title: Episode-Based Payment for Perinatal Care in Medicaid: Implications for Practice and Policy.
abstract: Medicaid is an important source of health insurance coverage for low-income pregnant women and covers nearly half of all deliveries in the United States. In the face of budgetary pressures, several state Medicaid programs have implemented or are considering implementing episode-based payments for perinatal care. Under the episode-based payment model, Medicaid programs make a single payment for all pregnancy-related medical services provided to women with low- and medium-risk pregnancies from 40 weeks before delivery through 60 days postpartum. The health care provider who delivers a live birth is assigned responsibility for all care and must meet certain quality metrics and stay within delineated cost-per-episode parameters. Implementation of cost- and quality-dependent episode-based payments for perinatal care is notable because there is no published evidence about the effects of such initiatives on pregnancy or birth outcomes. In this article, we highlight challenges and potential adverse consequences related to defining the perinatal episode and assigning a responsible health care provider. We also describe concerns that perinatal care quality metrics may not address the most pressing health care issues that are likely to improve health outcomes and reduce costs. In their current incarnations, Medicaid programs' episode-based payments for perinatal care may not improve perinatal care delivery and subsequent health outcomes. Rigorous evaluation of the new episode-based payment initiatives is critically needed to inform policymakers about the intended and unintended consequences of implementing episode-based payments for perinatal care.
authors.affiliation: Department of Health Policy and Management, University of Pittsburgh Graduate School of Public Health, the Center for Women's Health Research and Innovation, University of Pittsburgh, the Division of General Internal Medicine, University of Pittsburgh School of Medicine, and the Center for Health Equity Research and Promotion, VA Pittsburgh Healthcare System, Pittsburgh, Pennsylvania; and the Department of Internal Medicine, Division of Hospital Medicine, and the Department of Obstetrics and Gynecology, University of Tennessee, Graduate School of Medicine, Knoxville, Tennessee.
authors.forename: Marian
authors.initials: M
authors.lastname: Jarlenski
authors.forename: Sonya
authors.initials: S
authors.lastname: Borrero
authors.forename: Trey
authors.initials: T
authors.lastname: La Charité
authors.forename: Nikki B
authors.initials: NB
authors.lastname: Zite
mesh_terms: D005260:Female; D006291:Health Policy; D006801:Humans; D008484:Medicaid; D018743:Perinatal Care / Q000191:economics*; D010818:Practice Patterns, Physicians' / Q000191:economics*; D011247:Pregnancy; D012051:Reimbursement Mechanisms; D014481:United States