Author: John T. Sullivan, M.D., M.B.A.
ASA Monitor 03 2017, Vol.81, 36-37.
John T. Sullivan, M.D., M.B.A., is Associate Chief Medical Officer, Northwestern Memorial Hospital, and Professor of Anesthesiology, Northwestern Feinberg School of Medicine, Chicago.
The future health care landscape certainly portends pressures from patients, payers and society to focus on the value of our care delivery; a focus on quality alone may not be sufficient as cost forms half of the value equation. The impact of value-based care policies on obstetric anesthesia care is unknown, but it will be imperative for our subspecialty to be proactive in deliberations.
Value-based care is defined as care quality divided by cost. Fee-for-service health care reimbursement has been criticized because care value is degraded by incentives to deliver higher volume of care with less emphasis on improving outcomes or containing costs, particularly in procedural-based specialties such as our own. Alternative payment structures are being investigated with regard to their impact on care quality and cost. Among these are bundled care models.
Obstetric care is a natural target for bundled care payment. Reimbursement under this model would provide a single payment for delivery services (or all pregnancy care) independent of mode of delivery (e.g., vaginal delivery versus cesarean) with modifications for achieving defined quality measures. For obstetric care, this would have the theoretical benefit of improving quality and limiting cost by reducing incentives for pursuing interventions that may not improve outcomes (e.g., some cesarean deliveries) but currently pay more under fee-for-service models. Bundled care would force a greater degree of collaboration between providers who would also have to equitably divide reimbursement. Obstetric care is particularly well-suited for applications of this payment model because it is a defined episode of care (delivery admission or duration of pregnancy), is high volume (most common reason for hospital admission in the United States), is relatively expensive and comprises a predictable array of services.1
There are several important questions relevant to obstetric anesthesia care delivery and value. First, how is quality defined in our sphere of care? Second, how does our existing cost structure appear in the lens of value-based care? Third, how would our discipline fare with models of alternative reimbursement such as bundled payments?
Quality has not been precisely defined within obstetric anesthesia. In fact, leaders in our community have been divided on endorsement of some proposed quality measures (e.g., incidence of unintended dural puncture, general anesthesia rate for cesarean delivery, patient satisfaction), enough so that I thought it made an ideal debate topic for last year’s SOAP Annual Meeting. Quality outcomes should be meaningful, valid and feasible to measure, and their implementation should have limited unintended consequences.2 For example, if general anesthesia rate for cesarean delivery is deemed a negative quality measure, would that unsafely disincentivize conversion to general anesthesia when it becomes necessary? Pain scores, a quality measure used widely in many anesthetic domains, has limitations when natural childbirth is desired.
Cost is somewhat easier to measure in obstetric anesthesia as compared with quality. Equipment and medications used are relatively cheap; however, our expertise is expensive when accounted for by time. In a fee-for-service model, we are generally reimbursed base units for labor analgesia plus a time modifier that may or may not be subject to a cap. Innovations for delivering labor epidural analgesia, including programmed intermittent epidural bolus (PIEB) and patient-controlled epidural analgesia (PCEA), certainly add value to our services by improving analgesia quality and reducing our resource-intensive interventions. But fewer face-to-face interactions may impact overall care quality, patient satisfaction and reimbursement under some traditional payment structures.
Speculating on the impact of alternative payment models on our practice is challenging due to the large number of variables and uncertainty over the direction of policy and legislation. Anesthetic care, although expensive, is not necessarily the obvious target for value improvement within obstetrics. Much of our care is mandatory (cesarean deliveries) or highly requested (neuraxial labor analgesia), and from an economist’s perspective, it represents a small fraction of the total cost for admissions for delivery (4.8 percent for vaginal delivery and 3.9 percent for cesarean delivery).3 The primary target for value improvement is reduction of unnecessary cesarean deliveries with higher associated morbidity and approximately 50 percent higher cost.1 Obstetric anesthesia complications rates are relatively low compared with obstetric complications.
Perhaps the best strategic approach as a specialty would be to ensure we are well represented in health care policy discussions and to articulate the value that our practice adds beyond the delivery of labor analgesia and anesthesia for surgical procedures. Providing labor analgesia is one of the most rewarding professional endeavors that we engage in, but our most valuable contributions to obstetric care may be to address the concerningly high levels of maternal morbidity and mortality in the United States related to hemorrhage, hypertensive disorders, sepsis, comorbidities and other causes. Obstetric anesthesiologists have unique skills as peripartum consultants that can be employed to reduce obstetric mortality and serious morbidity.
Lally S Transforming maternity care: a bundled payment approach. Integrated Healthcare Association website. http://www.iha.org/sites/default/files/resources/issue-brief-maternity-bundled-payment-2013.pdf. Published September 2013. Last accessed January 13, 2017.
Desirable attributes of a quality measure. Agency for Healthcare Research and Quality website. https://www.qualitymeasures.ahrq.gov/help-and-about/quality-measure-tutorials/desirable-attributes-of-a-quality-measure. Updated July 15, 2016. Last accessed January 16, 2017.
Truven Health Analytics™. The cost of having a baby in the United States. http://transform.childbirthconnection.org/wp-content/uploads/2013/01/Cost-of-Having-a-Baby1.pdf. Published January 2013. Last accessed January 16, 2017.