One Pacific Northwest health system is pioneering a new model of pregnancy care that aims to improve quality while lowering costs.

Providence Health & Services, a not-for-profit integrated health system, has embarked on a unique program that marries evidence-based innovations in care delivery with innovations in payment design to transform the delivery and financing of prenatal, labor, delivery and post-natal care. 

Launched in January 2013, the program is showing promising results in patient satisfaction, cost reductions and quality improvements. Its architects claim it’s the only such pregnancy and maternity bundled-care model in the U.S.

“Passionate, engaged clinical leadership that has been involved from the beginning is critical to the success of any disruptive innovation in healthcare.”

 “Maternity care has been fragmented, expensive and often unsatisfying,” says Kathy Criswell, executive, Women and Children’s program at Providence Health & Services Oregon. “To address this challenge, we created an innovative, high value model of care delivery that successfully meets the needs of women experiencing a healthy pregnancy. It is an example of meeting our national imperative to bend the healthcare cost curve through care transformation.” 

Around the country, providers and payers are testing out a new payment model called a “bundled payment.” A bundled payment model assigns a fixed, negotiated fee to cover a set of treatment services for specific conditions and encourages providers to work together to manage costs while meeting specified quality metrics. Bundled payments are being used for such care episodes as knee and hip replacements, cardiac and other surgeries. 

Other bundles typically expire at discharge or, in some cases, up to 30 days after discharge to include post-acute care services. But because a pregnancy lasts nine months, the Providence Health & Services pregnancy bundle, dubbed “the Pregnancy Care Package,” lasts the entire length of the pregnancy, through the delivery and the typical postpartum visit six weeks after delivery.

The Providence Health & Services pregnancy bundle was first demonstrated in 2013 at a nurse-midwife based clinic in Portland, Ore., called the Providence Maternal Care Clinic, near Providence Portland Medical Center. Results in the first year have shown a 10% reduction in overall pregnancy costs, a C-section rate of 19% and 97% of patients surveyed said they would recommend the clinic and its model of care.     

To create the bundle, Providence Health & Services looked at the entire care a woman receives from the time of a positive pregnancy confirmation through delivery and postpartum care. This includes check-ups, prenatal tests, education, psychosocial support, labor, delivery, the hospital stay, and postpartum care.  This analysis took into account the so-called Triple Aim of healthcare — which carries the goal of delivering high-quality care at low costs with optimal patient satisfaction.

“Throughout the design phase we continually asked our clinicians and caregivers what was necessary and evidence-based and what was superfluous relative to achieving Triple Aim objectives,” says Amy Winkelman, a director in Strategic Planning and Innovation at Providence Health & Services Oregon. “This was our design team’s primary criteria to include or exclude features.”

Providence Health & Services redesigned the care approach to be team-based with a nurse midwife leading the team. Nurse midwives are not only less costly than obstetricians, but numerous studies have found that women who use nurse midwives tend to have better care outcomes with their pregnancies.

With the nurse midwife as the “team anchor,” the core team supporting the pregnant woman includes a “patient navigator” to help with her provider and health plan needs, and doulas, trained coaches who assist during labor and delivery. Doulas are not normally covered by health insurance, and this marked the first time that Providence Health & Services directly hired doulas. Other care team members include hospital RNs, obstetricians, pediatricians and social workers.

Care visits at the clinic include both individual and group visits. Group visits, co-facilitated by a nurse-midwife and patient navigator, include 8-10 women of the same gestational age. Patient education on the birthing process, proper prenatal and postpartum care is also a core component of the program.

Approximately 85% of pregnancies in the U.S. are normal, low-risk and do not require the care of a specialist physician. Providence Health & Services says this re-designed model of care is appropriate for this vast majority of women who will benefit from more predictable out-of-pocket costs. Also, women receive more patient-centered, appropriate care with fewer unnecessary tests and procedures. Women who have complications and/or high-risk pregnancies (including expecting multiples) needing the care of a maternal fetal medicine specialist are not appropriate for this bundle.

The key to innovation is finding the right combination of leadership and project support, those at Providence Health & Services say.

“Passionate, engaged clinical leadership that has been involved from the beginning is critical to the success of any disruptive innovation in healthcare,” says Lisa Chickadonz, nurse-midwife lead for the pregnancy care package at Providence Health & Services Oregon. “We had the perfect marriage. We had a fabulous idea, a really engaged sponsor and funding and support from the region at the highest levels. That mix is what enabled us to be where we are.”

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