Scope of Covered Services: Recommendations and Action Steps

1. Identify an essential package of evidence-based maternity care services for healthy childbearing women and newborns, and additional essential services of benefit to women and newborns with special needs.

  • Designate a federal agency or the Institute of Medicine to convene an independent multi-stake-holder panel to specify an essential package of evidence-based maternity services for healthy women and newborns and for those with special conditions or risks. Ensure the package includes mental health services and support services such as language translation and care coordination for all women who need them.
    • Ensure that the essential package includes recommendations on indications for services, frequency, suitable providers, and the evidence base relating to both benefits and harms.
    • Require included services to meet a high standard of evidence, ideally one or more up-to-date, well-conducted systematic reviews indicating meaningful contribution to health outcomes. Although public and private insurers could cover services that warrant further research, those services should be identified as such. These distinctions could help to guide resource allocation, encourage recognition of areas of uncertainty in decision making, and identify research gaps with potential to improve maternity care quality and value. Interventions that are proven to be of no benefit should go on a ‘‘Do Not Pay’’ list.
    • Ensure that relevant stakeholders have an opportunity for public feedback on the inventory of well-supported services and those that are excluded.
    • Widely disseminate the panel’s report and ensure that it is accessible to a broad range of stakeholders.

2. Carry out research to evaluate the comparative effectiveness and safety of priority maternity services that require further evidence before they can be considered for inclusion in the essential services list.

  • Within the national comparative effectiveness research program, apply established criteria to identify research priorities among the forms of maternity care that lack the evidence base to clarify whether they can be placed on the list of essential services, and carry out research to assess the safety and effectiveness of identified priority maternity services (National Business Coalition on Health, 2009).
  • Establish a process for updating the status of maternity services and informing the stakeholders as the evidence base evolves.

3. Use determinations about comparative effectiveness of maternity services to make coverage decisions and improve the quality of maternity care.

  • Ensure that essential maternity services are covered services in all benefits packages for all women. By contrast, to avoid waste and possible harm, ensure that public and private insurers do not cover maternity services proven to be of no benefit. Coverage options for maternity services of unknown effectiveness include: exclusion from scope of covered services, or tiered insurance plans that require purchasers or consumers who choose plans with coverage of services that lack strong evidence of benefit to pay more for them.
  • Use the results of comparative effectiveness work to identify essential, uncertain, and disproven maternity services to inform a broad range of quality improvement activities. These should include health professions education, quality improvement programs, and the development of clinical practice guidelines, performance measures, and decision tools for health professionals and childbearing women.
  • Ensure that health systems provide women and families and providers with decision tools to help them understand benefits, harms, and trade-offs and make informed decisions. Give special attention to informing women about comparative benefits and harms of alternatives, such as no test versus test A versus test B.

Lead Responsibilities

Multi-stakeholder collaboration is necessary to identify and implement essential maternity services. Key stakeholders include all types of maternity caregivers; experts in nutrition, mental health, and oral health of childbearing women and newborns; pediatricians and other newborn care providers; epidemiologists and other researchers; public and private insurers; health business groups and coalitions; and consumers and advocates.

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Reference

National Business Coalition on Health. (2009). A research agenda for value-based benefit design: Recommendations from a multi-stakeholder workshop. Washington, DC: National Business Coalition on Health.