Steve Calvin M.D. on pregnancy care, health care reform, and innovation

Our BirthBundle® payment proposal

It has been a long while since I posted anything here.  We have been busy putting together a proposal to the Centers for Medicare and Medicaid Services (CMS) encouraging them to pay for perinatal care as a single payment for the 70% of mothers who are low-risk.  Our BirthBundle® proposal is open for public comments for another two weeks.  A group of experts will be assessing our proposal and reaching a decision by the end of the year.  If you have time please read it and comment.  The link is at: https://aspe.hhs.gov/documents-public-comment-physician-focused-payment-model-technical-advisory-committee

 

At the Minnesota Health Action Group Meeting

The Minnesota Health Action Group (MNHAG) brings together employers, payers and providers to find innovative patient-focused solutions to the many problems in our current healthcare system. A couple of years ago Carolyn Pare, MNHAG Executive Director, invited us to be part of the organization’s comprehensive study of the maternity care system in Minnesota.   A great deal of good came from that effort.   Today we were invited to address the MNHAG 9th Employer Leadership Summit on the topic of bundled payment for maternity care.   My colleague Tricia Balazovic, who keeps the Minnesota Birth operating and who is a major developer of the BirthBundle, is joining me in presenting the compelling case for improving care by bundling payment.  The program brochure is at: http://mnhealthactiongroup.org/wp-content/uploads/2016/04/2016Agenda_Print_FINAL.pdf

 

 

A short video that is well worth watching

Neel Shah is a very smart young OB/GYN who really understands the issues.  Take a look at this video:

http://www.greatbigstory.com/stories/the-c-section-detective-dr-neel-shah-tries-to-solve-a-growing-problem

Neel and his colleagues at www.ariadnelabs.org are doing some great research on maternity and newborn care models and their design.  He will likely be studying what we are up to here at the Minnesota Birth Center.  Stay tuned.

Collaboration on the Maternity Care Team

The increasing success of the Minnesota Birth Center (MBC) is directly dependent on excellent professional collaboration.  This April, just three years after starting in Minneapolis, we opened our new St. Paul site.  Check it out at www.theminnesotabirthcenter.com.   When MBC mothers need hospital care our certified nurse midwives collaborate closely with inpatient provider colleagues (nurses and physicians) at the two hospitals near our centers.  The nine CNMs on the MBC team have the unique dual skill set of support for out of hospital birth while also having the ability to care for mothers in the hospital.  Continuity of care is the ideal for a maternity care team.

Allina Health is a non-profit hospital system where I worked for two decades before this MBC adventure.   Excellent care is provided to mothers and babies within Allina hospitals.  Recently, Children’s Hospitals and Clinics of Minnesota partnered with Allina to build Mother Baby Centers in Minneapolis and St. Paul.  This safety net is ideal for the MBC commitment to CNM-directed primary maternity care.  The specifics of professional collaboration are of great interest to others who want to provide MBC-like care in their communities.  Later this week at the American Association of Birth Centers national meeting in Scottsdale AZ I will be on a panel that addresses this issue.  Information regarding the panel and how to access a live feed are available here.

 

 

The discomfort of birth is no laughing matter.

My wife Cindy describes the discomfort of labor as “pain with a purpose”.    Dealing with that pain is one of the biggest challenges that mothers face at the end of pregnancy.  Many mothers think that the only pain management options are the two extremes of just gritting their teeth or of requesting an immediate epidural block.  In a birth center the pain management strategies don’t include epidural blocks or injected narcotics but they do include position changes, massage, coaching encouragement and the very helpful warm water soak in a birthing tub.   Sometimes these are not enough.  It would be helpful to have a safe option that fills in the gap before moving to the hospital and the (sometimes absolutely necessary) use of needles and drugs.

Nitrous oxide, popularly known as laughing gas, is that option.  Most know nitrous oxide from the higher doses used for dental procedures but it is widely used for labor pain in many other countries and a few locations in the U.S.  During birth it is self-administered by mask in a 50:50 nitrous oxide/oxygen mix.   It is safe for mother and baby, FDA approved and very effective for the mothers who just need to take the edge off the pain.  It has rapid onset and is gone within minutes.  We started to use nitrous oxide this month and it quickly led to three local TV stories and then a great story on the national Today Show.  The links are below.

Many of us believe that one factor in the rise in cesarean section rates is maternal anxiety.   Uncontrolled pain (or even its anticipation) is a cause of some of that anxiety.  Nitrous oxide is a good option for some of these mothers.  I personally think that another factor in the rise of cesarean sections is healthcare provider anxiety.  Our midwife team is a very calm and capable bunch so they don’t need the nitrous oxide but during my career I have worked in settings where some of the physicians and nurses could have used a couple of puffs.

http://www.today.com/parents/laughing-gas-now-pain-relief-option-women-labor-2D80441166

 

http://kstp.com/article/stories/S3680439.shtml

 

http://minnesota.cbslocal.com/2015/01/20/laughing-gas-now-an-option-for-mothers-in-labor/

 

http://www.kare11.com/video/4018961259001/1/Laughing-gas-getting-popular-among-women-giving-birth

 

http://abcnews.go.com/Health/laughing-gas-now-popular-option-women-giving-birth/story?id=28406973

 

Is non-profit status essential for healthcare organizations?

A young attorney colleague and I co-wrote a commentary in the January 4, 2014 issue of the Minneapolis Star Tribune.  In it we constructively critique the virtual non-profit healthcare monopoly that we have in Minnesota:

http://www.startribune.com/opinion/commentaries/287380091.html

We hope to encourage discussion of how the current system could be improved.  We are finding that the midwife-led team based approach of the BirthBundleTM is a great option.  2015 will see expansion of our model and we are excited to partner with a non-profit payer (UCare) on a pilot program.  More later.

 

Single Episode Payment for Pregnancy Care: A Bundle of Joy or a Problem?

Things have been very busy at the Minnesota Birth Center.  The gestation of a better maternity and newborn care system continues and things are going well.   I am always happy to talk about this topic and next Wednesday (11/12) I will be part of a discussion with the same title as this blog post.   For the last decade or so I have been associated with the Program in Human Rights and Health at the University of Minnesota School of Public Health.  We cover all kinds of topics.  The issues and questions raised by bundling health care services are very important.  The presentation will be webcast and the link can be found at www.phrm.umn.edu     The best reason to attend live or watch as a podcast is because Katy Kozhimannil PhD, MPA from the Division of Health Policy and Management will be the discussant.  Katy is one of the most knowledgable and engaging maternal and child health care research and policy experts in the country.  You will benefit from her insights.

Where Does it Hurt? – A great and insightful read.

Jonathan Bush, co-founder and CEO of athenahealth has written a book that you must read:

Where Does it Hurt?: An Entrepreneur’s Guide to Fixing Health Care  is available in print and as an e-book.  I  have been a fan of Bush’s approach to health care for awhile and I couldn’t put the book down.  I gave it to some friends and colleagues at the Minnesota Birth Center and they are enjoying it too.

Full disclosure – we use athenahealth as our cloud-based EHR, billing, scheduling, and patient communication platform.  It is a key component in our efforts to reform and improve pregnancy and newborn care.  Bush and others started their journey in healthcare with a failed attempt at birth centers in California.  The timing wasn’t good.   It is now. This book will give you some insights into what drives us in pushing ahead with the BirthBundleTM.

What is the Product?

By some accounts nearly a trillion dollars of healthcare spending is wasted in the US every year.  As an observer of the system since starting medical school 38 years ago I am convinced that those numbers are accurate.  Inefficient and unnecessary medical care is a massive fiscal boulder dragging down the US economy.  Stagnant or declining incomes of the middle class and an unsustainable social safety net are direct consequences.  

 

Though many of the players in the system agree about the magnitude and seriousness of the situation their fingers all point away from themselves. Government, insurers, hospitals, health systems, and physicians look everywhere but in the mirror.  So much of this expensive mess is due to distorting subsidies, burdensome regulation, and a lack of price transparency that make healthcare the least competitive segment of the US economy. That is about to change.

 

It is going to change when we decide what products we actually want from the healthcare system. Until now the system has told us what products are available and what they will cost. William Sage is a physician, attorney, and academic at the University of Texas.  He has written a great article in Health Affairs that argues that we will never get anywhere until we define the products that we want and then make providers compete on quality, satisfaction, and cost.  His article can be accessed at:  

http://content.healthaffairs.org/content/33/6/1076.full.pdf+html

 

The concept of defining the product relates directly to our maternity and newborn care reform efforts here in Minnesota.  What is the product that mothers want in pregnancy care?  Is it a disorganized and expensive string of visits, ultrasounds, labs, and fetal tests followed by a medicalized birth experience?  The current system insists on selling sketchy components as their product and they do so because that is how they get paid.

 

In the current fee for service system the focus is on billing and coding to maximize each provider’s share of the pregnancy care financial pie.  The focus will shift when the product is a single price comprehensive maternity and newborn care package delivered by a motivated team of providers and facilities.  That is where our BirthBundleTM comes in.  We are founded on a foundation of midwife-led birth centers, backed up by collaborative obstetricians, a great cloud-based health IT platform in athenahealth, and forward thinking hospitals – all organized by the Natal Network Inc.

 

Progress has been slow but this real life product is now within sight. We provide it through the virtual (and we believe virtuous) network described above.  By the end of the year we will pilot the BirthBundleTM with a commercial insurer and a public program insurer here in Minnesota.  The clinical, patient engagement, and cost outcomes of the pilot will be studied by colleagues at the University of Minnesota School of Public Health.  I anticipate that we will break (not just bend) the cost curve while serving satisfied and engaged mothers with the excellent care that they deserve.  Stay tuned.

Insight from my sister (and Doc Searls)

My sister DeVon once told me, “Health care is just a high tech service industry”.   She is right.  Unfortunately most of our pregnancy care system is a medical/industrial model that does customer service very poorly and at outrageous cost.  Something needed to be done and we are doing our little bit here in Minnesota.  Our maternity/newborn care improvement efforts are meant to better serve mothers, babies, and fathers.   We are seeing overwhelming interest and real success as we deliver high quality midwife-directed primary maternity care within the context of a true team of nurse midwives, doulas, and physicians.  Eventually this will be done for a single package price through the BirthBundleTM.
 
I have been wondering why we are having such success.  Here is one thought.  Two years ago I had the privilege of meeting Doc Searls at a small conference in Minneapolis.  He is an American original and full of insights.  His recent book, The Intention Economy, is a great read and a fresh description of where we should be going in our our economic relationships – which always have a personal component.  Doc Searls motivates me.  He says that, “Markets are conversations.”  We would do well to remember that.  
 
Though I thought the following quote was by Doc Searls it was by Chris Locke one of Doc’s co-authors of The Cluetrain Manifesto.  The following, with my addition in parentheses, is what I hear loud and clear from the strong women who choose to support and give birth in a new model of care: 
 
“We are not seats or eyeballs or end users or consumers (nor “births” or “patients”); we are human beings — and our reach exceeds your grasp … Deal With It.”