The Centers for Medicare and Medicaid Services' federal maternal health requirements may be open ended enough to further cement a patchwork of disparate policies, according to providers.
CMS included the first Medicare participation requirements tied to maternal health in its fiscal 2025 proposed pay rule for hospital outpatient departments. The rule would require hospitals adopt protocols around maternal health quality assessment and improvement, as well as obstetrics unit staffing, provider training and emergency delivery services. Maternal health advocates say CMS' standards could lay out a starting point for improvement, but providers are worried the agency's focus on quality collaboratives could lead to a set of standards that are far from uniform.
Related: How CMS might use Medicare to improve maternal health
CMS has more direct influence on hospital operations through its Medicare program than through Medicaid, so the agency's decision to use obstetric conditions of participation as a lever to improve maternal health standards makes sense, said Lisa Satterfield, director of health and payment policy for the American College of Obstetricians.
But providers are concerned the proposed requirements aren't based on clinical evidence, which may be due to the lack of research on labor and delivery practices across the country, Satterfield said.
The agency doesn't dictate specifics, such as the clinical quality standards hospitals should have in place for maternal healthcare, the type of training obstetrical staff should receive, what transfer protocols should be used or how many supplies facilities should store for emergency delivery services.
Instead, CMS says hospitals should follow policies that line up with best practices from organizations such as the American College of Obstetricians and Gynecologists, the Society for Maternal-Fetal Medicine, the Alliance for Innovation on Maternal Health and The Joint Commission.
The agency also encourages hospitals and birthing centers to work with perinatal quality collaboratives in their state, which many already do, according to Dr. Adam Lewkowitz, an obstetrician-gynecologist with Women and Infants Hospital in Providence, Rhode Island. Most of the collaboratives are funded by the Centers for Disease Control and Prevention and each developed their own evidence-based standards in partnership with state health agencies, patient advocacy groups, perinatal clinicians and public health leaders.
The California Maternal Quality Care Collaborative, for example, has created guideline sets with specific implementation instructions around clinical procedures and obstetrics unit structuring. The Commonwealth Fund's latest scorecard on women's health says these guidelines have helped reduce the leading causes of preventable death and complications for mothers and infants in the state.
CMS' proposed requirements acknowledge hospitals may already be following different guidelines based on their geography and patient population, and the agency is likely trying to maintain some flexibility and listen to feedback from providers, said Alice Lam, managing director at consulting firm Manatt Health.
However, leaving the requirements open ended means there will still be a lot of variation in how hospitals provide maternal care services, Satterfield said.
“This was an opportunity to make some of these things a little bit more clear,” she said. “There should definitely be a baseline of what constitutes safe care and all patients who are receiving care for pregnancy should have the resources they need for safe labor and delivery.”
Still, CMS’ proposed maternal health requirements are a step toward real benchmarks for hospitals to meet around birthing services and perinatal care outcomes, said KJ Hertz, senior director of federal affairs at March of Dimes, a nonprofit maternal and infant health advocacy organization.
For example, the draft regulation would require hospitals to incorporate data and recommendations from state Maternal Mortality Review Committees into their quality improvement efforts. This is likely to drive hospitals that aren't already working with state perinatal quality collaboratives to do so, according to Elisabeth Burak, senior fellow at the Georgetown Center for Children and Families, a health policy and research organization.
Another requirement asks hospitals to identify outcome disparities between different demographics of pregnant patients, which would be helpful in understanding where inequities exist and focusing health systems' quality improvement strategies, Burak said.
Hospitals that aren’t already participating in statewide maternal health quality initiatives and that don't have funding to hire enough staff for obstetrics units or provide additional training may struggle to meet CMS' proposed requirements, Lewkowitz said.
CMS estimates the maternal health additions to its conditions of participation will cost hospitals an average of $70,671 annually to implement the requirements, amounting to $4.46 billion across the industry over 10 years.
“Finances drive everything in the hospital,” Lewkowitz said. “I wish that when they come up with these policies they would increase reimbursement for obstetrics care, for example, to accommodate these changes, to allow hospitals to implement them a little bit easier.”
Satterfield said labor and delivery units, as well as obstetricians and gynecologists, are underpaid by Medicaid programs. She said Medicare reimbursement for cesarean and vaginal delivery is lower than it should be, which in turn informs Medicaid payments.
Despite flaws in the proposed requirements, providers are generally grateful for the federal prioritization of maternal health issues, Satterfield said.
“This administration really is working hard to make a difference in maternal health outcomes,” she said. “We would just like to ensure that what is put forward will not inadvertently stress a system that's already struggling.”
