Four years ago, the American College of Obstetricians and Gynecologists and the Society for Maternal-Fetal Medicine released a joint consensus statement on maternal level-of-care designations (MLOCD).
The goal of the designations was to standardize levels of maternal care as a means of improving maternal and infant outcomes. The consensus statement defined five designations, ranging from Birth Center, which generally means a midwife overseeing birth, with transport available to Level IV, which involves comprehensive care at a regional perinatal healthcare center.
Since then, several states, including Indiana, Arizona and Maryland, have adopted maternal care designations, and last year Georgia passed legislation designating perinatal levels of care. While there are significant differences in designation by state, they all rely on a tiered framework ranging from basic to comprehensive care.
Given that the state-level move toward maternal leveling is growing, how can an organization best prepare for the change? Here are four ways:
1. Up your designation game before you’re required to: If appropriate, prepare to become a Level III or IV provider. It is likely that, given greater media focus on maternal outcomes and more consumerism in healthcare generally, expectant families will carefully consider a hospital’s designation.
Under the ACOG/SMFM consensus document, Level III and IV designations require an OB/GYN to be onsite at all times and also require an MFM, anesthesiologist, specialty and critical care physicians to be available at all times. These requirements are most likely to be viewed positively by savvy healthcare consumers.
There are several models for 24/7 obstetrical coverage, but most hospitals realize the greatest benefit from a management model, in which hospitals contract with outside companies to recruit and manage OB/GYN hospitalists who provide a wide array of services, implement the program, and oversee its operation.
For example, under an Obstetrical Emergency Department model, all OB patients presenting with an emergency condition are seen by a physician or midwife alongside the obstetrical nurse. Hospitalist clinicians act as emergency first responders for all patients in labor and delivery to improve outcomes in an emergent situation. That model is 100% compliant with the maternal leveling recommendations.
2. Ascertain the percent of payer volume attributable to Medicaid births and accelerate accordingly. One of the key requirements of the Texas maternal leveling designations is that after Sept. 1, 2020, a hospital without a designation will no longer be eligible for Medicaid reimbursement for OB care. And while reimbursement for Medicaid births is traditionally lower than that of private payers, half of U.S. states report that at least half of their state's births are financed by Medicaid. If maternal leveling is adopted in states that impose similar requirements, many organizations that fail to work strategically toward a rapid designation may be at financial risk.
Bonus: while some hospitals are challenged by finding an OB to deliver unassigned or Medicaid patients’ babies, some OB hospitalist companies (like OBHG) care for all patients regardless of payer status.
3. Collaborate not just within a system but within a region. The only thing predictable about labor and delivery is that it is unpredictable. A 2013 study in the Journal of Midwifery & Women’s Health found that about 16% of births planned at birth centers ended up in a hospital. Of that group, 4.5% were referred to a hospital before being admitted to the birth center and 11.9% transferred to the hospital during labor. To optimize patient care, organizations should begin a dialogue with their community partners. When a patient’s circumstances change mid-delivery or even midpregnancy, hospitals that have transfer arrangements in place may be able to better work through reimbursement issues.
4. Share data for future improvements. Taken alone, MLOCDs are not a silver bullet. A 2016 study published in the journal Obstetrics & Gynecology found no association between MLOCD and improvement in maternal morbidity. However, researchers noted that “level 4 hospitals have a higher proportion of patients with pre-existing comorbidities, and even multivariable adjustment may not account for potentially important confounding. Prospective designation of hospital level and evaluation with patient outcomes is necessary to truly determine the impact of MLOCD and regionalization on maternal outcomes.”
Several state health departments have instituted adoption of the Alliance for Innovation on Maternal Health protocols by OB hospital labor and delivery units to supplement the maternal leveling designation. The AIM is a national data-driven maternal safety and quality improvement initiative based on proven implementation approaches to improving maternal safety and outcomes whose end goal is to eliminate preventable maternal mortality and severe morbidity across the United States.
Policymakers, health regulators and hospital administrators will benefit from pooled evidence-based outcomes data to better determine the impact of MLOCD and make necessary adjustments to enhance patient care. When viewed strategically and approached proactively, MLOCD have the potential to benefit both patient care and organizational bottom lines.