OB-GYN pay overhaul spells changes for maternal care

• Changing how the specialty is reimbursed could promote more personalized care and better data on patient needs.

State of play: Starting Jan. 1, OB-GYNs will be able to bill insurers for each individual service they provide to patients under new medical codes adopted by the American Medical Association.

• The new approach will replace a lump-sum "bundled payment" system that insurers have primarily used to pay for prenatal visits, delivery and postpartum care since the 1990s.
• The change is the result of a yearslong advocacy effort from OB-GYNs, who say the bundled system doesn't reflect the complexity of modern obstetrics care.

"This will be incredibly important for public health," said John Patrick Horton, an Emory Healthcare OB-GYN and vice chair of the American College of Obstetricians and Gynecologists' health economics and coding committee.

Between the lines: The change is expected to make it easier for doctors to tailor care to patient needs — and get paid for doing so, Horton said.

• For example, the bundled payment typically covers just one postpartum visit while more than half of pregnancy-related deaths in the United States occur within one year of birth. Adding postpartum visits for higher-risk patients could prevent deaths, providers say.
• The new system also will ensure that prenatal care providers who have to transfer patients to a more intensive care setting still get paid for the care they provided.
• "There are possibilities available now [for innovation] where before, it felt constrained," said Joy Burkhard, founder of the Policy Center for Maternal Mental Health.

Yes, but: The ability to bill for more customized care could drive up costs and medical spending, some advocates and policymakers say.

• Rep. Buddy Carter (R-Ga.) sent a letter to the AMA last month urging the organization to reconsider the coding changes.
• "Under an unbundled framework, unnecessary visits, tests, scans, and services simply become additional billing opportunities," Carter wrote.
• Employers are ready to spend on high-quality, integrated maternity care, said Elizabeth Mitchell, CEO of the Purchaser Business Group on Health. But returning to what amounts to fee-for-service payment feels like a step backward, she said.

Reality check: Most commercial health insurers still will be required to cover preventive maternity care at no out-of-pocket cost to enrollees. The cost of lab tests, ultrasounds and other care not classified as preventative is already excluded from the bundled payments.

• Investing more money into maternal care could pay dividends by preventing emergencies down the line, according to Heartland Forward, a think tank. And the change could actually mean fewer prenatal visits for low-risk pregnancies, ACOG says.

Still, it's too soon to know how this will affect the amount of care used, and it's likelier that costs will increase, one insurance industry leader told Axios.

• Snafus implementing the system or increased use of some higher-cost services could result in more out-of-pocket expenses for patients.
• "The unintended consequences of not implementing this right are significant," said Burkhard, of the Policy Center for Maternal Mental Health.

What we're watching: The Centers for Medicare and Medicaid Services is expected to propose base payments for the new system this month. The new codes were designed to be budget-neutral compared with the old system.

• Meanwhile, health insurers are pushing for more time to implement the payment changes.
• "At a minimum, these changes require an adequate transition period to better protect against potential costs and negative consequences," said Chris Bond, a spokesperson for the industry group AHIP.

Go deeper: Health care's solvable problem: maternal mortality