Optimizing Alternative Payment Models Could Advance Equity and Improve Outcomes in Pregnancy

LDI Fellows Identify a Population Approach to Align Payments with High-Quality Care

December 18, 2023

By:

Kaday Kamara, MPH

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The push is on to create a new payment system for U.S. health care. For years, administrators and policymakers have tried to move from fee-for-service–paying for each aspect of care–toward alternative payment models (APMs), which set a budget for an episode of treatment or a group of patients while offering incentives to improve quality.

The federal government expects to use APMs for all Medicare and most Medicaid payments by 2030. But uptake has been slow, especially in pregnancy care. While Medicaid covers more than 40% of pregnancy services, few state programs now require APMs for pregnancy care.

In a new JAMA Viewpoint, LDI Senior Fellow Sindhu Srinivas and Associate Fellows Jordan Stone and Arina Chesnokova, assert that APMs represent a promising opportunity to improve maternal health outcomes and reduce racial disparities. The authors review the current state of pregnancy-focused APMs in such states as Arkansas and Tennessee, and offer recommendations to guide the development of these models.

Recommendations

Planning for the cost of care for the full reproductive population, instead of a single pregnancy episode. This would help to incentivize the use of critical services, such as chronic disease management, contraceptive use, and mental health care, with potential to reduce maternal morbidity and mortality.
Expanding quality metrics beyond episodic process measures, such as timing of prenatal care initiation. Instead, payment should incentivize high-value care from pre-pregnancy through the extended postpartum period, an example would be the rate of success in establishing primary care follow-up for patients with pregnancy-related conditions that influence subsequent health outcomes.
Testing both core and novel measures across state Medicaid programs and adapting them over time.
Advancing equity through budgets and payment mechanisms designed to support, rather than penalize, organizations that disproportionately serve Medicaid patients.

Following this publication, the Centers for Medicare & Medicaid Services announced the new Transforming Maternal Health Model that promises to improve outcomes, reduce costs, and enable state implementation of value-based care. The details of the model and of the state application process are forthcoming in the Spring of 2024.

The article, “Alternative Payment Models in Pregnancy to Improve Outcomes and Advance Equity,” was published on November 20, 2023 in JAMA. Authors include Jordan S. Stone, Arina E. Chesnokova, and Sindhu K. Srinivas.