Transforming maternal health: A strategic roadmap for states

Nationwide, States are working to improve maternal health care for women enrolled in Medicaid by taking a whole-person approach to pregnancy, childbirth and postpartum care. This effort aims to enhance outcomes while reducing overall program costs.

At a recent Medicaid Enterprise Systems Community (MESC) Conference, Optum leaders Suman Challagulla, managing director, Consulting; James Lukenbill, analytics strategic product manager; and Tim Prinz, director, Strategic Growth, shared a roadmap for states regardless of where they are in their maternal health transformation journey.

The speakers provided insights into value-based payment arrangements, analytics for maternal health and strategic consulting. Further, they demonstrated real-life application by discussing a current Washington, D.C. case study.

In the United States, Medicaid covers more than 40% of births. In rural communities, this number rises to nearly 50%.¹ Increasingly, states are moving toward 3 value-based care models — episode of care, maternity medical homes and pay for performance — to improve outcomes and cost.

This model is based on a bundled payment for prenatal and postpartum care.

When designing an episode of care model, consider the following:

• Services: What services will/will not be included in the model?
• Attribution: What methodology will be used to attribute beneficiaries to participating providers?
• Risk: Will you use a custom risk adjustment approach or a risk adjustment grouper?
• Quality: What are the State's goals and priorities, and what quality measures will you focus on?
• Data: What do you want to report to participating providers and with what frequency?

To determine if a provider is eligible for shared savings:

1. Identify a benchmark.
2. Calculate episode of care cost.
3. Examine quality outcomes.
4. Examine performance outcomes.
5. Compare provider performance and quality to benchmark.

This is a team-based, patient-centered care model that addresses medical, behavioral and social needs with a multidisciplinary team. Typically, a non-profit organization coordinates care between the individual and the team of providers.

In this model, incentives are tied to specific cost and quality benchmarks. 

• States typically calculate cost and quality benchmarks and expect providers to achieve those benchmarks over time.
• As long as they show a certain level of progress, providers are eligible to participate in the incentive for bonus payments.

Each model presents a unique set of benefits and challenges:

Episode of care

Benefits

• Well-defined episodes
• Dyadic care
• Right‑sized care
• Alignment with payers

Challenges

• Complex analytics
• Risk of “shorting” care

Maternity medical homes

Benefits

• Multidisciplinary teams
• High‑touch care
• Different ways to build in payment incentives

Challenges

• Implementation burden
• Unclear certification requirements

Pay for performance

Benefits

• Operationally easier to implement
• Flexible in design
• Targeted to specific goals

Challenges

• Performance plateaus
• Limited outcome impact

Effectiveness in improving patient care through these models shows mixed results. However, overall efforts have shown some degree of improved health outcomes:²

Maternity medical homes results

North Carolina

• Lower preterm births
• Reduction in low birth rate pregnancies
• Stronger impact for Black patients

Texas

• $824,000 savings*
• 54% reduction in emergency room visits
• 31% reduction in inpatient days

Wisconsin

• Increase in postpartum care to 85.5%
• Mixed birth outcomes
• Increase in behavioral health access

Episode of care results

Arkansas

• Increased chlamydia screening
• Lower emergency department visits
• Reduced HIV screenings
• Decreased C-sections
• $396 savings per episode

Ohio

• Realized cost savings
• Increased GBS screenings
• No change in C-sections

Tennessee

• $632 savings per episode
• Increased HIV and GBS screenings
• Decreased C-sections

Pay for performance results

Reviews of various programs have revealed mixed results. Pay for performance programs may improve process measures but not health outcomes (prenatal visit timeliness, etc.).

It is critical to understand what services are included and excluded in the designs of the models. This provides guidance to providers on incentives and makes clear the state’s objectives. The examples below illustrate the varying services included in State models, based on their respective priorities.^2,4,6,13

Connecticut

• Included: All provider services (hospital, labs, pharmacy), birth education, care coordination
• Excluded: Behavioral health, DME (blood pressure monitors, breast pumps), NICU, nutrition, oral health, pediatrics, respiratory care

New Jersey

• Included: All provider services (hospital, labs, pharmacy)
• Excluded: Contraception, dental, doula, lactation, neonate costs

Pennsylvania

• Included: Prenatal, delivery and postpartum (60 days), infant care
• Excluded: Contraceptive care (LARC placement)

Payment structures and quality measures also differ across states. While there is commonality with some quality measures (e.g., C-section, screenings), states select measures based on their priorities as shown below.^6,17,18,19

Colorado

• Payment structure: Year 1: Upside only; Later: Downside risk
• Quality measures: C-section, elective delivery, prenatal risk, postpartum depression screening

Connecticut

• Payment structure: Year 1: Upside only; Year 4: Full risk sharing
• Quality measures: Adverse events, doula use, behavioral health risk, breastfeeding, C-section (NTSV), low birth weight, prenatal/postpartum care, preterm birth/labor, contraception

New Jersey

• Payment structure: Year 1: Shared savings; Future: Downside risk plus bonuses
• Quality measures: Delivery mode, gestational diabetes, prenatal depression, postpartum/neonatal visit costs

Pennsylvania

• Payment structure: Up/downside risk; equity stratification
• Quality measures: Depression screening, IET, immunization status, prenatal/postpartum care, SDOH screening, well-child visits

Suman Challagulla explains that with payment structures, “We want to incentivize providers to participate in the model, so we don’t include risk right away. We want providers to feel comfortable and participate in the shared savings and then eventually introduce risk.” 

CMS is focusing on challenges to maternal and infant health outcomes with its Transforming Maternal Health (TMaH) model. “It allows States to participate while also fine-tuning the model based on their goals,” says Challagulla. 

Fragmented care

Response: Whole-person care delivery across prenatal to postpartum; encourages workforce expansion

Limited behavioral health and SDOH access

Response: Emphasizes behavioral health and community partnerships

Racial and geographic disparities

Response: Requires equity strategies and data stratification

Inconsistent metrics and incentives

Response: Aligns with CMS pillars and supports value-based payment models

Operational uncertainty

Response: Offers flexible, adaptable framework with consulting support

Data-driven decisions support value-based payment models. “There are many types of analytics states can use to apply a whole-person approach to serving the population,” says James Lukenbill. The following overview highlights key analytics that drive smarter, more coordinated strategies.

• Integrated data: Historical care management, claims and utilization data for the full population to identify those with specific needs and wants, leading to person-level connection of clinical and nonclinical data
• Descriptive analytics: Population health, social determinants, behavioral, consumer, eligibility, care management and claims help create reports to identify opportunity areas for intervention
• Diagnostic analytics: Consumer analytics models to identify common traits and propensities at geographic, provider and member levels
• Predictive analytics: Statistical and predictive models that identify the high-risk, high-want patients based on their propensities and characteristics
• Prescriptive analytics: Identify, recommend and implement care management outreach campaigns to the identified patients

Data from these resources can be leveraged in a state’s value-based payment model. Together, this information makes up the Medicaid maternity toolkit:

1. SDOH information to improve patient care

• Social determinants of health (SDOH) information from eligibility system
• Z-code analysis from claims data
• Consumer data-driven models (social vulnerability index, etc.)

2. Clinical data to identify a need (before claims exist), allowing for early action

• Admission, discharge, transfers from Health Information Exchange

3. Grouper-driven analysis to understand where the opportunities lie

• HEDIS measures
• Episode and risk groupers

When we look more closely at groupers, they provide valuable analytic tools for maternity analysis. These are specific groupers and how they apply to maternal health:

Patient Centered Episodes of Care System (PACES) — Episode grouper for clinical measurement, episode-based performance tracking

PROMETHEUS — Episode grouper for value-based maternity care, complication tracking, potentially avoidable care, bundled payment

Episode Treatment Groups (ETG) — Episode grouper for utilization benchmarking, provider profiling, network analysis

Medicaid Episode Grouper System (MEGS) — Episode grouper for maternity care analysis, episode-based payment modeling

Chronic Illness and Disability Payment System (CDPS) — Risk adjustment grouper for Medicaid risk modeling, cost predictor

3M Clinical Risk Groups (CRGs) — Risk stratification grouper for Medicaid risk stratification, chronic condition management, maternal risk profiling

AHRQ Clinical Classifications Software (CCS) — Diagnostic classification grouper for research, utilization benchmarking, high-level cost and diagnosis trend analysis

“If you’re considering a grouper specifically for maternity care, PACES and Prometheus would be top contenders,” says Lukenbill.

What’s the best path forward for your state? Strategic consulting can help you decide. Effective consulting aims to understand a state’s unique situation and provide guidance on decisions related to improving maternal health in the state. 

“At Optum, strategic consulting begins and ends with data and analytics to make informed decisions,” says Tim Prinz. “We use data to identify key problem areas and opportunities in your business processes and operations and to inform best options, solutions and starting points.”

Strategic consulting provides the needed support to achieve success with maternal health outcomes. It involves:

Strategic project management

• Utilize end-to-end project management, prioritizing program design, seamless implementation and milestone achievement to support the advancement of model goals.

Analytics-driven recommendations

• Identify next best actions and key recommendations, leveraged from analytic results.

Partner collaboration

• Support stakeholder engagement and build partnerships to improve outcomes and meet maternal health goals.
• Build relationships with alternative providers (doulas, etc.) to enhance the maternal health workforce.

APM development

• Design and implement alternative payment models through expert advice, process optimization and performance measurement to align payment with outcomes.
• Design and implement performance monitoring tools and dashboards to provide real-time insight into progress and outcomes.

Quality measurement and reporting

• Leverage expertise and experience to identify key performance indicators and key outcomes measures to advance maternal health outcomes.

HRSN screening support

• Improve the ease of data collection and centralize referrals to better serve both patients and providers and improve maternal health outcomes.

When addressing maternal health, states face funding challenges, and Medicaid cuts create an uncertain future. “We understand how important funding is, so the emphasis is on how we can be innovative together to find new ways to fund these initiatives,” says Prinz.

Maternal mortality is an issue in Washington, D.C.

• Maternal mortality in Washington, D.C. is 35% higher than the national average.²⁰
• Black pregnant women make up half of all births in Washington, D.C. but account for 90% of all pregnancy-related deaths.²⁰

Several years ago, Optum was asked to help address this situation. Strategic consulting analytics further revealed important contributors to birth outcomes in the district:²¹

• About 1,270 pregnant women in Washington, D.C. seek housing services annually.
• Homeless pregnant women are predicted to have a higher probability of developing hypertension.
• 18.5% of pregnant women received inadequate prenatal care, compared to the national average of 14.8%.
• Women with chronic health conditions are 69% more likely to experience preterm birth.
• 70% of pregnancy-related deaths occur within Wards 7 and 8.

Building on the data, Optum moved from problem-solving ideation to go-forward solution areas using the steps outlined below. 

Discovery

Optum conducted over 20 stakeholder interviews, core CHC CEO convening and OAS analysis and research.

We identified 4 key needs specific to maternal health disparities:

• Timely entry into prenatal care
• Improved experience at points of care (bias)
• Housing and shelter support
• Increasing education and awareness of nontraditional care resources

Narrowing focus

We narrowed the focus to homelessness and perinatal care.

This decision was driven by:

• Stakeholder guidance
• Existing efforts in D.C.
• External research
• Unique Optum and UHG assets

Current focus

We developed go-forward solution areas.

These stakeholder validated solution areas, designed and implemented collaboratively, focus on:

• Housing and perinatal navigators
• Tactical job aids and tools for housing
• Housing and health data exchange

A community equity collaboration was formed that included the Optum Center for Health Equity and stakeholders in the Washington, D.C. area to create a perinatal housing navigator program called Housing Our Newborns, Empowering You (HONEY). The program focuses on addressing perinatal and housing challenges and has received a $2 million grant from HRSA and $3.75 million awarded from the Day One Fund.

“The program has been up and running for about 18 months now,” says Prinz. “In that time, we’ve helped more than 800 women and have had notable success in outcomes.”

This proof of concept has generated millions of dollars in additional funding.