A Strong Start for Families: Maternity Care Episodes

Thursday, May 23, 2019
By: Remedy Partners

Should we take the temperature of the state of healthcare in the U.S. today using maternal mortality, the system would be found to be ailing and urgently in need of change. Current trends in maternity care in the United States show an increase in the use of costly, medically unnecessary interventions, such as elective cesarean deliveries, which have resulted in higher costs and poorer outcomes for mothers and babies.


The U.S. is the only industrialized nation with a rising maternal mortality rate; between 2000 and 2014, there was a 26% increase in the maternal mortality rate in the U.S.(1)  U.S. providers do not perform well in obstetrics when compared with other industrialized nations.(2) In fact, the rate of maternal mortality in the U.S. is 14 in 1,000, ranking it 47 out of 183 countries.(3) Pregnancy, labor and birth contribute to the single largest group of diagnoses, by cost, for employers providing health insurance benefits.(4)


Fee-for-service payment mechanisms for labor and delivery create incentives for hospitals to perform complex, costly procedures. In a recent comprehensive report on evidence-based maternity care, the “perverse incentives of payment systems” are listed as one of the pervasive barriers to evidence-based care.(5) Due to the fee schedule, the average costs for cesarean deliveries are almost 50% higher than those for vaginal deliveries.(6)

Often under a fee-for-service payment model, prenatal care, labor and birth, and postpartum care are viewed and care delivered as three distinct treatment periods. By viewing them as separate, there is no incentive for team-based care, care coordination and other types of interactions and care delivery that support positive cost and quality outcomes.(7)


Episode-based payment addresses the disconcerting lack of perinatal outcome benefits associated with the increasing use of costly obstetrical interventions over the last twenty years, by aligning incentives for better maternal and neonatal outcomes.

This incentivizes collaborative care teams, care coordination and new types of clinical delivery models resulting in lower cost, higher quality outcomes and more satisfied mothers.

In the maternal bundle quality and cost are very tightly linked, because good prenatal care can lead to full gestation and normal birthweight of the baby – and this is a significant saver on the total cost of the global maternity episode

Thanks to continued efforts by the Florida Perinatal Quality Collaborative, maternal outcomes are improving in the Sunshine state but more needs to be done because those efforts can't be sustained without a change in payments. Florida employers that are members of the Florida Alliance for Healthcare Value are committing in increasing numbers to adopt episode of care payment for maternity and that's what will change outcomes for the better for current and future generations of Floridians.
[1] MacDorman, M., Declercq, E., Cabral, H., Morton, C., “Is the United States Maternal Mortality Rate Increasing? Disentangling trends from measurement issues: Short title: U.S. Maternal Mortality Trends.” Obstet Gynecol. 2016 Sep; 128(3):447-55.

(2) Kaiser Family Foundation analysis of data from Institute of Health Metrics and Evaluation, Global Burden of Disease Study 2017 (GBD 2017) Data Downloads.

(3) The World Bank. Maternal Mortality Ratio, 2015. https://data.worldbank.org/indicator/SH.STA.MMRT?most_recent_value_desc=false&year_high_desc=false

(4) Wier LM., Andrews RM. The national hospital bill: the most expensive conditions by payer, 2008. Statistical brief #107. March 2011. In: Healthcare Cost and Utilization Project (HCUP) Statistical Briefs. Rockville, MD: Agency for Healthcare Research and Quality (US) www.ncbi.nlm.nih.gov/books/NBK53976/.

(5) Sakala C, Corry M. Evidence-based maternity care: what it is and what it can achieve. Childbirth Connection, the Reforming States Group, and the Milbank Memorial Fund. 2008 October. Available at www.milbank.org/reports/0809MaternityCare/0809MaternityCare.html.

(6) Thomson Healthcare. The healthcare costs of having a baby. 2007 June. 

(7) Health Care Payment and Learning Action Network. “Clinical Episode Payment Models.” 2016.

Remedy Partners 5/23/2019

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