Bundle of JoyTM:

Maternal & Infant Health Trends Series

Report 2: The Added Cost of Complications During and After Delivery

Every new mother and child deserves the best beginning possible, at the most affordable price point. We’re working to make that possible. Premier’s Bundle of JoyTM Campaign is focused on ensuring mothers and babies are always at the center of care, and supported by the latest evidence, the best doctors and the most successful practices.


Premier provides the following resources for healthcare organizations to join us in our campaign to improve maternal and infant health.

+ Data-driven Insights

+ Maternal & Infant Outcomes Dashboard

+ Performance Improvement Services

+ New Payment Models & Policy

Learn more about the campaign

Every new mother and child deserves the best beginning possible, at the most affordable price point. We’re working to make that possible. Premier’s Bundle of JoyTM Campaign is focused on ensuring mothers and babies are always at the center of care, and supported by the latest evidence, the best doctors and the most successful practices.


Premier provides the following resources for healthcare organizations to join us in our campaign to improve maternal and infant health.

+ Data-driven Insights

+ Perinatal Quality Dashboard

+ Performance Improvement Services

+ New Payment Models & Policy

Learn more about the campaign

Data-driven Insights:
The following maternal and infant health trends analysis leverages the Premier Healthcare Database and is used to help hospitals and the nation better understand and target solutions to this national problem. Premier’s analytic capabilities and data assets are used to study specific therapeutic interventions and assess clinical efficacy over time to implement new solutions for unmet medical needs. This is the first of several analyses on maternal and infant health trends.

Every new mother and child deserves the best beginning possible, at the most affordable price point. We’re working to make that possible. Premier’s Bundle of JoyTM Campaign is focused on ensuring mothers and babies are always at the center of care, and supported by the latest evidence, the best doctors and the most successful practices.


Premier provides the following resources for healthcare organizations to join us in our campaign to improve maternal and infant health.

+ Data-driven Insights

+ Perinatal Quality Dashboard

+ Performance Improvement Services

+ New Payment Models & Policy

Learn more about the campaign

Maternal & Infant Outcomes Dashboard: 
The industry’s only integrated analytics dashboard enables a comprehensive analysis of an organization’s select perinatal and neonatal data sets, including peer-level and regional benchmarks and individualized reports assessing quality and outcomes. Premier continues to develop innovative analytics solutions to enable hospitals and health systems to benchmark and assess performance against its comprehensive maternal and infant database.

Every new mother and child deserves the best beginning possible, at the most affordable price point. We’re working to make that possible. Premier’s Bundle of JoyTM Campaign is focused on ensuring mothers and babies are always at the center of care, and supported by the latest evidence, the best doctors and the most successful practices.


Premier provides the following resources for healthcare organizations to join us in our campaign to improve maternal and infant health.

+ Data-driven Insights

+ Perinatal Quality Dashboard

+ Performance Improvement Services

+ New Payment Models & Policy

Learn more about the campaign

Performance Improvement Services:
Premier provides one-to-one consulting support as well as collaborative initiatives to advance and scale national efforts to improve maternal and infant health. In July 2019, Premier announced it is working with 10 leading hospitals on a Perinatal Collaborative designed to reach zero preventable maternal and neonatal harm and deaths. Learnings from the collaborative will be shared nationally. In January 2020, the QUEST® quality improvement collaborative will launch a new perinatal specialty network to further test and adopt evidence-based strategies to improve care and the overall experience for women, infants and their families.

Every new mother and child deserves the best beginning possible, at the most affordable price point. We’re working to make that possible. Premier’s Bundle of JoyTM Campaign is focused on ensuring mothers and babies are always at the center of care, and supported by the latest evidence, the best doctors and the most successful practices.


Premier provides the following resources for healthcare organizations to join us in our campaign to improve maternal and infant health.

+ Data-driven Insights

+ Perinatal Quality Dashboard

+ Performance Improvement Services

+ New Payment Models & Policy

Learn more about the campaign

New Payment Models and Policy:
Premier is working with private and public organizations to test and scale new payment models and reforms to improve maternal healthcare.

Every new mother and child deserves the best beginning possible, at the most affordable price point. We’re working to make that possible. Premier’s Bundle of JoyTM Campaign is focused on ensuring mothers and babies are always at the center of care, and supported by the latest evidence, the best doctors and the most successful practices.

 

Premier provides the following resources for healthcare organizations to join us in our campaign to improve maternal and infant health.

+ Data-driven Insights

+ Maternal & Infant Outcomes Dashboard

+ Performance Improvement Services

+ New Payment Models & Policy

Learn more about the campaign

Every new mother and child deserves the best beginning possible, at the most affordable price point. We’re working to make that possible. Premier’s Bundle of JoyTM Campaign is focused on ensuring mothers and babies are always at the center of care, and supported by the latest evidence, the best doctors and the most successful practices.

 

Premier provides the following resources for healthcare organizations to join us in our campaign to improve maternal and infant health.

+ Data-driven Insights

+ Maternal & Infant Outcomes Dashboard

+ Performance Improvement Services

+ New Payment Models & Policy

Learn more about the campaign

Data-driven Insights:
The following maternal and infant health trends analysis leverages the Premier Healthcare Database and is used to help hospitals and the nation better understand and target solutions to this national problem. Premier’s analytic capabilities and data assets are used to study specific therapeutic interventions and assess clinical efficacy over time to implement new solutions for unmet medical needs. This is the first of several analyses on maternal and infant health trends.

Every new mother and child deserves the best beginning possible, at the most affordable price point. We’re working to make that possible. Premier’s Bundle of JoyTM Campaign is focused on ensuring mothers and babies are always at the center of care, and supported by the latest evidence, the best doctors and the most successful practices.

 

Premier provides the following resources for healthcare organizations to join us in our campaign to improve maternal and infant health.

+ Data-driven Insights

+ Maternal & Infant Outcomes Dashboard

+ Performance Improvement Services

+ New Payment Models & Policy

Learn more about the campaign

Perinatal Quality Dashboard: 
The industry’s only integrated analytics dashboard enables a comprehensive analysis of an organization’s select perinatal and neonatal data sets, including peer-level and regional benchmarks and individualized reports assessing quality and outcomes. Premier continues to develop innovative analytics solutions to enable hospitals and health systems to benchmark and assess performance against its comprehensive maternal and infant database.

Every new mother and child deserves the best beginning possible, at the most affordable price point. We’re working to make that possible. Premier’s Bundle of JoyTM Campaign is focused on ensuring mothers and babies are always at the center of care, and supported by the latest evidence, the best doctors and the most successful practices.

 

Premier provides the following resources for healthcare organizations to join us in our campaign to improve maternal and infant health.

+ Data-driven Insights

+ Maternal & Infant Outcomes Dashboard

+ Performance Improvement Services

+ New Payment Models & Policy

Learn more about the campaign

Performance Improvement Services:
Premier provides one-to-one consulting support as well as collaborative initiatives to advance and scale national efforts to improve maternal and infant health. In July 2019, Premier announced it is working with 10 leading hospitals on a Perinatal Collaborative designed to reach zero preventable maternal and neonatal harm and deaths. Learnings from the collaborative will be shared nationally. In January 2020, the QUEST® quality improvement collaborative will launch a new perinatal specialty network to further test and adopt evidence-based strategies to improve care and the overall experience for women, infants and their families.

Every new mother and child deserves the best beginning possible, at the most affordable price point. We’re working to make that possible. Premier’s Bundle of JoyTM Campaign is focused on ensuring mothers and babies are always at the center of care, and supported by the latest evidence, the best doctors and the most successful practices.

 

Premier provides the following resources for healthcare organizations to join us in our campaign to improve maternal and infant health.

+ Data-driven Insights

+ Maternal & Infant Outcomes Dashboard

+ Performance Improvement Services

+ New Payment Models & Policy

Learn more about the campaign

New Payment Models and Policy:
Premier is working with private and public organizations to test and scale new payment models and reforms to improve maternal healthcare.

Analyzing the Prevalence of Preventable Complications, their Pre-Existing Risk Factors and the Correlation to Cost

The U.S. birthrate fell to 3.78 million babies in 2018, the fourth consecutive year of decline in the number of babies born across the nation1. While fewer babies are being born, the cost of delivering them is rising. Labor and delivery cost the U.S. healthcare system more each year, in part due to preventable complications and manageable chronic conditions.

The maternal population today has more comorbidities than ever, both pregnancy-related, such as preeclampsia, and preexisting conditions, such as chronic pain, diabetes, behavioral health disorders and obesity2. Pre-existing conditions and comorbidities also increase the likelihood of a woman experiencing a severe maternal morbidity (SMM) factor. SMM factors are unexpected outcomes of labor and delivery and include heart failure, heart attacks and sepsis. Premier recently identified a 36 percent increase in SMM rates from 2008-2018, including a 79 percent higher SMM rate for black women than white women. The increase in SMM rates could be due to several factors, such as changes in coding, age, race, payer, type of delivery, substance use, region and hospital type.

Complications contribute directly to higher healthcare costs.

Complications add, on average, 20 percent to the cost of a vaginal delivery and 25 percent to the cost of a cesarean delivery. SMM, meanwhile, escalates the episodic cost of care by anywhere from a few hundred dollars up to $25,000. Correspondingly, women with SMM stay in the hospital about 70 percent longer than those without SMM complications.

These incremental additions come on top of the steadily climbing cost to hospitals to perform deliveries that have no complicating conditions. Over the three-year period from 2015 to 2018, the average cost to the hospital to perform a vaginal delivery without complications rose nearly 13 percent, while the average cost for a cesarean delivery without complications increased more than 17 percent.
 
These are key findings from a Premier analysis that examined how cost varies for maternal patients based on type of delivery, complications, existence of chronic conditions, demographics and more. The analysis surveyed the cost of delivery for women from 2008 through 2018, and specifically examined the hospital discharges of 2.7 million maternal patients across 613 hospitals from 2015 through 2018 to drill into cost variation by complications.
Severe Maternal Morbidity and Complications
U.S. hospitals are demonstrating a dramatic decrease in delivery-related maternal deaths
More than a third of SMM cases are potentially preventable3, and SMM adds thousands of dollars to the average cost per patient, incurring additional length of stay and ongoing treatment, sometimes for decades after. In 2018, SMM affected 153 of every 10,000 vaginal births and 324 of every 10,000 cesarean deliveries. The SMM rate has increased 36 percent since 2008.

Cost and Length of Stay

The cost of a vaginal delivery with SMM is nearly 80 percent more than the cost of a vaginal delivery without SMM factors. Accordingly, women who experience SMM factors associated with their vaginal deliveries stay in the hospital about 70 percent longer.
 
The cost for a cesarean delivery with SMM is increasing at a rate of $500 per year, while the cost of a vaginal delivery with SMM is increasing at a rate of about $200 per year. A cesarean delivery with SMM costs nearly double that of a cesarean without SMM, and its 5.6 day-length of stay outpaces the average hospital stay of 4.5 days4 .
Figure 1:
Average Cost Average Length of Stay
Vaginal Delivery without SMM or Complicating Conditions $5,681 2.3 days
Vaginal Delivery with Complicating Conditions $6,691 2.9 days
Vaginal Delivery with SMM $10,720 3.9 days
Cesarean Delivery without SMM or Complicating Conditions $8,491 3.2 days
Cesarean Delivery with Complicating Conditions $10,852 4.2 days
Cesarean Delivery with SMM $17,927 5.6 days

Average Cost by Delivery Type

Figure 2:

Average Length of Stay by Delivery Type

Figure 3:

The Most Expensive Morbidity Factors

The SMM factors that incur the highest cost across both vaginal and cesarean deliveries are cardiac arrest, acute myocardial infarction (heart attacks), acute respiratory distress syndrome (ARDS, in which fluid collects in the lungs’ air sacs) and shock.

Incremental Additional Cost per Case of Severe Maternal Morbidity Factors for a Vaginal Delivery

U.S. hospitals are demonstrating a dramatic decrease in delivery-related maternal deaths
Figure 4:

Incremental cost shown is in addition to base cost per case of $5,681 for vaginal delivery without complications or SMM

On average, having one of the top five SMM factors for a vaginal delivery adds $13,600 to the base cost of $5,681 for a vaginal delivery without SMM or complicating conditions.

Incremental Additional Cost per Case of Severe Maternal Morbidity Factors for a Cesarean Delivery

Figure 5:

Incremental cost shown is in addition to base cost per case of $8,491 for C-section delivery without complications or SMM

On average, having one of the top five SMM factors for a cesarean adds $22,650 in addition to the base cost of $8,491 for a cesarean without SMM or complicating conditions.

Preeclampsia/Eclampsia and Hemorrhage

Two maternal harm complications that are among the leading causes of preventable SMM and mortality are preeclampsia/eclampsia and hemorrhage.
 
Preeclampsia and eclampsia are complications that are categorized by high blood pressure and signs of damage to another organ system, most often the liver and the kidneys. The cost of a delivery with eclampsia or preeclampsia is $12,392, about 74 percent more than a delivery without these complications.
 
Obstetric hemorrhage is extensive bleeding that may occur before or after delivery, but more than 80 percent of cases occur postpartum5 . It is estimated that 75 percent of deaths related to obstetric hemorrhage are preventable6 . The cost of a delivery with hemorrhage is $10,337, about 45 percent more than a delivery without hemorrhage.

By Payer

SMM is more likely to affect patients who cannot afford their care or lack insurance. The rate of occurrence of SMM factors is approximately 4 percent higher for patients on charity/indigent care, indicative of the lack of reliable prenatal care for this population. Similarly, patients with Medicaid as a payer had a 3 percent higher rate. Patients with commercial insurance account for the smallest proportion of deliveries with SMM factors, 1.7 percent.
Pre-Existing Risk Factors: Chronic Conditions, Behavioral Health and Substance Use Disorders
U.S. hospitals are demonstrating a dramatic decrease in delivery-related maternal deaths
A pregnant woman today is more likely to have a pre-existing condition than in decades past, primarily due to the rising prevalence of chronic diseases in the American population. Pre-existing conditions present significant risk factors for labor and delivery complications. From obesity to diabetes, chronic diseases now affect almost half of all American adults. As many women are having babies later in life, chronic conditions can play a greater role in deliveries.

Chronic Conditions

Three common conditions that result in higher maternal healthcare costs are chronic pain, diabetes, and obesity. Having one of these conditions adds, on average, $1,006 to the base cost of an uncomplicated vaginal delivery and $2,264 to the base cost of an uncomplicated cesarean delivery.
 
Pre-existing, chronic conditions such as heart disease and diabetes are linked to negative health outcomes and a higher cost of care for both mothers and babies. Poorly controlled diabetes in pregnant women, for example, presents an increased risk for preeclampsia, hypertension and adverse birth outcomes. Meanwhile, recent studies indicate that up to 25 percent of women are obese prior to becoming pregnant7, which places them at greater risk for pregnancy comorbidities like heart disease, stroke, diabetes, and certain types of cancer. Women with chronic conditions are more likely to have complicated cesarean deliveries, resulting in costs that are up to 90 percent higher than an uncomplicated vaginal delivery.

Cost of Chronic Conditions for a Vaginal Delivery

Figure 6:

Cost of Chronic Conditions for a Cesarean Delivery

Figure 7:

Behavioral Health

A hospital codes mental disorders complicating childbirth to include anxiety, depression and psychosis. Perinatal mood and anxiety disorders affect up to one in seven pregnant and postpartum women, yet half of perinatal women with a diagnosis of depression are not treated. The estimated economic impact is $7.5 billion for not treating mental health disorders in the mother’s first year8.
 
Behavioral health disorders complicating childbirth add 27 percent to the cost of an otherwise uncomplicated vaginal delivery and nearly 36 percent to the cost of an uncomplicated cesarean delivery.

Average Cost of a Vaginal Delivery with a Behavioral Health Disorder

Figure 8:

Average Cost of a Cesarean Delivery with a Behavioral Health Disorder

Figure 9:

Neonatal Abstinence Syndrome

Substance use disorders are playing a greater role in perinatal health, as mothers with substance use disorders increased 153 percent from 2008 to 2018, and the percent of babies with neonatal abstinence syndrome (NAS) rose 140 percent. In 2014, NAS contributed to nearly 7 percent of total neonatal hospital costs, up from 1.6 percent ten years prior9. The neonatal intensive care unit is one of the highest-cost treatment locations in the hospital, and research shows that babies born with NAS require this level of intensive care. Research suggests these babies stay in the hospital nearly 3.5 times longer, on average, than non-affected babies (16.6 hospital days vs. 4.9), and cost the hospital more than triple compared to non-affected babies ($16,893 vs. $5,610)10.


Learn more about the external factors affecting cost and care variation for mothers and babies, and five ways providers can overcome them
This is Premier’s first analysis on the cost of maternal healthcare, and its second in its series on maternal and infant health trends, conducted as part of its Bundle of Joy™ campaign. The campaign is designed to test and scale measurable improvement in the quality, safety and cost of care for mothers and babies in the U.S. Premier’s analyses on the key drivers of maternal and infant mortality and morbidity, as well as the costs associated with these trends, will serve as a baseline for measuring hospital improvement.


Methodology

Findings were derived from the Premier Healthcare Database, which Premier used to analyze the cost of delivery for 8.9 million women (approximately 25 percent of births nationally) from 2008 through 2018. Premier specifically examined the hospital discharges of 2.7 million maternal patients treated at 613 hospitals across 42 states from 2015-2018 to drill into cost variation by complications.


Pain Points & Solutions

The healthcare industry, patients, patient advocates and lawmakers are coming together to advance improvements for expecting and new mothers and newborns. With the mounting scrutiny and public pressure, providers will need to accurately document, report and demonstrate concrete progress in their maternal outcomes. To do so, they’ll need to internalize and overcome the variation in the cost and care for this population, which has been affected by multiple factors, including incongruent regulations, fee-for-service payments and socioeconomic inequalities.

Differing regulations at the state level obfuscate the industry’s ability to assemble and analyze information about maternal disparities.
For years, with a lack of federal regulations or reporting requirements for perinatal healthcare, states have been able to decide which maternal health services they cover beyond hospital care, the data they collect on expectant mothers and how they choose to respond to the outcomes. Medicaid finances nearly 45 percent of births and Medicaid coverage continues to vary state by state11, resulting in major gaps in publicly available maternal healthcare information. While some states collect patient demographics such as race, ethnicity, income and health insurance, others do not.
 
The lack of federal standards has also resulted in inconsistencies in the way states record and investigate maternal deaths, meaning the U.S. has not recognized an official annual count of pregnancy-related fatalities or an official maternal mortality rate for more than a decade12.
 
The fee-for-service reimbursement model does not incent wellness care for mother and baby.
Under current regulations, payment systems prevent providers from assuming accountability for overall cost and outcomes or coordinating with their peers for the health of the mother and baby. As part of a patient’s hospital stay, payers will often bill mothers separately for the facility fee, the provider’s fee, and sometimes a global maternity fee that incorporates prenatal and postpartum care. This bifurcation of payments does not incent providers to code the stay, or bill the payer, with a lens toward the mother’s or baby’s overall outcomes. This can lead to perinatal variability, uncoordinated care, unnecessary interventions and higher costs. By reimbursing providers once a complication has developed, providers are incentivized to allocate more dollars and resources toward treating mothers and babies who are sick as opposed to preventing the negative outcomes in the first place.
 
Social disparities remain a top reason for variation in maternal health care.
Access to, and compliance with, comprehensive prenatal care helps women manage conditions and reduce the likelihood of complications. Yet, women who are socioeconomically disadvantaged or of racial minorities are shown to receive less prenatal and postpartum care, and therefore they have documented worse outcomes13. Barriers to care for them include cost, access, geographical constraints, education level and other social influencers of health.
 
These long-held norms are beginning to shift at the federal level, as public pressure pushes lawmakers toward more standardized reporting, definitions and coverage for maternal healthcare.
Payers are experimenting with maternity care bundled payment programs to incent better care coordination across the entire episode of maternity care, while legislators, trade associations and watchdog groups are advocating for greater transparency. A few examples:
  • In December 2018, the federal government signed the Preventing Maternal Deaths Act, which mandates that states investigate the deaths of women who die within a year of being pregnant. 
  • Legislation in process aims to better standardize maternal care, enabling providers to prevent and respond to complications arising from childbirth and help reduce maternal deaths.
  • Starting in July 2020, The Joint Commission will begin publicly reporting hospitals that have a consistently high cesarean birth rates using hospital-reported data from 2018 and 2019.14
 
Hospitals and health systems will play an important role in helping abate the rising costs related to maternal healthcare.
In 2019, Premier announced a Perinatal Collaborative with 11 leading hospitals, working to reduce risk and reach zero preventable maternal and neonatal harm and deaths. Participants focus on preventing adverse events, ensuring patients are treated in the correct and most appropriate setting, and increasing the delivery of evidence-based care to help reduce variation and control cost. The results of the collaborative are being collected and will be shared publicly.
Armed with meaningful insights, optimal technology and an eye toward models that incent coordinated and reliable care, providers are helping steer the ship toward high-value, cost-efficient care for pregnant women and new mothers.
 
Premier members are improving maternal health in five key ways:
 

Business intelligence analytics and insights: Leaders require access to comprehensive clinical data that aggregates risk factors, volumes, outcomes and complications for their maternal population. A perinatal dashboard is a highly valued tool to accomplish this work. With the right business intelligence capabilities, providers collect data, identify patients at higher risk for adverse outcomes and plan interventions, helping circumvent costly complications. The analytics leveraged should be able to assimilate elements from all nationally recognized maternal safety care bundles and incorporate the 80-plus measures that target identified indicators related to harm and death. This is critical to standardize the care that mothers receive and reduce variation in cost irrespective of age, race or payer.

Highly reliable care: Armed with business intelligence and the knowledge of which patients need additional support, hospitals can standardize and customize their perinatal care by developing evidence-based practices, including interventions to address scenarios for high-risk patients as they work toward zero harm. Highly reliable concepts are fully aligned with the nationally endorsed guidelines and strategies. Providers should craft standard care guidelines to incorporate not just the national maternal safety bundles, but also operational and quality measures, including length of stay, readmissions, cost and efficiency, as well as medical indicators for risk factors and other clinical conditions such as preeclampsia and behavioral health protocols.

Technology to enable adherence: As staff and clinicians create and adopt standardized care models and train around them, leaders need to evaluate adherence to evidence-based guidelines – or barriers that are preventing it. Embedding a data-enabled clinical decision support (CDS) solution into the workflow can help support clinicians in delivering real-time, patient-specific best practices that are based directly on the organization’s standardized care guidelines. CDS analytics can also show how clinicians respond to the organization’s point-of-order alerts, demonstrating to leaders the effectiveness of a hospital’s standardized care guidelines. This ensures the right care is provided at the right time, helps improve adherence to evidence-based guidelines and prevents variation that may result in harm and additional costs.

Risk-stratification to support at-risk patients. It’s critical that organizations collect socioeconomic information from patients such as social determinants of health, whether through screening tools or other methods, to help women who may lack the resources to properly care for themselves and growing babies. Using results from risk-stratification, providers should identify and modify care for pregnant women who exhibit risk factors for maternal mortality or morbidity, including obesity; substance or opioid use disorders; heart disease; hypertension; and chronic disease such as diabetes. These conditions can often exacerbate pregnancy-related complications, and left untreated, these conditions can worsen post-pregnancy, resulting in additional care, cost and emotional stress.

Payment models that incent whole-person, value-based care. Because of barriers to healthcare access, women of color, lower socioeconomic status and those living in rural areas are more likely to exhibit risk factors for adverse maternal outcomes, and thereby higher costs for care. As payers introduce financial models that incent providers to coordinate care as efficiently and cost-effectively as possible, risk-stratification will identify women who need more hands-on guidance. Care models that are tailored to specific groups of women based on risk assessments could de-emphasize overmedicalization, such as Cesarean deliveries for low-risk women, and guide more resources toward women who are higher-risk. Progressive organizations are also exploring high-value alternatives, such as direct-to-employer payment models, in which providers strategically coordinate quality care and are less likely to recommend unnecessary and costly interventions15.

Learn more & join us in our effort to improve maternal health

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