Why Should Health Insurance Exchanges Drive Higher-Quality Health Care?

Do you remember the last time you had a headache and your doctor used leeches to restore you to good health? Fortunately, neither do I.  That’s because the practice of bloodletting – the most common surgical procedure for almost two thousand years because it was thought to improve health – is now generally considered to be, well, bad for patients.

Which leads me to the recent Washington Post article about elective deliveries of babies by labor induction or C-section before they are full term.  A few weeks may not sound like much time, but it is critical in the last few weeks of pregnancy, when major organs like the brains, lungs, and liver are still growing.  Despite multiple studies showing that early elective deliveries increase a baby’s risk of neonatal complications and even death – and decades-old clinical guidelines from the American College of Obstetricians and Gynecologists recommending against this practice – such elective deliveries still occur in 10 to 15 percent of births.

Elective deliveries scheduled for convenience or comfort instead of medical reasons have become so common that patient groups, clinicians, the federal government, and now private health insurance companies are taking action.  For instance, the March of Dimes’ Healthy Babies are Worth the Wait campaign is educating pregnant women and encouraging health professionals to participate in quality improvement initiatives. The Institute for Healthcare Improvement Perinatal Improvement Community is helping teams of providers achieve the goal of “zero incidence of elective deliveries prior to 39 weeks.”  Provider collaboratives to reduce early elective deliveries have formed in states including California, Kentucky, New Jersey, Ohio, and West Virginia.  Such initiatives are already demonstrating success – for example, West Virginia’s initiative reduced the rate of elective deliveries prior to 39 weeks by 50% in the first six months.

Both public and private payers are now building on these provider-driven collaborative efforts, changing their payment policies to encourage best practices in maternal and newborn care.  Medicaid, which funds 42% of births in the U.S., has launched the Strong Start for Mothers and Newborns initiative to “support providers in reducing early electives deliveries prior to 39 weeks,” as well as the Expert Panel for Improving Maternal and Infant Health Outcomes to “identify specific opportunities and strategies to provide better care, while reducing the cost of care for mothers and infants covered by Medicaid/CHIP.”  States are beginning to alter their Medicaid payment policies to discourage elective deliveries: Texas stopped paying for them altogether, while Washington State began paying a bonus to hospitals that met quality targets including reducing early elective deliveries, and South Carolina reduced its rate of early elective deliveries from 9 to 4.6% after the Medicaid program changed its payment policies.  Beginning on January 1, 2013, United Healthcare also began paying hospitals a bonus if they take steps to reduce their rates of early elective deliveries.

What does this have to do with the new health insurance exchanges soon to be launched in all 50 states and DC?  The Affordable Care Act requires the Qualified Health Plans (QHPs) participating in health insurance exchanges to report on quality measures and implement quality improvement strategies to improve health outcomes, reduce hospital readmissions, improve patient safety, implement wellness and health promotion activities, and reduce health disparities.  The ACA also directs the Secretary of Health and Human Services to develop and administer a quality rating system that will be available to consumers shopping for plans. In December, HHS issued a Request for Information Regarding Health Care Quality for Exchanges in preparation for implementing these initiatives.

HHS has indicated that it will use a phased approach to accreditation and quality data reporting in the federally-facilitated exchange, with reporting requirements related to all QHP issuers beginning in 2016.  In the meantime, states running their own exchanges, as well as those that take on plan management functions through a State Partnership Exchange, will have opportunities to strengthen or modify requirements for Qualified Health Plans in their states to drive additional improvements in quality.  In addition, both states and the federal government will have an important role to play when it comes to harmonizing quality standards between Medicaid and the exchanges.  With estimated costs for early elective deliveries that are 17.4% higher than normal delivery costs – not to mention the importance of giving every newborn a healthy start in life – exchanges should have plenty of incentive to make sure that QHPs are putting the right payment and quality mechanisms in place to promote evidence-based maternal and newborn care.

In the words of The Institute for Healthcare Improvement, “The challenge is to ensure that these guidelines are applied to every patient, every time.”  With only one-third of hospitals reporting that they meet the Leapfrog Group’s target goal of 5% or less for early elective deliveries, it’s clear that the country has a long way to go before all mothers and newborns are receiving the gold standard of care.  The challenge for the new health insurance marketplaces will be to make sure that the health plans they offer are promoting the highest standard of care for everybody enrolled in their plans – even the very youngest of members.

The opinions expressed here are solely those of the individual blog post authors and do not represent the views of Georgetown University, the Center on Health Insurance Reforms, any organization that the author is affiliated with, or the opinions of any other author who publishes on this blog.