An Examination of the Strong Start Initiative Group Prenatal Care (GPC) Model: A Focus

on Clinical Outcomes, Financial Sustainability, & Cost Variation

Brandon J. Lock

Georgetown University School of Nursing & Health Studies

Department of Health Systems Administration HESY 484 - Paying for Health Care: Principles & Innovations

Objective

This paper will examine the impact of the Center for Medicare and Medicaid

Innovation (CMMI) funded enhanced prenatal care model, after two years of funding, to

increase access to care, decrease costs, and increase quality of care. Primary research and

analysis will involve reviewing the preliminary data and evaluations of the Strong Start

initiative, with a specific focus on the group prenatal care (GPC) model. Secondary

research and analysis will involve evaluating the scope of the GPC enhanced prenatal

care model to improve access to effective medical care by reviewing independent

evaluation reports, external data from systematic literature review, financial retrospective

analyses from various payer perspectives, and a GPC financial modeling tool.

Background

The CMMI began funding the Strong Start for Mothers and Newborns initiative in

February of 2013, under section 3021 of the Affordable Care Act (ACA), aiming to

improve maternal and infant outcomes for pregnancies covered by Medicaid and the

Children’s Health Insurance Program (CHIP). The initiative funds three enhanced

prenatal care models: maternity care homes, group prenatal care, and birth centers. In the

first year of the initiative there were 27 awardees and 213 provider sites, across 30 states,

the District of Columbia, and Puerto Rico, with a proposed target of serving up to 80,000

women. The cooperative agreements are over a four-year time frame for a total of $41.4

million. In addition to the awards, CMMI commissioned a five-year independent

evaluation of the initiative to evaluate the implementation and impacts of the initiative on

health delivery, health outcomes, and cost of care by conducting qualitative case studies,

participant-level process evaluations, and impact analysis (CMS, 2014).

Parallel to the launch of this initiative, stakeholders including the Childbirth

Connection, Catalyst for Payment Reform, and the Center for Healthcare Quality and

Payment Reform (CHQPR) commissioned a report in January of 2013 to focus national

attention on the need to better align maternity care payment and quality. As evaluation

data and results became publicly available, interested researchers subsequently conducted

a systematic literature review of the costs of pregnancy in the US to identify the overall

cost of pregnancy, cost of pregnancy-related complications, cost of unintended

pregnancy, cost of planned pregnancy, and cost of pregnancy by facilities in order to

identify key cost drivers. With these studies and reports, and after two years of funding

and implementation, the Strong Start initiative can be more thoroughly examined for its

impact on health delivery, health outcomes, and cost of care. This initiative provides a

unique foundation for understanding the pooling of risk and reimbursement in the context

of improving access to effective medical care for a common and costly medical event

with high cost variance. Additionally, the financial model created by the New York

group, provides a base-line tool and evaluation mechanism for estimating the financial

costs associated with a GPC prenatal care model that could build a supportive case in

favor of the long-term sustainability of GPC, as it relates to this initiative.

Year 1 Evaluation

The independent evaluation of the initiative involves three primary components of

qualitative case studies, participant-level process evaluation, and impact analysis. The

qualitative case studies evaluate the design, implementation, barrier or challenges, and

the success factors. The participant-level process evaluation looks at demographics, risk

characteristics, service use, and outcomes. The impact analysis evaluates rates of

premature birth, low birth weight, Medicaid/CHIP costs through pregnancy and 1st year

after birth, and variation by model type, awardee, site, and type of services offered and

received. According to the year 1 evaluation, 12 of 27 awardees (44%) are implementing

GPC and 42 of 213 (19.7%) of provider sites offer GPC (CMS, 2014). Demographic

information indicates that the highest number of sites and awardees are in the South,

more than half of the provider sites are in urban or metropolitan areas compared to one

quarter of sites that are in rural areas, and clinical sites operate in a wide variety of

settings including hospitals and health systems, health plans, community-based providers,

Federally Qualified Health Centers (FQHCs), nationally-certified birth centers, Indian

health services clinics, local health departments, and physician groups. Awardees have

set overarching goals of reducing preterm birth, decreasing rates of low birth weight,

decreasing costs of care, increasing outreach to Medicaid/CHIP women, increasing rates

of breastfeeding, and recruiting a range of 50-2000 women in each cohort.

The cross cutting findings, early observations, and emerging issues identified in

the first year offer some hope and significant opportunity for improvement in the areas of

enrollment and implementation. The enrollment process has been time-intensive, due to

several factors including awardee hiring needs, enrollee eligibility screening, staff

training/engagement, and materials development. This has significantly impacted

enrollment, with the number of enrollees being lower than expected at 7,569 women as of

2014. Additionally, there are specific demographic challenges with participants

experiencing high levels of emotional and psychosocial need, within the social

determinants of health framework, and factors such as food insecurity, very low income

or chronic unemployment, unstable housing, lack of reliable transport, unmet medical

needs, and low levels of education about self-care, nutrition, and healthy pregnancy.

Outside of the structural and demographic challenges, there are service delivery

constraints due to Medicaid/CHIP requirements and model sustainability because of the

time-limited nature of the initiative. Similarly, there were several unique challenges

observed during the implementation process such as establishing a consistent and

effective process for identifying and enrolling eligible patients, integrating enhanced

services into existing models of care, retaining women in the program, and complying

with reporting data requirements. An important observation is that the consistency in

implementation practices varies considerably across models and among sites, the nuances

are in the facilitation by different types of providers, the consistency of facilitators, and

the composition of the group. However, whether these variations have an impact on the

experiences and outcomes at this point is still unmeasured and unknown.

With these challenges in mind the recommended strategies for improvement

include developing an “opt out” enrollment process; having more effective messaging

about Strong Start; disseminating best practices to promote supportive and engaged

participant relationships with prenatal care providers and other site staff; willingness to

adapt programs to the specific needs of the site and target population; and the

development of dedicated, skilled, and resourceful program staff. There are some hopeful

results indicating that women participating in this initiative are having lower than average

Cesarean section (C-section) rates of preterm deliveries than the nation as a whole and

that participants are expressing overwhelming satisfaction with their prenatal care. The

future considerations for the initiative are that selection bias remains a concern, the

incremental benefits may be challenging to detect, significant model overlap at several

sites will influence the ability to detect model-specific differences in the impacts, and that

data burden and data collection fatigue may lead to incomplete submissions and poor

quality data.

Year 2 Evaluation

In the second year of evaluation, the proposed target of 80,000 women was

adjusted to 50,000 and many awardees launched or discontinued certain operations and

models, which lead to a 7% decrease in the total number of sites from 213 to 199.

However, the number of sites offering GPC increased from 42 (19.7%) to 54 (27%)

(CMS, 2015). Compared to year one, enrollment accelerated at the end of 2014 and

surpassed 23,000 by the end of Quarter 1 of 2015. With significant enrollment issues

identified in year one, CMMI worked with awardees to provide eligibility adjustments by

eliminating the requirement that women be identified with an additional risk factor for

preterm birth beyond their Medicaid status, allowed women up to 29 weeks’ gestation to

be enrolled, and allowed women with “pending” Medicaid eligibility to be enrolled. As

previously indicated, the increased possibility of selection bias was examined in further

detail and the changes in eligibility have influenced the composition of participants,

however only 7% of women have been enrolled after 28 weeks’ gestation and GPC

appears least likely to have enrolled women in their third trimesters.

In regards to participant demographics, the second year evaluation data indicates

that enrollees are more likely to have had a previous preterm birth than women generally,

which is the strongest predictor of having another preterm delivery. Additionally, the

rates of having had a previous low weight baby are lower than the general population, but

approximately 20% of participants with previous pregnancies reported shorter inter-

pregnancy intervals (less than 18 months), which is another strong predictor of poor birth

outcomes (CMS, 2015). One interesting trend observed in year two is that depression is a

particularly prevalent risk factor, with 25% of participants with this condition being

enrolled in a GPC model. It’s important to recognize that the GPC model’s group

component could be an embedded mechanism for addressing this by helping women

build relationships, facilitating participant mutual support and learning, and providing the

added benefit of knowledge that there are others experiencing many of the same risks,

stress factors, and circumstances that they are experiencing.

The second year evaluation provides a stronger set of quantitative results.

Participants enrolled in GPC received 10 prenatal care visits on average, with visits

lasting approximately 2 hours. With implementation, there are clearer and more

coordinated staffing roles, stronger relationships with obstetrical providers that are

enhancing coordination of service delivery and referrals, and the universal hiring of

administrative staff for data collection and reporting occurred. Results from the Quarter 1

2015 Exit Form Survey show that C-section prevalence among women receiving care

may be lower than the national average and Case Study observations indicate drastic

improvements in prenatal and postpartum visit attendance rates, positive changes in

nutrition/exercise, increased knowledge and confidence about labor and delivery, fewer

unnecessary visits to the ED, and increased access to and use of contraception (CMS,

2015). Lastly, most awardees hope to sustain the programs after the initiative ends and

are planning for the future, with one health-plan based awardee already succeeding in

receiving supplemental reimbursement for GPC in its Medicaid payments.

Synthesis

The National Partnership for Women & Families states that human birth is the

most common operating room procedure (2015). The report The Cost of Having a Baby

in the United States supports and defends this claim stating that, “Routine maternity care

is technology-intensive and expensive and that combined maternal and newborn care is

the most common and costly type of hospital care for all payers (Truven, 2013).”

Therefore, one of the greatest opportunities for improving health care value is in

maternity care because it is something that impacts everyone at the beginning of life and

continues to have an impact on a significant number of women during one or more

episodes of care. Even though this is a well-documented and common procedure,

determining the cost of care for pregnancy is an extremely difficult task. Huynh provides

a relatively recent systematic literature review of the cost of pregnancy in the US and

identifies several different cost-drivers which are inpatient care, pregnancy delivery,

multiple births, complicated C-sections, high-risk pregnancy, preterm birth, low birth

weight, complications due to conditions such as hypertension, diabetes, anemia, and

cancer, and in vitro fertilization (IVF) (2013). While this does not provide a method for

discerning the independent effects of the cost-drivers or the relative importance of each

factor, it does provide a starting point for knowing which variables are contributing to

cost and how they might be incorporated into a financial model.

While childbirth is a major life and population event it’s important to note that the

US birth rate has been declining over the past two decades and that overall costs

associated with pregnancy have been increasing. Interestingly, the two birthing methods,

vaginal or C-section, have distinct and observable payment variations which Childbirth

Connection highlights by showing that the more expensive of the two, the C-section rate,

peaked in 2009 at 32.9% and has since dropped to 32.2% as of 2014 (2015). Because of

these payment variations, it’s important to understand the reasons behind the variation as

well as the declining pregnancy rate and the high C-section rate. The Huynh review

suggests that there are multiple factors that contributing to the differences in pregnancy

rates. Factors including social and behavioral changes in sexual activity, marriage,

divorce, and cohabitation, which affect patterns of intercourse, the social and economic

context of childbearing, and the introduction of contraceptive methods. Childbirth

Connection explains how many assume that the leading factors for the C-section trend are

the belief that more and more women are asking for the procedure that have no medical

rationale, and/or that the number of women who genuinely need a C-section is increasing,

and/or that liability pressure is driving rates (2015). The organization suggests that the

reasons for the high rate are the low priority of enhancing women’s own abilities to give

birth, the side effects of common labor interventions, refusal to offer the informed choice

of vaginal birth, casual attitudes about surgery and variation in professional practice style,

limited awareness of the harms that are more likely with C-sections, professional

expectations for work-life balance, and women’s great trust in their maternity care. While

the organization presents limited quantitative evidence, the proposed reasons are certainly

provocative and should be considered when evaluating the design of an enhanced

prenatal care model such as GPC.

In this complex payment and delivery environment, the Truven Analytics’ report

explains that reducing unwarranted practice variation and the overuse of some

interventions and underuse of others requires a multi-faceted strategy that includes

payment reform, changes in benefit structures, public education, and provider

engagement to successfully drive the needed improvement. This report provides a

reference perspective on the charges and payments for maternal and newborn care by

analyzing the 2010 MarketScan Commercial and Medicaid databases. However, the data

from this report should be considered within the landscape that Huynh provides from the

systematic literature review of 40 pregnancy-cost studies, which shows that 19 (48%)

incorporated hospital billing data that comprised individual hospital data or cost

information from the Agency for Healthcare Research & Quality and Healthcare

Utilization Project (AHRQ-HCUP), 8 (20%) used cost data from managed care programs,

5 (13%) used cost data from medical claims databases, and 3 (8%) used data from

national surveys (2013). Additionally, the heterogeneous nature of the datasets is further

complicated by the mixed distribution of payer perspectives with 3 studies from the

federal government, 2 studies from state governments, 9 studies from commercial payers,

3 studies from institutional, 3 studies from societal, and 10 studies that were

undetermined.

Within this landscape, the Truven study defines cost as, “the amount that

employers or Medicaid managed care plans and Medicaid programs and others pay

hospitals, clinicians, and other service providers (2013).” The report states that the

commercial average total charge for care was ($32,093) for vaginal and ($51,125) for

C-section and that the average total payment for all maternal and newborn care was

($18,329) for vaginal and ($27,866) for C-section. The Medicaid average total charge

for care was ($29,800) for vaginal and ($50,373) for C-section and that the average total

payment for all maternal and newborn care was ($9,131) for vaginal and ($13,590) for

C-section. The major trend is that Commercial and Medicaid payers paid approximately

50% more for C-sections and Commercial payers paid approximately 100% more than

Medicaid. The report breaks down the data further by source of payment, where the

payment went (e.g. facilities or maternity care providers), and by phase of care (e.g.

prenatal, intrapartum, and post-discharge). The key points from the secondary-level of

data analysis, related to GPC, are that primary insurance covers the bulk of the payment

with some cost-sharing for commercially-insured patients (~10-12%) in the form of out-

of-pocket costs and that anywhere from (59-66%) of payment went to facilities and

anywhere from (20-25%) of payment went to maternity care providers, with the rest of

payment flowing to anesthesiology, radiology/imaging, pharmacy and laboratory

services. These are important payment distinctions to make and consider when evaluating

the financial sustainability of GPC based on the flow of payment within the healthcare

continuum. With regards to prenatal care, which is the scope of GPC, commercial

payments for vaginal was ($3,180) and for C-section was ($3,580). Medicaid payments

for vaginal was ($2,405) and for C-section was ($2,589). The final section of the report

provides a landscape view of variability by state with the total commercial maternal care

costs for vaginal ranging from ($10,318 to $16,888) and C-section ranging from ($13,943

to $21,307).

Multiple studies have demonstrated improved prenatal outcomes for GPC

compared to traditional prenatal care measured by rate of prematurity and low birth

weight, fewer C-section deliveries, improved breastfeeding outcomes, and improved

maternal satisfaction with care. The numerous Strong Start initiative sites (54 as of year

2) piloting GPC provide an excellent testbed for examining clinical outcomes as well as

financial costs associated with running a GPC program, which are currently not well

established. A group recently developed a mathematical cost-benefit model for an urban

underserved practice running a GPC program and found that GPC could be financially

sustainable and possibly a net income generator for an outpatient clinic (Rowley, 2016).

The model projects that the adjusted revenue per pregnancy would be $989.93 for

traditional care and $1080.69 for GPC and that cost neutrality for GPC was achieved

when each group enrolled an average of 10.652 women with an enriched staffing model

and 4.801 women when groups were staffed by a single nurse and single clinician. The

study reports that the New York State Department of Health defines adequate prenatal

care as at least seven prenatal visits over the course of pregnancy and that total number of

completed prenatal visits have been shown to exert a positive impact on preterm delivery

rates.

While model projections are promising, it’s important to recognize the necessary

inputs, outputs, limitations, and scalability of the model. The excel model cost projections

for GPC cost and revenue are contingent on variables including group size, payor mix,

patient no-show rate, staffing levels, supply usage, and overhead costs. There is a degree

of robustness to this model, because it allows users to adjust all of these variables and

customize the model to changing situations and needs using ubiquitously available

software. This report provides a template and methodology for doing this, where the team

analyzed 5.5 years of data to determine practice demographics, payor mix, and usual

revenues (Rowley, 2016). The limitations of the model are that it does not include the

most common off-the-shelf GPC solution cost (CenteringPregnancy Network), where

costs of implementation are approximately $20,000 over the first 2 years with ongoing

annual membership of $500 per year and that it assumes that patients who start with the

GPC model will stay in that model of care.

Conclusion

The GPC model, while still in its infancy, provides a strong theoretical construct

and a developing implementation construct for offering an enhanced prenatal care model

that is potentially financially sustainable, could lead to measureable quality

improvements in outcomes, and could reduce price variation through negotiated

reimbursement with payers due to market shifts towards patient satisfaction and quality

of care. The Strong Start initiative has provided funding for three enhanced prenatal care

models and the GPC model experienced a significant increase in awardee site uptake,

despite an overall decrease in total sites going into year 2. As both the initiative’s

evaluation report and financial model indicate, it remains to be seen as to the ability of

the GPC model to address systemic participant-level demographic challenges and the

recruitment and retention requirements to keep costs low and realize project cost savings.

However, the relatively large national volumes associated with pregnancy and prenatal

care indicate significant marketplace demand and the extreme variations in cost indicate

unregulated marketplace supply. Overall, the GPC model offers a strong enhanced

prenatal care model that is outcomes-driven, makes the case for financial sustainability, is

well aligned with market shifts in payment, and could better align market supply and

demand through reduced pregnancy cost-variation.

References:

Rowley, Rebecca A., et al. "Group Prenatal Care: A Financial Perspective." Maternal and child health journal 20.1 (2016): 1-10.

Huynh, Lynn, et al. "Systematic Literature Review of the Costs of Pregnancy in the US." PharmacoEconomics 31.11 (2013): 1005-1030. The Cost of Having a Baby in the United States. Rep. Truven Health Analytics Marketscan Study, 1 Jan. 2013. Web. Centers for Medicare & Medicaid Services (CMS). "Strong Start for Mothers and Newborns Initiative: enhanced prenatal care models." Volume 1 (2014)

Centers for Medicare & Medicaid Services (CMS). "Strong Start for Mothers and Newborns Initiative: enhanced prenatal care models." Volume 2 (2015). WhyistheU.S.CesareanSectionRateSoHigh?ChildbirthConnection–AProgramoftheNationalPartnershipforWomen&Families.September2015.