Discussion
As far as we know, this is the first study in which the budget impact has been assessed of implementing aCTG in primary care. The results of the base-case analysis suggest that, based on the best information available, implementing MLC-aCTG would result in an increase in actual costs of €311 763 and €1 247 052 for implementation rates of 25% and 100%, respectively, and a decrease in reimbursement of almost €7 538 335 and €30 153 342 million per year, for implementation rates of 25% and 100%, respectively. Our study focused on healthy pregnant women with a specific aCTG indication who received the aCTG in primary care as an alternative to temporary hospital admission during which an aCTG is conducted. Several studies of other innovations in maternity care focussing on out-of-hospital care for high-risk pregnancies had evaluated similar interventions. The trial of Bekker et al suggests that home telemonitoring of CTG and blood pressure measurements in pregnancy care is an acceptable alternative to monitoring selected women with complications in hospital, and therefore, has the potential to reduce admissions and costs in obstetric care.4 van den Heuvel et al reported that using a digital platform for blood pressure and symptom monitoring in antenatal care for high-risk women is associated with lower costs than conventional care while observed maternal and neonatal outcomes are similar.5 Our findings showed that the reimbursement of implementing the MLC-aCTG care path might be substantially lower than those of the OLC-aCTG care path and concord with the studies that conclude that out-of-hospital care reduces healthcare costs. However, the cost savings are not reflected in the actual costs incurred by midwifery practices. Compared with obstetrician led, the actual costs of performing an aCTG are higher in MLC. This difference can be explained by the fact that MLC professionals spend more time in attendance during the aCTG, as shown by the time-driven activity-based costing calculation. The break-even analysis shows that income would increase for midwifery practices by performing aCTGs, although at high expenses (eg, in three regional maternity care networks, on average 1799 aCTGs need to be performed together to break even). Hence, midwifery practices must perform sufficient aCTGs to cover costs adequately. The hospital would lose income, but overhead costs like housing costs, personal staff and equipment in obstetrician-led would initially not decrease.28 29 The expectation is that hospitals would use the freed-up capacity to provide more care for pregnant women at increased risk. This will further improve the specialised care for those pregnant women who need it most while providing additional revenue for hospitals given the more specialised procedures needed.28 However, in the short term, task-shifting aCTG from OLC to MLC would result in a financial burden for hospitals. This means the current reimbursement policy does not support the proposed care path change for maternity care networks.29–33 As healthcare costs and hospital capacity problems continue to increase worldwide to unsustainable levels, innovations that reduce costs and increase hospital capacity are urgently needed.3 Besides, in terms of women’s satisfaction levels, performing aCTGs in primary MLC, thereby improving continuity of care, seems to be a valuable change in the organisation of maternity care in the Netherlands.12 However, a fee-for-service payment model is an important barrier to implementing innovations such as MLC-aCTG.29 32 33 Within this traditional payment, all maternity care providers (such as gynaecologists and midwives) are paid separately, which hinders collaboration between disciplines. Moreover, fee-for-service models are known to incentivise healthcare professionals to increase the number of medical diagnostic tests and interventions (as long as the price is above marginal costs) and increase overtreatment and low-value care, which is not contributing to the integration of MLC and OLC.34 35 Stakeholders in Dutch maternity care agree that a different payment model is needed.33 Within the traditional payment model, all maternity care providers (such as obstetricians and midwives) are paid separately, which hinders collaboration between the different disciplines. However, opinions differ about a new payment model’s preferred design and the conditions it should meet.35 In terms of further research, it is important to explore the facilitators and barriers for healthcare professionals in MLC and OLC regarding the implementation of MLC-aCTG and explore the possibilities of improving payment models in integrated maternity care. This study has several strengths. First, we analysed the actual costs and reimbursement both at a national level. Second, for the cost calculation, we used time-driven activity-based costing, which helps care providers understand the major cost drivers and find points of action for lowering costs.3 36 Third, we performed a probabilistic sensitivity analysis to estimate the uncertainty surrounding our budget impact estimates.37 However, some limitations need to be addressed. We used different data sources to estimate the actual costs of MLC-aCTG and OLC-aCTG, including a specifically conducted survey, prospective cohort data and national registry data. Although we tried to be as precise as possible in estimating costs, actual costs in clinical practice may differ from our estimations. Unfortunately, we do not have data for training and CTG equipment costs in OLC, and we assumed in our study equal costs for these components in OLC-aCTG and MLC-aCTG. However, these costs are expected to be lower in OLC, given that the volume of CTGs is higher. This may lead to a lower rate of actual costs of OLC-aCTG. In our analyses, we only focused on the actual costs of performing the aCTG in MLC or OLC without considering a possible impact on the percentage of women that remain in MLC in either of the two care models. Since we expect that more women will stay in MLC when the aCTG is conducted in MLC than in OLC, where the chance of medical interventions is lower,38 we expect total childbirth costs to be lower for MLC-aCTG. Future research should address this, for example, in a large prospective cohort study. We chose to focus on the direct material costs, which comprise the majority of expenses incurred in clinical practice. We did not consider the costs of sterilisation, housekeeping, finance, and information and communication technology. Although this might have impacted the costs, we do not expect this would alter our conclusion as this difference will be minimal compared with the costs we have included.
Finally, in this study, we performed a budget impact analysis considering the financial consequences of implementing MLC-aCTG. It was not possible to perform a cost-effectiveness analysis that included outcomes such as safety and women’s satisfaction with the data we had available. However, we have assessed quality of care and women’s satisfaction in separate publications and have shown that there are no differences in the quality of aCTG assessment between primary care midwives, hospital-based midwives, residents and obstetricians.10 In addition, our previous work has shown reassuring maternal and perinatal outcomes after MLC-aCTG and high levels of women’s satisfaction with this care.11 12 Considering the impact of costs, quality and satisfaction together is crucial when implementing a value-based healthcare innovation such as MLC-aCTG.
Conclusion
Our findings suggest that shifting aCTG from secondary OLC to primary MLC may increase the associated actual costs for healthcare professionals. At the same time, it might reduce reimbursement. In terms of further research, it is important to explore the facilitators and barriers for healthcare professionals in MLC and OLC regarding the implementation of MLC-aCTG and explore the possibilities of improving payment models in integrated maternity care.