Update on the Bree Collaborative’s maternity bundled payment model

Childbirth is the most expensive cost for hospitals, Medicaid agencies, and most commercial health plans. In the United States, over 50,000 mothers have life-threatening complications due to childbirth annually, and the US has the highest maternal mortality rate among developed countries. There are also far-reaching disparities when it comes to maternal health, with black mothers 3-4 times more likely than white mothers to die in childbirth. 

These stats point to many areas for improvement in maternal care in the country. 


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The Dr. Robert Bree Collaborative — a group of stakeholders that work to identify evidence-based strategies to improve quality, costs, and outcomes of care — has focused on improving maternal care in Washington State for several years.

In 2012, the Bree Collaborative created a list of recommendations focused on eliminating early elective deliveries, decreasing elective early induction of labor, and decreasing the variation in C-section rates in Washington hospitals — all of which are associated with adverse health outcomes for mothers and babies, according to the report. 

Then, last summer the Bree Collaborative took a next step further in obstetrics and worked to create a bundled payment model for maternity care.

By definition, a bundled payment would give providers a fixed payment for all of the care involved in the pre-natal, labor and delivery, and postpartum care. The goal of the bundled payment is to incentivize coordination and collaboration among providers, which the Bree Collaborative hopes will then improve efficiency, lower costs, and improve outcomes.

“When we talk about our bundle, we are sort of assigning the obstetrician, or midwife, or family practice doctor — whoever is delivering the baby — as the accountable entity,” says Ginny Weir, MPH, Director of the Bree Collaborative. “This means they are the recipient of the bundle and are responsible for organizing how other entities get paid. I think that care coordination piece is really key as to why bundled payments work.”

Services covered through the draft bundled payment model include: prenatal screenings for cardiovascular disease and behavioral health, vaccinations, education, labor and delivery facility and professional services, two postpartum visits, patient supports, among others.

“We have very specific language for screening for cardiovascular disease and behavioral health conditions including depression and opioid use disorder. And then there is also language about the referral processes to support these gestational parents if they do screen positive for something like depression or for something like cardiovascular disease.

Those changes will be really helpful in creating a more standardized process across the state for identifying and then supporting women that screen positive,” said Weir.  

The Bree Collaborative has previously developed bundled payment models for surgeries like knee and hip replacements, lumbar fusion, and coronary artery bypass surgery. The maternity bundled payment would differ in that it would cover an extensive period of time and care. The draft payment model specifies that the fixed payment would include prenatal care (270 days prior to delivery), labor and delivery, and postpartum care (84 days post-delivery).   

“Bundles have been used mostly for procedural care, for surgical care,” says Weir. “But we have seen from other partners around the country, a desire to thread bundled payments from this more limited focus on surgical care, to other ways of delivering care too.”

Potential challenges that come with a bundled payment model include the administrative tasks that are created for providers, and apprehension from rural providers who are concerned about being adequately reimbursed.

The maternal bundled payment model will be presented at the next Bree Collaborative meeting in November, after which time there will be a four-week public comment period. Through this feedback, the Collaborative will make adjustments and address concerns. The model will then be sent to the Health Care Authority, which acts as the Collaborative’s main implementation pathway.

Weir also says they hope to attract employer groups that are purchasing health care for their employees.   

“There’s a benefit in the commercial population as well,” says Weir. “I think that if we create this sort of change in all these different areas, and health plans, and purchasers, and delivery-systems, we could really create a different and more comprehensive birth experience for people.”