Health+Benefits Vital Signs the March 2023 issue

Employers’ Role in Reducing Maternal Deaths

Q&A with Brittany Bono and Corina Leu, senior associates in Total Health Management, Mercer
By Tammy Worth Posted on March 1, 2023

The report notes that the United States has one of the highest rates of maternal mortality of high-income countries, that much of this is preventable, and that employers can support better birth outcomes for their employees. In 2020, the latest data, 861 women died of maternal causes in the United States, according to the CDC.

What made you decide to take up this topic?

Bono: We wrote this now because of Roe v. Wade and the Dobbs decision. That has created an opportunity for us to talk more about reproductive health and women’s health in general. It’s been bubbling up for a while; this whole issue has been becoming more and more discussed. We’ve seen a lot more information lately about how the U.S. is just not quite doing enough in reproductive health and pregnancy support—and in all areas of women’s health—so that made us want to put together this report to offer suggestions of how employers can help. It’s a huge issue, but there are lots of innovative solutions. In terms of budget or implementation, there are small things that can make a really big impact.

Leu: We play an important role in helping employers with a variety of strategies, and when you look at the landscape of the U.S. and how Americans receive benefits, more than half are through their employers. Because the number of workers ages 20 to 60 who get care through their employers is so high, those employers play an important role in supporting people when there is a public health emergency. What we saw in our research is that, when it comes to maternal mortality and morbidity, we have a state of emergency that is happening. We’re working on helping employers come to the table with actionable steps to help solve the problem.

Telehealth access from vendors can be key here, too. With some of the biggest issues people have, like lactation or blood clots, having someone you can go to to ask a question in the middle of the night is crucial.
Brittany Bono, senior associate in Total Health Management, Mercer
You found that it wasn’t any particular clinical issue that is causing this problem but it’s more systemic—often due to racial discrimination or medical treatment bias. Poor outcomes occur because of things like breastfeeding support not offered in areas where rates are low or medical interventions, like inducing labor, are done without consent among certain populations, correct?
Leu: The root causes of the problem are mostly nonmedical issues. We see that systemic inequity has profound implications for women’s health in the U.S. Too many healthcare providers are dismissing pain as something that is natural that women and birthing people have to bear. We found that things that arise from systemic inequity, or gender bias or unfair inequitable structures cause severe mortality and morbidity to rise. For the most part, these things are largely preventable. But we don’t see the trends improving, which is why we are asking employers to come to the table and follow the steps we offer.
One of the main actions you mentioned was collecting data on at-risk populations. How does that help provide better maternal care?

Bono: By collecting demographic information that hasn’t historically been collected, the employer can send that to insurance companies. Employers are already sending information to insurers in their eligibility reports, so some of that demographic information is already going over. If they add a few fields, like race and ethnicity, insurers can use that to connect people to more appropriate providers. And if employers are requesting this information about providers in their listing, it’s more likely that insurers will include that on their websites.

One of biggest points we tried to communicate in the report is creating provider concordance; there is really something to be said of the relationship between a patient and provider, how comfortable and encouraged a patient feels, and how that can support better medical care. We think plan members should have a choice—as much as possible—of their providers and location for birth. This would allow someone to determine if they want an epidural or slower induction or if they prefer a birth out of a hospital; we want them to choose the options that are best for them.

Employers can be an example by collecting and using this data and putting pressure on insurers to make sure appropriate care is available for all employees. We have seen it in other areas of health where this pressure has been successful. Like in behavioral health, it has expanded over the last few years as the number of employees presenting with mental health concerns has grown and demand for services has increased. We are seeing it in the employer space, some improvements in matching employees with providers who come from similar backgrounds to provide better care. If they can do it in behavioral health, they can do it for OB-GYNs and midwives as well.

You also highly recommend the use of midwives and doulas. What kind of benefit coverage is out there now for these providers, and how could it be improved?

Bono: As for midwives, what we most commonly see is that certified nurse midwives are covered. Some insurance covers birthing centers, and we see some plans that cover home births. But there is still a lot of confusion about what is covered, if something is freestanding or a birthing center, what kind of providers can you have, etc. It is complicated, and sometimes you have to do some digging into your plan design to find out what is available.

Increasing the options available for pregnant people could have a positive impact on health outcomes and labor and delivery costs. If better care helps avoid unnecessary interventions or deaths related to pregnancy or birth, it is beneficial to all of those involved. We have seen compelling data about members’ outcomes when they have access to midwives and alternative birthing options and locations. Oftentimes at a birthing center, patients go home much sooner, don’t have an extended medical facility stay, and there is often no medical intervention at all—no IVs or anesthesia—so employers are avoiding a lot of delivery costs.

1.  Provide financial reimbursement for doulas through a pretax benefit like health savings or flexible spending accounts.

2.  Review plan limitations on out-of-hospital births and offer coverage for women who prefer this kind of delivery.

3.  Review access and inclusion for licensed freestanding birth centers and certified nurse midwives.

4.  Ensure your insurance carrier and vendors offer search capabilities based on race, ethnicity, sexual orientation, gender and training. Request carriers and vendors perform a diversity audit.

5.  Collect race and ethnicity data from plan members and hold vendors accountable for good outcomes among at-risk populations.

6.  Review maternity coverage, paying attention to virtual care and alternative providers.

7.  Support new parents for a year postpartum with paid leave, lactation consultants, virtual health and phased return to work.

8.  Provide training for managers to support pregnant women and new parents from diverse family types.

9.  Create inclusive benefits communication and package benefits to help parents navigate all available resources.

How can employers include this in their plans if they aren’t covered by their insurance provider?
Bono: Some employers are getting interested in the concept of doula support. The cost for employers is quite affordable: it ranges from $600 to $1,500 per birth, depending on geography and the services they offer. Working with a doula can be important for improving outcomes and patient experience. We are seeing some employers administering reimbursement for doula expenses through something like a lifestyle spending account or vendors offering an add-on benefit. Some insurers that offer telehealth are providing 24/7 access to doctors, nutritionists and others who specialize in pregnancy, and they include doulas as well. The main goal here is allowing people to ask questions up front and have a trusted person to give support to members.
In the report you mentioned that employers can use their existing benefits infrastructure to inform at-risk employees and members about their risks and offer them services and support their care choices. How can employers do this?

Leu: Training for managers is crucial here because that training can support employees and families who are expecting and new parents. Managers can help reduce stigma and make sure employees know what benefits are provided and how to get access to them.

Bono: Manager support and training is critical, and so is getting creative about employee communications. Businesses need to make sure communications are designed in a way that reaches people at the right time and are neatly packaged together. For instance, when someone becomes pregnant, employers can send information out to that employee about leave, doula reimbursement and postpartum care.

You also said that telehealth is a beneficial component to obstetric and postpartum care, correct?
Bono: We are seeing some vendors getting extensive with the telehealth solutions available, and a lot are providing it in the pregnancy and fertility space. There are a lot of care navigation solutions out there where patients have a single point of contact or team they can go to at any time via phone, chat or video to ask questions, plan, prepare and understand their options.
In the report you noted that more than half of all maternal deaths occur after delivery—up to one year postpartum. What can employers do to help prevent this?

Bono: The goal here, as with pregnancy and labor and delivery, is to increase access to midwives or freestanding birth centers. Lots of midwives do home visits after delivery, and there are more postpartum visits with nurse midwives than there are with OB-GYNs [instead of one visit at six weeks, many midwives have three to five visits in the first six weeks postpartum]. There are even some postpartum-focused doulas. If benefits cover explicitly postpartum, they can come to someone’s home and take an evening shift so parents can get sleep or teach a new mom how to get into a routine with feeding.

Telehealth access from vendors can be key here, too. With some of the biggest issues people have, like lactation or blood clots, having someone you can go to to ask a question in the middle of the night is crucial.

Paid family leave has been a hot topic in the past year or so. How does that benefit new parents?
Bono: What I see, anecdotally, is that standard maternity or parental leave ranges from about six to 10 weeks. If that is paired with short-term disability, it usually gets people back to work three to four months postpartum. It’s important to have leave if an employer can and to allow people to determine what is best for them to return to work. Maybe people return part-time or work shorter days or phase in more gradually. Employers need to support people so they don’t go zero to 60 when their leave ends.
Most labor and delivery benefits are relatively standard, as you mentioned. Do you recommend employers review what they offer and seek innovative vendors and plans?
Bono: I do think revisiting an employer’s benefits is necessary. They can make it more expansive without adding a lot of cost. If they can increase options, improve health outcomes and create a more positive experience with birth and delivery, I see it as a win-win for everyone. Employers may learn a lot about what is available, like coverage of midwives, birth centers, out-of-hospital births and other types of pregnancy-related providers. They may even start thinking about chiropractors that specialize in pregnancy or pelvic floor physical therapy.
Tammy Worth Healthcare Editor Read More

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