CMS Proposes Maternal-Health Hospital Standards

Federal officials intend to compel US hospitals to improve obstetrical services, with a plan that could result in a potential loss of Medicare and Medicaid funds for institutions that fail to comply with the demands.

The Centers for Medicare and Medicaid Services (CMS) on July 10 announced this proposal, tucking its plan for new conditions of participation for obstetrician services into the draft 20205 rule on Medicare payments for outpatient hospital services.

The conditions of participation (COP) requirements are considered the most powerful tool CMS has for trying to improve the quality of medical care. With the new obstetric COP requirement, CMS said it intends to address what it sees as potential shortfalls in training, staffing, transfer protocols, and emergency services readiness.

In practice, hospitals, CMS, and accrediting bodies like the Joint Commission usually try to address deficiencies to prevent what would be a devastating financial loss for a hospital.

“CMS is using all of our tools to improve the safety, quality, and timeliness of the care that hospitals provide to pregnant women,” said Dora Hughes, MD, MPH, acting chief medical officer of the agency, in a press release about the proposal.

CMS estimated the proposal may add new annual expenses of $70,671 per hospital. For comparison, this figure would represent far less than 1% of the total $1.4 trillion spent on hospital care in the United States in 2022.

CMS said it is trying to address the reasons women in the United States face more risk in giving birth than those in other nations. There were 22 maternal deaths for every 100,000 live births in this country in 2022, compared with 8.6 deaths per 100,000 live births or lower that year in Canada, France, the United Kingdom, Germany, and Japan, CMS said.

But CMS is seeking to impose this new requirement at a time amid growing concerns about “maternity care deserts.”

Reasonable Asks?

Between 2011 and 2021, one out of every four rural hospitals in America stopped providing obstetrics services, said Senate Finance Chairman Ron Wyden (D-Ore.) at a May hearing. Wyden last year was part of a fight to try to prevent the closure of a birthing center in Baker City in rural eastern Oregon.

The federal government should focus first on helping hospitals keep obstetrical facilities open, said Elizabeth Powers, MD, MHA, the health services officer of the Winding Waters Clinic in Enterprise, Oregon.

“Until we can ensure access to services, we can’t even work on quality,” Powers told Medscape Medical News. “If you’re thinking about a Maslow’s hierarchy of achieving health outcomes, access is your foundation, and without a shift in payment, that foundation is eroded.”

In the draft rule, CMS sketched broad mandates about staffing and training. For example, the agency proposes requiring if a hospital offers obstetrical services, “the services must be well organized and provided in accordance with nationally recognized acceptable standards of practice.”

That means CMS likely will need to provide further guidance for hospitals if it proceeds with this plan for obstetric COP requirements, said Soumi Saha, PharmD, JD, senior vice president of government affairs at Premier, Inc., a healthcare consultancy and purchasing organization.

Premier is among the many groups, including the American Hospital Association, that oppose the COP proposal.

Saha said a better approach would be to consolidate the work being done through the US Department of Health and Human Services (HHS), including earlier CMS projects, to address maternal health in a cohesive way. The Centers for Disease Control and Prevention has programs, as does the HHS Office on Women’s Health.

“How do we really get to a holistic, national, unified approach to addressing this issue that is led by HHS at the top level as the top agency and trickles down consistently versus having all of these kinds of disparate programs in place?” she said.

In recent years, the federal and state governments have taken many steps to try to improve maternal healthcare.

These include the extension of Medicaid benefits to new mothers out to 12 months following delivery in most states. CMS also has encouraged hospitals to participate in voluntary statewide or national programs to improve the quality of perinatal care. Last year the agency launched a “Birthing-Friendly” designation icon for qualifying hospitals on its Care Compare online tool.

Support and Opposition

CMS is accepting comments on the draft 2025 hospital outpatient rule, which includes the obstetric COP proposal, through September 9.

Supporters of the obstetric COP approach included the American Nurses Association (ANA), which urged CMS to consider how staffing shortages can undermine patient care in creating COP requirements.

“Nurses are professionals providing critical healthcare services to patients; they should not have to fight for allotted breaks and other challenges created by antiquated views of the profession and payment policies that disincentivize adequate nurse staffing,” wrote Debbie Hatmaker, PhD, RN, ANA’s chief nursing officer, in a June 7 comment to CMS.

The American College of Obstetricians and Gynecologists (ACOG) and the Association of American Medical Colleges (AAMC) also objected to the prospect of new conditions of participation for maternal healthcare. They detailed their concerns in separate comments submitted in June 2024.

ACOG said it feared many hospitals might opt to close labor and delivery (L&D) units due to new CMS COP requirements, especially if these take effect “without important and direct stakeholder engagement and buy-in.” More than 200 rural hospitals across the United States stopped providing L&D services in the last decade, wrote Christopher M. Zahn, MD, ACOG’s interim chief executive officer, in a comment to CMS.

“The reason for these closures is varied. Many rural hospitals that still have L&D units continue to lose money on patient services overall, and their ability to continue to deliver maternity care is at risk,” Zahn wrote.

The AAMC urged CMS to focus on using other strategies such as quality measures to try to improve maternal health and to drop the COP approach. CMS must consider how many clinicians play a role in successful births, including those who see patients during their pregnancies, wrote Jonathan Jaffery, MD, MS, AAMC’s chief healthcare officer, in a comment to the agency.

“Hospitals do have a critical role in improving maternal healthcare equity, especially for labor and delivery outcomes,” he wrote, “but cannot be held solely responsible for implementing much-needed improvements and solutions.”

Kerry Dooley Young is a freelance journalist based in Washington, DC.