1. Simpson, Kathleen Rice PhD, RNC, FAAN

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Hospitals and healthcare systems are under pressure to adopt standardized evidence-based care practices known to minimize risks of complications for medical-surgical patients or they will face significant reductions in reimbursement from third party payers. Can this type of scrutiny and financial disincentive process soon be expected for perinatal care? Consider what has happened recently in the medical-surgical specialty. As of October 1, 2008, the Centers for Medicare and Medicaid Services (CMS) are no longer paying for treatment to correct an adverse event for 12 specific hospital-acquired conditions (HACs) that it deems could have been reasonably prevented with the implementation of accepted evidence-based practices (CMS, 2008). Further HACs that will fall under these rules are being considered for implementation this year. When CMS promulgates rules for hospital reimbursement, they are often adopted by private healthcare insurance companies. Included in the CMS list are three Never Events (serious, preventable errors that should never happen) such as operating on the wrong patient or wrong body part and leaving a surgical object inside the patient. A list of never events specific to perinatal care has been proposed (Simpson, 2006) and many of these perinatal never events may be subject to CMS financial disincentives in the future, especially considering that Medicaid is the payer for over 43% of births in the United States (National Governors Association, 2008).

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There are several perinatal care practices that could be targeted if we as a group do not take the initiative to minimize or eliminate practices that are inconsistent with current evidence and professional standards/guidelines and known to be associated with preventable adverse outcomes. These include, but are not limited to, birthing babies electively before 39 completed weeks of gestation with subsequent neonatal morbidity or administering excessive amounts of the high-alert medication oxytocin (medication error) with associated unrecognized and untreated uterine tachysystole that leads to fetal compromise and an unnecessary emergent cesarean birth (adverse drug event). Administering higher than recommended doses of prostaglandin agents such as misoprostol for cervical ripening and labor induction that produce similar outcomes may also be considered nonevidence-based care and therefore subject to the same financial disincentives. Development of neonatal group B streptococcus or HIV infection after failure to provide intrapartum chemoprophylaxis, given there is time to do, so are further examples. Unlike the CMS rule which denies payments to hospitals for these conditions, in obstetrics, some preventable events are directly associated with provider decisions (e.g., birthing babies electively before 39 completed weeks of gestation), thus reduction in provider payments may also be considered.


Do we really want the government intervening when we should be able to address these problems ourselves? Doesn't every mother and baby deserve evidence-based perinatal care as a general principle? Perhaps financial disincentives or payment reduction for nonperformance would promote safer care for mothers and babies; however, we can avoid this government intervention by hospitals and healthcare systems taking a more active role in accountability for care that is provided in their institutions and the administrative and clinical leadership team insisting that perinatal care is consistently based on current evidence and professional standards and guidelines.


Selected Perinatal Clinical Practices that May Be Targeted for Financial Disincentives

Elective Births Before 39 Completed Weeks of Gestation


* Increases risk of neonatal morbidity and mortality


* Possible actions by healthcare payers:


Deny full payment for mothers' care (limit reimbursement to pay for only spontaneous uncomplicated labor and vaginal birth if labor is electively induced before 39 weeks or uncomplicated repeat cesarean birth if the mother had prior cesarean birth)


Deny full payment for babies admitted to higher level of care with symptoms of iatrogenic prematurity (limit reimbursement to pay for only normal nursery care)


Deny provider payment



Cesarean Birth For Indeterminate/Abnormal Fetal Heart Rate Pattern Due to Unrecognized and Untreated Oxytocin-Induced Uterine Tachysystole


* Unnecessary cesarean birth (adverse drug event) due to mismanagement of oxytocin, a high-alert medication


* Possible actions by healthcare payers:


Deny full payment for mothers' care (limit reimbursement to pay for only uncomplicated labor and vaginal birth)


Deny full payment for babies admitted to a higher level of care (limit reimbursement to pay for only normal nursery care)





Centers for Medicare and Medicaid Services. (2008). Hospital-acquired conditions in acute inpatient prospective payment system hospitals. Washington, DC: Author. [Context Link]


National Governors Association. (2008). Issue brief: Maternal and child health update. Washington, DC: Author. [Context Link]


Simpson, K. R. (2006). Obstetrical never events. MCN: The American Journal of Maternal Child Nursing, 31(2), 136. [Context Link]