Bundles of joy are the focus of one of the latest efforts to implement bundled payments.

Seeking to spur widespread adoption of alternative payment models, or APMs, the federally affiliated Health Care Payment Learning and Action Network has set its sights on the high-volume admissions related to maternity and newborn care. Combined maternal and newborn stays represent more than 20 percent of all hospital stays, according to the Agency for Healthcare Research and Quality. 

HCPLAN is a collaborative network of public and private stakeholders working to advance the federal government’s goal that 50 percent of all health care payments will be through alternative payment models by 2018. The network’s clinical episode payment work group has identified maternity care — along with elective joint replacement and coronary artery disease — as a top priority for episode-based payments.

Work group members see plenty of opportunities for improvement in maternity and newborn care. The U.S. cesarean section rate is high — more than 30 percent of births, according to the World Health Organization — despite the expense and potential danger to mom and baby. More than 9 percent of births are pre-term, including many early elective deliveries, which increases the need for neonatal intensive care. The nation’s infant and mortality rates are high, and racial/ethnic disparities for infant outcomes are disturbing.

Geisinger Health Plan has used the bundled-payment approach for maternity care at Geisinger Health System for six years — and with good results, says John B. Bulger, D.O., Geisinger’s chief medical officer for population health. Early elective deliveries almost immediately dropped to zero when the obstetrics department started to focus on processes of care. That resulted in fewer C-sections and reduced NICU use.“It is a win-win-win because the baby is healthier, happier, the mother is healthier and happier, and the population is healthier and happier because it is less costly to the system,” he says.

Geisinger’s perinatal care bundle, available only for low-risk pregnancies, includes all prenatal, labor and delivery, and postpartum care for the mother only; the baby’s care is not covered in the bundle.

Despite Geisinger’s success, its particular approach has not been widely adopted. A handful of payers and health systems are experimenting with maternity care bundles, but most are waiting for somebody else to figure out best practices. The first challenge is the sheer length of the episode.

“We feel pretty strongly that an episode should include prenatal, postpartum and — ideally — 30 days of newborn care,” says Brynn Rubinstein, senior manager for Transform Maternity Care at the Pacific Business Group on Health. “It’s really hard to navigate all of the providers that a woman and baby might see, and all of the other conditions related to pregnancy, or unrelated to pregnancy, and how to include those in the episode.”

Rubinstein, who is working with plans and purchasers to implement the recommendations outlined in HCPLAN’s white paper on maternity care episode payments, says purchasers are tired of the variation in cost and quality of maternity and newborn care.

“While there are many obstacles to navigate, they are all challenges that can be overcome,” she says. “It may take a few years, but they can absolutely be overcome, and we need to start today.”