinicians at St. Monica’s, an addiction treatment facility in Lincoln, Nebraska, find that pregnancy often opens a window of opportunity to engage women in addiction treatment. Most of their patients are pregnant or already have children, and they come from across the state seeking help for addictions to alcohol and drugs, mostly methamphetamines. Their treatment approach is informed by the research of Stephanie Covington, Ph.D., L.C.S.W., which suggests men and women need different approaches to addiction treatment because the underlying trauma that often fuels addiction may have different roots.
St. Monica's seeks to build women’s support networks by creating a home-like environment, with women sharing responsibility for cooking and cleaning and participating in group counseling sessions that enable them to recognize common experiences. “Where they turn that corner is learning that they often experience similar things in terms of the trauma, sexual abuse, or trafficking,” says Mary Barry-Magsamen, St. Monica’s CEO. “They realize everyone in the room experienced something like that and they are more alike than different.” And while many programs require women to complete treatment before reuniting with their children, St. Monica’s allows younger children in the homes, so their mothers can have support, oversight, and practice with parenting skills.
There have been other efforts to address substance use disorder in the context of pregnancy. For example, Ohio State University’s Substance Abuse Treatment, Education and Prevention Program Clinic partners with a local treatment center to offer co-located obstetric and addiction care for women with opioid use disorder. And the Horizons Program at University of North Carolina School of Medicine offers prenatal and postpartum care to pregnant women with substance use disorder.
Enhancing Support During the "Fourth Trimester" and Beyond
New Jersey’s Healthy Women Healthy Families initiative places as much emphasis on the postpartum period as the prenatal one in recognition that after childbirth women are still at risk as they undergo major physical and psychological adjustments in addition to adapting to life with a newborn. During this vulnerable period, the onus is often put on women to ask for help. Along with New Jersey’s state-led initiative, there are several efforts underway to offer more continuous support to women after childbirth, beyond the typical six-week postpartum visit.
Brigham and Women’s Cardiometabolic Clinic in Maternal-Fetal Medicine
One effort is being led by clinicians at Brigham and Women’s Hospital, which in 2011 created the Cardiometabolic Clinic in Maternal-Fetal Medicine to offer closer oversight during the postpartum period to women who experienced preeclampsia during pregnancy. (Preeclampsia involves high blood pressure and potentially changes in a mother’s kidney, liver, or blood-clotting systems.) They were motivated by growing evidence of the long-term risks of preeclampsia, which were documented in a startling study that followed more than 1 million women for eight years after childbirth. It found that women’s risk of developing premature cardiovascular disease doubled if they had experienced preeclampsia or related complications during pregnancy. Risks tripled among those who’d experienced poor fetal growth, quadrupled among those who’d had a stillborn baby, and were seven times greater if they smoked and had other preexisting risk factors. “If we had a better lens on women’s health, this news would be on the front page of USA Today,” says Ann Celi, M.D., M.P.H., an internist and pediatrician who leads the clinic.
Celi works with a team of maternal-fetal medicine specialists, internists, and nutritionists who provide intensive follow up in the weeks and months after delivery for women who experienced preeclampsia — about 2 percent of the women who deliver at the Brigham each year. They focus on proactively stabilizing women’s blood pressure through medication management, provide nutrition and lactation counseling, and engage in other efforts to set women on healthier courses. All women receive home blood pressure monitors as well as mental health and social referrals as needed. A study of 412 women who received care at the clinic found nearly half required medication adjustments. It also found high rates of engagement with nutrition consultations (86.8% attended) and primary care referrals (79.5% kept scheduled appointments.)
Northwestern’s Navigating New Motherhood
Clinicians at Northwestern Memorial Hospital’s Prentice Ambulatory Care Clinic, which provides prenatal and postpartum care to low-income women (nearly all are covered by Medicaid, 55% are African American, and 30% are Hispanic), in 2015 developed the Navigating New Motherhood program to offer enhanced support to women through the postpartum period. Based on the model of oncology navigators — who help cancer patients overcome barriers and find the resources they need to receive timely treatment — Northwestern’s navigator meets with women in the hospital after childbirth to offer services. In the first year, only seven of 218 women declined. The navigator then helps women schedule postpartum and any other medical visits and uses texting to check in on women regularly, answer their questions, and remind them of upcoming appointments. The navigator may also attend postpartum visits with women and help connect them to housing, nutrition, or other benefits.
Compared with patients who received treatment at the clinic the previous year, a study found those who received navigation support were more likely to attend postpartum visits (88% vs. 70%) undergo depression screening, and receive influenza and HPV vaccinations. “One of the things we found was that prior to meeting the navigator women didn’t appreciate the importance of the postpartum visit. They felt healthy and well and prioritized the baby and getting back to work,” says Lynn Yee, M.D., M.P.H., who developed the model and serves as an assistant professor at Northwestern’s Feinberg School of Medicine. The navigation program is now being expanded, and its effects will be tested in a randomized control trial.
Alison Stuebe, M.D., associate professor in the Department of Obstetrics and Gynecology at the University of North Carolina School of Medicine, has helped define ideal postpartum care. In a Q&A she describes what it will take to get there.
“I think there is a sense that once the candy is out of the wrapper, we’re done with the wrapper.”
Promoting Continuity of Care
Federally qualified health centers and other clinics that provide both primary and obstetric care are another model for supporting women’s comprehensive needs. Community of Hope, a federally qualified health center in Washington, D.C., has evolved a suite of services to support women of reproductive age that ramps up when they become pregnant. In addition to nine midwives (five full-time equivalents), the health center has perinatal navigators who work with pregnant women through pregnancy and six months after delivery to help them find social supports and make sure they find ongoing primary care. A group care coordinator leads group prenatal care sessions and a reproductive care coordinator helps women develop contraception and pregnancy plans. The health center also partners with Mamatoto Village, which trains community health workers to support women through pregnancy, childbirth, and the first months of parenting.
The fact that women can see Community of Hope clinicians before, during, and after delivery promotes continuity and helps ensure problems don’t get missed, says Ebony Marcelle, C.N.M., M.S., director of midwifery for the health center. “When women come for the early postpartum group and the baby needs a weight check, we will see the baby,” she says. “If she comes in with a baby and the [pediatric] provider sees she has not had a postpartum visit, we try to get her seen that day.”
Lessons and Policy Implications
Uninterrupted access to insurance is the greatest lever for change.
While these programs illustrate the benefits of increasing clinical oversight and social supports during the prenatal and postpartum periods, their spread may be hampered by states’ differing rules governing Medicaid eligibility. In states like Texas, many women who qualify for Medicaid while pregnant (because their income is less than 203 percent of the federal poverty level, or $52,273 for a family of four) will not meet the much narrower eligibility requirements for coverage after giving birth (income at 17 percent of the federal poverty level, or $4,378 for a family of four).
Changes in payment could help.
In addition to expanding coverage, states can modify Medicaid reimbursement to promote adoption of supportive maternal services. South Carolina’s Medicaid program has enhanced reimbursement for CenteringPregnancy programs, while New Jersey’s Medicaid program will reimburse doulas per client, Asare says.
Health plans can also pay for services such as maternal health navigator programs or blood pressure monitors for women at risk of hypertension. Technology platforms could be leveraged to scale promising approaches. Penn Medicine has used text messaging to collect blood pressure readings and educate women about the risks of hypertension in the postpartum period.
Expanding the workforce could help address unmet needs.
The success of these programs to date suggests that community health workers, doulas, navigators, and other nonmedical staff play critical roles in supporting women throughout their pregnancies and in the months and even years after childbirth. Understanding which approaches work best and finding sustainable funding sources will encourage their spread.
Greater focus on the quality of care offered to women is needed.
Maternal mortality reviews are one way to understand the root causes of maternal deaths and identify potential gaps in health care quality. While only about half of states and some cities conduct these reviews, the Preventing Maternal Deaths Act, signed into law in December 2018, establishes a federal infrastructure for collecting and analyzing information on every maternal death. In addition, there is a proposed revision of Healthcare Effectiveness Data and Information Set (HEDIS) measures for 2020 to measure receipt of early postpartum visits (between one and 21 days after delivery) in addition to later postpartum visits. But aside from these measures, data gauging the quality of maternal care are generally lacking.
To expand measurement and improve performance, Beth Israel Deaconess Medical Center in Boston recently established a population health program for women of reproductive age. Chloe A. Zera, M.D., M.P.H., who heads the effort, plans to focus on high-frequency, high-variability conditions, including hypertension and behavioral health. “We want to encourage all of primary care to prioritize reproductive health,” she says. To spur improvement, the health system may look at measures of quality that aren’t tracked elsewhere. “Something we care about — screening for diabetes after pregnancy with gestational diabetes, for example —is not a recognized quality metric. It hasn’t percolated up to that level,” she says.
Better training of primary care and obstetric providers is needed.
For example, internists and specialists need to be aware of the long-term cardiovascular risks among women who had preeclampsia or other pregnancy complications and work together to ameliorate them. A recent survey found that gynecologists were significantly more likely than internists to recognize the risk, but less likely than internists to know how to follow up.
In addition, obstetric and primary care clinicians need to be incentivized to work together to ensure women make safe transitions from postpartum to ongoing care. “The handoff is almost ceremonial, even though it’s incredibly important to a person’s well-being,” says Neel Shah, M.D., M.P.P., assistant professor of obstetrics, gynecology, and reproductive biology at Harvard Medical School.
In addition, pediatricians can play a key role by assessing how mothers are doing during well-baby visits and creating opportunities for parents to support one another.
To make meaningful progress, health care professionals need to address implicit bias and acknowledge the role of structural racism in maternal health.
While programs intended to educate women about their health and encourage them to speak up are important, they can only go so far in a health care system with a long history of racial and gender bias. Research has found that clinicians spend less time with black than white women, more frequently discount their symptoms and complaints, and undertreat their pain.
Reducing racial disparities will require an intentional focus on structural racism and implicit bias. In our September 2018 issue on Reducing Racial Disparities in Health Care by Confronting Racism, we shared several examples of how health care organizations are partnering with patients to identify problems and taking concrete steps to address them. Laurie Zephyrin, M.D., the Commonwealth Fund’s vice president for health care delivery system reform, outlined other strategies in her recent Stat op-ed, Pregnancy-Related Deaths Reflect How Implicit Bias Harms Women. We Need to Fix That.
And as the programs featured in this issue illustrate, the path forward must include a comprehensive and longitudinal approach to maternal health that does a better job of identifying when and how women may need additional support. “If we in health care can send a message to women that we care about them and that we are there to help them, that will go a long way,” says Celi of Brigham and Women’s Hospital.Off
Martha Hostetter and Sarah Klein, “In Focus: Improving Health for Women by Better Supporting Them Through Pregnancy and Beyond,” Transforming Care (newsletter), Oct. 1, 2019. https://doi.org/10.26099/st8x-kf47Martha Hostetter
The September/October 2019 issue of Transforming Care focuses on efforts to support women through pregnancy and the postpartum period, highlighting innovative approaches to maternal care that show promise in reducing racial disparities in maternal health outcomes.Women's Health https://doi.org/10.26099/st8x-kf47 Show Link false false Controlling Health Care Costs Off Editorial Advisory Board, October 2019
Special thanks to Editorial Advisory Board member Allison Hamblin and guest adviser Karla Silverman, for their help with this issue.
Anne-Marie J. Audet, M.D., M.Sc., senior medical officer, The Quality Institute, United Hospital Fund
Eric Coleman, M.D., M.P.H., professor of medicine, University of Colorado
Michael Chernew, Ph.D., professor of health policy, Harvard Medical School
Marshall Chin, M.D., M.P.H., professor of healthcare ethics, University of Chicago
Don Goldmann, M.D., chief medical and scientific officer, Institute for Healthcare Improvement
Laura Gottlieb, M.D., M.P.H., assistant professor of family and community medicine, University of California, San Francisco, School of Medicine
Carole Roan Gresenz, Ph.D., senior economist, RAND Corp.
Allison Hamblin, M.S.P.H., vice president for strategic planning, Center for Health Care Strategies
Thomas Hartman, vice president, IPRO
Clemens Hong, M.D., M.P.H., medical director of community health improvement, Los Angeles County Department of Health Services
Lauren Murray, director of consumer engagement and community outreach, National Partnership for Women & Families
Kathleen Nolan, M.P.H., regional vice president, Health Management Associates
J. Nwando Olayiwola, M.D., M.P.H., associate professor of family and community medicine, University of California, San Francisco, School of Medicine
James Pelegano, M.D., M.S., assistant professor of healthcare quality and safety, Thomas Jefferson University
Harold Pincus, M.D., professor of psychiatry, Columbia University
Chris Queram, M.A., president and CEO, Wisconsin Collaborative for Healthcare Quality
Sara Rosenbaum, J.D., professor of health policy, George Washington University
Michael Rothman, Dr.P.H., executive director, Center for Care Innovations
Guest adviser: Karla Silverman, R.N., C.N.M., M.S., Senior Clinical Officer, Center for Health Care Strategies
Mark A. Zezza, Ph.D., director of policy and research, New York State Health FoundationOff Publications of Note: July–September 2019
Secret Shopper Survey Finds Many Buprenorphine Prescribers Do Not Offer New Appointments
To assess real-world access to buprenorphine treatment for uninsured or Medicaid-covered patients, researchers contacted publicly listed prescribers and posed as patients seeking treatment for heroin addiction. In six communities with a high burden of opioid-related mortality (the District of Columbia, Maryland, Massachusetts, New Hampshire, Ohio, and West Virginia), they found clinicians offered new appointments to 54 percent of Medicaid contacts and 62 percent of uninsured (self-pay) contacts. Twenty-seven percent of Medicaid and 41 percent of uninsured contacts were offered an appointment with the possibility of buprenorphine prescription at the first visit. The median wait time to first appointment was six days for Medicaid contacts and five days for uninsured contacts. The median wait time from first contact to possible buprenorphine induction was eight days for Medicaid contacts and seven for the uninsured. The researchers say the short wait times suggest there are opportunities to increase access using the existing prescriber workforce. Tamara Beetham et al., “Access to Office-Based Buprenorphine Treatment in Areas with High Rates of Opioid-Related Mortality: An Audit Study,” Annals of Internal Medicine 171, no. 1 (July 2019):1-9.
A Population-Based Intervention Reduces Hospitalizations Among Children
An initiative that aimed to reduce hospitalizations among children living in two high-morbidity, high-poverty neighborhoods in Cincinnati, Ohio, decreased the inpatient bed-day rate by 18 percent from the 2012-15 baseline to the improvement phase (2015-18). Hospitalizations decreased by 20 percent. There was no similar decrease in demographically comparable neighborhoods. The initiative focused on chronic disease management, transitions in care, mitigation of social risk, and use of actionable, real-time data. Andrew F. Beck et al., “Cooling the Hot Spots Where Child Hospitalization Rates Are High: A Neighborhood Approach to Population Health,” Health Affairs 38, no. 9 (September 2019):1433-41.
Supportive Services Improve Access to Care, Preventive Services, and Satisfaction Among Health Center Patients
A study of patients served by health centers funded by the Health Resources and Services Administration found in 2014 those who received supportive services that addressed social challenges and barriers to accessing care had 1.92 times more health center visits, an 11.78–percentage-point higher probability of getting a routine check-up, a 16.34–percentage-point higher likelihood of having a flu shot, and a 7.63–percentage-point higher probability of a patient definitely recommending the health center to others. The supportive services included care coordination, health education, transportation, and assistance obtaining food, shelter, and benefits. Dahai Yue et al., “Enabling Services Improve Access to Care, Preventive Services, and Satisfaction Among Health Center Patients,” Health Affairs 38, no. 9 (September 2019):1468-74.
Racial Disparities Found in Home and Community-Based Services for Dual Eligibles
A study that compared outcomes for older adults dually eligible for Medicare and Medicaid who received home and community-based services (HCBS) to those receiving institutional care found overall hospitalization rates were similar in both groups even though nursing facility users were generally sicker based on their claims histories. The researchers also found among HCBS users, blacks were more likely to be hospitalized than non-Hispanic whites and the gap widened among blacks and whites with dementia. Medicaid HCBS spending was also higher for whites than for blacks, and higher Medicare and Medicaid hospital spending for blacks and Hispanics did not offset this difference. They concluded that services need to be carefully targeted to avoid adverse outcomes and disparities in access to high-quality care. Rebecca J. Gorges, Prachi Sanghavi, and R. Tamara Konetzka, “A National Examination of Long-Term Care Setting, Outcomes, and Disparities Among Elderly Dual Eligibles,” Health Affairs 38, no. 7 (July 2019):1110-18.
AIM Model Significantly Reduces Hospital Days and Expenses for Patients in the Last Month of Life
The Advanced Illness Management (AIM) program at California’s Sutter Health, which informed the development of a new Medicare payment model for serious illness care, reduced hospital days for seriously ill patients in the last month of life by 1,361 per 1,000 Medicare beneficiaries, hospital deaths by 8.2 percent, inpatient payments by $6,127, and the total cost of care by $5,657 per beneficiary. In a Health Affairs article, the developer of the model and current staff describe the lessons they learned changing the focus of care for advanced illness from hospital to home. Brad Stuart, Elizabeth Mahler, and Praba Koomson, “A Large-Scale Advanced Illness Intervention Informs Medicare’s New Serious Illness Payment Model,” Health Affairs 38, no. 6 (June 2019):950-56.
ACOs Aren’t Taking Advantage of Serious Illness Programs
A national survey of accountable care organizations (ACOs) found 94 percent at least partially identified seriously ill patients, but only 8 percent to 21 percent widely implemented serious illness initiatives, such as advance care planning or home-based palliative care. The authors selected six ACOs with successful programs for case studies and found common themes. The ACOs saw the need for upfront investment beyond shared savings to build the necessary infrastructure and workforce; the importance of establishing a business case to gain organizational buy-in; and the necessity of using data and information technology to manage populations. The authors also consider how quality measures, risk adjustment, attribution methods, support for rural ACOs, and enhancing timely access to data affect adoption of these models. William K. Bleser et al., “ACO Serious Illness Care: Survey and Case Studies Depict Current Challenges and Future Opportunities,” Health Affairs 38, no. 6 (June 2019):1011-20.
Study Finds Readmissions Reductions Continue at Safety-Net Hospitals, But Disparities Persist at Non-Safety–Net Hospitals
A study that examined disparities in rates of 30-day readmissions for three conditions following the 2010 passage the law creating the Hospital Readmission Reduction Program found disparities in readmission rates among blacks and whites were already decreasing prior to implementation. The reductions were largest at safety-net hospitals. They found in 2007, blacks had 13 percent higher odds of readmission if treated in safety-net hospitals, compared with 5 percent higher odds in 2010; this trend continued following implementation of the penalties under the readmission reduction program. By contrast, racial disparities continue to persist at non-safety–net hospitals, which face much lower penalties under the program. The study examined readmissions for acute myocardial infarction, congestive heart failure, or pneumonia at hospitals in five states (Arizona, Florida, Nebraska, New York, and Washington State). Cameron M. Kaplan, Michael P. Thompson, and Teresa M. Waters, “How Have 30-Day Readmission Penalties Affected Racial Disparities in Readmissions? An Analysis from 2007 to 2014 in Five States,” Journal of General Internal Medicine 34, no. 5 (June 2019):878-83.
Improvements to the Hospital Readmissions Reduction Program Recommended
The authors of a New England Journal of Medicine commentary describe ways of addressing the limitations and unintended consequences of the Hospital Readmissions Reduction Program, including the tendency of hospitals to rely on observation stays to avoid readmissions, the program’s failure to factor in risk of death, and inadequate risk adjustment to allow fair comparisons of hospitals. They suggest using a “return-to-hospital” metric to capture emergency department visits and observation stays, which could strengthen hospitals’ incentive to focus on improving care transitions and post-discharge care. They recommend creating an outcome measure that combines hospital returns with deaths within 30 days to ensure there are financial incentives to reduce mortality. They also suggest adding data on prior hospital utilization, functional status, and frailty to improve risk models and using revenue generated from the program to help resource-poor hospitals improve. Rishi Wadhera, Robert W. Yeh, and Karen E. Joynt Maddox, “The Hospital Readmissions Reduction Program — Time for a Reboot,” New England Journal of Medicine 380, no. 24 (June 2019):2289-91.
ACOs in Rural and Underserved Areas Lowered Medicare Spending
A study of accountable care organizations (ACOs) in rural and underserved areas that received upfront investment from the Centers for Medicare and Medicaid Services (CMS) as part of the ACO Investment Model (AIM) found they reduced total Medicare spending by $28.21 per Medicare beneficiary per month or $131 million in aggregate, relative to a comparison group of beneficiaries in markets where providers did not participate. Over this period, CMS made $76.2 million in prepayments to the ACOs and paid an additional $6.2 million in shared savings. After accounting for these costs, the aggregate net reduction was $48.6 million, or $10.46 per beneficiary per month. Decreases in the number of hospitalizations and use of institutional post-acute care contributed to the observed reduction in overall spending. As part of the AIM program, eligible ACOs participating in the Medicare Shared Savings Program received prepayment of shared savings. Matthew J. Trombley et al., “Early Effects of an Accountable Care Organization Model for Underserved Areas,” New England Journal of Medicine 381, no. 6 (August 2019):543-51.
Analysis of Medicare Claims Data Using Machine Learning Identifies Subgroups of High-Need, High-Cost Patients
Using an open-source, machine learning method to describe subgroups of high-need, high-cost (HNHC) patients covered by Medicaid found the largest subgroups were characterized by mental and behavioral health conditions. The researchers also found marked heterogeneity in patient costs across subgroups. An unexpected HNHC patient population they identified: patients with pregnancy-related complications. The study examined the clinical characteristics of patients of Mount Sinai Health System in New York City. Sudhakar V. Nuti et al., “Characterizing Subgroups of High-Need, High-Cost Patients Based on Their Clinical Conditions: A Machine Learning-Based Analysis of Medicaid Claims Data,” Journal of General Internal Medicine 34, no. 8 (August 2019):1406-8.
Interdisciplinary Transitional Care Reduces ED Visits, Hospitalizations, and Readmissions for Medicaid Beneficiaries
A study examining the effect of SafeMed — an intensive, interdisciplinary transitional care program that emphasized medication adherence and rapid primary care follow-up for high-need, high-cost Medicaid and Medicare patients — found participation was associated with 7 percent fewer hospitalizations, 31 percent fewer 30-day readmissions, and reduced medical expenditures over six months. Improvements were limited to Medicaid patients, who experienced statistically significant decreases of 39 percent in emergency department visits, 25 percent declines in hospitalizations, and 79 percent reductions in 30-day readmissions. Medication adherence was unchanged. James E. Bailey et al., “Effect of Intensive Interdisciplinary Transitional Care for High-Need, High-Cost Patients on Quality, Outcomes, and Costs: a Quasi-Experimental Study,” Journal of General Internal Medicine 34, no. 9 (September 2019):1815-24.
Disadvantaged Neighborhoods, Safety-Net Hospital Status Are Independent Predictors of Readmission Risk
Researchers found living in a disadvantaged neighborhood in Maryland and being discharged from a hospital that treats a significant number of such patients are independently associated with 30-day hospital readmission rates. The study found, in 2015, patients living in neighborhoods in the 90th percentile of the area disadvantage index — a composite of income, employment, education, and housing measures — had a readmission rate of 14.1 percent, compared with 12.5 percent for similar patients living in neighborhoods at the 10th percentile. The researchers also calculated a “safety-net index,” based on the mean disadvantage of discharged patients from a given hospital. They found hospitals in the 90th percentile on the safety-net index had a readmission rate of 14.8 percent compared with 11.6 percent of patients discharged from hospitals in the 10th percentile. The association of readmission risk with the hospital’s safety-net index was approximately twice the observed association with the patient’s neighborhood disadvantage status. Stephen F. Jencks et al., “Safety-Net Hospitals, Neighborhood Disadvantage, and Readmissions Under Maryland’s All-Payer Program: An Observational Study,” Annals of Internal Medicine 171, no. 2 (July 16, 2019):91-98.Off On Theme On Health Disparities Gender Based Disparities Infant Mortality Maternal Health Health System Improvement
Alison Stuebe, M.D., is an associate professor in the Department of Obstetrics and Gynecology at the University of North Carolina School of Medicine and a distinguished scholar in infant and young child feeding at the Gillings School of Global Public Health. She served as lead author of the American College of Obstetricians and Gynecologists’ May 2018 committee opinion outlining the features of optimal postpartum care. The opinion encourages clinicians to take a more comprehensive approach by, among other things, incorporating education, contraceptive counseling, and screening for social challenges. Stuebe also took part in the Alliance for Innovation on Maternal Health, a four-year collaborative that brought hospitals in eight states together to reduce maternal mortality and morbidity. As part of that work, Stuebe helped develop a set of best practices for postpartum care, which lays out strategies for ensuring women’s medical, behavioral, reproductive health, and social service needs are met. Transforming Care asked Stuebe about what stands in the way of achieving these goals.
Transforming Care: The committee opinion and best practice guidelines you helped develop are quite explicit about how clinicians can strengthen postpartum care — by improving communications during pivotal transitions, offering more extensive education to patients, and connecting them to community resources including home visiting programs, lactation support groups, and food banks. What are the biggest impediments to ensuring these recommendations become common practice?
Stuebe: The major rate-limiting step is the way postpartum care is reimbursed. The global payment for obstetric care includes postnatal visits — one for vaginal deliveries and two for cesarean sections — but providers typically get paid whether or not women have any visits. I don’t think anyone is cynically not scheduling postpartum visits, but there is no incentive for staff to take time out of their day to call women or take other steps to make sure they come in. When it comes to billing, providers may also be unaware of what is and is not routine postpartum care. If someone has a hypertensive crisis, managing that is not routine care, but providers may not know how to code those visits, and insurers may deny payment if they do. The bottom line is we have to find a way to pay for this care if people are going to do it.
Transforming Care: What would you like to see happen?
Stuebe: One option would be to have a separate bundle for care that is provided from birth to 12 weeks out for mother and baby. You can imagine postpartum centers that focus exclusively on the needs of the mother-baby dyad, with lactation consultants and physical therapists, as well as family physicians and midwives. I’d love to see the Medicaid waiver program test such models. The Health Resources and Services Administration’s Maternal and Child Health Bureau is looking to fund innovation that promotes maternal health, so that’s another opportunity.
Transforming Care: How do you make the case it’s worth the investment?
Stuebe: We can extrapolate from programs that offer supports, such as one in North Carolina called Family Connects Durham, which was created as a childhood abuse and neglect prevention strategy. It covers a nurse home visit for all families with newborns in Durham County, regardless of their insurance status. The nurse does a head-to-toe assessment of mom and baby and makes referrals to community agencies. They found that for every dollar spent, $3 were saved in emergency department visits for the child alone. They also found moms receiving this service were less likely to experience depression and anxiety.
One of the challenges for making the case for change is that we lack measures that quantify outcomes that matter to women. The main metric is the Healthcare Effectiveness Data and Information Set measure: Has the woman had a postpartum visit between 21 and 56 days postpartum? That’s a very blunt instrument, and it may not be that accurate. In one study we did of women whose babies were in the neonatal intensive care unit we found a large gap between visits based on insurance claims and what was recorded in the electronic health record (E.H.R.). In the current system, postpartum care is kind of a black hole, and it’s really hard to wrap our arms around whether people are getting what they need.
Transforming Care: Toward that end, you recommend that clinicians measure whether they are eliciting women’s preferences for breastfeeding and contraception and track the extent to which those goals are achieved. How do you advance this cause?
Stuebe: I think the E.H.R. vendors can help a lot by tracking outcome measures that assess the mother’s intentions — something like, did you stop breastfeeding sooner than you wanted to? Asking about goals for contraception is also critically important given this country’s history with coercive contraception. I worry a lot about the implicit assumption that we should push to place long-acting contraception (LARC) before she goes home after giving birth, especially in settings where women don’t have or are in danger of losing insurance. What if she loses insurance and she doesn’t like the implant and she wants it removed? I worry that in our enthusiasm for postpartum LARC, we don’t think about the unintended consequences. Part of it is that I think as a society we don’t value women when they don’t have babies inside of them. I think there is a sense that once the candy is out of the wrapper, we’re done with the wrapper.
Transforming Care: Do you see any bright spots, such as organizations that are moving the ball forward when it comes to optimal postpartum care?
Stuebe: Yes. Community Care of North Carolina, North Carolina’s medical home program, pays clinicians an extra $150 for providing a postpartum visit that meets specific criteria, such as scheduling follow-up care for women who have experienced gestational hypertension or preeclampsia or are at risk for postpartum depression. There’s also the work of Elizabeth Howell, M.D., M.P.P., in New York, who has shown spending 15 minutes talking to new mothers about what to expect postpartum and following up with a phone call reduced depression rates and increased breastfeeding rates through six months postpartum. It doesn’t require a private doula moving in with you for six weeks. It can be pretty basic and still make a difference. That’s why the 4th Trimester Project has developed. It led to a new website called newmomhealth.com. This resource provides expert-written information on how to cope with common postpartum issues. It’s been co-designed with mothers, who have given us feedback that they want to be given options. We need to listen to moms — every mom, every time — not just tell her what to do.
Transforming Care: Any last thoughts on how we can improve postpartum care?
Stuebe: We need to extend pregnancy Medicaid coverage from 60 days to a full year postpartum. This is critically important in states that haven’t expanded Medicaid, where women fall off a cliff at 60 days without the safety net of Medicaid expansion to provide them with access to care. We know mortality rates are higher in the year after giving birth, and the idea that mothers don’t need health care after this magical 60 days is shortsighted and antihuman.Off
Martha Hostetter and Sarah Klein, “Q&A with Alison Stuebe, M.D.: Strategies for Ensuring Women’s Needs Are Met,” Transforming Care (newsletter), Oct. 1, 2019. https://doi.org/10.26099/xmv7-y266Martha Hostetter
Hear what it will take to improve care for women after childbirth in a Q&A with Alison Stuebe, M.D., the lead author of an American College of Obstetricians and Gynecologists Committee Opinion encouraging clinicians to take a more comprehensive approach to postpartum care.Women's Health Strategies for Ensuring Women’s Needs Are Met https://doi.org/10.26099/xmv7-y266 Show Link false false Improving Health Care Quality Off On Theme On Health Disparities Gender Based Disparities Maternal Health Infant Mortality Health System Improvement