Director of the Arizona Health Care Cost Containment System
Elliott Main, MD
Medical Director for California Maternal Quality Care Collaborative (CMQCC)
As the LAN pivots from a conceptual learning phase into an action and implementation phase, we believe episode based payments generally and maternity care specifically have great potential. We are looking to support stakeholders interested in implementing maternity care payment models and engaging them in a Maternity Multi-Stakeholder Action Collaborative (MAC)
What is the MAC?
The MAC is designed to provide support and resources to organizations that want to drive improvement in maternity care outcomes via alternative payment. Our objective is to provide MAC participants with opportunities to accelerate the development and implementation of maternity care episode payments. In the short term, participation in the MAC will provide a structured resource to share ideas and promising practices. In the long term, MAC participation will make your organization a leader in the movement toward aligned adoption of maternity episode payment as an alternative payment model.
Why Maternity Care?
Maternity care cost varies significantly by payer (commercial or Medicaid), by type of birth (vaginal or cesarean section), and by setting (hospital or birth center). Prenatal care, labor and birth, and postpartum care are often paid for and delivered as three distinct periods when in reality, they are all three phases of one episode in a woman’s life. To incentivize coordination across the practitioners and settings where the full spectrum of maternity services are provided, episode payment can be used with the goals of improving patient care, increasing coordination across services and providers, and lowering health care costs.
The LAN invites your organization to be a MAC participant and join other stakeholders interested in improving maternity care via alternative payment models.
We understand that organizations may not be at the same stage of designing, testing, and implementing APMs. The LAN wants to work with your organization regardless of where it fits in that spectrum, and will provide an opportunity for participating organizations to collaborate with one another in a structured environment to learn “best practices” for implementation, using the LAN Clinical Episode Payment recommendations as a guidepost. MAC participants will be influential stakeholders in the process of setting maternity care goals and determining how best to achieve them. The LAN will use these discussions as guidance for creating practical tools to help payers, providers, and purchasers to redesign maternity care delivery.
Join our collaborative effort to improve outcomes for women and their babies. Lend your voice as we develop new and more effective ways to coordinate care. Shape the future of maternity care delivery.
The following terms are defined within the white paper as it relates to clinical episode payment models.
Clinical Episode Payment
A clinical episode payment is a bundled payment for a set of services that occur over time and across settings. This payment model can be focused on a: setting (such as a hospital or a hospital stay); procedure (such as elective surgery); or condition (such as diabetes).
Clinical Episode Payment Work Group
The LAN Guiding Committee convened the Clinical Episode Payment (CEP) Work Group to create a set of recommendations that can facilitate the adoption of clinical episode-based payment models.
Clinical Episode Payment Models
Clinical episode payment models are different from traditional fee-for-service (FFS) health care payment models, in which providers are paid separately for each service they deliver. Instead, clinical episode payment models take into consideration the quality, costs, and outcomes for a patient-centered course of care over a set period of time and across multiple settings.
Core Set of Logic
This will assist the industry in developing the capacity for grouping claims into bundles by standardizing some of the logic and allowing each payer to customize some of the more specific rules.
The design elements address questions stakeholders must consider when designing an episode-based payment model, including, but not limited to, the definition, the duration of the episode, and what services are to be included.
Clinical episode payment models are different from traditional fee-for-service (FFS) health care payment models, in which providers are paid separately for each service they deliver.
Operational considerations relate to implementing an episode payment model, including the roles and perspectives of stakeholders, data infrastructure issues, and the regulatory environment in which APMs must operate.