11/15/22: Embedding Equity into Perinatal Health to Improve Maternal Outcomes

Thank you for participating in this month’s Maternal Health Hub Learning Community session on Embedding Health Equity in Perinatal Care featuring Rebecca Whitaker, PhD, Brianna Van Stekelenburg, and Montgomery Smith from the Duke Margolis Center for Health Policy, and Pooja Mehta, MD from Cityblock Health.

View the slides and meeting recording. 

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The Duke Margolis team presented findings from their recently released report: Embedding Equity into Perinatal Health Alternative Payment Models to Improve Maternal Health Outcomes. The report identifies episode-based perinatal bundles as a strategy states have used to improve maternal and infant health outcomes. However, these models are not designed to address the needs of the whole person or coordinate care across the care continuum, which has resulted in limited data on the effectiveness of these bundles. Duke Margolis found that to truly improve equitable perinatal care with the goal of improving maternal and neonatal health outcomes, perinatal care needs to be embedded into population health payment models.

The report outlines six key strategies to adapt existing perinatal bundles to better address health equity:

• Develop multi-payer approaches to perinatal care delivery to encourage greater provider participation by reducing burden and improving care coordination.
• Extend the length of the bundle further into the postpartum period. This is even more important as states take up the 12-month Medicaid postpartum coverage extension.
• Incorporate the infant into the bundle, which requires linking data between the birthing individual and the newborn.
• Increase access to care outside of facility-based settings including birth centers, doulas, and midwives.
• Integrate behavioral health and services to address the existence of social drivers of health into maternity care.
• Encourage the expansion of the perinatal workforce to provide access to doulas, midwives, and other community services.

Another recommended strategy put forth in the issue brief is to link perinatal care bundles with a population-based payment model. This allows for better care of the whole person, including their pregnancy, delivery, and post-partum periods, as well as their needs before and after their maternity care journey.

The Duke Margolis team acknowledged that linking episode and population health models is not an easy task. Speakers outlined four strategies to link perinatal bundles to population-based models of care, which were adapted from a Health Affairs article. The strategies are ordered by increasing financial integration – progressing along the categories allows for greater opportunities to be flexible with payment to respond to an individual’s needs.

• Contractual Requirements: A contractual clause in the provider contract that is not necessarily tied to performance, but provides additional payment to coordinate care.
• Purchased Services Model: One entity purchases or outsources services to the other. Each payment model has separate spending and outcome targets, but the primary care provider has an interest in improving health outcomes.
• Gainsharing model: Both entities take on risk for perinatal care and overall population health, and both are eligible for savings if both meet cost reduction and quality thresholds.
• Blended Accountability Model: Savings and quality improvements for perinatal episode are shared between the entity responsible for the bundle and the population-based model.

Transforming maternity care payment from traditional fee-for-service to an episode/population-health linkage model is a positive step, but there are specific infrastructure needs that are critical to success. The Duke Margolis team shared the importance of investing in data infrastructure to collect patient data and enable interoperable data sharing between payers, providers, and community-based organizations. Further, they emphasized how important it is to support 1) independent and rural provider participation in these models, and 2) investments in perinatal workforce and telehealth to increase access to care. They noted how particularly in the case of mandatory models, having these supports is crucial, since they establish a glide path to assuming risk that will allow for participation among small and rural organizations.

The Duke Margolis analysis features Cityblock Health as an example of a primary care provider that is intentionally integrating perinatal health into a population-based model. Pooja Mehta, MD, Head of Women’s Health, Cityblock Health, provided an overview of the organization and its work regarding perinatal care. The following serves as a summary:

• Cityblock Health – based in Charlotte, North Carolina – is a primary care model backed by technology that works in an entirely value-based context. The company takes on population-level risk with Medicaid and public payers to provide care for their beneficiaries. The company is not specifically geared towards perinatal care, but because they take on full risk for patients, perinatal health strategies are a necessary investment to care for those members that do become pregnant.
• Cityblock Health takes care of the individual before, during, and after pregnancy, regardless of how the pregnancy ends. Cityblock Health has several levers in place to address perinatal care:
• Using claims data to determine early pregnancy and unmet reproductive needs: Community Health Workers (employed by Cityblock and trained as doulas) perform outreach to patients identified by the claims data as in need of services.
• Providing access to a community based interdisciplinary team lead by a midwife: The team also includes a behavioral health specialist and a skilled perinatal RN.
• Using their own care management platform to coordinate care for members and to allow members and staff on their care team to interact
• Creating and executing on a hospital-based quality improvement strategy: This includes educating obstetric and postpartum care providers in the community about Cityblock Health’s services.

The last fifteen minutes of the meeting were reserved for discussion. The following serves a summary for the questions asked by participants:

• A participant asked Dr. Mehta to share two components of Cityblock’s model that are key for organization’s looking to replicate.
  • Mehta shared three important things Cityblock Health learned from interviews with community members. First, beneficiaries want access to behavioral health services. Second, it is important to offer inpatient perinatal doula support from the outset, even if the doula is not used. Third, beneficiaries want access to an interdisciplinary community-based team that is responsive to their needs.
• One participant noted that while the concept of nesting a maternity bundle within a population health model is important, there are current episode models that are experiencing success at engaging with specialists, and are truly providing a holistic care approach. They emphasized that the concept of stand-alone bundles should not be left out of the conversation.
• One participant asked how Cityblock Health provides the needed postpartum services (for either birthing person or infant) in the event that a pregnancy does not culminate in a live birth.
  • Mehta shared that this event has not occurred at Cityblock, but it is something their team has thought about. Cityblock Health tries to be a presence in an individual’s life that is not just tied to risk attribution.