HCTTF Urges CMS to Test an Alternative Payment Model for Maternity Care

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Re: Testing a Maternity Care Payment Model

Dear Administrator Verma and Deputy Administrator Adam Boehler:

The Health Care Transformation Task Force (HCTTF) writes to strongly urge the Centers for Medicare and Medicaid Services (CMS) to test an alternative payment model (APM) through the Center for Medicare and Medicaid Innovation (CMMI) for maternity care. There is a well-documented maternal health crisis in the United States, so we believe improved maternal and infant health should be an important priority for the Department of Health & Human Services that builds upon the foundation of the Strong Start initiative and Maternal Opioid Misuse model. There is also widespread agreement that current fee-for-service reimbursement structures do not facilitate the most effective delivery of maternity care, yet uptake of outcomes-driven maternity care models in the market has been minimal. Administrator Verma has championed the importance of improving maternal and child health outcomes, and a new APM to transform maternity care delivery could be a major value-based payment initiative with long-lasting impact.

The overall trends in maternity outcomes in the United States are concerning, particularly the increased rate of pregnancy-related deaths and growing disparities in outcomes for vulnerable populations. Further, more than 50,000 women annually experience serious maternal morbidity (“near miss”), a figure that is also rising. There is also unwarranted practice variation, overuse of unneeded care, and underuse of evidence-based care, leading to rising costs without associated improvements in outcomes and patient experience. The variations in care delivery and outcomes indicate a clinical area that could be positively impacted by a value-based payment paradigm.

Today, HCTTF released a report, Expanding Access to Outcomes-Driven Maternity Care through Value-Based Payment, that highlights the significant activity that many have undertaken on maternal health. Yet, the dial has not been moved in a meaningful way, and the need and opportunity have grown in significance as the crisis has grown.

CMS can serve an important role by helping states transform how maternal health care is delivered. We believe CMS should test a multi-payer maternity care model in order to advance industry understanding and adoption of the most effective models for maternity care payment. The Medicaid program provides the greatest opportunity to test and encourage adoption of alternatives to fee-for-service for maternity payment, which pays for about half of all births in the country, and we believe a partnership with commercial payers will amplify the model’s impact.

A multi-payer model could use an approach akin to CPC+ or the Oncology Care Model to partner with commercial payers and Medicaid MCOs and/or offer a competitive funding opportunity to support states in implementing a model that improves quality of care and reduces cost for states and the federal government. CMS should also commit to expediting the approval process for Medicaid state plan amendments and waivers to implement a maternity care APM that holds states and providers accountable for improved outcomes, and provide guidance about how to do so through State Medicaid Director letters. The importance of improving maternal and infant health is a public health objective that should outweigh any associated burden of aligning efforts across CMMI, the Center for Medicaid and CHIP Services, and state Medicaid programs.

The design elements of a maternity APM should address the unique health needs of the covered population, building upon the Administration’s efforts to improve care for pregnant women with opioid use disorder through the Maternal Opioid Misuse model. The APM should cover a comprehensive perinatal episode, including prenatal, delivery, and postpartum care for the mother and pediatric care for the infant up to twelve months after delivery. CMS should also track patient experience. There is growing support for a year of postpartum coverage given the long tail of adverse maternal health outcomes; the AMA and ACOG have adopted policies to this effect. Therefore, participating state Medicaid programs should be encouraged to extend postpartum coverage for women up to a year. In particular, the model should address the following objectives:

• Improved prenatal care utilization: According to the CDC, the rate of women receiving adequate prenatal care services and receiving care in the first trimester can vary 20 percentage points among U.S. states, and the rate also varies significantly by age, race, education and source of payment.
• Reducing the rate of unnecessary Cesarean section (C-section) deliveries: Deliveries by C-sections now account for almost one-third of all births; an estimated 35 percent of all C-sections are low-risk births.
• Improved healthy birth weight rate: Birth weight is a marker of general health and a determinant of infant mortality and long term physical and psychosocial development.
• Healthy postpartum recovery for mother & baby: Over half of pregnancy-related deaths occur postpartum, and ACOG and AMA have recommended expanded and enriched postpartum care to address this gap.
• Reduced racial disparities in morbidity and mortality: Maternal mortality rates for Black and Native women are three higher than for non-Hispanic white women, and they have a higher likelihood of experiencing severe maternal morbidity and complications.
• Improved screening and treatment for perinatal mood and anxiety disorders (PMADs): One in seven women are affected by PMADs, which include prenatal and postpartum anxiety and depression; a 2019 Mathematic study found that the estimated average cost of untreated PMADs is $32,000 per each mother-child pair.

As with any payment model, there are many complexities associated with designing a maternal health APM. HCTTF stands ready to work with CMMI and states to advance progress in this important area that will benefit future generations of our fellow citizens.

This letter was submitted via email on July 16, 2019.