A Balancing Act: Methods to Even Out Healthcare’s Quality/Cost/Equity Equation
With Mothers’ Lives on the Line, Equal Access to Quality Care Is Imperative
By Dr. Ellen Stang
High cost does not necessarily equal high quality, as the United States’ healthcare record proves. Despite outspending every other Organisation for European Economic Co-operation and Development country on healthcare expenditure by nearly twofold, the U.S. has the lowest overall life expectancy and the highest incidence of chronic disease, suicide, and obesity.
Tragically, our maternal mortality rate is also the worst of all developed nations. Just recently, the CDC reported that 861 pregnant women and new mothers died in the U.S. last year—a 14% spike in fatalities year-over-year. While this alone warrants an urgent cry for overall quality improvement in maternal care, the issue is even more complicated. Just underneath the surface, discrepancies in outcome data shed light on health inequities lurking in plain sight. Within the report, demographic data revealed that one-third of the women who died were Black, a threefold higher fatality rate than that of white women. When addressing quality measures to improve overall maternal mortality rates, equitable care standards and access must be central to the conversation. Perhaps NCQA says it best: “High-quality care is equitable care.”
In the sections that follow, I’ll outline three methods that can help healthcare stakeholders promote equitable, high-quality care for all expecting and new mothers.
Quality care is standardized
While the oft-discussed concept of the “patient journey” signals a standardized pathway for all patients, in truth, the experience is fragmented, winding, and too often varied based on demographic or other socioeconomic factors. While individualized care is important, unwanted variations in care can compromise high-quality outcomes. Today, data collection can help organizations pursue an analytical approach to care standardization. Universal data collection can help identify health inequities, gaps in care, and solutions for patient engagement and cost mitigation. Plus, it can shine a light on best practices for care administration and outcome monitoring.
Social determinants of health (SDOH) are receiving increasing recognition within the healthcare landscape for their outsized impact on overall health outcomes. Broadly, SDOH are a set of lifestyle, economic, and circumstance factors—such as income, food security, sense of community, education, and access to healthcare—that are believed to drive 80% of an individual’s long-term overall health.
Standardizing screenings to include demographic and SDOH questions can go a long way in identifying risk factors for potential life-threatening complications during—and in the months after—childbirth. By screening for common reasons that patients skip prenatal and postpartum appointments, avoid medically necessary care, and miss lactation or health milestone education, organizations can prevent new mothers and infants from falling through cracks in the healthcare system. To help expand visibility, CMS is recommending that all providers begin collecting race, ethnicity, and language data, which would be a first step toward standardizing a broader array of critical health information.
Today, according to a 2020 KFF survey, organizations don’t always screen for the lifestyle factors that play a large role in overall health. While 80% of privately insured women were asked about diet, exercise, and lifestyle during checkups, only 63% of uninsured women were asked the same questions. A similar discrepancy exists for alcohol or drug use: 70% of privately insured women were screened, as compared to 50% of uninsured women. In our experience, standardizing collection of these metrics can make an outsized impact on both maternal and infant health.
To address some of these gaps among our patient population, in 2020, our ProgenyHealth Informatics team evaluated the impact of dispatching educational material to homes where screening identified a smoker. Exposure to secondhand smoke in the home is associated with a higher risk of sudden infant death syndrome and other illnesses that often result in unplanned hospital readmissions, including ear infections, respiratory problems, and even tooth decay. The documentation made an impact. Of all smoking households that did not receive educational materials, 22% of infants were readmitted within 30 days—whereas only 5.6% of infants within households that received educational materials required readmission. Standardized screening for lifestyle, tobacco and alcohol use, and other metrics can help systems create evidence-based standards that fill gaps in care and improve overall quality for both mother and infant.
Quality care is personal
Trust is an important foundation for any relationship, including the provider-patient dynamic. Yet 55% of Black Americans say they distrust the healthcare system, and seven out of 10 respondents report being treated unfairly during medical appointments. These feelings are not unfounded—a recent study found that two out of three clinicians hold unconscious implicit bias against Black and Latino patients.
The resulting distrust is correlated with worsened health outcomes, according to studies. Not only are Black mothers three times more likely to die from childbirth than white women, but they are three times more likely to face postpartum depression and have the highest risk of childbirth complications, including preeclampsia, heart failure, and blood clots. To reduce these disparities, healthcare organizations must invest in regaining trust; for example, they can expand access to care to learn more about preexisting and chronic conditions so that a patient’s full picture of health may be taken into account.
Helping patients feel heard, represented, and understood can go a long way to improving their desire to seek care. Studies show that patients often prefer to select doctors who resemble themselves. Racially concordant healthcare relationships have been shown to improve levels of comfort and trust. Wherever possible, diverse hiring practices in medical settings can help ensure that individuals of all races, ages, genders, ethnicities, orientations, and perspectives are represented. Examining implicit bias and providing training for all medical staff can also help equip healthcare providers with awareness of the ways that institutionalized unconscious prejudice may impact the recommendations and overall quality of care they provide. In February 2021, the California legislature passed a bill into law requiring all new nursing graduates to undergo implicit bias training. Nationally, hospitals nationwide can follow suit by administering voluntary training to existing and undergraduate care providers. Only with new understanding can real change occur.
Quality care is comprehensive
Truly quality care takes a holistic approach to a patient’s overall lifestyle and socioeconomic situation outside of the hospital walls. As over 50% of all maternal fatalities occur post-discharge and within one year of delivery, expanding comprehensive postpartum care coverage is critically important in the effort to boost maternal safety and quality metrics.
Across the maternity experience, doulas and midwives help bridge the gap between formal care providers and expecting mothers, acting as educators, advocates, and guides. By building a relationship with expecting mothers, they offer reliable, trustworthy, continuous support. This has been shown to help during delivery, with these mothers experiencing improved rates of spontaneous vaginal birth and an overall decrease in birth complications. The relationship also helps ease the transition into new motherhood. The presence of doulas and midwives has been shown to impact a variety of key postpartum quality metrics, including increasing breastfeeding rates, building maternal self-reliance, and lowering rates of depression among new mothers.
Similarly, new mothers benefit from ongoing support after delivery and returning home. With nearly 20 years supporting NICU babies and their mothers, we’ve learned that comprehensive case management programs can make all the difference in improving access and minimizing gaps in care. In one recent case, a first-time mother had a learning disability documented in her medical file. This prompted our case management team to reach out proactively to prepare her with additional education on routine newborn care. While there were concerns she would be unable to care for her infant, these educational efforts helped ensure that mother and baby could remain together. Our team filed paperwork so that the baby was included within the mother’s SNAP benefits and would receive coverage under her health plan.
Later, our case manager learned that this same mother was living with poorly controlled insulin-dependent diabetes. While this could have become a dangerous situation, the case manager provided additional support by connecting her with a physician, ensuring she received an insulin pump and making sure she was comfortable managing her own health. These efforts ensured she was then able to properly care for her baby as well. This case is one of many that help illustrate how vital personalized care management can be. By addressing the whole person, we were able to help ensure the best overall health outcomes for both mother and baby.
To achieve the greatest impact on maternal quality measures, healthcare organizations and providers must work to improve various quality levers, such as standardizing protocols, screenings, and applications of care; working to build inclusive, trusting, and personalized care relationships; and expanding the maternal care continuum for a more comprehensive view of motherhood, from prenatal family planning through one year postpartum. Only when the institutional view of the maternity journey has been expanded can all healthcare stakeholders more effectively balance the quality/cost/equity equation.
Ellen Stang, MD, is the founder and CEO of ProgenyHealth. She also serves as a member of the National Board of Trustees for the March of Dimes and is a member of the Board of Trustees of Gwynedd Mercy University.