How to Prepare for Texas’ New Maternal Care Levels

Dr. Marc Zepeda works for Ob Hospitalist Group as site director of OB hospitalists at Baylor Scott & White Medical Center – McKinney (Courtesy of Ob Hospitalist Group).

Last November, D CEO Healthcare detailed the steps that Texas has taken to address the state’s maternal mortality rate, which is unacceptably high even after a revision of the mortality data.

One of the important initiatives enacted by the legislature and signed by the governor is maternal level-of-care designations (MLOCD). MLOCDs, which were endorsed three years ago by the American College of Obstetricians and Gynecologists (ACOG), the Society for Maternal Fetal Medicine, and others, are aimed at standardizing care and improving maternal and infant outcomes.

Texas joins a handful of other states, including Indiana, Arizona, and Maryland in adopting maternal care designations. While the ACOG consensus statement defines five designations, ranging from Birth Center (generally, a midwife overseeing birth, with transport available) to Level I (Basic Care) to Level IV (Comprehensive Care – Regional Perinatal Center), Texas law designates four levels of maternal care. It combines Birthing Center care and Level I designation.

On September 1, 2020 Texas will require the maternal level of care designation for all hospital providers that render neonatal/maternal inpatient services and receive Medicaid reimbursement for obstetrical services. Hospitals applying for the MLOCD will be evaluated by ACOG and the Texas EMS Trauma and Acute Care Foundation.

Given this sea change for hospitals, how can organizations best prepare for the change? Here are three ways:

Step it up (prepare to become a Level III or IV provider). Under the new Texas law, Level III and IV designations require an OB/GYN to be onsite at all times and also require an Maternal-Fetal Medicine specialist, an anesthesiologist,  and specialty and critical care physicians to be available at all times. While these standards are most likely to be viewed positively by savvy healthcare consumers, they also require hospitals to initiate 24/7 obstetrical coverage.

Most hospitals realize the greatest financial and operational benefit from a management model, in which the hospital contracts with an outside company to recruit and manage OB/GYN hospitalists who provide a wide array of services, implement the program, and oversee its operation. At providers like Ob Hospitalist Group (OBHG), many programs feature an Obstetrical Emergency Department (OBED). Under an OBED model, all OB patients presenting with an emergency condition are seen by a physician or midwife alongside the obstetrical nurse. Hospitalist clinicians act as emergency first responders for all patients in Labor and Delivery to improve outcomes in an emergent situation.

Determine the payer volume percentage attributable to Medicaid births – and increase accordingly. One of the key requirements of the Texas maternal leveling designations is that after September 1, 2020, a hospital without a designation will no longer be eligible for Medicaid reimbursement for OB care. And while reimbursement for Medicaid births is traditionally lower than that of private payers, organizations with high Medicaid volume that fail to work strategically toward a rapid designation may be at financial risk.

Another advantage: while some hospitals are challenged by finding an OB to deliver unassigned or Medicaid patient’s babies, some OB hospitalist companies care for all patients, regardless of payer status.

Collaborate regionally. A 2013 study in the Journal of Midwifery and Women’s Health found that about 16 percent of births planned at birth centers ended up in a hospital (of that group, 4.5% were referred to a hospital before being admitted to the birth center and 11.9% transferred to the hospital during labor). To optimize patient care, organizations should begin a dialogue with their community partners. When a patient’s circumstances change mid-delivery or even mid-pregnancy, hospitals that have transfer arrangements in place may be able to better work through reimbursement issues.

When viewed strategically and approached proactively, MLOCDs have the potential to benefit both patient care and organizational bottom lines.

Dr. Marc Zepeda works for Ob Hospitalist Group as site director of OB hospitalists at Baylor Scott & White Medical Center – McKinney.


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