1/18/23: NBEC and NCQA’s Birth Equity Accountability Through Measurement Project

Thank you for participating in this month’s Maternal Health Hub Learning Community session on NBEC and NCQA’s Birth Equity Accountability Through Measurement Project featuring Dr. Susan Perez, PhD, MPH, Research and Strategy Consultant at the National Birth Equity Collaborative (NBEC) and Dr. Whitney Graves, PhD, MPH, Phyllis Torda Health Care Quality and Equity Fellow, NCQA.

View the recording here and slides here.

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Dr. Susan Perez of NBEC, began by sharing how the partnership between NBEC and NCQA developed, noting that both organizations, while very different, bring equally important perspectives and expertise to the table: NCQA with quality measurement, and NBEC with the health equity perspective. Both organizations were cognizant of the potential for unequal power dynamics to occur during this partnership, and engaged in honest conversations from the start when there was a need to reconcile differences.

Dr. Perez then discussed the Birth Equity Accountability Through Measurement (BEAM) Project, the goal of which is to create, test, and implement a quality measurement approach that aligns all levels of the health care system towards birth equity. The project formed out of the lack of existing quality measures that focus on the health equity and clinical aspects of birthing care and outcomes. This project strives to create a measurement framework that supports equitable care for birthing people by addressing racist policies and practices, centers patients’ voices in measurement, and promotes joint accountability for all organizations participating in the patient’s care.

While several types of quality measures exist – accountability, quality improvement, and surveillance – the project’s measurement framework will focus primarily on measures for public reporting and accountability.

The BEAM project has three phases. The first phase will establish a birth equity quality measurement framework that promotes system alignment, as well as generate measure concepts to develop and test in Phase 2. To develop the framework, NBEC and NCQA are performing an environmental scan of existing literature as well as conducting interviews with stakeholders. Phase 2 will develop and test measures for the framework, and Phase 3 will inform national evaluation programs for quality improvement and accountability.

Dr. Whitney Graves, of NCQA, shared the status of the environmental scan and stakeholder interviews. While the systematized review of literature, gray literature search, and interviews are still in process, Dr. Graves shared preliminary results from their measurement scan which looked at both accountability and surveillance measures across the prenatal, labor and delivery, and postpartum periods. Initial results show that hospital-level measures focus only on avoiding non-recommended delivery procedures and harmful outcomes for newborns; state Medicaid and health plan measures focus only on access to one prenatal and one postpartum visit, as well as depression screening and immunizations; no mortality or morbidity outcome measures are used for accountability (only for surveillance); and no accountability measures exist that assess patient-reported outcomes or experiences, despite the existence of validated tools. Overall, there is no standard approach to measuring disparities in care or outcomes. These findings will influence the development of the measurement framework, as well as future measures that need to be developed.

A robust discussion followed the presentation. The following serves as a summary:

• One participant asked if the team could share more specific examples of the types of measures to be developed and where they will be applied.
  • NBEC shared that because the measurement framework is still in the development phase, it is difficult to know the exact measures that will result from the project. Dr. Perez noted that at the start of this collaboration, both teams had to reassess and get rid of preconceived notions about measurement in health care to fully understand how to build a framework that addresses birth equity.
• Another participant asked if providers are being included in the stakeholder interviews. Dr. Perez and Dr. Graves confirmed that they are.
• Several participants were curious about workforce issues such as lack of doulas and certified nurse-midwives, and if the project will include staffing or process measures to address these identified disparities.
  • These topics have come up and will likely be included in the final product, but it is difficult to decide sometimes how “upstream” the project should start. For example, is it out of scope to create measures that hold health systems accountable for investing in diverse medical school students?
• Another participant queried if the project would address the need for more comprehensive data collection to support stratification of measures by race, ethnicity, language, and other variables that correlate with health inequities.
  • Perez shared that the measure stratification issue would be a component of the project as it moves into the measure development phase.
• A participant asked the team to share more about their decision to focus on the accountability measures, versus measure that are more geared toward internal quality improvement.
  • Graves responded that the team chose accountability as a way to be able to compare data across health systems in a standardized way. Further, a study that NBEC conducted on patient and stakeholder feedback showed that system accountability emerged as a top five priority for those interviewed.
  • Similarly, another participant asked if the team is thinking about structural measures, such as requiring hosptials to invest in a medical school pipeline for individuals in the community they serve.
    • The NBEC/NCQA team shared that this is on their radar.
  • Last, a participant asked about the steps the two organizations took to build the trust needed to partner on such a project.
    • NBEC and NCQA shared that it took a lot of difficult conversations and a long time, over a year of conversations and missteps, to develop trust. Originally, a lot of the conversations were vague and high level, which resulted in both sides stepping away from the relationship before it could move forward. But both organizations wanted the project to happen so were able to come back to the table and have productive conversations.

The Maternal Health Hub staff shared two updates with the group:

1. The Hub released a resrouce “Using Managed Care Organization Contracts as a Lever to Address Health Equity in Maternity Care,” which describes the innovative ways states are using the Medicaid Managed Care contracting process to address health equity, including to improve equity and close gaps in outcomes for maternity care.
2. The Purchaser Business Group on Health released the Hospital Guide to Integrating the Freestanding Birth Center Model. PBGH is hosting a webinar on January 31^st, at 12pm PST to discuss the resource and how to integrate birth center care into hosptial services lines. Register here to attend: https://pbgh.zoom.us/meeting/register/tZEkfumrqTIqGNVZHYcYUYHKWhsCPQW0VJjv