Download delivering higher-value maternity care

DELIVERING HIGHER-VALUE
MATERNITY CARE
Designing Alternative Payment Models
for Better Care, Lower Spending, and
Financially Viable Maternity Care Providers
Harold D. Miller
President and CEO
Center for Healthcare Quality and Payment Reform
www.CHQPR.org
How Do You Control Growing
Healthcare Spending?
$
TOTAL
HEALTH
CARE
SPENDING
TOTAL
HEALTH
CARE
SPENDING
TOTAL
HEALTH
CARE
SPENDING
TOTAL
HEALTH
CARE
SPENDING
TIME
© Center for Healthcare Quality and Payment Reform www.CHQPR.org
2
Typical Strategy #1:
Cut Provider Fees for Services
$
TOTAL
HEALTH
CARE
SPENDING
TOTAL
HEALTH
CARE
SPENDING
TOTAL
HEALTH
CARE
SPENDING
SAVINGS
Cut
Provider Fees
TOTAL
HEALTH
CARE
SPENDING
BY
PAYERS
© Center for Healthcare Quality and Payment Reform www.CHQPR.org
3
Typical Strategy #2:
Shift Costs to Patients
$
TOTAL
HEALTH
CARE
SPENDING
TOTAL
HEALTH
CARE
SPENDING
TOTAL
HEALTH
CARE
SPENDING
SAVINGS
TOTAL
HEALTH
CARE
SPENDING
BY
PAYERS
Higher
Cost-Share &
Deductibles
© Center for Healthcare Quality and Payment Reform www.CHQPR.org
4
Typical Strategy #3:
Delay or Deny Care to Patients
$
TOTAL
HEALTH
CARE
SPENDING
TOTAL
HEALTH
CARE
SPENDING
TOTAL
HEALTH
CARE
SPENDING
SAVINGS
TOTAL
HEALTH
CARE
SPENDING
BY
PAYERS
Lack of
Needed Care
© Center for Healthcare Quality and Payment Reform www.CHQPR.org
5
Results of the Typical Strategies
•
•
•
•
•
•
•
Small providers forced out of business
Consolidation of providers to resist cuts in fees
Shifts in care to higher-cost settings
Increases in utilization to offset losses in revenue
Patients avoiding necessary care due to high cost-sharing
Large increases in health insurance premiums
Inability to afford health insurance
© Center for Healthcare Quality and Payment Reform www.CHQPR.org
6
Results of the Typical Strategies
•
•
•
•
•
•
•
Small providers forced out of business
Consolidation of providers to resist cuts in fees
Shifts in care to higher-cost settings
Increases in utilization to offset losses in revenue
Patients avoiding necessary care due to high cost-sharing
Large increases in health insurance premiums
Inability to afford health insurance
IS THERE A BETTER WAY?
© Center for Healthcare Quality and Payment Reform www.CHQPR.org
7
The Right Focus: Spending
That is Unnecessary or Avoidable
$
AVOIDABLE
SPENDING
NECESSARY
SPENDING
AVOIDABLE
SPENDING
AVOIDABLE
SPENDING
NECESSARY
SPENDING
NECESSARY
SPENDING
AVOIDABLE
SPENDING
NECESSARY
SPENDING
TIME
© Center for Healthcare Quality and Payment Reform www.CHQPR.org
8
Avoidable Spending Occurs
In All Aspects of Healthcare
$
AVOIDABLE
SPENDING
NECESSARY
SPENDING
© Center for Healthcare Quality and Payment Reform www.CHQPR.org
9
Avoidable Spending Occurs
In All Aspects of Healthcare
SURGERY
• Unnecessary surgery
• Use of unnecessarily-expensive implants
• Infections and complications of surgery
• Overuse of inpatient rehabilitation
$
AVOIDABLE
SPENDING
NECESSARY
SPENDING
© Center for Healthcare Quality and Payment Reform www.CHQPR.org
10
Avoidable Spending Occurs
In All Aspects of Healthcare
SURGERY
• Unnecessary surgery
• Use of unnecessarily-expensive implants
• Infections and complications of surgery
• Overuse of inpatient rehabilitation
$
AVOIDABLE
SPENDING
CANCER TREATMENT
• Use of unnecessarily-expensive drugs
• ER visits/hospital stays for dehydration
and avoidable complications
• Fruitless treatment at end of life
NECESSARY
SPENDING
© Center for Healthcare Quality and Payment Reform www.CHQPR.org
11
Avoidable Spending Occurs
In All Aspects of Healthcare
SURGERY
• Unnecessary surgery
• Use of unnecessarily-expensive implants
• Infections and complications of surgery
• Overuse of inpatient rehabilitation
$
AVOIDABLE
SPENDING
NECESSARY
SPENDING
CANCER TREATMENT
• Use of unnecessarily-expensive drugs
• ER visits/hospital stays for dehydration
and avoidable complications
• Fruitless treatment at end of life
CHEST PAIN DIAGNOSIS/TREATMENT
• Overuse of high-tech stress tests/imaging
• Overuse of cardiac catheterization
• Overuse of PCIs, high-priced stents
© Center for Healthcare Quality and Payment Reform www.CHQPR.org
12
Avoidable Spending Occurs
In All Aspects of Healthcare
SURGERY
• Unnecessary surgery
• Use of unnecessarily-expensive implants
• Infections and complications of surgery
• Overuse of inpatient rehabilitation
$
AVOIDABLE
SPENDING
NECESSARY
SPENDING
CANCER TREATMENT
• Use of unnecessarily-expensive drugs
• ER visits/hospital stays for dehydration
and avoidable complications
• Fruitless treatment at end of life
CHEST PAIN DIAGNOSIS/TREATMENT
• Overuse of high-tech stress tests/imaging
• Overuse of cardiac catheterization
• Overuse of PCIs, high-priced stents
MATERNITY CARE
• Unnecessary C-Sections
• Early elective deliveries
• Underuse of birth centers
• Complications of delivery
© Center for Healthcare Quality and Payment Reform www.CHQPR.org
13
The Right Goal: Less Avoidable $,
$
AVOIDABLE
SPENDING
AVOIDABLE
SPENDING
AVOIDABLE
SPENDING
AVOIDABLE
SPENDING
NECESSARY
SPENDING
TIME
© Center for Healthcare Quality and Payment Reform www.CHQPR.org
14
The Right Goal: Less Avoidable $,
More Necessary $
$
AVOIDABLE
SPENDING
AVOIDABLE
SPENDING
AVOIDABLE
SPENDING
AVOIDABLE
SPENDING
NECESSARY
SPENDING
NECESSARY
SPENDING
NECESSARY
SPENDING
NECESSARY
SPENDING
TIME
© Center for Healthcare Quality and Payment Reform www.CHQPR.org
15
Win-Win for Patients & Payers
Lower
Spending
for
Payers
$
AVOIDABLE
SPENDING
NECESSARY
SPENDING
SAVINGS
SAVINGS
SAVINGS
AVOIDABLE
SPENDING
AVOIDABLE
SPENDING
AVOIDABLE
SPENDING
NECESSARY
SPENDING
Better
Care
for
NECESSARY Patients
SPENDING
NECESSARY
SPENDING
TIME
© Center for Healthcare Quality and Payment Reform www.CHQPR.org
16
Barriers in the Payment System
Create a Win-Lose for Providers
$
SAVINGS
AVOIDABLE
SPENDING
NECESSARY
SPENDING
AVOIDABLE
SPENDING
BARRIERS
IN THE
CURRENT
PAYMENT
SYSTEM
NECESSARY
SPENDING
© Center for Healthcare Quality and Payment Reform www.CHQPR.org
17
Barrier #1: No $ or Inadequate $
for High-Value Services
$
AVOIDABLE
SPENDING
NECESSARY
SPENDING
No Payment or
Inadequate Payment for:
• Services delivered
outside of face-to-face
visits with providers, e.g.,
phone calls, e-mails, etc.
• Communication among
providers to manage
patient needs
• Services delivered by
non-physicians (nurses,
midwives, homecare aides)
• Services in non-traditional
settings (e.g., birth centers)
• Non-medical services,
e.g., transportation
• Additional time for patients
with higher intensity needs
UNPAID
SERVICES
© Center for Healthcare Quality and Payment Reform www.CHQPR.org
18
Barrier #2: Avoidable Spending
May Be Revenue for Providers…
$
MARGIN
AVOIDABLE
SPENDING
PROVIDER
REVENUE
NECESSARY
SPENDING
COST
OF
SERVICE
DELIVERY
© Center for Healthcare Quality and Payment Reform www.CHQPR.org
19
…And When Avoidable Services
Aren’t Delivered…
$
MARGIN
AVOIDABLE
SPENDING
AVOIDABLE
SPENDING
PROVIDER
REVENUE
NECESSARY
SPENDING
COST
OF
SERVICE
DELIVERY
NECESSARY
SPENDING
© Center for Healthcare Quality and Payment Reform www.CHQPR.org
20
…Providers’ Revenue
May Decrease…
$
MARGIN
AVOIDABLE
SPENDING
AVOIDABLE
SPENDING
PROVIDER
REVENUE
NECESSARY
SPENDING
COST
OF
SERVICE
DELIVERY
NECESSARY PROVIDER
SPENDING REVENUE
© Center for Healthcare Quality and Payment Reform www.CHQPR.org
21
…But Fixed Costs Don’t Vanish
Many Fixed Costs of Services
Remain When Volume Decreases
$
• Leases & staff in provider practice
• Costs of hospital emergency room
and labor & delivery suite
MARGIN
AVOIDABLE
SPENDING
AVOIDABLE
SPENDING
PROVIDER
REVENUE
NECESSARY
SPENDING
COST
OF
SERVICE
DELIVERY
COST
OF
NECESSARY PROVIDER SERVICE
SPENDING REVENUE DELIVERY
© Center for Healthcare Quality and Payment Reform www.CHQPR.org
22
…But Fixed Costs Don’t Vanish
and New Costs May Be Added…
Many Fixed Costs of Services
Remain When Volume Decreases
And New Costs May Be Incurred,
$
• Costs of unpaid provider services
• Costs of collecting quality data
MARGIN
AVOIDABLE
SPENDING
AVOIDABLE
SPENDING
PROVIDER
REVENUE
NECESSARY
SPENDING
COST
OF
SERVICE
DELIVERY
COST OF
NEW SVCS
COST
OF
NECESSARY PROVIDER SERVICE
SPENDING REVENUE DELIVERY
© Center for Healthcare Quality and Payment Reform www.CHQPR.org
23
…Leaving Providers With Losses
(or Bigger Losses Than Today)
Many Fixed Costs of Services
Remain When Volume Decreases
And New Costs May Be Incurred,
Potentially Causing Financial Losses
$
MARGIN
AVOIDABLE
SPENDING
AVOIDABLE
SPENDING
PROVIDER
REVENUE
NECESSARY
SPENDING
COST
OF
SERVICE
DELIVERY
LOSS
COST OF
NEW SVCS
COST
OF
NECESSARY PROVIDER SERVICE
SPENDING REVENUE DELIVERY
© Center for Healthcare Quality and Payment Reform www.CHQPR.org
24
Small Payment Bonuses
Usually Won’t Offset the Losses
Many Fixed Costs of Services
Remain When Volume Decreases
And New Costs May Be Incurred,
Potentially Causing Financial Losses
That Aren’t Offset by Small Bonuses
$
MARGIN
AVOIDABLE
SPENDING
AVOIDABLE
SPENDING
PROVIDER
REVENUE
NECESSARY
SPENDING
COST
OF
SERVICE
DELIVERY
LOSS
P4P
COST OF
NEW SVCS
COST
OF
NECESSARY PROVIDER SERVICE
SPENDING REVENUE DELIVERY
© Center for Healthcare Quality and Payment Reform www.CHQPR.org
25
A Payment Change isn’t Reform
Unless It Removes the Barriers
BARRIER #1
BARRIER #2
© Center for Healthcare Quality and Payment Reform www.CHQPR.org
26
CMS “Alternative Payment Models”
Currently in Place
TYPE OF PROVIDER
CMS PROGRAM
PAYMENT STRUCTURE
Health Systems,
Multi-Specialty Groups,
PHOs, and IPAs
Accountable Care
Organizations
(MSSP & Pioneer)
FFS
+
Shared Savings on
Attributed Total Spending
FFS
+
PMPM $ for Attributed Patients
+
Shared Savings on
Attributed Total Spending
(for State or Region)
FFS
+
PMPM $ for Attributed Patients
+
Shared Savings on
Attributed Total Spending
(for 6-month window)
FFS
+
Bonuses/Penalties on
Attributed Total Spending
Primary Care
Comprehensive
Primary Care Initiative
Specialty Care
Oncology Care Model
Hospitals and
Post-Acute Care
Comprehensive Care
for Joint Replacement
© Center for Healthcare Quality and Payment Reform www.CHQPR.org
27
CMS “Alternative Payment Models”
Don’t Change Current Payments
TYPE OF PROVIDER
CMS PROGRAM
PAYMENT STRUCTURE
Health Systems,
Multi-Specialty Groups,
PHOs, and IPAs
Accountable Care
Organizations
(MSSP & Pioneer)
FFS
+
Shared Savings on
Attributed Total Spending
FFS
+
PMPM $ for Attributed Patients
+
Shared Savings on
Attributed Total Spending
(for State or Region)
FFS
+
PMPM $ for Attributed Patients
+
Shared Savings on
Attributed Total Spending
(for 6-month window)
FFS
+
Hospital Bonuses/Penalties for
Attributed Total Spending
Primary Care
Comprehensive
Primary Care Initiative
Specialty Care
Oncology Care Model
Hospitals and
Post-Acute Care
Comprehensive Care
for Joint Replacement
© Center for Healthcare Quality and Payment Reform www.CHQPR.org
28
…Most Only Provide More $
After Other Spending is Reduced
TYPE OF PROVIDER
CMS PROGRAM
PAYMENT STRUCTURE
Health Systems,
Multi-Specialty Groups,
PHOs, and IPAs
Accountable Care
Organizations
(MSSP & Pioneer)
FFS
+
Shared Savings on
Attributed Total Spending
FFS
+
PMPM $ for Attributed Patients
+
Shared Savings on
Attributed Total Spending
(for State or Region)
FFS
+
PMPM $ for Attributed Patients
+
Shared Savings on
Attributed Total Spending
(for 6-month window)
FFS
+
Hospital Bonuses/Penalties for
Attributed Total Spending
Primary Care
Comprehensive
Primary Care Initiative
Specialty Care
Oncology Care Model
Hospitals and
Post-Acute Care
Comprehensive Care
for Joint Replacement
© Center for Healthcare Quality and Payment Reform www.CHQPR.org
29
Problems With “Shared Savings”
• Providers receive no upfront resources to improve care
management for patients
• Already efficient providers receive little or no additional
revenue and may be forced out of business
• Providers who have been practicing inefficiently or
inappropriately are paid more than others
• Providers could be rewarded for denying needed care as well
as by reducing overuse
• Providers are placed at risk for costs they cannot control and
random variation in spending
• Shared savings bonuses are temporary and
“re-benchmarking” leaves providers with inadequate payment
to deliver necessary services
© Center for Healthcare Quality and Payment Reform www.CHQPR.org
30
Medicare ACOs Aren’t Succeeding
Due to Flaws in Shared Savings
2013 Results for Medicare Shared Savings ACOs
•
•
•
•
46% of ACOs (102/220) increased Medicare spending
Only 24% (52/220) received shared savings payments
After making shared savings payments, Medicare spent more than it saved
Net loss to Medicare: $78 million
2014 Results for Medicare Shared Savings ACOs
•
•
•
•
45% of ACOs (152/333) increased Medicare spending
Only 26% (86/333) received shared savings payments
After making shared savings payments, Medicare spent more than it saved
Net loss to Medicare: $50 million
2015 Results for Medicare Shared Savings ACOs
• 48% of ACOs (189/392) increased Medicare spending
• Only 30% (119/392) received shared savings payments
• After making shared savings payments, Medicare spent more than it saved
• Net loss to Medicare: $216 million
© Center for Healthcare Quality and Payment Reform www.CHQPR.org
31
Current APMs are Problematic
Because Payers Designed Them
HOW PAYMENT REFORMS ARE DESIGNED TODAY
Medicare and
Health Plans
Define
Payment Systems
Providers Have
To Change Care
to Align With
Payment Systems
Patients and
Providers
May Not
Come Out Ahead
© Center for Healthcare Quality and Payment Reform www.CHQPR.org
32
Providers Need to Design
Payments to Support Good Care
HOW PAYMENT REFORMS ARE DESIGNED TODAY
Medicare and
Health Plans
Define
Payment Systems
Providers Have
To Change Care
to Align With
Payment Systems
Patients and
Providers
May Not
Come Out Ahead
THE RIGHT WAY TO DESIGN PAYMENT REFORMS
Providers
Redesign Care
and Identify
Payment Barriers
Payers Change
Payment to
Support
Redesigned Care
Patients Get
Better Care and
Providers Stay
Financially Viable
© Center for Healthcare Quality and Payment Reform www.CHQPR.org
33
How Do You a Good
Alternative Payment Model?
1. Identify opportunities to improve care and reduce
avoidable spending
2. Identify the barriers in the payment system that
prevent implementing the improvements
3. Payers give healthcare providers flexible, adequate
resources to overcome the barriers in the current
payment system
4. Healthcare providers take accountability for
achieving the improvements in care and reductions
in spending
© Center for Healthcare Quality and Payment Reform www.CHQPR.org
34
How Do You a Good
Alternative Payment Model?
1. Identify opportunities to improve care and reduce
avoidable spending
2. Identify the barriers in the payment system that
prevent implementing the improvements
3. Payers give healthcare providers flexible, adequate
resources to overcome the barriers in the current
payment system
4. Healthcare providers take accountability for
achieving the improvements in care and reductions
in spending
WIN: Better Care for Patients
WIN: Lower Spending for Payers
WIN: Financially Successful Healthcare Providers
© Center for Healthcare Quality and Payment Reform www.CHQPR.org
35
Start By Identifying Opportunities to
Reduce Avoidable Spending
1. Identify opportunities to improve care and reduce
avoidable spending
2. Identify the barriers in the payment system that
prevent implementing the improvements
3. Payers give healthcare providers flexible, adequate
resources to overcome the barriers in the current
payment system
4. Healthcare providers take accountability for
achieving the improvements in care and reductions
in spending
WIN: Better Care for Patients
WIN: Lower Spending for Payers
WIN: Financially Successful Healthcare Providers
© Center for Healthcare Quality and Payment Reform www.CHQPR.org
36
• Hospital-acquired infections
• Medical errors
• Hospital readmissions
PROCEDURE
$
COMPLICATIONS
Opportunity Area #1:
Identify Avoidable Complications
© Center for Healthcare Quality and Payment Reform www.CHQPR.org
37
Savings
PROCEDURE
COMPLICATIONS
COMPLICATIONS
$
PROCEDURE
Opportunity Area #1:
Reduce Avoidable Complications
© Center for Healthcare Quality and Payment Reform www.CHQPR.org
38
COMPLICATIONS
Warranty
•
•
PROCEDURE
•
PROCEDURE
$
COMPLICATIONS
Payment Solution #1:
(Limited) Warranty
•
WARRANTY PAYMENT
Higher payment to support
higher-quality care
No additional payment to correct
preventable complications
Savings from reducing avoidable
complications
Not an outcome guarantee
© Center for Healthcare Quality and Payment Reform www.CHQPR.org
39
• Unnecessary post-acute care
• Unnecessary consultations
• Unnecessarily expensive drugs,
medical devices, etc.
PROCEDURE
INEFFICIENCY
COMPLICATIONS
Warranty
PROCEDURE
PROCEDURE
$
COMPLICATIONS
Opportunity Area #2:
Identify Inefficiencies in Delivery
© Center for Healthcare Quality and Payment Reform www.CHQPR.org
40
PROCEDURE
INEFFICI
ENCY
INEFFICIENCY
Savings
PROCEDURE
COMPLICATIONS
Warranty
PROCEDURE
PROCEDURE
$
COMPLICATIONS
Opportunity Area #2:
Reduce Inefficiencies in Delivery
© Center for Healthcare Quality and Payment Reform www.CHQPR.org
41
INEFFICI
ENCY
Bundle
PROCEDURE
PROCEDURE
INEFFICIENCY
COMPLICATIONS
Warranty
PROCEDURE
PROCEDURE
$
COMPLICATIONS
Payment Solution #2:
Bundle for Entire Procedure
BUNDLED PAYMENT
• Single payment to
support all of the
services needed to
deliver a treatment
• Higher payments for
patients with higher
needs rather than
higher payments just
because more services
were delivered
• Savings from reducing
unnecessary services
© Center for Healthcare Quality and Payment Reform www.CHQPR.org
42
INEFFICI COMPLIENCY CATIONS
Procedural Episode
Bundle + Warranty
PROCEDURE
PROCEDURE
$
INEFFIC- COMPLIIENCY CATIONS
Payment Solution #3:
Episode = Bundle + Warranty
EPISODE PAYMENT
• Bundle: Single payment for
all services related to
a treatment
• Warranty: No additional
payment to address
complications that occur
after treatment is completed
© Center for Healthcare Quality and Payment Reform www.CHQPR.org
43
INEFFICI
ENCY
Bundle
HOSPITAL
PROCEDURE
INEFFICIENCY
Procedural Episode
Bundle + Warranty
HOSPITAL
PROCEDURE
COMPLICATIONS
Warranty
HOSPTIAL PROCEDURE
HOSPTAL PROCEDURE
$
COMPLICATIONS
Most Bundles/Warranties/Episodes
Are for Hospital-Based Procedures
© Center for Healthcare Quality and Payment Reform www.CHQPR.org
44
INEFFICI
ENCY
HOSPITAL
PROCEDURE
HOSPITAL
PROCEDURE
INEFFICIENCY
HOSPITAL
PROCEDURE
LOWER-COST
SITE OF
SERVICE
• Outpatient
surgery
• Drugs
administered in
physician
offices
• Births in birth
centers
COMPLICATIONS
HOSPTIAL PROCEDURE
HOSPTAL PROCEDURE
$
COMPLICATIONS
Opportunity Area #3:
Using Lower-Cost Sites of Service
© Center for Healthcare Quality and Payment Reform www.CHQPR.org
45
LOWER-COST
TREATMENT
INEFFICI
ENCY
HOSPITAL
PROCEDURE
HOSPITAL
PROCEDURE
INEFFICIENCY
HOSPITAL
PROCEDURE
LOWER-COST
SITE OF
SERVICE
• Physical
therapy instead
of joint or back
surgery
• Medication
therapy instead
of invasive
procedure
• Vaginal delivery
instead of
C-Section
COMPLICATIONS
HOSPTIAL PROCEDURE
HOSPTAL PROCEDURE
$
COMPLICATIONS
Opportunity Area #4:
Using Lower-Cost Treatments
© Center for Healthcare Quality and Payment Reform www.CHQPR.org
46
LOWER-COST
TREATMENT
LOWER-COST
SITE OF
SERVICE
HOSPITAL
PROCEDURE
HOSPITAL
PROCEDURE
HOSPITAL
PROCEDURE
INEFFICI
ENCY
INEFFICIENCY
HOSPTIAL PROCEDURE
COMPLICATIONS
COMPLICATIONS
$
HOSPTAL PROCEDURE
To Capture Those
Savings Opportunities…
Savings
Savings
© Center for Healthcare Quality and Payment Reform www.CHQPR.org
47
CONDITION-BASED PAYMENT
• Single (bundled) payment for all
services needed to treat a
condition
• Higher payments for patients
with more severe conditions
• Savings from reducing
unnecessary treatments or using
lower-cost treatments
LOWER-COST
TREATMENT
Condition-Based
Payment
LOWER-COST
SITE OF
SERVICE
HOSPITAL
PROCEDURE
INEFFICI
ENCY
HOSPITAL
PROCEDURE
HOSPITAL
PROCEDURE
INEFFICIENCY
COMPLICATIONS
HOSPTIAL PROCEDURE
HOSPTAL PROCEDURE
$
COMPLICATIONS
Payment Option 4:Condition-Based
Payment, Not a Procedural Episode
© Center for Healthcare Quality and Payment Reform www.CHQPR.org
48
Condition-Based Payments
Needed Across Healthcare
• Knee Osteoarthritis
– Home-based rehab instead of facility-based rehab
– Physical therapy instead of surgery
• Chest Pain
– Non-invasive imaging instead of invasive imaging
– Medical management instead of invasive treatment
• Chronic Disease Management
– Improved education and self-management support
– Avoiding hospitalizations for exacerbations
• Maternity Care
– Vaginal delivery instead of C-Section
– Term delivery instead of early elective delivery
– Delivery in birth center instead of hospital
© Center for Healthcare Quality and Payment Reform www.CHQPR.org
49
All of These Payment Options Can
Be Used in Maternity Care
Normal
Pregnancy
Delivery
© Center for Healthcare Quality and Payment Reform www.CHQPR.org
50
Bundles to Encourage Providers
to Reduce Hospital Costs
Bundled Payment
OB $$$
C-Section
Normal
Pregnancy
Delivery
Hospital $$$
Bundled Payment
Vaginal OB/CNM $$
Delivery
Hospital $$
© Center for Healthcare Quality and Payment Reform www.CHQPR.org
51
Warranties to Support Reductions
in Delivery-Related Complications
Bundled Payment with Warranty (Episode)
OB $$$
C-Section
Hospital $$$
Complications
No Complications
Bundled Payment with Warranty (Episode)
Normal
Pregnancy
Delivery
Vaginal
Delivery
OB/CNM $$
Complications
Hospital $$
No Complications
© Center for Healthcare Quality and Payment Reform www.CHQPR.org
52
Condition-Based Payment to
Encourage More Vaginal Deliveries
Condition-Based Payment
OB $$$
C-Section
in Hospital Hospital $$$
Normal
Pregnancy
Delivery
Vaginal OB/CNM $$
Delivery
in Hospital Hospital $$
Complications
No Complications
Complications
No Complications
© Center for Healthcare Quality and Payment Reform www.CHQPR.org
53
Condition-Based Payment To
Encourage Use of Birth Centers
Condition-Based Payment
OB $$$
C-Section
in Hospital Hospital $$$
Normal
Pregnancy
Delivery
Vaginal OB/CNM $$
Delivery
in Hospital Hospital $$
CNM $
Delivery in
Birth Center Birth Ctr $
Complications
No Complications
Complications
No Complications
Complications
No Complications
© Center for Healthcare Quality and Payment Reform www.CHQPR.org
54
Payment Can Also Move
Upstream to Improve Outcomes
Population-Based Payment/Maternity ACO-CCO
Higher-Risk
Pregnancy
Total
Patient
Population
PreConception
Care
Lower-Risk
Pregnancy
Avoided
Pregnancy
© Center for Healthcare Quality and Payment Reform www.CHQPR.org
55
Basic Condition-Based Payment
Has Best Opportunities for Savings
Condition-Based Payment
OB $$$
C-Section
in Hospital Hospital $$$
Normal
Pregnancy
Delivery
Vaginal OB/CNM $$
Delivery
in Hospital Hospital $$
CNM $
Delivery in
Birth Center Birth Ctr $
Complications
No Complications
Complications
No Complications
Complications
No Complications
© Center for Healthcare Quality and Payment Reform www.CHQPR.org
56
Making the Numbers Work:
A Hypothetical Example
© Center for Healthcare Quality and Payment Reform www.CHQPR.org
57
Making the Numbers Work:
A Hypothetical Example
WARNING TO THOSE
WITH MATH PHOBIA:
Lots of Numbers Coming Quickly;
Slides Available for
Detailed Review Afterwards
© Center for Healthcare Quality and Payment Reform www.CHQPR.org
58
Making the Numbers Work:
A Hypothetical Example
WARNING TO THOSE
WITH MATH PHOBIA:
Lots of Numbers Coming Quickly;
Slides Available for
Detailed Review Afterwards
Examples are all simplified for purposes of presentation
but the principles and conclusions are realistic
© Center for Healthcare Quality and Payment Reform www.CHQPR.org
59
Payment to Birth Center
$/Patient
Birth Center
Midwife
Birth Center
Total
$2,200
$4,000
$6,200
© Center for Healthcare Quality and Payment Reform www.CHQPR.org
60
Payment for Hospital Delivery
$/Patient
Birth Center
Midwife
Birth Center
Total
Hosp. Vaginal
OB-GYN Vag.
Hospital Vag.
Total
$2,200
$4,000
$6,200
$3,300
$7,500
$10,800
© Center for Healthcare Quality and Payment Reform www.CHQPR.org
61
Payment for C-Section
$/Patient
Birth Center
Midwife
Birth Center
Total
$2,200
$4,000
$6,200
Hosp. Vaginal
OB-GYN Vag.
Hospital Vag.
Total
$3,300
$7,500
$10,800
Hosp C-Section
OB-GYN C-S
Hospital C-S
Total
$3,600
$12,000
$15,600
© Center for Healthcare Quality and Payment Reform www.CHQPR.org
62
Birth Center Deliveries Are
Dramatically Less Expensive
$/Patient
Birth Center
Midwife
Birth Center
Total
Hosp. Vaginal
OB-GYN Vag.
Hospital Vag.
Total
Hosp C-Section
OB-GYN C-S
Hospital C-S
Total
$2,200
$4,000
$6,200
$3,300
$7,500
$10,800
-43%
-60%
$3,600
$12,000
$15,600
© Center for Healthcare Quality and Payment Reform www.CHQPR.org
63
Birth Center Deliveries Are
Dramatically Less Expensive
$/Patient
Birth Center
Midwife
Birth Center
Total
Hosp. Vaginal
OB-GYN Vag.
Hospital Vag.
Total
Hosp C-Section
OB-GYN C-S
Hospital C-S
Total
$2,200
$4,000
$6,200
$3,300
$7,500
$10,800
-43%
-60%
But not every delivery
can be done in a birth center,
and not every woman
will want to try…
…so what is the real savings
opportunity??
$3,600
$12,000
$15,600
© Center for Healthcare Quality and Payment Reform www.CHQPR.org
64
Assume a Typical Current
Distribution of Births
CURRENT
$/Patient # Pts
Birth Center
Midwife
Birth Center
Total
$2,200
$4,000
$6,200
Hosp. Vaginal
OB-GYN Vag.
Hospital Vag.
Total
$3,300
$7,500
$10,800
Hosp C-Section
OB-GYN C-S
Hospital C-S
Total
$3,600
$12,000
$15,600
Total Pmt/Cost
20
Type of Delivery
Birth
Center
2%
CSection
680
68%
Hospital
Vaginal
300
30%
1000
100%
© Center for Healthcare Quality and Payment Reform www.CHQPR.org
65
Average Overall Spending
is More Than $12,000 Per Birth
CURRENT
$/Patient # Pts
Total $
Birth Center
Midwife
Birth Center
Total
$2,200
$4,000
$6,200
20
$44,000
$80,000
$124,000
680
$2,244,000
$5,100,000
$7,344,000
300
$1,080,000
$3,600,000
$4,680,000
Hosp. Vaginal
OB-GYN Vag.
Hospital Vag.
Total
$3,300
$7,500
$10,800
Hosp C-Section
OB-GYN C-S
Hospital C-S
Total
$3,600
$12,000
$15,600
Total Pmt/Cost
$12,148 1000 $12,148,000
© Center for Healthcare Quality and Payment Reform www.CHQPR.org
66
What if We Could Deliver 30%
of Babies in the Birth Center?
CURRENT
$/Patient # Pts
Total $
Birth Center
Midwife
Birth Center
Total
$2,200
$4,000
$6,200
FUTURE
$/Patient # Pts
Total $
Chg
20
$44,000
$80,000
$124,000
300
1400%
680
$2,244,000
$5,100,000
$7,344,000
500
-26%
300
-33%
Hosp. Vaginal
OB-GYN Vag.
Hospital Vag.
Total
$3,300
$7,500
$10,800
Hosp C-Section
OB-GYN C-S
Hospital C-S
Total
$3,600
$12,000
$15,600
$1,080,000
$3,600,000
$4,680,000
200
Total Pmt/Cost
$12,148 1000 $12,148,000
1000
© Center for Healthcare Quality and Payment Reform www.CHQPR.org
67
15% Savings on Maternity Care?
CURRENT
$/Patient # Pts
Total $
Birth Center
Midwife
Birth Center
Total
$2,200
$4,000
$6,200
FUTURE
$/Patient # Pts
Total $
20
$44,000
$80,000
$124,000
680
$2,244,000
$5,100,000
$7,344,000
300
$1,080,000
$3,600,000
$4,680,000
Hosp. Vaginal
OB-GYN Vag.
Hospital Vag.
Total
$3,300
$7,500
$10,800
Hosp C-Section
OB-GYN C-S
Hospital C-S
Total
$3,600
$12,000
$15,600
Total Pmt/Cost
$12,148 1000 $12,148,000
Chg
300
$660,000
$1,200,000
$1,860,000 1400%
500
$1,650,000
$3,750,000
$5,400,000
-26%
200
$720,000
$2,400,000
$3,120,000
-33%
1000 $10,380,000
-15%
© Center for Healthcare Quality and Payment Reform www.CHQPR.org
68
Viewed from the Perspective
of the Maternity Providers…
© Center for Healthcare Quality and Payment Reform www.CHQPR.org
69
Good for the Midwives
Midwife
CURRENT
FUTURE
$/Patient # Pts
Total $
$/Patient # Pts
Total $
Chg
$2,200
20
$44,000
$2,200 300
$660,000 1400%
© Center for Healthcare Quality and Payment Reform www.CHQPR.org
70
Bad for the OB-Gyns
Midwife
OB-GYN
Vaginal Birth
C-Section
Subtotal
CURRENT
FUTURE
$/Patient # Pts
Total $
$/Patient # Pts
Total $
Chg
$2,200
20
$44,000
$2,200 300
$660,000 1400%
$3,300
$3,600
680
300
980
$2,244,000
$1,080,000
$3,324,000
$3,300
$3,600
500
200
700
$1,650,000
$720,000
$2,370,000
-29%
© Center for Healthcare Quality and Payment Reform www.CHQPR.org
71
Good for the Birth Center
Midwife
OB-GYN
Vaginal Birth
C-Section
Subtotal
Birth Center
CURRENT
FUTURE
$/Patient # Pts
Total $
$/Patient # Pts
Total $
Chg
$2,200
20
$44,000
$2,200 300
$660,000 1400%
$3,300
$3,600
$4,000
680
300
980
$2,244,000
$1,080,000
$3,324,000
$3,300
$3,600
20
$80,000
$4,000
500
200
700
$1,650,000
$720,000
$2,370,000
300
$1,200,000 1400%
-29%
© Center for Healthcare Quality and Payment Reform www.CHQPR.org
72
Bad for the Hospital
Midwife
OB-GYN
Vaginal Birth
C-Section
Subtotal
Birth Center
Hospital
Vaginal Birth
C-Section
Subtotal
CURRENT
FUTURE
$/Patient # Pts
Total $
$/Patient # Pts
Total $
Chg
$2,200
20
$44,000
$2,200 300
$660,000 1400%
$3,300
$3,600
680
300
980
$2,244,000
$1,080,000
$3,324,000
$3,300
$3,600
500
200
700
$1,650,000
$720,000
$2,370,000
$4,000
20
$80,000
$4,000
300
$1,200,000 1400%
$7,500
$12,000
680
300
980
$5,100,000
$3,600,000
$8,700,000
$7,500
$12,000
500
200
700
$3,750,000
$2,400,000
$6,150,000
-29%
-29%
© Center for Healthcare Quality and Payment Reform www.CHQPR.org
73
Good for the Payer
Midwife
OB-GYN
Vaginal Birth
C-Section
Subtotal
Birth Center
Hospital
Vaginal Birth
C-Section
Subtotal
Total Spending
CURRENT
FUTURE
$/Patient # Pts
Total $
$/Patient # Pts
Total $
Chg
$2,200
20
$44,000
$2,200 300
$660,000 1400%
$3,300
$3,600
680
300
980
$2,244,000
$1,080,000
$3,324,000
$3,300
$3,600
$4,000
20
$80,000
$7,500
$12,000
680
300
980
$5,100,000
$3,600,000
$8,700,000
$12,148 1000 $12,148,000
500
200
700
$1,650,000
$720,000
$2,370,000
$4,000
300
$1,200,000 1400%
$7,500
$12,000
500
200
700
$3,750,000
$2,400,000
$6,150,000
-29%
1000 $10,380,000
-15%
-29%
© Center for Healthcare Quality and Payment Reform www.CHQPR.org
74
Win-Lose Outcome
Midwife
OB-GYN
Vaginal Birth
C-Section
Subtotal
Birth Center
Hospital
Vaginal Birth
C-Section
Subtotal
Payer
CURRENT
FUTURE
$/Patient # Pts
Total $
$/Patient # Pts
Total $
Chg
$2,200
20
$44,000
$2,200 300
$660,000 1400%
$3,300
$3,600
680
300
980
$2,244,000
$1,080,000
$3,324,000
$3,300
$3,600
$4,000
20
$80,000
$7,500
$12,000
680
300
980
$5,100,000
$3,600,000
$8,700,000
$12,148 1000 $12,148,000
500
200
700
$1,650,000
$720,000
$2,370,000
$4,000
300
$1,200,000 1400%
$7,500
$12,000
500
200
700
$3,750,000
$2,400,000
$6,150,000
-29%
1000 $10,380,000
-15%
-29%
© Center for Healthcare Quality and Payment Reform www.CHQPR.org
75
Should Birth Centers Care That
Hospitals & OB-GYNs Lose $?
• Birth centers can’t offer a complete replacement for
hospital/OB-GYN maternity care
• Mothers wouldn’t use the birth center without a
hospital/OB-GYN backup
• The birth center can’t give an accurate price/cost estimate to
payers or mothers without a committed price from the
hospitals & OB-GYNs
© Center for Healthcare Quality and Payment Reform www.CHQPR.org
76
Will Physicians and Hospitals Raise
their Prices to Offset Losses?…
Midwife
OB-GYN
Vaginal Birth
C-Section
Subtotal
Birth Center
Hospital
Vaginal Birth
C-Section
Subtotal
Payer
CURRENT
FUTURE
$/Patient # Pts
Total $
$/Patient # Pts
Total $
$2,200
20
$44,000
$2,200 300
$3,300
$3,600
680
300
980
$2,244,000
$1,080,000
$3,324,000
$4,600
$5,100
$4,000
20
$80,000
$4,000
300
$7,500
$12,000
680
300
980
$5,100,000
$3,600,000
$8,700,000
$10,500
$17,000
500
200
700
$12,148 1000 $12,148,000
500
200
700
Chg
$2,300,000
$1,020,000
$3,320,000
0%
$5,250,000
$3,600,000
$8,850,000
3%
0%
2%
1000
© Center for Healthcare Quality and Payment Reform www.CHQPR.org
77
…If So, Total Spending
Will Increase
Midwife
OB-GYN
Vaginal Birth
C-Section
Subtotal
Birth Center
Hospital
Vaginal Birth
C-Section
Subtotal
Payer
CURRENT
FUTURE
$/Patient # Pts
Total $
$/Patient # Pts
Total $
Chg
$2,200
20
$44,000
$2,200 300
$660,000 1400%
$3,300
$3,600
680
300
980
$2,244,000
$1,080,000
$3,324,000
$4,600
$5,100
$4,000
20
$80,000
$7,500
$12,000
680
300
980
$5,100,000
$3,600,000
$8,700,000
$12,148 1000 $12,148,000
500
200
700
$2,300,000
$1,020,000
$3,320,000
$4,000
300
$1,200,000 1400%
$10,500
$17,000
500
200
700
$5,250,000
$3,600,000
$8,850,000
3%
0%
2%
1000 $14,030,000
+15%
0%
© Center for Healthcare Quality and Payment Reform www.CHQPR.org
78
If the Payer Can’t Be Assured of
Savings, Status Quo is Better
Midwife
OB-GYN
Vaginal Birth
C-Section
Subtotal
Birth Center
Hospital
Vaginal Birth
C-Section
Subtotal
Payer
CURRENT
FUTURE
$/Patient # Pts
Total $
$/Patient # Pts
Total $
Chg
$2,200
20
$44,000
$2,200 300
$660,000 1400%
$3,300
$3,600
680
300
980
$2,244,000
$1,080,000
$3,324,000
$4,600
$5,100
$4,000
20
$80,000
$7,500
$12,000
680
300
980
$5,100,000
$3,600,000
$8,700,000
$12,148 1000 $12,148,000
500
200
700
$2,300,000
$1,020,000
$3,320,000
$4,000
300
$1,200,000 1400%
$10,500
$17,000
500
200
700
$5,250,000
$3,600,000
$8,850,000
3%
0%
2%
1000 $14,030,000
+15%
0%
© Center for Healthcare Quality and Payment Reform www.CHQPR.org
79
Episodes Limited to Birth Center
Services Won’t Be of Much Interest
OB $$$
C-Section
in Hospital Hospital $$$
Normal
Pregnancy
Delivery
Vaginal OB/CNM $$
Delivery
in Hospital Hospital $$
Birth Center Episode
CNM $
Delivery in
Birth Center Birth Ctr $
Hospital
Delivery
$$$
Total cost is not predictable
for either insurance plan or consumer
© Center for Healthcare Quality and Payment Reform www.CHQPR.org
80
Birth Center Would Be at Risk for
Hospital Costs in a Full Episode
OB $$$
C-Section
in Hospital Hospital $$$
Normal
Pregnancy
Delivery
Vaginal OB/CNM $$
Delivery
in Hospital Hospital $$
Birth Center Episode
CNM $
Delivery in
Birth Center Birth Ctr $
Hospital
Delivery
$$$
© Center for Healthcare Quality and Payment Reform www.CHQPR.org
81
Payers (and Patients) Want a
Comprehensive Solution
Condition-Based Payment
OB $$$
C-Section
in Hospital Hospital $$$
Normal
Pregnancy
Delivery
Vaginal OB/CNM $$
Delivery
in Hospital Hospital $$
CNM $
Delivery in
Birth Center Birth Ctr $
© Center for Healthcare Quality and Payment Reform www.CHQPR.org
82
Do Hospitals Have to Lose for
Birth Centers & Payers to Win?
Midwife
OB-GYN
Vaginal Birth
C-Section
Subtotal
Birth Center
Hospital
Vaginal Birth
C-Section
Subtotal
Payer
CURRENT
FUTURE
$/Patient # Pts
Total $
$/Patient # Pts
Total $
Chg
$2,200
20
$44,000
$2,200 300
$660,000 1400%
$3,300
$3,600
680
300
980
$2,244,000
$1,080,000
$3,324,000
$3,300
$3,600
$4,000
20
$80,000
$7,500
$12,000
680
300
980
$5,100,000
$3,600,000
$8,700,000
$12,148 1000 $12,148,000
500
200
700
$1,650,000
$720,000
$2,370,000
$4,000
300
$1,200,000 1400%
$7,500
$12,000
500
200
700
$3,750,000
$2,400,000
$6,150,000
-29%
1000 $10,380,000
-15%
-29%
© Center for Healthcare Quality and Payment Reform www.CHQPR.org
83
What Should Matter to Hospitals is
Margin, Not Revenues (Volume)
© Center for Healthcare Quality and Payment Reform www.CHQPR.org
84
Hospital Costs Are Not
Proportional to Utilization
7% reduction
in cost
.
Costs
100
99
98
97
96
95
94
93
92
91
90
89
88
87
86
85
84
83
82
81
20% reduction in volume
$1,000
$980
$960
$940
$920
$900
$880
$860
$840
$820
$800
$000
Cost & Revenue Changes With Fewer Patients
#Patients
© Center for Healthcare Quality and Payment Reform www.CHQPR.org
85
Reductions in Utilization Reduce
Revenues More Than Costs
7% reduction
in cost
20% reduction in volume
Revenues
Costs
100
99
98
97
96
95
94
93
92
91
90
89
88
87
86
85
84
83
82
81
20% reduction
in revenue
$1,000
$980
$960
$940
$920
$900
$880
$860
$840
$820
$800
$000
Cost & Revenue Changes With Fewer Patients
#Patients
© Center for Healthcare Quality and Payment Reform www.CHQPR.org
86
Causing Negative Margins
for Hospitals
$1,000
$980
$960
$940
$920
$900
$880
$860
$840
$820
$800
Revenues
Costs
100
99
98
97
96
95
94
93
92
91
90
89
88
87
86
85
84
83
82
81
Payers Will Be
Underpaying For
Care If
Deliveries,
Surgeries, Etc.
Are Reduced
$000
Cost & Revenue Changes With Fewer Patients
#Patients
© Center for Healthcare Quality and Payment Reform www.CHQPR.org
87
But Spending Can Be Reduced
Without Bankrupting Hospitals
Cost & Revenue Changes With Fewer Patients
100
99
98
97
96
95
94
93
92
91
90
89
88
87
86
85
84
83
82
81
$000
Payers Can
$1,000
Still Save $
$980
Without Causing
$960
Negative Margins
$940
for Hospital
$920
$900
$880
Revenues
$860
Costs
$840
$820
$800
#Patients
© Center for Healthcare Quality and Payment Reform www.CHQPR.org
88
Need to Understand Hospital
Costs, Not Just Hospital Payment
Midwife
OB-GYN
Vaginal Birth
C-Section
Subtotal
Birth Center
Hospital
Vaginal Birth
C-Section
Subtotal
Total Spending
CURRENT
FUTURE
$/Patient # Pts
Total $
$/Patient # Pts
Total $
Chg
$2,200
20
$44,000
$2,200 300
$660,000 1400%
$3,300
$3,600
680
300
980
$2,244,000
$1,080,000
$3,324,000
$3,300
$3,600
$4,000
20
$80,000
$7,500
$12,000
680
300
980
$5,100,000
$3,600,000
$8,700,000
$12,148 1000 $12,148,000
500
200
700
$1,650,000
$720,000
$2,370,000
$4,000
300
$1,200,000 1400%
$7,500
$12,000
500
200
700
$3,750,000
$2,400,000
$6,150,000
-29%
1000 $10,380,000
-15%
-29%
© Center for Healthcare Quality and Payment Reform www.CHQPR.org
89
Fixed Costs Are Significant for
Standby Services Like Maternity
Midwife
OB-GYN
Vaginal Birth
C-Section
Subtotal
Birth Center
Hospital
Fixed Cost
Variable Cost
Margin
Subtotal
Total Spending
CURRENT
FUTURE
$/Patient # Pts
Total $
$/Patient # Pts
Total $
Chg
$2,200
20
$44,000
$2,200 300
$660,000 1400%
$3,300
$3,600
$4,000
680
300
980
$2,244,000
$1,080,000
$3,324,000
$3,300
$3,600
20
$80,000
$4,000
500
200
700
$1,650,000
$720,000
$2,370,000
300
$1,200,000 1400%
-29%
50%
45%
5%
$8,700,000
$12,148 1000 $12,148,000
© Center for Healthcare Quality and Payment Reform www.CHQPR.org
90
Costs Are What Matter In
Determining Adequacy of Payment
Midwife
OB-GYN
Vaginal Birth
C-Section
Subtotal
Birth Center
Hospital
Fixed Cost
Variable Cost
Margin
Subtotal
Total Spending
CURRENT
FUTURE
$/Patient # Pts
Total $
$/Patient # Pts
Total $
Chg
$2,200
20
$44,000
$2,200 300
$660,000 1400%
$3,300
$3,600
$4,000
680
300
980
$2,244,000
$1,080,000
$3,324,000
$3,300
$3,600
20
$80,000
$4,000
500
200
700
$1,650,000
$720,000
$2,370,000
300
$1,200,000 1400%
-29%
50% $4,350,000
$3,995 45% $3,915,000
5%
$435,000
980 $8,700,000
$12,148 1000 $12,148,000
© Center for Healthcare Quality and Payment Reform www.CHQPR.org
91
What Happens When # of
Hospital Deliveries is Reduced?
Midwife
OB-GYN
Vaginal Birth
C-Section
Subtotal
Birth Center
Hospital
Fixed Cost
Variable Cost
Margin
Subtotal
Total Spending
CURRENT
FUTURE
$/Patient # Pts
Total $
$/Patient # Pts
Total $
Chg
$2,200
20
$44,000
$2,200 300
$660,000 1400%
$3,300
$3,600
$4,000
680
300
980
$2,244,000
$1,080,000
$3,324,000
$3,300
$3,600
20
$80,000
$4,000
50% $4,350,000
$3,995 45% $3,915,000
5%
$435,000
980 $8,700,000
$12,148 1000 $12,148,000
500
200
700
$1,650,000
$720,000
$2,370,000
300
$1,200,000 1400%
-29%
700
© Center for Healthcare Quality and Payment Reform www.CHQPR.org
92
Hospital Still Needs to Support
Fixed Costs of Maternity Services
Midwife
OB-GYN
Vaginal Birth
C-Section
Subtotal
Birth Center
Hospital
Fixed Cost
Variable Cost
Margin
Subtotal
Total Spending
CURRENT
FUTURE
$/Patient # Pts
Total $
$/Patient # Pts
Total $
Chg
$2,200
20
$44,000
$2,200 300
$660,000 1400%
$3,300
$3,600
$4,000
680
300
980
$2,244,000
$1,080,000
$3,324,000
$3,300
$3,600
20
$80,000
$4,000
50% $4,350,000
$3,995 45% $3,915,000
5%
$435,000
980 $8,700,000
$12,148 1000 $12,148,000
500
200
700
$1,650,000
$720,000
$2,370,000
300
$1,200,000 1400%
-29%
$4,350,000
0%
700
© Center for Healthcare Quality and Payment Reform www.CHQPR.org
93
Variable Costs Will Decrease
With Fewer Admissions
Midwife
OB-GYN
Vaginal Birth
C-Section
Subtotal
Birth Center
Hospital
Fixed Cost
Variable Cost
Margin
Subtotal
Total Spending
CURRENT
FUTURE
$/Patient # Pts
Total $
$/Patient # Pts
Total $
Chg
$2,200
20
$44,000
$2,200 300
$660,000 1400%
$3,300
$3,600
$4,000
680
300
980
$2,244,000
$1,080,000
$3,324,000
$3,300
$3,600
20
$80,000
$4,000
50% $4,350,000
$3,995 45% $3,915,000
5%
$435,000
980 $8,700,000
$12,148 1000 $12,148,000
500
200
700
$1,650,000
$720,000
$2,370,000
300
$1,200,000 1400%
$4,350,000
$2,796,429
$3,995
-29%
0%
-29%
700
© Center for Healthcare Quality and Payment Reform www.CHQPR.org
94
Assume the Hospital’s Margin
Doesn’t Change
Midwife
OB-GYN
Vaginal Birth
C-Section
Subtotal
Birth Center
Hospital
Fixed Cost
Variable Cost
Margin
Subtotal
Total Spending
CURRENT
FUTURE
$/Patient # Pts
Total $
$/Patient # Pts
Total $
Chg
$2,200
20
$44,000
$2,200 300
$660,000 1400%
$3,300
$3,600
$4,000
680
300
980
$2,244,000
$1,080,000
$3,324,000
$3,300
$3,600
20
$80,000
$4,000
50% $4,350,000
$3,995 45% $3,915,000
5%
$435,000
980 $8,700,000
$12,148 1000 $12,148,000
500
200
700
$1,650,000
$720,000
$2,370,000
300
$1,200,000 1400%
$4,350,000
$2,796,429
$435,000
$3,995
-29%
0%
-29%
0%
700
© Center for Healthcare Quality and Payment Reform www.CHQPR.org
95
Hospital Can Accept Lower
Revenue & Maintain Services…
Midwife
OB-GYN
Vaginal Birth
C-Section
Subtotal
Birth Center
Hospital
Fixed Cost
Variable Cost
Margin
Subtotal
Total Spending
CURRENT
FUTURE
$/Patient # Pts
Total $
$/Patient # Pts
Total $
Chg
$2,200
20
$44,000
$2,200 300
$660,000 1400%
$3,300
$3,600
$4,000
680
300
980
$2,244,000
$1,080,000
$3,324,000
$3,300
$3,600
20
$80,000
$4,000
50% $4,350,000
$3,995 45% $3,915,000
5%
$435,000
980 $8,700,000
$12,148 1000 $12,148,000
500
200
700
$1,650,000
$720,000
$2,370,000
300
$1,200,000 1400%
700
$4,350,000
$2,796,429
$435,000
$7,581,429
$3,995
-29%
0%
-29%
0%
-13%
© Center for Healthcare Quality and Payment Reform www.CHQPR.org
96
Cost Per Hospital Delivery Will
Increase…
Midwife
OB-GYN
Vaginal Birth
C-Section
Subtotal
Birth Center
Hospital
Fixed Cost
Variable Cost
Margin
Subtotal
Total Spending
CURRENT
FUTURE
$/Patient # Pts
Total $
$/Patient # Pts
Total $
Chg
$2,200
20
$44,000
$2,200 300
$660,000 1400%
$3,300
$3,600
$4,000
680
300
980
$2,244,000
$1,080,000
$3,324,000
$3,300
$3,600
20
$80,000
$4,000
50% $4,350,000
$3,995 45% $3,915,000
5%
$435,000
$8,878 980 $8,700,000
$12,148 1000 $12,148,000
500
200
700
$1,650,000
$720,000
$2,370,000
300
$1,200,000 1400%
700
$4,350,000
$2,796,429
$435,000
$7,581,429
$3,995
$10,831
-29%
0%
-29%
0%
-13%
© Center for Healthcare Quality and Payment Reform www.CHQPR.org
97
Cost Per Hospital Delivery Will
Increase…But Total Spend Declines
Midwife
OB-GYN
Vaginal Birth
C-Section
Subtotal
Birth Center
Hospital
Fixed Cost
Variable Cost
Margin
Subtotal
Total Spending
CURRENT
FUTURE
$/Patient # Pts
Total $
$/Patient # Pts
Total $
Chg
$2,200
20
$44,000
$2,200 300
$660,000 1400%
$3,300
$3,600
$4,000
680
300
980
$2,244,000
$1,080,000
$3,324,000
$3,300
$3,600
20
$80,000
$4,000
50% $4,350,000
$3,995 45% $3,915,000
5%
$435,000
$8,878 980 $8,700,000
$12,148 1000 $12,148,000
500
200
700
$1,650,000
$720,000
$2,370,000
300
$1,200,000 1400%
700
$4,350,000
$2,796,429
$435,000
$7,581,429
$3,995
$10,831
-29%
0%
-29%
0%
-13%
© Center for Healthcare Quality and Payment Reform www.CHQPR.org
98
Some Savings Achieved, But
Not As Dramatic As Predicted
Midwife
OB-GYN
Vaginal Birth
C-Section
Subtotal
Birth Center
Hospital
Fixed Cost
Variable Cost
Margin
Subtotal
Total Spending
CURRENT
FUTURE
$/Patient # Pts
Total $
$/Patient # Pts
Total $
Chg
$2,200
20
$44,000
$2,200 300
$660,000 1400%
$3,300
$3,600
$4,000
680
300
980
$2,244,000
$1,080,000
$3,324,000
$3,300
$3,600
20
$80,000
$4,000
50% $4,350,000
$3,995 45% $3,915,000
5%
$435,000
$8,878 980 $8,700,000
$12,148 1000 $12,148,000
500
200
700
$1,650,000
$720,000
$2,370,000
300
$1,200,000 1400%
$4,350,000
$3,995
$2,796,429
$435,000
$10,831 700 $7,581,429
$11,811 1000 $11,811,429
-29%
0%
-29%
0%
-13%
-3%
© Center for Healthcare Quality and Payment Reform www.CHQPR.org
99
Lower Birth Center Costs With
Higher Volume Increases Savings
Midwife
OB-GYN
Vaginal Birth
C-Section
Subtotal
Birth Center
Hospital
Fixed Cost
Variable Cost
Margin
Subtotal
Total Spending
CURRENT
FUTURE
$/Patient # Pts
Total $
$/Patient # Pts
Total $
Chg
$2,200
20
$44,000
$2,200 300
$660,000 1400%
$3,300
$3,600
$4,000
680
300
980
$2,244,000
$1,080,000
$3,324,000
$3,300
$3,600
20
$80,000
$3,500
50% $4,350,000
$3,995 45% $3,915,000
5%
$435,000
$8,878 980 $8,700,000
$12,148 1000 $12,148,000
500
200
700
$1,650,000
$720,000
$2,370,000
300
$1,050,000 1213%
$4,350,000
$3,995
$2,796,429
$435,000
$10,831 700 $7,581,429
$11,661 1000 $11,661,429
-29%
0%
-29%
0%
-13%
-4%
© Center for Healthcare Quality and Payment Reform www.CHQPR.org
100
Bigger Savings Possible If Hospital
Can Reduce L&D Capacity
Midwife
OB-GYN
Vaginal Birth
C-Section
Subtotal
Birth Center
Hospital
Fixed Cost
Variable Cost
Margin
Subtotal
Total Spending
CURRENT
FUTURE
$/Patient # Pts
Total $
$/Patient # Pts
Total $
Chg
$2,200
20
$44,000
$2,200 300
$660,000 1400%
$3,300
$3,600
$4,000
680
300
980
$2,244,000
$1,080,000
$3,324,000
$3,300
$3,600
20
$80,000
$3,500
20% $1,740,000
$6,658 75% $6,525,000
5%
$435,000
$8,878 980 $8,700,000
$12,148 1000 $12,148,000
500
200
700
$1,650,000
$720,000
$2,370,000
300
$1,050,000 1213%
$1,740,000
$6,658
$4,660,714
$435,000
$9,827 700 $6,879,214
$10,959 1000 $10,959,214
-29%
0%
-29%
+10%
-21%
-10%
© Center for Healthcare Quality and Payment Reform www.CHQPR.org
101
Win-Win-Win for Patients, Payers
Birth Center, and Hospital…
Midwife
OB-GYN
Vaginal Birth
C-Section
Subtotal
Birth Center
Hospital
Fixed Cost
Variable Cost
Margin
Subtotal
Total Spending
CURRENT
FUTURE
$/Patient # Pts
Total $
$/Patient # Pts
Total $
Chg
$2,200
20
$44,000
$2,200 300
$660,000 1400%
$3,300
$3,600
$4,000
680
300
980
$2,244,000
$1,080,000
$3,324,000
$3,300
$3,600
20
$80,000
$3,500
50% $4,350,000
$3,995 45% $3,915,000
5%
$435,000
$8,878 980 $8,700,000
$12,148 1000 $12,148,000
500
200
700
$1,650,000
$720,000
$2,370,000
300
$1,050,000 1213%
$4,350,000
$3,995
$2,796,429
$435,000
$10,831 700 $7,581,429
$11,661 1000 $11,661,429
-29%
0%
-29%
0%
-13%
-4%
© Center for Healthcare Quality and Payment Reform www.CHQPR.org
102
Problem: OB-Gyn Practice Loses,
And It Has Fixed Costs to Cover
Midwife
OB-GYN
Vaginal Birth
C-Section
Subtotal
Birth Center
Hospital
Fixed Cost
Variable Cost
Margin
Subtotal
Total Spending
CURRENT
FUTURE
$/Patient # Pts
Total $
$/Patient # Pts
Total $
Chg
$2,200
20
$44,000
$2,200 300
$660,000 1400%
$3,300
$3,600
$4,000
680
300
980
$2,244,000
$1,080,000
$3,324,000
$3,300
$3,600
20
$80,000
$3,500
50% $4,350,000
$3,995 45% $3,915,000
5%
$435,000
$8,878 980 $8,700,000
$12,148 1000 $12,148,000
500
200
700
$1,650,000
$720,000
$2,370,000
300
$1,050,000 1213%
$4,350,000
$3,995
$2,796,429
$435,000
$10,831 700 $7,581,429
$11,661 1000 $11,661,429
-29%
0%
-29%
0%
-13%
-4%
© Center for Healthcare Quality and Payment Reform www.CHQPR.org
103
Problem: OB-Gyn Practice Loses,
And It Has Fixed Costs to Cover
Midwife
OB-GYN
Vaginal Birth
C-Section
Subtotal
Birth Center
Hospital
Fixed Cost
Variable Cost
Margin
Subtotal
Total Spending
CURRENT
FUTURE
$/Patient # Pts
Total $
$/Patient # Pts
Total $
Chg
$2,200
20
$44,000
$2,200 300
$660,000 1400%
$3,300
$3,600
$4,000
680
300
980
$2,244,000
$1,080,000
$3,324,000
$3,300
$3,600
20
$80,000
$3,500
50% $4,350,000
$3,995 45% $3,915,000
5%
$435,000
$8,878 980 $8,700,000
$12,148 1000 $12,148,000
500
200
700
$1,650,000
$720,000
$2,370,000
300
$1,050,000 1213%
$4,350,000
$3,995
$2,796,429
$435,000
$10,831 700 $7,581,429
$11,661 1000 $11,661,429
-29%
0%
-29%
0%
-13%
-4%
Birth Center needs cooperation from physicians to succeed
because the Birth Center can’t complete all deliveries itself
© Center for Healthcare Quality and Payment Reform www.CHQPR.org
104
If Midwives Are Already Doing Many
Deliveries, Negative Impact is Lower
Midwife
OB-GYN
Vaginal Birth
C-Section
Subtotal
Birth Center
Hospital
Fixed Cost
Variable Cost
Margin
Subtotal
Total Spending
CURRENT
FUTURE
$/Patient # Pts
Total $
$/Patient # Pts
Total $
$2,200 200
$440,000
$2,200 300
$660,000
$3,300
$3,600
$4,000
500
300
800
$1,650,000
$1,080,000
$2,730,000
$3,300
$3,600
20
$80,000
$3,500
50% $4,350,000
$3,995 45% $3,915,000
5%
$435,000
$8,878 980 $8,700,000
$12,148 1000 $12,148,000
Chg
50%
400
300
700
$1,320,000
$1,080,000
$2,400,000
300
$1,050,000 1400%
$4,350,000
$3,995
$2,796,429
$435,000
$10,831 700 $7,581,429
$11,691 1000 $11,691,429
-12%
0%
-29%
0%
-13%
-2%
© Center for Healthcare Quality and Payment Reform www.CHQPR.org
105
If Birth Rate Is Increasing,
Savings With No Negative Impact
Midwife
OB-GYN
Vaginal Birth
C-Section
Subtotal
Birth Center
Hospital
Fixed Cost
Variable Cost
Margin
Subtotal
Total Spending
CURRENT
FUTURE
$/Patient # Pts
Total $
$/Patient # Pts
Total $
$2,200 200
$440,000
$2,200 300
$660,000
$3,300
$3,600
$4,000
500
300
800
$1,650,000
$1,080,000
$2,730,000
$3,300
$3,600
20
$80,000
$3,500
50% $4,350,000
$3,995 45% $3,915,000
5%
$435,000
$8,878 980 $8,700,000
$12,148 1000 $12,148,000
Chg
50%
500
300
800
$1,650,000
$1,080,000
$2,730,000
300
$1,050,000 1213%
$4,350,000
$3,995
$3,195,918
$435,000
$9,976 800 $7,980,918
$11,292 1100 $12,420,918
0%
0%
-18%
0%
-8%
4%
10% Increase in Births = Only 4% Increase in Spending
© Center for Healthcare Quality and Payment Reform www.CHQPR.org
106
What If There Are Competing
Maternity Care Providers?
Midwife
OB-GYN
Vaginal Birth
C-Section
Subtotal
Birth Center
Hospital
Fixed Cost
Variable Cost
Margin
Subtotal
Providers
Other Providers
Total Spending
CURRENT
$/Patient # Pts
Total $
$2,200
20
$44,000
$3,300
$3,600
$4,000
$3,995
$8,878
$12,148
$12,148
680
300
980
20
$2,244,000
$1,080,000
$3,324,000
$80,000
50% $4,350,000
45% $3,915,000
5%
$435,000
980 $8,700,000
1000 $12,148,000
1000 $12,148,000
$24,296,000
© Center for Healthcare Quality and Payment Reform www.CHQPR.org
107
What if Maternity Provider Group #1
Offers Birth Center Svc + Savings?
Midwife
OB-GYN
Vaginal Birth
C-Section
Subtotal
Birth Center
Hospital
Fixed Cost
Variable Cost
Margin
Subtotal
Providers
Other Providers
Total Spending
CURRENT
FUTURE
$/Patient # Pts
Total $
$/Patient # Pts
Total $
$2,200
20
$44,000
$3,300
$3,600
$4,000
$3,995
$8,878
$12,148
$12,148
680
300
980
20
$2,244,000
$1,080,000
$3,324,000
$80,000
$3,500
50% $4,350,000
45% $3,915,000
5%
$435,000
980 $8,700,000
1000 $12,148,000
1000 $12,148,000
$11,661
$12,148
Chg
$24,296,000
© Center for Healthcare Quality and Payment Reform www.CHQPR.org
108
If Patients Shift Away From
Other Maternity Providers
Midwife
OB-GYN
Vaginal Birth
C-Section
Subtotal
Birth Center
Hospital
Fixed Cost
Variable Cost
Margin
Subtotal
Providers
Other Providers
Total Spending
CURRENT
FUTURE
$/Patient # Pts
Total $
$/Patient # Pts
Total $
$2,200
20
$44,000
$3,300
$3,600
$4,000
$3,995
$8,878
$12,148
$12,148
680
300
980
20
$2,244,000
$1,080,000
$3,324,000
$80,000
50% $4,350,000
45% $3,915,000
5%
$435,000
980 $8,700,000
1000 $12,148,000
1000 $12,148,000
Chg
$3,500
$11,661 1500
$12,148 500
$24,296,000
© Center for Healthcare Quality and Payment Reform www.CHQPR.org
109
…And Many New Patients
Use Birth Center…
Midwife
OB-GYN
Vaginal Birth
C-Section
Subtotal
Birth Center
Hospital
Fixed Cost
Variable Cost
Margin
Subtotal
Providers
Other Providers
Total Spending
CURRENT
FUTURE
$/Patient # Pts
Total $
$/Patient # Pts
Total $
Chg
$2,200
20
$44,000
$2,200 450
$990,000 2150%
$3,300
$3,600
$4,000
$3,995
$8,878
$12,148
$12,148
680
300
980
20
$2,244,000
$1,080,000
$3,324,000
$80,000
50% $4,350,000
45% $3,915,000
5%
$435,000
980 $8,700,000
1000 $12,148,000
1000 $12,148,000
$3,500
450
$1,575,000 2150%
$11,811 1500
$12,148 500
$24,296,000
© Center for Healthcare Quality and Payment Reform www.CHQPR.org
110
…OB-GYNs Will Still See
More Patients…
Midwife
OB-GYN
Vaginal Birth
C-Section
Subtotal
Birth Center
Hospital
Fixed Cost
Variable Cost
Margin
Subtotal
Providers
Other Providers
Total Spending
CURRENT
FUTURE
$/Patient # Pts
Total $
$/Patient # Pts
Total $
Chg
$2,200
20
$44,000
$2,200 450
$990,000 2150%
$3,300
$3,600
$4,000
$3,995
$8,878
$12,148
$12,148
680
300
980
20
$2,244,000
$1,080,000
$3,324,000
$80,000
50% $4,350,000
45% $3,915,000
5%
$435,000
980 $8,700,000
1000 $12,148,000
1000 $12,148,000
$3,300
$3,600
750
300
1050
$3,500 450
$2,475,000
$1,080,000
$3,555,000
7%
2150%
$11,811 1500
$12,148 500
$24,296,000
© Center for Healthcare Quality and Payment Reform www.CHQPR.org
111
…The Hospital Will Have
More Deliveries…
Midwife
OB-GYN
Vaginal Birth
C-Section
Subtotal
Birth Center
Hospital
Fixed Cost
Variable Cost
Margin
Subtotal
Providers
Other Providers
Total Spending
CURRENT
FUTURE
$/Patient # Pts
Total $
$/Patient # Pts
Total $
Chg
$2,200
20
$44,000
$2,200 450
$990,000 2150%
$3,300
$3,600
$4,000
$3,995
$8,878
$12,148
$12,148
680
300
980
20
$2,244,000
$1,080,000
$3,324,000
$80,000
50% $4,350,000
45% $3,915,000
5%
$435,000
980 $8,700,000
1000 $12,148,000
1000 $12,148,000
$3,300
$3,600
750
300
1050
$3,500 450
$3,995
$10,831 1050
$11,811 1500
$12,148 500
$2,475,000
$1,080,000
$3,555,000
7%
2150%
$4,350,000
$4,194,643
$478,500
$9,023,143
10%
4%
$24,296,000
© Center for Healthcare Quality and Payment Reform www.CHQPR.org
112
…With Significant Savings to Payer
Compared to the Status Quo
Midwife
OB-GYN
Vaginal Birth
C-Section
Subtotal
Birth Center
Hospital
Fixed Cost
Variable Cost
Margin
Subtotal
Providers
Other Providers
Total Spending
CURRENT
FUTURE
$/Patient # Pts
Total $
$/Patient # Pts
Total $
Chg
$2,200
20
$44,000
$2,200 450
$990,000 2150%
$3,300
$3,600
$4,000
$3,995
$8,878
$12,148
$12,148
680
300
980
20
$2,244,000
$1,080,000
$3,324,000
$80,000
$3,300
$3,600
750
300
1050
$3,500 450
$2,475,000
$1,080,000
$3,555,000
7%
2150%
50% $4,350,000
45% $3,915,000
5%
$435,000
980 $8,700,000
1000 $12,148,000
1000 $12,148,000
$4,350,000
$3,995
$4,194,643
$478,500
$10,831 1050 $9,023,143
$11,811 1500 $15,368,143
$12,148 500 $6,074,000
10%
4%
$24,296,000
$21,442,143
-12%
© Center for Healthcare Quality and Payment Reform www.CHQPR.org
113
Win-Win-Win for Providers, Patients,
Payers With Better Delivery System
Midwife
OB-GYN
Vaginal Birth
C-Section
Subtotal
Birth Center
Hospital
Fixed Cost
Variable Cost
Margin
Subtotal
Providers
Other Providers
Payer
CURRENT
FUTURE
$/Patient # Pts
Total $
$/Patient # Pts
Total $
Chg
$2,200
20
$44,000
$2,200 450
$990,000 2150%
$3,300
$3,600
$4,000
$3,995
$8,878
$12,148
$12,148
680
300
980
20
$2,244,000
$1,080,000
$3,324,000
$80,000
$3,300
$3,600
750
300
1050
$4,000 450
$2,475,000
$1,080,000
$3,555,000
7%
2150%
50% $4,350,000
45% $3,915,000
5%
$435,000
980 $8,700,000
1000 $12,148,000
1000 $12,148,000
$4,350,000
$3,995
$4,194,643
$478,500
$10,831 1050 $9,023,143
$11,811 1500 $15,368,143
$12,148 500 $6,074,000
10%
4%
$24,296,000
$21,442,143
-12%
© Center for Healthcare Quality and Payment Reform www.CHQPR.org
114
Teamwork By All Providers Needed
to Offer Condition-Based Pmt
Condition-Based Payment
OB $$$
C-Section
in Hospital Hospital $$$
Normal
Pregnancy
Delivery
Vaginal OB/CNM $$
Delivery
in Hospital Hospital $$
Birth Center Episode
CNM $
Delivery in
Birth Center Birth Ctr $
MATERNITY
CARE
TEAM:
Birth Center
+
Midwives
+
OB-GYNs
+
Hospital
© Center for Healthcare Quality and Payment Reform www.CHQPR.org
115
Promote Outcomes/Experience,
Don’t Overpromise Savings
• Promoting the Value of Birth Centers
– Focus on good experience for mother and good outcomes for mother & baby
– Don’t promise dramatic savings for payers or mothers
© Center for Healthcare Quality and Payment Reform www.CHQPR.org
116
Look for Win-Win Opportunities
to Expand Birth Centers
• Promoting the Value of Birth Centers
– Focus on good experience for mother and good outcomes for mother & baby
– Don’t promise dramatic savings for payers or mothers
• Focus Expansion Efforts Where Win-Win-Win Opportunities Exist
–
–
–
–
–
–
Communities with overcapacity in hospital labor & delivery
Communities with OB-GYN practices where physicians are retiring
Communities where midwives are already doing many deliveries in hospital
Communities with competing maternity care providers
Communities with growing populations
Communities with large, local employers who can push for change
© Center for Healthcare Quality and Payment Reform www.CHQPR.org
117
Proceed Cautiously/Collaboratively
in Small & Low-Income Communities
• Promoting the Value of Birth Centers
– Focus on good experience for mother and good outcomes for mother & baby
– Don’t promise dramatic savings for payers or mothers
• Focus Expansion Efforts Where Win-Win-Win Opportunities Exist
–
–
–
–
–
–
Communities with overcapacity in hospital labor & delivery
Communities with OB-GYN practices where physicians are retiring
Communities where midwives are already doing many deliveries in hospital
Communities with competing maternity care providers
Communities with growing populations
Communities with large, local employers who can push for change
• Proceed Cautiously Where Expansion Could Be Problematic
– Hospitals with large numbers of Medicaid patients and low Medicaid payments
where the hospital covers losses with commercial maternity care patients
– Communities with Critical Access Hospitals where labor & delivery is a
major inpatient service and a primary surgical service
– Communities with one OB-GYN
– Communities with declining populations
© Center for Healthcare Quality and Payment Reform www.CHQPR.org
118
Increase Awareness of Birth
Centers In Advance of Expansion
http://www.post-gazette.com/business/biz-opinion/2011/03/06/regional-insights-better-maternity-care-can-reduce-health-care-costs/201103060506
© Center for Healthcare Quality and Payment Reform www.CHQPR.org
119
If We Do It Right:
A Better Maternity Care System
• Better Care for Patients
– Mothers can receive high quality care with the best outcomes for
themselves and their babies
• Lower Spending for Payers & Patients
– Mothers can receive the lowest cost service that addresses their needs,
not the service that generates the highest revenues or margins for
providers
• Financially Viable Healthcare Providers
– Birth centers, midwives, physicians, and hospitals are all paid
adequately to deliver the high-quality care that patients need
© Center for Healthcare Quality and Payment Reform www.CHQPR.org
120
Learn More About Win-Win-Win
Payment and Delivery Reform
www.PaymentReform.org
© Center for Healthcare Quality and Payment Reform www.CHQPR.org
121
CHQPR Resources
on Maternity Care
www.PaymentReform.org
© Center for Healthcare Quality and Payment Reform www.CHQPR.org
122
For More Information:
Harold D. Miller
President and CEO
Center for Healthcare Quality and Payment Reform
[email protected]
(412) 803-3650
www.CHQPR.org
www.PaymentReform.org