New Rule Lays Groundwork for Hospital Transparency and Accountability for Maternity Care

Last month, CMS finalized a rule that lays the groundwork for a major step forward for hospital accountability for maternity care. Tucked inside an annual final rulemaking on Medicare hospital payment, CMS added a new requirement for hospitals to publicly report maternity care quality metrics. Depending on the hospital’s performance, hospitals may be awarded a new public designation certifying the hospital is “birthing friendly.” The administration plans to roll out the public website next fall based on just one measure, but will likely add more metrics in the future.

Medicare–unlike Medicaid–is a fully federal program, which provides HHS with a strong lever to use its payments to drive hospital quality improvements. While Medicare is a health coverage program predominantly serving seniors 65 and older, it directly funds hospitals across the nation and has oversight authority for health and safety standards in health care facilities.

The vast majority of births each year–98.4 percent in 2017–occur in hospitals, including most births financed by Medicaid. In this rule, CMS rightly sought to use its direct reach into hospital quality through Medicare to also bring transparency to the quality of maternity care amidst the nation’s ongoing maternal health crisis that disproportionately affects Black women. Repeated, well-documented instances of mothers experiencing racial bias, rough handling, and insurance-related bias during hospital maternity care adds to the urgency of leveraging every tool at CMS’s disposal. This new rule has the potential to use accountability and transparency to improve the quality of maternity care delivered in hospitals in ways that could spur health system practice changes that seek to make care more equitable.

So how might this work in practice? First, some background is helpful. Each year, Medicare must update its payment policies for hospitals that receive Medicare funding. In its 2021 rulemaking, CMS added a measure that would begin to assess the quality of maternity care received in hospitals. The “maternal morbidity structural measure” requires hospitals to report if they are (1) participating in a structured state or national Perinatal Quality Improvement (QI) Collaborative; and (2) implementing patient safety practices or bundles as part of these QI initiatives. Hospitals attested to their actions on the measure for the first time in May 2022. CMS is still analyzing the data.

In the 2022 final rule, CMS went further. The agency will now use the hospital-level data from the maternal morbidity structural measure to populate a public page on its Care Compare website. CMS plans to post measure data for October to December 2021 on the Care Compare website in Fall 2022, and post initial results for the hospital designation beginning in Fall 2023.

CMS plans to add more metrics to the designation in future rulemaking, including a hospital’s rate of c-sections for low-risk births and rate of severe obstetric complications. We strongly support adding more data, as it will provide a fuller picture of the quality of care that birthing people can expect to receive at any individual hospital. CCF submitted comments on the proposed rule here.

As the public reporting evolves, increasing transparency will also help state Medicaid programs and Medicaid managed care companies identify which hospitals perform well for Medicaid patients on maternity care metrics and which do not. Medicaid covers a disproportionate share of births among women of color, young women and women living in rural areas—all populations that are at greater risk of experiencing severe maternal morbidity and mortality.

As the nation’s single largest payer of maternity care, the Medicaid program has a clear interest in understanding how individual hospitals are performing.  State Medicaid programs could also use the data to facilitate access to higher-performing hospitals, both for birth care and care in the postpartum period–more critical now that 34 states have extended postpartum Medicaid for one year after the end of pregnancy. The hospital designation’s requirement to publicly report hospital-level data on maternal health outcomes, ideally disaggregated by race, ethnicity, payer and other factors, will help beneficiaries choose a birth hospital and promote greater transparency and accountability for Medicaid spending in maternity care.

The strategic use of Medicare rulemaking to drive improvement in hospital-based maternity care is part of the administration’s overall maternal health strategy, outlined in the recent White House Blueprint for Addressing the Maternal Health Crisis. CMS also recently released more specific plans on how the agency plans to address maternal health.

It’s encouraging to see federal leaders using multiple levers to address the maternal health crisis that continues to engulf the country, causing the greatest harm for Black and Brown pregnant and postpartum people. It will take changes at every level–including federal, state and individual communities–to ensure that every family has the opportunity to a healthy start.

Maggie Clark is a Program Director at the Georgetown University McCourt School of Public Policy’s Center for Children and Families.