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Wednesday Apr 11, 2018

More Investment in Primary Care Would Help Mothers, Babies

In 2012, I chaired a Dr. Robert Bree Collaborative(www.breecollaborative.org) workgroup that created obstetrics care recommendations,(www.breecollaborative.org) including pay-for-performance metrics for delivery care of patients covered by the state of Washington, either through Medicaid or the state employee health insurance.

[newborn baby being examined]

Our recommendations had three key goals:

  • Eliminate all elective deliveries before the 39th week (i.e., those deliveries for which there is no appropriate documentation of medical necessity).
  • Decrease elective inductions of labor between 39 weeks and up to 41 weeks.
  • Decrease unsupported variation among Washington hospitals in the primary cesarean section rate.

We were successful. By preventing nearly 8,000 C-section deliveries during the five years following the report's release and nearly twice as many unnecessary neonatal intensive care unit admissions, we reduced the direct cost of health care to the state by an estimated $60 million while also reducing maternal and infant morbidity.

There are more than 85,000 deliveries a year in our state, and approximately 25 percent of those deliveries are performed by family physicians. Fifteen percent of all deliveries in Washington occur in rural hospitals. As in many states, Medicaid pays for a significant number of those deliveries. Across Washington, more than 50 percent of women have their prenatal care and obstetrical services funded through Medicaid. In my community, 75 percent of all births are paid for by Medicaid.

Ohio data from a 2016 Kaiser Family Foundation study(khn.org) suggested that Medicaid funding was the chief -- if not the only -- reason that many rural hospitals were able to maintain obstetrical services. And a recent post on this blog by AAFP Board Chair John Meigs, M.D., highlighted how bringing a teaching health center program to his rural Alabama community allowed his small community hospital to re-establish obstetrical services.

In May, the collaborative's workgroup will revisit its recommendations for the first time, looking for new evidence that would suggest updates or changes. I have been asked to look at the potential of creating a proposal for bundled payment prenatal care and delivery services.

Our collaborative has done seminal work in creating quality bundles(www.breecollaborative.org) for total joint replacement -- both hip and knee -- and for single-level spine fusion, and these have been successful models for contracting for the services and ensuring patients high-value, high-quality care at the best possible cost, with care warranted by both hospital and surgeon.

So why would I focus on the topics of obstetrical quality, Medicaid funding, rural hospitals and family physicians?

I recently represented Washington at the CDC's Maternal Mortality Review Program. We resumed collecting and reviewing maternal mortality data in our state in 2014, after a lapse of several years due to withdrawal of state funding. Our recent data indicate -- a finding confirmed by other states that reported at this conference -- that in addition to the expected pregnancy-related causes of maternal mortality (such as maternal hemorrhage and complications of hypertension), many associated causes of maternal morbidity and mortality are related to conditions that precede pregnancy and persist afterward -- particularly substance abuse, mental health disorders, metabolic disorders, morbid obesity, chronic hypertension, intimate partner violence, chronic homelessness, inadequate nutrition and smoking.

These and many other factors are all linked to overwhelming social determinants of health issues(nam.edu) that are not likely be solved or even adequately addressed during the course of prenatal care. The medical issues alone require long-term continuity of care for adequate treatment, along with significant community support systems that include substance use treatment, mental health counseling, nutrition support, housing and violence-prevention programs, none of which is funded under our current system of Medicaid fee-for-service. That system, which varies state by state when it comes to income eligibility levels, typically provides coverage only for the current pregnancy and 42 days post-delivery.

The challenges, particularly for family physicians in rural communities,(www.nap.edu) are that the funding model for Medicaid is untenable and the economics are such that family practices cannot survive in rural communities unless there is a significant change in the payment model for primary care. The dollars that flow to a rural hospital for a Medicaid delivery may help keep the doors open, but the limited dollars that flow to a family physician for prenatal care and delivery for an individual with many chronic conditions (who will need ongoing care well beyond the period of Medicaid eligibility limited to pregnancy) makes it unlikely that practice will thrive economically, or that those physicians will be able to cover the added malpractice insurance costs associated with providing obstetrical care.

Couple that with the challenges of providing the breadth of resources to address substance use disorders, mental health issues and the other social determinants of health I mentioned above, and it may not be possible to maintain maternity services in the community. When that happens, women do not stop becoming pregnant, they simply do not get access to early prenatal care, frequently drive long distances for care,(www.washingtonpost.com) present emergently to a local hospital that is not prepared for obstetrical emergencies, and have poor obstetrical outcomes, including more frequent maternal and infant deaths.

So, is it time to create a Medicaid prenatal care and delivery quality bundle? Perhaps that might work in a large city where there are competing horizontally and vertically integrated closed systems providing the full spectrum of prenatal care and delivery. It will not work in my community, where there is no integration between a community hospital, several independent practices and three federally qualified healthcare centers, and I cannot see it working in a small rural community where the resources to address complex social determinants issues are lacking.

What we really need is payment reform and universal access. Instead of 5 percent of health care dollars going to primary care, it should be 12 percent to 15 percent. Give my 19-year-old, 26-weeks pregnant, complex Medicaid OB patient with gestational diabetes, morbid obesity and depression continuous coverage -- not just for this pregnancy and for 42 days postpartum, but ongoing coverage -- so I can treat her depression, help her lose weight and help her get herself healthy.

Rhode Island proved that increasing the primary care spend on Medicaid patients(www.pcpcc.org) from 5 percent to 12 percent saved on the overall cost of care, and Oregon is going to do the same. The AAFP has looked at how the major economically developed countries in the world have funded health care, particularly primary care, and it is clear: The larger the investment in primary care, the better the outcomes.(www.nejm.org) 

Carl Olden, M.D., is a member of the AAFP Board of Directors.

Posted at 11:40AM Apr 11, 2018 by Carl Olden, M.D.

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