November 15, 2019

Warren, Blunt Rochester, Colleagues Question HHS and CMS on Efforts to Reduce Maternal Mortality

With U.S. Facing Maternal Mortality and Morbidity Crisis, Alternative Payment Models Have Potential to Improve Delivery of Maternal Health Care

Text of Letter (PDF)

Washington, D.C. - United States Senator Elizabeth Warren (D-Mass.) and Representative Lisa Blunt Rochester (D-Del.) led eight of their Senate and House colleagues in requesting information from the U.S. Department of Health and Human Services (HHS) and Centers for Medicare and Medicaid Services (CMS) about HHS' use of alternative payment models (APMs) to reduce maternal mortality and improve the delivery of maternal health care. The lawmakers' letter comes as the United States faces a growing maternal mortality and morbidity crisis, exacerbated by significant racial disparities in maternal health outcomes and limited access to maternal care in rural and other underserved areas.

Joining Senator Warren and Representative Blunt Rochester in sending the letter were Senators Kirsten Gillibrand (D-N.Y.), Cory Booker (D-N.J.), Senate Democratic Whip Richard Durbin (D-Ill.), and Tammy Baldwin (D-Wisc.) and Representatives Robin Kelly (D-Ill.), Black Maternal Health Caucus Co-Chairs Lauren Underwood (D-Ill.) and Alma Adams (D-N.C.), and Jan Schakowsky (D-Ill.).

The maternal mortality rate in the United States is higher than in any other developed country, and in the past twenty years, it has doubled -making the United States the only industrialized nation with an increasing maternal mortality rate. APMs, which can align incentives to provide high-quality and cost-efficient care, have the potential to play a critical role in improving maternal health outcomes.

In their letter to HHS and CMS, the lawmakers noted that there is widespread support for exploring the use of APMs to incentivize proper maternal care, and asked the agencies to provide more information on the Center for Medicare and Medicaid Innovation's (CMMI) work to address the maternal mortality and morbidity crisis. The lawmakers urged the agencies to pursue APMs focusing on high-quality, patient-centered care that would reduce disparities in maternal health outcomes and increase access to health care in rural areas. They also called on CMMI, in developing APMs, to take steps to ensure that patients in high-risk communities are not left behind, hospitals operating in underserved communities are not unfairly penalized, and existing health inequities are not exacerbated by implementation of new payment and delivery models.

"We have an urgent responsibility to pregnant individuals, recent parents, and families across the United States to improve maternal health outcomes, including through the delivery of care," wrote the lawmakers. "We urge CMMI to consider how APMs can be used to innovate in the area of maternal health care delivery."

The lawmakers asked the agencies to answer the following questions about CMMI's use of APMs to test innovative ways of delivering maternal health care, and requested a briefing on the matter by December 6, 2019.

  • What work has CMMI done to assess how different alternative payment models (APMs) could be implemented to combat high rates of maternal mortality and morbidity and improve maternal health outcomes in the U.S? What are the strengths of each of the following alternative payment models compared to traditional fee-for-service models in the provision of maternal health care, and in specifically improving maternal mortality and morbidity outcomes:
    • Retrospective bundled payments, prospective bundled payments, global budget payments, patient-centered medical homes, other types of health homes, and accountable care organizations?
  • What benefits can APMs provide over fee-for-service models with regards to the following:
    • Coordinating care and increasing access to the totality of a pregnant individual's health care needs, including pre-pregnancy, prenatal, postpartum, and mental health care; lowering health care costs; reducing racial disparities; increasing access to maternal care in rural areas, and increasing provider accountability?
  • How can APMs decrease the rate of medically inappropriate C-sections?
  • In terms of developing bundled payments for maternity care, careful consideration must be taken to properly define episodes of care and care teams in order to properly encompass the medical needs of individuals during pregnancy, at delivery, and postpartum.
    • In existing bundled payment programs, episodes are often triggered at delivery or assigned to one provider who delivers the baby. This way of defining an episode, however, disincentivizes team-based care. How is CMMI thinking about solving for these concerns in developing APMs for maternity care.
    • How, if at all, has CMMI considered incorporating maternity care teams-involving providers including pediatric care providers, optometrists, certified nurse midwives, dentists, pharmacists, and behavioral health providers, as well as lab technicians, community health workers, and doulas-into potential APMs in order to incentivize a whole person/family approach to maternal care?
    • Reports from state maternal mortality review committees have found that, in some states, the number of maternal deaths related to suicide and overdose increase later in the postpartum period. As our health care system works to increase access to the full spectrum of care during this critical period, how will CMMI address the needs of these patients, including behavioral health care needs, after an episode of care has ended or at specific inflection points in the postpartum period?
  • How has CMMI consulted with and incorporated the feedback of stakeholders, including pregnant individuals, families, and mothers across all demographic groups to ensure that the agency's work addresses the social and cultural needs of patient populations?
  • What quality measures does CMMI require as part of its demonstrations and consider most important in evaluating the success of APMs for maternal care? What gaps has CMMI identified in quality measures for maternal care and how is CMMI addressing these gaps?
  • As physicians are increasingly encouraged to participate in APMs, how will CMMI incentivize hospitals to engage in meaningful quality improvement?
  • To what extent does CMMI require its current APM participants to report quality data stratified by race, ethnicity, age, sex, and language?