Table 1
APM types and definitions.
| APM TYPE | DEFINITION |
|---|---|
| Pay-for-performance | In pay-for-performance, a bonus/malus is paid for attaining certain quality thresholds on top of the base FFS payment. Under FFS, providers are paid a fee for each service delivered [4]. The additional payments can be employed for improving coordination, care efficiency, quality of care or accessibility of care [19]. |
| Shared savings | In a shared savings model, individual providers are each paid on a FFS basis which is combined with a reconciliation between the target episode price and the actual average episode price after a period of time across all the episodes attributed to a provider. Based on a specific formula, which is either negotiated or established by the payer, the accountable provider can share in gains and/or losses with the payer. Shared savings models that only share in gains are called one-sided. In two-sided models also incurred losses are shared. |
| Bundled payments | Bundled payments are defined for a specific set of activities tied to an episode of care, such as maternity care, that includes more than one provider or organization. The entity receiving the bundled payment earns a higher margin if a patient has utilized less care, but also bears the financial risk of complications. In our definition, the main difference with shared savings is that savings or losses are not shared with the payer. There are two types of bundled payments, retrospective and prospective. In retrospective bundled payments, there is a virtual budget negotiated upfront, providers are paid by FFS and retrospectively, the target price is reconciled [20]. In a prospective bundled payment model a prospectively defined prize is paid as one payment to the accountable entity that in turn pays the individual providers [14]. |
| Global payments | In global payments the entire population and the entire continuum of care is included. The accountable provider is paid a fixed fee per head of the population. |
[i] APM: Alternative Payment Model; FFS: fee-for-service.
Figure 1
Study selection flow diagram according to Preferred Reporting Items for Systematic Review and Meta-Analysis (PRISMA).
Table 2
Key design elements of implemented alternative payment models in maternity care (more detailed information in Appendix S2).
| NO | INITIATIVE (ABBREVIATION) | GENERAL CHARACTERISTICS | TYPE OF APM | INCLUDED POPULATION | INCLUDED CARE SERVICES | RISK MITIGATION STRATEGIES | REFERENCES | ||||
|---|---|---|---|---|---|---|---|---|---|---|---|
| COUNTRY | YEAR OF IMPLEMENTATION | STATUS | POPULATION | SERVICES | TOTAL EXPENDITURES | ||||||
| 1 | Commissioning for Quality and Innovation, Payment Framework (CQUIN) | UK | 2007 | Permanent implementation | Pay for performance | Pregnancies ending in elective or emergency caesarean section | All perinatal hospital care | - | - | - | [23] |
| 2 | Texas Medicaid Program (Texas) | US (Texas, and later on also Georgia, Michigan, New Mexico, New York and South Carolina) | 2011 | Developed into initiative no. 3 | Pay for performance | Penalty for neonatal delivery before 37 weeks gestation that was not medically necessary | n.a. | - | - | - | [2425] |
| 3 | Horizon Blue Cross Blue Shield of New Jersey, Pregnancy Episodes of care program (Horizon) | US (New Jersey) | 2013 | Permanent implementation | Shared savings (one-sided). | Low-risk pregnancies (2013-present) and high-risk pregnancies (2015-present) | All prenatal outpatient care, all delivery-related care | Exclusion of pregnancies with comorbidities such as HIV and cancer. | Exclusion of neonatal care. | - | [25] |
| 4 | Baby+ Company | US (North Carolina, Tennessee, Colorado, Arkansas) | 2013 | Permanent implementation | Shared savings (one-sided). | Low-risk pregnancies | Care for mother and newborn | Exclusions of high-risk pregnancies | Exclusion of lab testing and ultrasounds | - | [17] |
| 5 | TennCare | US (Tennessee) | 2013 | Permanent implementation | Shared savings (two-sided) | Low- to medium-risk pregnancies with live births | Care for mother and newborn. | Exclusion based on clinical and cost-based criteria. | Exclusion of preconception care and neonatal care. | Total averages for benchmark for shared savings/losses are risk-adjusted | [262728293031] |
| 6 | Arkansas Health Care Payment Improvement Initiative (Arkansas) | US (Arkansas) | 2013 | Permanent implementation | Shared savings (two-sided). | Low- to medium-risk pregnancies with live births | Care for mother and newborn | Exclusion based on clinical and cost-based criteria. | Exclusion of neonatal and preconception care. | Total averages for benchmark for shared savings/losses are risk-adjusted. | [17273233343536] |
| 7 | Ohio Episode-Based Payment Model (Ohio) | US (Ohio) | 2015 | Permanent implementation | Shared savings (two-sided). | Low- to medium-risk pregnancies with live births | Care for mother only | Exclusion based on clinical and cost-based criteria. | Exclusion of prenatal medications, neonatal care and preconception care. | Risk adjustment for the calculation of the shared savings /losses. | [17273037] |
| 8 | Community Health Choice, Bundled Payment Pilot (CHC) | US (Texas) | 2015 | Pilot | Shared savings (two-sided) | All pregnancies | Care for mother and newborn | Individual stop loss provision. | Exclusion of level 4 neonatal intensive care. | Risk adjustment | [173839] |
| 9 | New York State’s Medicaid Maternity Care Value Based Payment Arrangement (New York) | US (New York state) | 2016 | Pilot | Shared savings (two-sided) | All pregnancies | Care for mother and newborn | Exclusion of mothers aged <12 or > 64 at the time of the delivery, maternal death, stillborn and multiple live births, HIV/aids or intellectually or developmentally disabled. | - | Risk adjustment | [404142] |
| 10 | Pacific Business Group on Health, Blended Case Rate (Pacific) | US (Southern California) | 2014 | Pilot | Bundled payment (only delivery phase) | All hospital deliveries | All care activities during labor and delivery for both vaginal and caesarean section births. | Exclusion of pregnancies that left against medical advice, transferred during labor, various comorbidities (e.g. HIV/aids, cancer, also gestational age <37 weeks, multi gestation 3+). No prospective risk adjustment. | - | - | [1733434445] |
| 11 | Minnesota Blended Payment (Minnesota BP) | US (Minnesota) | 2009 | Permanent implementation | Bundled payment (only delivery phase) | Uncomplicated births | Professional services and facility fees for vaginal or caesarean delivery and prenatal and postnatal care | Exclusion of complicated vaginal deliveries | - | - | [4647] |
| 12 | Minnesota Birth Centers, BirthBundle (BirthBundle) | US (Minnesota) | 2015 | Pilot stopped | Bundled payment (retrospective). | All pregnancies | Care for mother and newborn | - | - | - | [1748] |
| 13 | Bundled Payment for maternity care (The Dutch BP) | The Netherlands | 2017 | Pilot | Bundled payment (prospective) | All pregnancies | Bundle defined in four phases (prenatal, natal, postnatal and postnatal home assistance), covering all necessary care - according to the national care standardization guidelines | Risk stratification for bundled tariff. | - | Depending on the contract, risk corridors on where new negotiations are started - are negotiated. | [49505152] |
| 14 | Maternity Pathway Bundled Payment (Maternity Pathway BP) | England | 2013 | Permanent implementation | Bundled payment (prospective) | All pregnancies | All maternal and neonatal care in the prenatal, perinatal and postpartum phase | Risk stratification for bundle tariff. | Exclusion of health problems in neonates | - | [53] |
| 15 | Providence Health and Services, Pregnancy Care Package (Providence) | US (Oregon) | 2013 | Permanent implementation | Bundled payment (prospective) | Low-risk pregnancies | Care for mother and newborn | - | - | - | [17] |
| 16 | Geisinger Health System, Perinatal ProvenCare Initiative (GHS) | US (Pennsylvania) | 2007 | Permanent implementation | Bundled payment (prospective) | Low-risk pregnancies | Care for mother only | Exclusion of late referrals and high risk pregnancies | Exclusion of neonatal care | - | [173354] |
| 17 | Lead Maternity Care Model (LMC) | New Zealand | 2007 | Permanent implementation | Bundled payment (prospective) | All pregnancies | Care for mother only | -. | Exclusions of neonatal care and the consultation of obstetricians. | - | [555657] |
Figure 2
Level of integration and financial accountability of the alternative payment models in maternity care.
*episode is limited to the delivery phase in the hospital only, **episode is divided into three or four phases (prenatal, delivery, postnatal, maternity community care), ***integrated birth center; CQUIN: Commissioning for Quality and Innovation Payment Framework; Texas: Texas Medicaid Program; BirthBundle: Minnesota Birth Centers BirthBundle; Pacific: Pacific Business Group on Health Blended Case Rate; Minnesota BP: Minnesota Blended Payment; Providence: Providence Health and Services Pregnancy Care Package; Horizon: Horizon Blue Cross Blue Shield of New Jersey, Pregnancy Episodes of care Program; Arkansas: Arkansas Health Care Payment Improvement Initiative; Ohio: Ohio Episode-Based Payment Model; CHC: Community Health Choice, Bundled Payment Pilot; New York: New York States’ Medicaid Maternity Care Value Based Payment Arrangement; The Dutch BP: The Dutch Bundled Payments for Maternity Care; Maternity Pathway BP: Maternity Pathway Bundled Payment; GHS: Geisinger Health System Perinatal ProvenCare Initiative; LMC: Lead Maternity Carer.
Table 3
Effects of the alternative payment models in maternity care on health outcomes and health spending.
| INITIATIVE (ABBREVIATION) | TYPE OF APM | STUDY DESIGN | DATA COLLECTION PERIOD | RESULTS – HEALTH OUTCOMES | RESULTS – SPENDING | QUALITY APPRAISAL OF THE STUDY | REFERENCES |
|---|---|---|---|---|---|---|---|
| Geisinger Health System, Perinatal ProvenCare Initiative (GHS) | Bundled payment (prospective) | Observational study design. Pre-intervention period (n = 101); post-intervention period (n = 1,010) | Pre-intervention population: January 2008 – October 2008, Post-intervention population: April 2009 – June 2010. | Improvement on nearly all 103 indicators: e.g. 25% reduction in neonatal intensive care admissions and screening and prevention activities for smoking increased from 45% to 88%. | - | Weak | [54] |
| Arkansas Health Care Payment Improvement Initiative (Arkansas) | Shared savings (two-sided) | Difference-in-difference design. Pre-intervention: n = 2,454 (intervention); n = 20,824 (controls). Post-intervention: n = 1,737 (intervention); n = 15,291 (controls) | Pre-intervention: 2010 to 2012, Post-intervention: 2013 - 2014 | - | Perinatal spending decreased by 3.8% overall. The decrease was driven by the prices paid for inpatient facility care. | Moderate | [32] |
| Minnesota Blended Payment (Minnesota BP) | Bundled payment (only delivery phase) | Interrupted time series design. Experiment group n = 25,080; Control group n = 646,097 | 2006–2012 | There were no significant effects on maternal morbidity. | Spending dropped by $425.80. It continued to decrease in by $95.04 per quarter. | Moderate | [46] |
| Texas Medicaid Program (Texas) | Pay-for-performance | Difference-in-difference design. Experiment group n = 438,429. Control group 1 n = 895,543; control group 2 n = 1,691,896; control group 3 n = 573,382 | 2009–2013 | Gains of five days in gestational age and six ounces in birthweight. | - | Moderate | [24] |