Action step: Critically evaluate obstetrics unit finances and proactively plan for gap-filling services.
Historically, many providers have chosen to close OB units when birth volumes become more complex at the same time that a rising, unfavorable, Medicaid-heavy payer mix is met with clinician shortages. The business risks outlined in this report point to these scenarios becoming more common, particularly in areas where abortion is the most restricted.
If leaders do not judiciously assess their OB unit finances in the wake of these impacts, they risk broader facility insolvency. They also risk drops in quality, patient trust, and staff engagement that often come when demand and resources are mismatched. These are precedented risks that have driven the closure of roughly 200 labor and delivery (L&D) programs since 2004 and left over half of rural counties without an OB unit and without a practicing ob/gyn.
Implementation recommendations for leaders:
- Examine current OB unit finances and how they have shifted following Dobbs. Specifically, consider the following trended metrics across low-risk and high-risk births as well as for your program overall:
- Total direct volumes
- Payer mix
- Per-case reimbursement
- Fixed costs
- Variable costs
- Tracked downstream volumes and benefits, such as NICU days, outpatient follow-up visits, mental health, etc.
- Compare the relative costs, revenues, and market opportunity of obstetrics against other services and broader organizational aims. Leaders should assess the following to understand how reallocating limited dollars to another service may better align with financial, quality, and growth goals:
- Total revenue
- Market share
- Volume, revenue, and market share growth trends
- Comparable quality metrics, such as adverse events, readmissions, etc.
- Observed associations between volume and quality metrics
- Consider the input and buy-in of organizational stakeholders, clinicians, and patient representatives. With a workforce already facing burnout and limited resources as well as a patient population in turmoil, many parties have a stake in your decision. There are several forums for gathering this feedback:
- Group or one-on-one clinician discussions
- Clinician and patient surveys
- Town or community hall open mic events
- Cross-stakeholder working groups
- Openly communicate changes to the community, especially changes to the OB unit. Work with physicians to determine where patients will deliver, hold "town hall"-style meetings to discuss your decision-making process, and announce closures well in advance to give patients time to reconsider where to deliver.
- Should an obstetrics unit ultimately have to close, immediately begin practicing logistical coordination to the closest OB programs. To minimize unanticipated impact to surrounding OB units, prepare for site operations on moving day by holding a "mock move" to prepare staff, plan for EMS transfers, and incorporate local volunteers to help coordinate activities.
To further guide your rationalization decisions, reduce potential consequences of L&D closure, and understand the potential role of health plans in improving maternity outcomes, see our recent publications: Service rationalization toolkit, Leading service rationalization decisions, Communicating about rationalization decisions, How to mitigate the long-term effect of OB unit closures, and How 2 organizations provide accessible pregnancy care.
Action step: Support holistic women’s health across all service lines.
Despite the steps leaders can take to optimize their obstetrics programs and mitigate the business risks, there will be cases where it is not financially feasible to continue operating an L&D unit. In these cases, leaders must take steps to ensure gap-filling services. If providers do not ensure access to prenatal care and other women’s preventive services in the absence of an OB unit, they risk adverse patient outcomes. Studies have shown that a lack of prenatal care increases the likelihood that a patient will die from a pregnancy-related outcome by three to four times. These care gaps also decrease staff morale, reduce patient and community trust, and for systems in urban areas with comparably located OB units, a forfeit of up to 70% of the volumes that could have been captured at the initial site.
Even outside of direct unit closures, all providers can benefit from taking an expansive definition of women's health beyond pregnancy care, elevating the needs of patients across all service lines, and throughout all stages of the patient’s life. Some may take this opportunity to invest in women’s health as a dedicated service line, whose leaders have access to a unified data set that aggregates information related to women’s health from all parts of the business.
Of course, not all providers should create a women’s health service line. Rather, it is particularly timely for providers to assess the opportunities in their individual markets to determine how best to cater to patients who need these services. These opportunities may include shifting services to be closer to the patient by leveraging telehealth or consolidating services into women’s health ambulatory centers, for example.
Implementation recommendations for leaders:
- Perform an audit and identify opportunities to embed holistic women’s health services across your business. For example, providers can integrate behavioral health into ob/gyn and maternal health services. St. Joseph’s Health Care in Ontario, Canada, set up a Women’s Health Concerns Clinic to provide behavioral health assessments, consultations, and treatments for premenstrual syndrome, post-partum depression, and the menopause transition. Community partners and local primary care doctors routinely refer high-risk patients to the clinic early in their pregnancies. This preventive approach is so effective that the clinic reports a rate of post-partum depression less than half that seen by neighboring systems.
- Consider alternative access points using telehealth or mobile clinics. According to Advisory Board research, telehealth modalities such as virtual visits can be used to replace a portion of routine pregnancy checkups or facilitate consults with specialists. Maternal fetal medicine (MFM) specialists are scarce, and recruiting them to rural areas is difficult. Health systems can fill a service line gap by using telehealth to provide MFM services even if volumes don't support a full-time specialist. Additionally, some health systems have begun using mobile clinics to provide prenatal care.
- Train your existing workforce in women’s and maternal health. According to CMS, there are opportunities to leverage the existing health care workforce to improve access to maternal health services. For instance, health systems can train nurses to educate women about health risks and warning signs throughout pregnancy or leverage social workers to address substance misuse and mental health concerns. To prepare for pregnant patients seeking care in the ED, leverage emergency medical services in pre-hospital management of OB care for pregnant patients in trauma situations. Next, train ED staff to handle emergent deliveries and have protocols in place for complex patients.
Action step: Address the root causes of maternal health inequities.
The increased emphasis on racial health equity in the wake of the racial justice uprisings in 2020 led many health care organizations to name maternal health equity as a key priority. The overturning of Roe v. Wade presents a significant challenge to those efforts. Patients of color already face disproportionate rates of maternal mortality and morbidity (the maternal mortality rate for Black patients is 3.3x the rate for white patients). These patients will also be disproportionately impacted by abortion bans, sparking many fears that maternal health inequities will only worsen.
Expect the Dobbs ruling to increase scrutiny around your maternal health equity strategy. View this as an opportunity to renew and expand your investments. Because while many organizations have already made significant investments in maternal health (or at least made public statements of that commitment), most strategies are too narrowly focused on improving protocols for labor and delivery, even though the majority (64%) of pregnancy-related deaths occur before labor and in the immediate postpartum period. In addition, many conventional strategies aimed at supporting maternal health miss opportunities to address the root causes of maternal health inequity: enduring legacies of institutional racism hardwired into policy, social institutions, and culture; as well as the diminished priority of women's holistic health care across the life span, particularly in favor of fetal outcomes.
Though the root causes are complex, there's good news: The industry has surfaced proven action steps that can reduce disparities.
- Ensure evidence-based care standards are embedded into frontline practice. There are clinical protocols that, when used, can reduce the number of "near misses" during labor and delivery. All OB practices should immediately implement these "no regrets" standards, if they haven't already. Health plans can support provider organizations in making this transition, which requires an intentional and standardized approach to frontline training.
- Track performance and identify care gaps. Once provider organizations have no-regrets safety protocols in place, institute ongoing feedback mechanisms to monitor adherence to care standards and identify other gaps in maternal care. This includes expanding existing maternal mortality review boards to multidisciplinary perinatal review committees that can assess any "near miss" across the care journey and using race-stratified data and community input to identify care gaps (e.g., patient satisfaction, social needs).
- Tap into system- and community-based resources to design solutions in partnership with the most impacted groups, especially Black and Native American patients. Prioritize partnerships that connect frontline staff to ongoing cultural humility and clinical training, refer patients to perinatal-specific behavioral health care, address patient social needs, integrate midwifery and doula groups into care, and invest in telehealth capabilities to improve patient access.
For more on this issue, review our take on Addressing the Root Causes of Maternal Health Inequity.