Maternity Care Selection Criteria

Blue Cross Blue Shield Association is an association of independent Blue Cross and Blue Shield companies.

Program Selection Criteria:

2023 Maternity Care

Released July 2023

2013 Benefit Design Capabilities Survey

Blue Cross Blue Shield Association is an association of independent Blue Cross and Blue Shield companies.

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Blue Distinction Centers for Maternity Care| Program Selection Criteria

Document Overview

The Program Selection Criteria outlines the Quality, Business, and Cost of Care Selection Criteria and evaluation

processes used to determine eligibility for the Blue Distinction

Centers (BDC) for Maternity Care program (this

Program).

Sections of this document include:

1. Blue Distinction Centers for Maternity Care

2. Evaluation Process

3. Quality Evaluation

4. Quality Selection Criteria

5. Rationale For Required Selection Criteria

6. Quality Informational Measures

7. Business Selection Criteria

8. Cost of Care Selection Criteria

9. Cost of Care Evaluation

10. Appendix A: Obstetric Hemorrhage Patient Safety Bundle Elements

11. Appendix B: Severe Hypertension Patient Safety Bundle Elements

12. Appendix C: Safe Reduction of Primary Cesarean Births Patient Safety Bundle Elements

Blue Distinction Centers for Maternity Care

The BDC for Maternity Care program (Program) evaluates facilities (acute care hospitals, as well as children’s

hospitals) that offer maternity services for adult patients 18 years or older. This Program evaluates patient

outcomes and additional measures collected in the 2023 Maternity Care Provider Survey. Designation as a BDC for

Maternity Care differentiates facilities locally, as well as nationally, and includes two levels of designation:

• Blue Distinction Centers (BDC): Facilities recognized for their expertise in delivering specialty care.

• Blue Distinction Centers+ (BDC+): Facilities recognized for their expertise and cost-efficiency in

delivering specialty care.

Quality is key: only those facilities that first meet nationally established quality measures for BDC will be

considered for designation as a BDC+.

Designations are awarded to individual facilities (i.e., unique bricks-and-mortar facilities with unique addresses).

Any facility with multiple locations (different addresses) was evaluated separately for each location. Health

systems and other groups of multiple facilities/clinics are not designated collectively.

Evaluation Process

Blue Distinction Specialty Care programs establish nationally consistent and continually evolving approaches to

evaluating quality and value of care. The evaluation process include:

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Quality

A nationally consistent approach to evaluating quality and safety by incorporating quality measures with meaningful

impact, including care delivery system features and specific quality outcomes to which all can aspire.

Cost

A nationally consistent and objective approach for selecting BDC+ was used to address market and consumer

demand for cost savings and affordable healthcare.

Access

Blue members’ access to Blue Distinction Centers was considered to achieve the Program’s overall goal of

providing differentiated performance on Quality and, for the BDC+ designation, Cost of Care.

Data Sources

Objective data from the Provider Survey, Plan Survey, and National Blue Claims Dataset (Claims Data) information

were used to evaluate and identify facilities that meet the Program’s Selection Criteria. Table 1 below outlines the

data sources used for evaluation of this Program.

Table 1: Data Sources

Selection

Criteria

Components

Data Source

Blue

Distinction

Centers

(BDC)

Blue

Distinction

Centers+

(BDC+)

Quality

•

Quality data supplied by applicant facility in the Provider Survey

•

Local Blue Plan Quality Criteria (if applicable)

✓

Business

•

Data supplied by Blue Plan in the Plan Survey

•

Review of Blue Brands Criteria

•

Local Blue Plan Business Criteria (if applicable)

✓

Cost of Care

•

Blue Health Plan Claims Data

•

Local Blue Plan Cost Criteria (if applicable)

✓

Quality Evaluation

Blue Distinction Specialty Care programs establish a nationally consistent approach to evaluating quality and safety

by incorporating quality measures with meaningful impact. Selection Criteria continues to evolve through each

evaluation cycle, consistent with medical advances and measurement in this specialty area. The measurement

framework for this and other Blue Distinction programs were developed using the following guiding principles:

• Align with credible, transparent, nationally established measures with an emphasis on improved outcomes.

• Implement a nationally consistent evaluation approach.

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• Include metrics that close clinical care gaps recognized as affecting longevity and quality of life and/or

contributing to higher spend.

• Evolve the selection criteria, consistent with medical advances and objective measures demonstrating

improved outcomes. by including elements of behavioral/mental health, virtual care, equity, and social

determinants of health (where applicable).

• Apply a fair and equitable evaluation approach that identifies facilities that meaningfully differentiate the

delivery of care.

Quality Measure Selection

Facilities were evaluated on quality measures developed through a process that included input from the medical

community and quality measurement experts, and review of medical literature. This process also included an

analysis of national quality and safety initiatives, and a thorough analysis of meaningful quality measures. Quality

Selection Criteria includes general facility structure and process measures, and patient outcome measures specific

to maternity care. The evaluation was based on facility responses to the Provider Survey for cases performed

during the most recent 12 months prior to submitting the Provider Survey.

The selected measures are joined into the final aggregate scoring model for evaluating facilities. The goal of the

program is to create a final aggregate model that provides differentiated performance on quality, while still providing

Blue Member access to designated facilities in each of the top 100 MSAs for Maternity Care.

Furthermore, Quality Selection Criteria scoring was based on a 90% lower confidence limit (LCL) of the outcome

measures, not on the actual point estimate (or rate) of the quality outcome measures. This benefits each facility by

taking potential measurement error into account, based upon statistical confidence predictions. If a facility’s LCL is

equal to or below the threshold, then that facility’s performance is the same or better than that threshold and that

facility would meet the quality scoring threshold for that measure; but if a facility’s LCL is above the threshold, that

indicates that the facility performance is worse than that threshold and that facility will not meet the quality scoring

threshold for that measure.

For accuracy, patient outcome measures were evaluated only if the analytic measure volume (measure

denominator) reported was greater than or equal to 11. If the reported analytic measure volume was less than 11,

then that patient outcome measure was not evaluated due to insufficient data.

Quality Selection Criteria

Quality Selection Criteria are outlined in Tables 2-4, below. Scoring of quality measures is based on both required

and flexible measures.

• Table 2 outlines required quality measures. The facility must meet ALL required measures.

• Table 3 outlines required patient outcome measures. The facility must meet ALL required measures.

• Table 4 outlines flexible measures. The facility must meet a specific number of measures within each of

three flexible measure categories:

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1) Patient Outcome measures: Must meet 1 of 3 measures.

2) Patient Safety Bundles measures: Must meet 2 of 3 measures, and

3) Structure and Process measures: Must meet 2 of 4 measures.

Required Quality Measures

Table 2: Quality Measures (Required)

Table 2: Quality Selection Criteria: Required Measures

Facility must meet ALL measures

Measure Name

Data Source

Selection Criteria Description

National Accreditation

Provider Survey

Question #4

The facility is fully accredited by at least one of the following national

accreditation organizations:

• The Joint Commission (TJC) (without provision or condition) in the

Hospital Accreditation Program.

• Healthcare Facilities Accreditation Program (HFAP) of the

Accreditation Association for Hospital and Health Systems (AAHHS)

and is an acute care hospital. www.hfap.org.

• National Integrated Accreditation Program (NIAHO

)—Acute Care of

DNV GL Healthcare.

• Center for Improvement in Healthcare Quality (CIHQ) in the Hospital

Accreditation Program.

Quality Improvement

Program

Provider Survey

Question #19

Facility has an internal quality improvement program to assess maternity

care.

Obstetric Hemorrhage

Provider Survey

Question #21

Facility uses a standardized, facility-wide, stage-based obstetric

hemorrhage emergency management plan, with checklists and an

escalation policy.

Provider Survey

Question #22

Facility has implemented ALL the following

elements of the Obstetric Hemorrhage Patient

Safety Bundle:

• Facility uses an evidence-based risk

assessment tool for hemorrhage risk at

defined stages of labor (prenatal, on

admission, pre-birth, and on transition to

postpartum care) for all patients.

• Facility measures cumulative quantitative

blood loss on all patients.

• Facility performs active management of the

3rd stage of labor (department-wide

protocol).

• Facility completes multidisciplinary reviews

for monitoring of outcomes and process

metrics (at least) for OBH cases resulting in

4 or more units of blood products and/or

SMM Indicator (as defined by CDC) by the

facility’s perinatal quality improvement (QI)

committee.

Facility has

implemented at least

4 of the 6 bundle

elements.

(Refer to Appendix A

for a list of bundle

elements)

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Table 2: Quality Selection Criteria: Required Measures

Facility must meet ALL measures

Measure Name

Data Source

Selection Criteria Description

Severe Hypertension in

Pregnancy

Provider Survey

Question #23

Facility uses standardized protocols (with checklists and escalation

policies), which include a standardized response to maternal early

warning signs, listening and investigating patient-reported and observed

symptoms, and assessment of standard labs for the management of

patients with severe hypertension or related symptoms, as well as

obtaining appropriate consultation and maternal transport.

Provider Survey

Question #24

Facility uses standardized protocols (with checklists and escalation

policies) for management and treatment of severe hypertension,

eclampsia, seizure prophylaxis, and magnesium overdosage, as well as

postpartum presentation of severe hypertension/preeclampsia.

Provider Survey

Question #25

Facility has implemented ALL the following

elements of the Severe Hypertension in

Pregnancy Patient Safety Bundle:

• Facility has rapid access to standardized

medications used for severe

hypertension/eclampsia.

• Facility ensures accurate measurement and

assessment of blood pressure and initiates

treatment with antihypertensive.

medication(s) that are recommended to be

administered ASAP (preferably within 60

minutes of verification).

• Provides educational information, which

includes specific to warning signs/

symptoms of severe hypertension/

preeclampsia.

Facility has

implemented 4 or

more of the 6

bundle elements.

(Refer to Appendix B

for a list of bundle

elements)

Safe Reduction of

Primary Cesarean Birth

Provider Survey

Question #26

Facility has implemented ALL the following

elements of the Safe Reduction of Primary

Cesarean Birth Patient Safety Bundle:

• Facility uses standardized methods in the

assessment of the fetal heart rate status,

including interpretation and documentation

based on National Institute of Child Health

and Human Development (NICHD)

terminology, and encourages methods that

promote freedom of movement.

• Facility upholds standardized induction

scheduling, to ensure proper selection and

preparation of women undergoing induction

of labor.

• Facility utilizes standardized evidence-

based labor algorithms, policies, and

techniques, which allow for prompt

recognition and treatment of labor dystocia.

• Facility adopts policies that outline

standardized management of Category II

fetal heart rate patterns and uterine

tachysystole.

Facility has

implemented 5 or

more of the 8

bundle elements.

(Refer to Appendix C

for a list of bundle

elements)

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Table 2: Quality Selection Criteria: Required Measures

Facility must meet ALL measures

Measure Name

Data Source

Selection Criteria Description

Demographic Data

Collected

Provider Survey

Question #34

Facility collects the demographic data of race, ethnicity and spoken

language (REL) data preferred for healthcare during patient registration or

during a hospital visit.

System for Documenting

REL Data

Provider Survey

Question #35

Facility has an established system to document obtain self-reported race,

ethnicity, and primary language (REL) data directly from patients.

Drills for Serious

Adverse Maternal

Events

Provider Survey

Question #43

Facility holds drills or simulations for adverse maternal events.

Frequency of Drills for

Severe Adverse

Maternal Events

Provider Survey

Question #44

Facility holds drills or simulations AT LEAST every 12 months, or more

frequently.

PQC Involvement

Provider Survey

Question #47

Facility engages with its state Perinatal Quality Collaborative.

Prevention of Deep Vein

Thrombosis (DVT)

Provider Survey

Question #51

Facility routinely uses sequential compression devices (SCDs) for deep

vein thrombosis (DVT) prevention on patients at high risk for DVT.

Doulas

Provider Survey

Questions #53 and

#54

Facility employs doulas and/ or is supportive of participation by doulas in

labor support.

Local Blue Plan Quality

Criteria (if applicable)

Plan Survey

An individual Blue Plan, at its own independent discretion, may establish

and apply local quality requirements as additional Selection Criteria for

eligibility in a Blue Distinction Centers Program, for facilities located within

its Service Area.

Patient Outcome Measures (Required)

Facilities also must meet patient outcome measures for Maternity Care procedures, as reported in the Provider

Survey. Patient outcome measure evaluation requirements are outlined below in Table 3. For accuracy, a facility

must present sufficient data to meet the minimum analytic measure volume (measure’s denominator):

1) If the analytic measure volume is greater than or equal to 11, then then the patient outcome measure has

‘Sufficient Data’ for evaluation and the patient outcome measure will be evaluated.

2) If the analytic measure volume is less than 11, then the patient outcome measure has ‘Insufficient Data’

for evaluation, will not be evaluated, and the facility will not meet that measure.

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Blue Distinction Centers for Maternity Care| Program Selection Criteria

Table 3. Patient Outcome Measures (Required)

Quality Selection Criteria: Patient Outcome Measures (Required)

Facility must meet ALL measures

Measure Name

Data Source

Selection Criteria Description

Analytic Measure

Volume

Provider Survey

Questions #12, #13

and #16

Facility’s analytic measure volume is greater than or equal to 11 for the

following measures:

• PC-01 Elective Delivery Denominator

• PC-02 Cesarean Section Denominator

• Episiotomy Denominator (Measure is evaluated in the Patient

Outcome Measures Flexible criteria, outlined below in Table 4)

PC-01

Elective Delivery

Provider Survey

Question #12

Rate of patients delivering newborns with >=37 and <39 weeks gestation

completed lower confidence level (LCL) must be less than or equal to

4.00%.

PC-02

Cesarean Section

Provider Survey

Question #13

Rate of Nulliparous Patients who delivered a live term singleton newborn

in vertex presentation via cesarean section lower confidence level (LCL)

must be less than or equal to 24.00%

Flexible Measures – Structure/ Process and Patient Outcome Measures

Required flexible measures are grouped into 3 categories, shown in Table 4:

• Patient Outcomes Measures Facility must meet 1 of 3 measures

• Patient Safety Bundles Measures Facility must meet 2 of 3 measures

• Structure and Process Measures Facility must meet 2 of 4 measures

Table 4: Flexible Measures

Quality Selection Criteria: Flexible Measures

Measure Name

Data Source

Selection Criteria Description

Patient Outcome Measures Flexible Category: Must Meet 1 out of 3 Measures

Episiotomy Rate

Provider Survey

Question #16

Percent of women who received an episiotomy during a vaginal birth

lower confidence limit (LCL) must be less than or equal to 5.00%

Measure denominator must be at least 11 procedures for the measure to

be evaluated, explained above in Table 2.

PSI 18 (Obstetrical

Trauma with Instrument)

Provider Survey

Question #17

Hospital discharges with third- and fourth-degree obstetric traumas with

instrument-assisted vaginal deliveries lower confidence level (LCL) must

be less than or equal to 11.72% (AHRQ).

PSI 19 (Obstetrical

Trauma without

Instrument)

Provider Survey

Question #18

Hospital discharges with third- and fourth-degree obstetric traumas

without instrument-assisted vaginal deliveries lower confidence level

(LCL) must be less than or equal to 1.75% (AHRQ).

Patient Safety Bundles Measures Flexible Category: Must Meet 2 out of 3 Measures

Care for Pregnant and

Postpartum People with

Substance Use Disorder

Provider Survey

Question #27

Facility assesses all pregnant women for substance use disorders

(SUDs), using validated screening tool(s) to identify drug and alcohol use;

and incorporates a screening, brief intervention, and referral to treatment

(SBIRT) approach, in the maternity care setting.

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Quality Selection Criteria: Flexible Measures

Measure Name

Data Source

Selection Criteria Description

Postpartum Discharge

Transition

Provider Survey

Question #29C

Facility screens all patients for Post-Partum Depression prior to discharge

(using the Edinburgh Postnatal Depression Screen or another

standardized tool) and establishes a system of support and follow-up

within 30 days for those who screen positive.

Sepsis in Obstetrical

Care

Provider Survey

Question #30

Facility uses standardized protocols with checklists and escalation

policies (including a standard response to maternal early warning signs,

listening, investigating patient-reported and observed symptoms, and

assessment of standard labs for the management of patients with

symptoms of sepsis) and obtain critical care consult and transfers patients

when necessary.

Structure and Process Measures Flexible Category: Must Meet 2 out of 4 Measures

Frequency of Data

Sharing

Provider Survey

Question #20

Facility shares personal rates of maternal quality measures with OB

providers at least annually.

Unconscious Bias

Training

Provider Survey

Question #42

Facility has implemented trauma-informed protocols and anti-racist

training (unconscious bias/ respectful and equitable care) to address

healthcare team member biases and stigmas.

Physicians at Drills/

Simulations

Provider Survey

Question #45

Facility requires physicians (both privileged and hospital-based) who

provide obstetric care at your facility to participate in serious maternal

adverse event drills and/or simulations.

Ongoing Education and

Training

Provider Survey

Question #46

Facility requires ongoing (at least every 2 years) physician and nursing

education/ training of fetal heart rate monitoring, obstetric hemorrhage

management and severe hypertension in pregnancy management.

Rationale for Required Selection Criteria

The selection criteria chosen for the 2023 BDC Maternity Care Program places a renewed focus on the need for

improved maternity services, in alignment with the BCBS National Health Equity Strategy and the goal of reducing

racial disparities in maternal health by 50% in 5 years. Nationwide efforts have been put into place to address the

maternal health crisis in the United States. Severe maternal morbidity, which includes unexpected complications in

labor and delivery that result in significant short-term or long-term consequences to a women’s

health, has been

increasing and affects thousands of women in the United States each year. The selection criteria for the Maternity

Care Program aligns with actionable approaches recommended by organizations such as the Department of Health

and Human Services (HHS), American College of Obstetricians and Gynecologists (ACOG), Alliance for Innovation

on Maternal Health (AIM), and the California Maternal Quality Care Collaborative (CMQCC), to enhance outcomes

and reduce adverse events in maternal health care. The following categories offer background information and

suggestions for improvement on each of the required selection criteria, where applicable.

Throughout this document, the terms “mother,”” maternal,”” she” or “her” refer to a person who is pregnant, has given birth or is in the postpartum stage of

pregnancy. We recognize that not all people who have been pregnant or given birth identify with these terms, and that all people deserve to receive safe, equitable

healthcare.

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Quality Improvement Program

Having a robust quality improvement (QI) program is instrumental to making positive changes at the facility and

must be an organizational priority. Administrative support, staff involvement, and a multidisciplinary team are the

backbone of effective quality improvement programs. Facility and provider engagement should include data

collection, analysis, and data sharing to identify issues; focus on improvements when things go wrong; incorporate

evidence-based practices and standardized protocols to close gaps in care for all mothers; and have a commitment

to high reliability performance for ongoing quality improvement.

Patient Safety Bundles

Patient safety bundles have been developed by maternal health experts, to provide guidance on the

implementation and quality improvement efforts related to PREVENTABLE obstetric conditions that have a direct

correlation to severe maternal morbidity and mortality. AIM Patient Safety Bundles are based on five (5) major

components: Readiness; Recognition and Prevention; Response; Reporting and Systems Learning; and

Respectful, Equitable, and Supportive Care. Following these evidence-based actions, with defined rationales,

allows facilities to be prepared for adverse maternal complications and to improve maternal outcomes. Similarly,

CMQCC has developed toolkits for several obstetric emergencies and disorders, which outline research and

evidence-based practices that facilities can use to improve outcomes. Standardization of protocols and checklists,

using evidence-based practices, are vital in reducing patient harm, thanks to consistency and reliability of a process

that will apply to most patients.

Both AIM and CMQCC also provide suggestions and guidance for quality

improvement projects specific to each topic.

Recently, AIM Patient Safety Bundles and CMQCC toolkits have begun to include actionable steps that facilities

can take to provide more equitable maternal healthcare, as well as to address maternal mental health with the

incorporation of trauma informed care. Traumatic birth experiences can come from any unexpected outcome –

ranging from an unintended cesarean birth to obstetric complications, such as obstetric hemorrhage leading to

hysterectomy. As self-harm resulting from mental health conditions has been determined to be one of the top

causes of maternal mortality

, maternity care providers should be educated on how to identify trauma and

implement strategies to reduce the risk of re-traumatization, while providing care that offers patients a sense of

safety

. AIM also released a new maternal mental health tool kit recently, which facilities should review and

implement to prevent potential gaps in care, Perinatal Mental Health Conditions | AIM (saferbirth.org).

Although not part of the required selection criteria for the 2023 BDC Maternity Care Program, AIM Cardiac

Conditions in Pregnancy Bundle may become required in future Maternity Care evaluation cycles. Facilities should

take time to review the bundle and initiate implementation of a Cardiac Conditions screen and a standardized

protocol for managing maternal cardiac conditions when they are identified. CMQCC has developed an algorithm

BCBS National Health Equity Strategy: Maternal Health Compendium and Workbook, Blue Cross Blue Shield Association, April 2021

Clinical guidelines and standardization of practice to improve outcomes. ACOG Committee Opinion No. 792. American College of Obstetricians

and Gynecologists. Obstet Gynecol 2019;134: e122–5.

The use and development of checklists in obstetrics and gynecology. Committee Opinion No. 680. American College of Obstetricians and

Gynecologists. Obstet Gynecol 2016;128: e237–40

Pregnancy-Related Deaths: Data from Maternal Mortality Review Committees in 36 US States, 2017–2019 | CDC

Caring for patients who have experienced trauma. ACOG Committee Opinion No. 825. American College of Obstetricians and Gynecologists.

Obstet Gynecol 2021;137: e94–9

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for cardiovascular disease assessment in pregnant and postpartum women with recommendations for interventions

and referrals, when necessary.

Each of the required Patient Safety Bundles For Safer Birth | AIM are outlined below, with actionable items

highlighted that facilities should consider implementing on a priority basis, if they are not in place already .

Obstetric Hemorrhage

In the event of obstetric hemorrhage, early recognition is essential to successfully manage the hemorrhage. This

starts with using an evidence-based risk assessment tool upon admission to labor and delivery and upon admission

to postpartum, at minimum. Quantifying blood loss is a simple process facilities can have in place to measure a

mother’s blood loss, before, during, and for up to 24 hours after birth, or when clinically indicated. Pregnancy

doubles a woman’s blood volume, allowing her to lose almost 1 liter of blood before she starts to show clinical signs

and symptoms of hypovolemia. If obstetric hemorrhage is not recognized before that point, it is even more difficult

to manage. Utilizing standardized protocols and emergency checklists with the actio n items identified in the

Obstetric Hemorrhage patient safety bundle and toolkit will allow for effective management of the hemorrhage. A

facility should consider reviewing any case of hemorrhage in which the patient receives 4 or more liters of blood

products as part of their Quality Improvement program to determine opportunities for improvement and celebrate

the successes noted.

Severe Hypertension in Pregnancy

To recognize severe hypertension in pregnancy, facilities must first ensure that maternal care providers

understand how to measure blood pressure correctly, being sure to consider the patient’s physical position, recent

drug or medication use, and psychosocial status. Not identifying these factors (or identifying them incorrectly) can

lead inaccurate blood pressure assessment. Using standardized protocols and checklists with the action items in

the Severe Hypertension in Pregnancy patient safety bundle and toolkit, the facility should treat any sustained

blood pressure (≥160/≥110) quickly, regardless of the perceived reason for the severe range blood pressure.

Timely treatment from the second severe range blood pressure to the administration of antihypertensive

medication is data that would be beneficial for a facility to collect and then use to develop an appropriate

performance improvement plan for, if necessary.



Afshan B. Hameed, Christine H. Morton, and Allana Moore. Improving Health Care Response to Cardiovascular Disease in Pregnancy and Postpartum Developed

under contract #11-10006 with the California Department of Public Health, Maternal, Child and Adolescent Health Division. Published by the California Department of

Public Health, 2017, Cardiac Conditions in Obstetric Care | AIM (saferbirth.org)

Lagrew D, McNulty J, Sakowski C, Cape V, McCormick E, Morton CH. Improving Health Care Response to Obstetric Hemorrhage, a California Maternal Quality

Care Collaborative Toolkit, 2022

Quantitative blood loss in obstetric hemorrhage. ACOG Committee Opinion No. 794. American College of Obstetricians and Gynecologists. Obstet Gynecol

2019;134: e150–6

Obstetric Hemorrhage | AIM (saferbirth.org)

Druzin M, Shields L, Peterson N, Sakowski C, Cape V, Morton C. Improving Health Care Response to Hypertensive Disorders of Pregnancy,

a California Maternal Quality Care Collaborative Quality Improvement Toolkit, 2021

Severe Hypertension | ACOG

Severe Hypertension in Pregnancy | AIM (saferbirth.org)

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Safe Reduction of Primary Cesarean Birth

Cesarean birth is necessary at times, for the mother and/or baby’s safety. Unfortunately, cesarean births also occur

frequently when they are not necessary, needlessly increasing a woman’s risk of complications (such as

hemorrhage and infection) and putting her at risk for complications (such as uterine abruption and placenta accreta

spectrum in future pregnancies). Standardized induction protocols and labor admission processes/rules should be

in place to decrease mothers’ need for medical intervention to progress labor. As ACOG recommends, supporting

natural labor progress, with actions such as intermittent fetal heart rate monitoring, ambulation, and frequent

position changes, can improve a mother’s chance at a successful vaginal birth.

When slow labor progress or fetal

intolerance to labor is a concern, utilizing evidence-based algorithms from CMQCC can guide maternal care

providers to accurately diagnose labor dystocia and manage category II fetal heart rate tracings.

Although not a requirement of the 2023 BDC Maternity Care Program, it is of interest to consider employment

models for certain maternity care providers and their effect on maternal outcomes. Research has shown that

facilities whose care model includes Obstetric Hospitalists, Certified Nurse Midwives and/or doulas have better

outcomes, including lower cesarean birth rates, than those who use traditional employment models. These care

models offer an alternative to on-call requirements, which may surpass 24 hours at a time, leading to exhaustion

and a greater risk of medical error.

Utilizing obstetric hospitalists, CNMs, and/or doulas allows patients to receive

care from provider(s) who are more available and can offer greater labor support and patience than one who needs

to multitask office responsibilities, operative cases, and other laboring patients.

Facilities should review cases regularly for primary cesarean births and the causes attributed to them, comparing

the care documented to evidence based practices outlined by AIM and CMQCC, while looking fo r trends and

opportunities that may need to be addressed. Cesarean birth rates should be shared with the facility’s providers to

create awareness of the need for cesarean reduction and the leading contributors for potentially avoidable

cesarean births.

Care for Pregnant and Postpartum People with Substance Use Disorder Abuse

Screening every pregnant patient for substance abuse is the first step a facility can take to addressing substance

use disorder (SUD). Screening (with a validated verbal assessment tool), then providing Brief Intervention and a

Referral to Treatment (together, SBIRT) is an evidence-based tool that facilities can implement to identify patients

with SUD and then provide the resources and interventions necessary to improve outcomes for both mother and

infant. Management of SUD in pregnancy and postpartum can be challenging and requires collaboration with a

multidisciplinary team of SUD specialists to care for the mother properly and to keep her safe, both during

Approaches to limit intervention during labor and birth. ACOG Committee Opinion No. 766. American College of Obstetricians and Gynecologists. Obstet Gynecol

2019;133: e164–73

The obstetric and gynecologic hospitalist. Committee Opinion No. 657. American College of Obstetricians and Gynecologists. Obstet Gynecol 2016;127: e81–5.

Smith H, Peterson N, Lagrew D, Main E. 2016. Toolkit to Support Vaginal Birth and Reduce Primary Cesareans: A Quality Improvement Toolkit. Stanford, CA:

California Maternal Quality Care Collaborative

Safe prevention of the primary cesarean delivery. Obstetric Care Consensus No. 1. American College of Obstetricians and Gynecologists. Obstet Gynecol 2014;

123:693–711.

Safe Reduction of Primary Cesarean Birth | AIM (saferbirth.org)

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hospitalization and after discharge. Quality improvement topics may include ensuring that screening is completed

on all mothers, with follow through using evidence-based guidelines when a positive screen is identified.

Postpartum Discharge Transition

Discharge home after childbirth can be incredibly challenging for many families. Signs and symptoms of obstetric

complications can often be dismissed while caring for a new human and coping with fatigue and postpartum mood

changes. Facilities should develop guidelines for discharge teaching, with criteria for discharge to home and

coordinated care for follow up visits. Screening for comorbidities and social determinant of health concerns, such as

food insecurity and unstable housing, will allow maternity care providers to identify concerns and coordinate

appropriate follow up care and resources for the patient. Discharge teaching of post birth warning signs for the most

common obstetric complications, using tools such as a those developed by the Association of Women’s Health,

Obstetric and Neonatal Nurses (AWHONN)

, should be available in multiple languages and written with health

literacy in mind. Health education is essential in empowering mothers to speak up for themselves when they feel

something is not right and these tools can have a direct impact on maternal mortality and morbidity in the

postpartum period. Quality improvement plans might include assessing readmission rates for mothers who present

to the Emergency Department and are readmitted to the facility within 30 days of discharge, to provide insight into

trends of postpartum complications at your facility and to put a plan in place to reduce readmissions.

Sepsis in Obstetrical Care

Facilities should have a maternity specific sepsis protocol in place. Maternity care providers must have a clear

understanding of the difference in clinical features of sepsis between the pregnant and non-pregnant patient. Using

evidence-based guidelines provided by organizations such as AIM and CMQCC will direct maternity care providers

how to identify sepsis properly, based on laboratory values and risk factors specific to the pregnant or postpartum

patient, and how to manage the patient’s care if sepsis is diagnosed. CMQCC’s toolkit offers algorithms that

clinicians can use in their management of sepsis. Prompt recognition and initiation of treatment is necessary for

improving outcomes. Any case of confirmed sepsis also should be reviewed by the facility to determine

opportunities for improvement and to reduce the incidence of sepsis in the future.

Demographic Data Collection

Collecting self-reported demographic data (race, ethnicity, spoken language) is the first step facilities can take to

reduce racial disparities in healthcare. Facilities can use the data collected to stratify quality measures and make

changes to policies, procedures, patient safety goals and quality improvement goals to address equity. An

Opioid use and opioid use disorder in pregnancy. Committee Opinion No. 711. American College of Obstetricians and Gynecologists. Obstet Gynecol 2017;130:

e81–94

Crew E, Chowfla A, DuPlessis H, Lee H, Main E, McCormick E, Oldini C, Smith H, Robinson R, Waller C, Wong J. Mother and Baby Substance Exposure Toolkit.

Stanford, CA: California Maternal Quality Care Collaborative and California Perinatal Quality Care Collaborative. 2020. Acces sed from https://nastoolkit.org/.

Care for Pregnant and Postpartum People with Substance Use Disorder | AIM (saferbirth.org)

POST-BIRTH Warning Signs Education Program – AWHONN

Optimizing postpartum care. ACOG Committee Opinion No. 736. American College of Obstetricians and Gynecologists. Obstet Gynecol 2018;131: e140–50

Stuebe, Alison M. MD, MSc; Kendig, Susan JD, WHNP-BC; Suplee, Patricia D. PhD, RNC-OB; D'Oria, Robyn MA, RNC. Consensus Bundle on Postpartum Care

Basics: From Birth to the Comprehensive Postpartum Visit. Obstetrics & Gynecology 137(1): p 33-40, January 2021. | DOI: 10.1097/AOG.0000000000004206

Importance of social determinants of health and cultural awareness in the delivery of reproductive health care. ACOG Committee Opinion No. 729. American

College of Obstetricians and Gynecologists. Obstet Gynecol 2018;131: e43–8

Gibbs R, Bauer M, Olvera L, Sakowski C, Cape V, Main E. Improving Diagnosis and Treatment of Maternal Sepsis: A Quality Improvement Toolkit. Stanford, CA:

California Maternal Quality Care Collaborative

Blue Cross Blue Shield Association is an association of independent Blue Cross and Blue Shield companies.

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Blue Distinction Centers for Maternity Care| Program Selection Criteria

intervention as simple as communicating in a patient’s preferred language can increase trust, satisfaction and

improve outcomes.

Drills and Simulations for Adverse Maternal Events

Obstetric emergencies happen, and periodic drills and simulations improve the facility’s response and outcomes

when they do. Drills and simulations should follow established protocols and standardized interventions, using a

strategy that emphasizes effective communication, such as TeamSTEPPS, and include a multidisciplinary team,

requiring physicians, nurses, nursing assistants, and other care providers from all potentially involved departments

(anesthesiology, blood bank, pharmacy etc.) to attend. Resources for drills and simulations can be found with the

AIM Patient Safety Bundles and the CMQCC toolkits. Readiness is a core principle of patient safety bundles and

preparing for obstetrical emergencies allows faster and improved response along, with improved patient outcomes

by team members’ knowledge of designated roles, access to emergency supplies, effective communication, and

ongoing education and training.

Perinatal Quality Collaborative Involvement

Perinatal Quality Collaboratives (PQC) consist of maternal and neonatal health experts that develop initiatives

aimed at improving the quality of care for mothers and babies. PQCs assist facilities in implementing performance

improvement plans consisting of evidence-based practices and data collection targeted at an identified gap in

maternity care practices. Involvement with the applicable state’s PQC provides each facility with not only the

resources and expertise to be successful in improving outcomes, but also a community of support and

encouragement to maintain a path to continuous improvement.

Doulas

While hospital employed doulas may not be feasible everywhere, supporting their involvement during labor and

delivery is. Doulas do not have formal obstetric training; they are trained, however, to provide emotional, physical,

informational and resource support through pregnancy and into the postpartum period. Collaboration between all

maternity care providers and doulas within a facility not only enhances the patient experience, but also has been

shown to reduce cesarean birth rates and to lower incidences of maternal complications – which is why ACOG

reports that continuous labor support by a doula is “one of the most effective tools to improve labor and delivery

outcomes.”

Doulas also reduce racial disparities in maternal care, by serving as patient advocates for minority

groups – especially in the hospital setting, where mistrust of maternity care providers can exist. Doulas empower

patients to make the best personal decision for themselves and their babies by helping them to understand and

interpret what is happening to them in the hospital environment. Facilities are encouraged to assess their

relationships with doulas and determine an action plan to incorporate doulas as valuable members of their

maternity care team.

Makoul G, Donohue R, England W, Gorley T. 2023 Experience Perspective. NRC Health. https://nrchealth.com/resources (Accessed 05/31/2023)

Preparing for clinical emergencies in obstetrics and gynecology. Committee Opinion No. 590. American College of Obstetricians and Gynecologists. Obstet

Gynecol 2014; 123:722–5

Perinatal Quality Collaboratives | Perinatal | Reproductive Health | CDC

Safe prevention of the primary cesarean delivery. Obstetric Care Consensus No. 1. American College of Obstetricians and Gynecologists. Obstet Gynecol 2014;

123:693–711

Smith H, Peterson N, Lagrew D, Main E. 2016. Toolkit to Support Vaginal Birth and Reduce Primary Cesareans: A Quality Improvement Toolkit. Stanford, CA:

California Maternal Quality Care Collaborative. pp 102-105

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Blue Distinction Centers for Maternity Care| Program Selection Criteria

Unconscious Bias Training

Unconscious bias refers to attitudes and stereotypes held towards others that affect our understanding, actions,

and decisions in an unconscious manner.

Reducing racial disparities is another way that facilities can improve

maternal health outcomes. Research has proven that Black and Hispanic women experience higher rates of

childbirth complications, regardless of age or geographic location.

Unconscious bias and lack of cultural humility

and awareness can lead to unintended, but unequal treatment of patients from racial and ethnic minorities or from

marginalized social groups.

Unconscious bias training helps maternity care providers to recognize their own

biases and to understand how and why to deliver safe, equitable care to all patients. Standardization of protocols

and processes also ensures that the same care is provided to every patient, every time.

Regardless of their designation eligibility status, all applicant facilities should use the 2023 Maternity Care Provider

Survey results as a guide to improve care and to identify gaps in their Maternity Programs for which performance

improvement plans may be necessary. The structure and process measures highlighted in the survey have all been

correlated to improvements in maternal health outcomes and racial disparities. In the future, these elements and

more will be required for designation. Our Program recommends that facilities look closely at their own maternity

programs and develop a strategy for addressing the opportunities for improvement that they identify. As a next

step, BCBSA will begin working closely with Blue Plans, as they encourage facilities to implement performance

improvement activities that will enhance their maternity care programs and patient outcomes.

Quality Informational Measures

The informational measures outlined in Table 5 were included in the Provider Survey. These measures were not

scored but used as an educational tool for quality improvement. These informational measures may become

required Quality selection criteria, in future Program evaluation cycles.

Table 5: Informational Measures

Informational Measures

Not Scored

Measure Name

Source

Selection Criteria Description

The Joint Commission’s

(TJC) Perinatal Care

Certification or Advanced

Perinatal Care Certification

Provider Survey

Question #5

Facility has either attained, not attained, is in process of attaining or is not

in the process of attaining, TJC Perinatal Care Certification or Advanced

Perinatal Care Certification.

Centers for Medicare and

Medicaid Services’

Birthing-Friendly Hospital

Designation

Provider Survey

Question #6

Facility participates in a structured state or national Perinatal Quality

Improvement (QI) Collaborative and/or has implemented patient safety

practices or bundles as part of these CMS Birthing Friendly Designation QI

initiatives.

TJC/ American College of

Obstetricians and

Gynecologists (ACOG)

Provider Survey

Question #7

Facility has attained, is in process of attaining, or is not in the process of

attaining, a TJC/ACOG Levels of Care verification between I and IV.

Quick Safety Issue 23: Implicit bias in health care, the Joint Commission.

Racial Disparities in Maternal Health, Blue Cross Blue Shield Association Health of America Report, May 2021.

Implicit bias in health care professionals: a systematic review, Chloë FitzGerald, Samia Hurst, BMC Med Ethics. 2017.

Blue Cross Blue Shield Association is an association of independent Blue Cross and Blue Shield companies.

BDCMC01_072523 15

Blue Distinction Centers for Maternity Care| Program Selection Criteria

Informational Measures

Not Scored

Measure Name

Source

Selection Criteria Description

Levels of Care Verification

Program

Centers for Disease Control

and Prevention’s Levels of

Care Assessment Tool

(CDC LOCATe

)

Provider Survey

Question #8

Facility has attained, has not attained, or is not in the process of attaining a

CDC LOCATe

) Level of Care determination between Level I and Level

IV.

PC-02 Cesarean Section for

the past 24 months

Provider Survey

Question #14

Facility reports PC-02 Cesarean Delivery rates for the most recent 24

months, if available.

PC-07 Severe Obstetric

Complications

Provider Survey

Question #15

Facility reports PC-07 Severe Obstetric Complications rate, if available.

Cardiac Conditions in

Obstetric Care

Provider Survey

Question #32

and #33

Facility has implemented a standard protocol (with checklists and

escalation policies) for management of cardiac symptoms and conditions,

which includes multidisciplinary consultation and maternal transport when

necessary and has trained obstetric care providers to perform a basic

Cardiac Conditions Screen.

Patient Perception of Care

Provider Survey

Question #41

Facility collects information regarding patient perception of care (including,

but not limited to the patient’s perception of receiving unbiased, respectful

healthcare).

Postpartum Contraception

Provider Survey

Question #48

Facility provides postpartum women with access to placement of Long -

Acting Reversible Contraceptives (LARCs) with-in 3 days of birth.

Post-Birth Warning Signs

Provider Survey

Question #49

Facility has implemented the Association of Women’s Health , Obstetric and

Neonatal Nurses (AWHONN’s) Post-Birth Warning Signs for patient

discharge education.

Enhanced Recovery after

Cesarean Surgery

Provider Survey

Question #50

Facility has implemented Enhanced Recovery After Surgery (ERAS)

protocols for cesarean birth patients.

Navigator/ Support

Program

Provider Survey

Question #52

Facility offers an Obstetric Nurse Navigator program (or similar program),

which facilitates the mother’s access to pregnancy education, self-care,

and support systems (such as doulas).

Birthing Center

Provider Survey

Question #55

Facility is affiliated with a birthing center, either attached to or detached

from the facility.

Obstetric Hospitalists/

Laborists

Provider Survey

Question #56

Facility employs obstetric hospitalists/ laborists.

Business Selection Criteria

The Business Selection Criteria consists of the following components:

• Facility Performs Services

• Facility Preferred Provider Organization (PPO) Participation;

• Blue Brands Criteria; and

• Local Blue Plan Business Criteria (if applicable)

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Blue Distinction Centers for Maternity Care| Program Selection Criteria

A facility must meet ALL components listed below in Table 6 to meet the Business Selection Criteria for the Blue

Distinction Centers for Maternity Care designation.

Table 6. Business Selection Criteria

Business Selection Criteria

Facility Performs Services

Facility must perform maternity care services.

Facility PPO Participation

Facility must participate in the local Blue Plan’s BlueCard

Preferred Provider

Organization (PPO) network.

Blue Brands Criteria

Facility and its corporate family meet BCBSA criteria for avoiding conﬂicts with BCBSA

logos and trademarks.

Local Blue Plan Business

Criteria (if applicable)

An individual Blue Plan, at its own independent discretion, may establish and apply

local business requirements as additional Selection Criteria for eligibility in a Blue

Distinction Centers program, for providers located within its Service Area.

Note: Physician participation in the local Blue Plan’s PPO Network is not part of the Selection Criteria and evaluation for the

Program at this time but will become a requirement in the next evaluation cycle. Blue Cross Blue Shield and Local Blue

Plans believe that all patients should be protected from surprise medical bills. We are strongly committed to working with policy

makers, hospitals, and physicians on solutions to better protect consumers while preventing unintended costs an d disruptions to

the healthcare system.

Cost of Care Selection Criteria

In addition to meeting the Program’s nationally established, objective Quality and Business Selection Criteria for

BDC, facilities must meet ALL requirements of the following Cost of Care Selection Criteria in Table 7 to be

considered eligible for the BDC+ designation.

Table 7. Cost of Care Selection Criteria

Cost of Care Selection Criteria

Facility must meet ALL measures to be designated as BDC+

Measure Name

Selection Criteria Description

Episode Volume

The facility has greater than or equal to 5 matched episodes of cost data in both clinical

categories:

• Vaginal Delivery

• Cesarean Delivery

Composite Cost Index

Composite Cost Index must be less than or equal to the established threshold of 1.00.

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Blue Distinction Centers for Maternity Care| Program Selection Criteria

Cost of Care Selection Criteria

Facility must meet ALL measures to be designated as BDC+

Measure Name

Selection Criteria Description

Local Blue Plan Cost

Criteria

(If Applicable)

An individual Blue Plan, at its own independent discretion, may establish and apply local cost

requirements as additional Selection Criteria for eligibility in a Blue Distinction Centers program,

for facilities located within its Service Area.

Quality is key: Only those facilities that first meet nationally established quality and business measures for Blue

Distinction Centers will be considered for designation as a Blue Distinction Center+.

Cost of Care Evaluation

Cost of care measures were designed to address market and consumer demand for cost savings and affordable

healthcare. The Cost of Care Selection Criteria were used to provide a consistent and objective approach to identify

BDC+ facilities. The inputs and methodology used in the cost of care evaluation are explained below.

Cost of Care Methodology Framework

The cost of care evaluation uses a consistent framework to define and adjust episodes, and to establish and

compare the resulting cost measures.

Figure 1. Cost of Care Methodology Framework Illustration

Defining the Episodes

Cost of care evaluation was based on a nationally consistent analysis of Claims Data. To provide validity for

comparisons, cost analytics for the BDC Maternity Care program focus on vaginal and cesarean deliveries.

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Blue Distinction Centers for Maternity Care| Program Selection Criteria

Cost Data Sources

Each facility’s cost of care is calculated using adjusted allowed amounts for specific maternity care episodes of care

for actively enrolled Blue Members, derived from Blue Plans’ PPO Claims data from National Data Warehouse from

January 1, 2019, through August 31, 2022, paid through November 30, 2022, with episodes of care occurring between

June 1, 2020, through May 31, 2022.

Clinical Category Identification Criteria

To provide validity for comparisons, cost analytics for the BDC Maternity Care program fo cus on vaginal and

cesarean births. This section explains how Maternity Care episodes are characterized and identifies the subset of

episodes included in the comparison analysis.

Maternity episodes are triggered by inpatient deliveries – either vaginal or cesarean, using the Blue Claims data.

and by MS-DRGs (DRGs are assigned by Blue Health Intelligence

(BHI) to ensure consistency of approach) and

are listed in Table 8.

Table 8. Maternity Care MS-DRG Trigger Codes

Trigger Category

Code Type

Code

Code Description

Vaginal Deliveries

MS-DRG

805

Vaginal Delivery without Sterilization and/or D&C with MCC

MS-DRG

806

Vaginal Delivery without Sterilization and/or D&C with CC

MS-DRG

807

Vaginal Delivery without Sterilization and/or D&C

Cesarean Deliveries

MS-DRG

786

Cesarean Section without Sterilization with MCC

MS-DRG

787

Cesarean Section without Sterilization with CC

MS-DRG

788

Cesarean Section without Sterilization

CC – Complications or Comorbidities

MCC – Major Complications or Comorbidities

Costs associated with long-acting contraceptive (LAC) and sterilization procedures (IUD, Implant, and Tubal Ligation)

were flagged and excluded, using episode inclusion/exclusion criteria. This evaluation cycle used updated DRGs,

which provided more specificity and meaningfully reduced the number of episodes flagged for exclusion. The majority

of LAC and sterilization procedures were already removed from the beginning of the analysis because they were tied

to sterilization-specific delivery DRGs (i.e., 796, 797, 798, 783, 784, 785), which were excluded from the final trigger

code list.

Member Exclusion Criteria

• Exclude age <18 or >64 years.

• Exclude discharge status Left Against Medical Advice (LAMA) or discontinued care.

• Exclude expired or expired in a medical facility

• Exclude when primary payer is not a Blue Plan

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Blue Distinction Centers for Maternity Care| Program Selection Criteria

• Exclude members not continuously enrolled for the duration of the episode

• Exclude multiple birth (e.g., twins)

• Exclude gender equal to male or unknown

• Exclude if episode did not include both professional and facility claim.

• Exclude if episodes included claims for long-acting contraceptive (LAC) and/or sterilization procedures.

Clinical category costs are adjusted for the impact of significant patient co-morbidities, via risk adjustment methods.

No other clinical exclusions are applied.

Episode Duration

Each delivery episode type has time windows before and after the episode trigger event (in-patient hospitalization

for delivery) within which relevant services may be included. The trigger start date is the First Service Date from the

facility header claim identified as the trigger claim. The episode window for maternity begins 280 days prior to date

of admission of the index admission and ends 90 days following discharge from the index admission. Episodes are

included in the analysis only if the member is continuously eligible for relevant (primarily PPO) BCBS benefits

throughout the episode duration

Cost Components Included in Episode

After an episode was “triggered,” services must be linked to the episode in a comprehensive and consistent manner

to ensure completeness and comparability of costs. Services and related costs were included if they were logically

related to the episode – either vaginal delivery or cesarean delivery.

Table 9 below provides more detailed examples of professional services billed using the following routine obstetric

services codes during the episode duration:

Table 9: Professional Services Billed for Routine Obstetric Service Codes

CPT

OB Maternity Service

59425

Antepartum care only; 4-6 visits

59426

Antepartum care only; 7 or more visits

59400

Routine OB care including antepartum, vaginal delivery, postpartum

59409

Vaginal delivery only

59410

Vaginal delivery only including postpartum care

59412

External cephalic version, with or without tocolysis; antepartum manipulation

59414

Delivery of placenta (separate procedure)

59510

Routine OB care including antepartum, cesarean, and postpartum

59514

Cesarean delivery only

59515

Cesarean delivery only; including postpartum care

59610

Routine obstetric care including antepartum, vaginal delivery and postpartum care, after previous

cesarean

59612

Vaginal delivery only, after previous cesarean delivery (with or without episiotomy and/or forceps)

59614

Vaginal delivery only, after previous cesarean delivery; including postpartum care

59618

Routine obstetric care including antepartum care, cesarean delivery, and postpartum care, following

attempted vaginal delivery after previous cesarean delivery

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BDCMC01_072523 20

Blue Distinction Centers for Maternity Care| Program Selection Criteria

CPT

OB Maternity Service

59620

Cesarean delivery only, following attempted vaginal delivery after previous cesarean delivery;

59622

Cesarean delivery only, following attempted vaginal delivery after previous cesarean; including

postpartum

59430

Postpartum care only (separate procedure)

Adjusting Episode Costs

Adjustments in episode costs are needed for both the validity and fairness of cost comparisons among facilities and

included the following two types of adjustment:

• Factor adjustment – which adjusts for factors known to have a predictable impact on costs of care.

• Outlier management – which protects against rare, unpredictable high-cost and very low events that could

have a dramatic impact on average costs for a facility.

Two types of factor adjustments are made commonly in health cost comparisons:

• Adjustments for predictable cost differences related to geography; and

• Adjustments for predictable cost differences due to risk; or, more specifically, due to differences in the

clinical characteristics of patients and age that have a measurable and predictable impact on costs.

A geographic adjustment factor was applied to the episode cost, to account for geographic cost variations in

delivering care. Adjustments made for predictable cost differences related to geography used the 2023 Geographic

Adjustment Factors (GAFs) for 112 Geographic Practice Cost Index (GPCI) localities level, as defined by CMS.

Risk adjustment was used to adjust for variation in cost that may relate to differences in patient severity (with or

without comorbidity), as well as case mix, using the following steps:

• Identified patient severity levels, using the MS-DRG risk stratification system.

• Three separate age-bands (18-34 years, 35-39 years, and 40+ years) were created for better risk

assessment within each broad clinical category. As a result, there will be a total of nine sub-categories

to calculate nine risk adjustment factors under both vaginal and cesarean deliveries.

• Managed outliers through winsorization within risk bands. Outliers were identified in each risk band as

those values for which geographically adjusted costs were the top 2 percent and bottom 2 percent of

episode costs. Outlying cost values were truncated to these points, to preserve their considerations in

calculating the overall episode cost estimate while moderating their influence.

Calculated Risk Adjustment Factor

The mean of the geographically adjusted, winsorized episode costs for each clinical category/risk level combination

at the national level is the expected cost for that clinical category/risk level combination. The national expected cost

for each clinical category/risk level combination is divided by the national mean cost for the clinical category, to

calculate the Risk Ratio for each clinical category/risk level combination. The Risk Adjustment Factor (which is the

inverse of the Risk Ratio) is multiplied by each facility’s geographically adjusted and winsorized facility episode

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BDCMC01_072523 21

Blue Distinction Centers for Maternity Care| Program Selection Criteria

costs for each clinical category/risk level combination to normalize for risk, resulting in a final episode cost that is

both geographically adjusted, and risk adjusted.

Minimum Case Volume Requirement

For reliability, a minimum of 5 episodes are needed in each clinical category to be included in the cost calculation of

at the facility level. For maternity, this means that a facility must have 5 vaginal delivery episodes and 5 cesarean

delivery episodes to meet minimum case volume.

Establishing the Cost Measure

Each episode was attributed to the facility where the primary procedure/surgery occurred, based on trigger events

that occurred at that facility for each of the two clinical categories: vaginal delivery and cesarean delivery. Each

facility has a separate calculation for the Clinical Category Facility Cost (CCFC) based on the median value of the

adjusted episode costs. Confidence intervals (90 percent) were calculated around each Clinical Category Facility

Cost (CCFC) measure; the Upper Confidence Limit (UCL) of the measure was divided by the National Median

Episode Cost to become the Clinical Category Facility Cost Index (CCFCI). The combined cost index of the median

UCL was rounded down to the nearest 0.025 to give facilities the benefit of the doubt and to avoid situations where

a facility narrowly missed BDC+ eligibility by an immaterial margin. The rounded median UCL was the measure

used for cost scoring. For reliability, a minimum of five procedures was required within a clinical category for the

data to be included in the calculation of a Composite Facility Cost Index (CompFCI) for a facility.

Using each of the Clinical Category Facility Cost Index values, an overall Composite Facility Cost Index (CompFCI)

was calculated for the facility. Each Clinical Category Cost Index was weighted by that facility’s own volume and

facility costs to calculate a composite measure of cost called the Composite Facility Cost Index.

Composite Facility Cost Indices (CompFCI) for each facility, calculated using the UCL of individual clinical category

facility cost indices (CCFI), were then compared to the cost threshold set by BCBSA. A facility was selected for

BDC+ designation if the CompFCI was lower than or equal to the cost threshold set by BCBSA, demonstrating that

the expected composite facility cost index was lower than or equal to the cost threshold cost index.

Questions

Contact your local Blue Plan with any questions.

Blue Distinction Centers (BDC) met overall quality measures for patient safety and outcomes, developed with input from the medical community.

A Local Blue Plan may require additional criteria for facilities located in its own service area; for details, contact your Local Blue Plan. Blue

Distinction Centers+ (BDC+) also met cost measures that address consumers’ need for affordable healthcare. Each facility’s cost of care is

evaluated using data from its Local Blue Plan. Facilities in CA, ID, NY, PA, and WA may lie in two Local Blue Plans’ areas, resulting in two

evaluations for cost of care; and their own Local Blue Plans decide whether one or both cost of care evaluation(s) must meet BDC+ national

criteria. National criteria for BDC and BDC+ are displayed on www.bcbs.com. Individual outcomes may vary. For details on a facility’s in-network

status or your own policy’s coverage, contact your Local Blue Plan and ask your facility before making an appointment. Neither Blue Cross and

Blue Shield Association nor any Blue Plans are responsible for non-covered charges or other losses or damages resulting from Blue Distinction

or other provider finder information or care received from Blue Distinction or other providers.

Blue Cross Blue Shield Association is an association of independent Blue Cross and Blue Shield companies.

BDCMC01_072523 22

Blue Distinction Centers for Maternity Care| Program Selection Criteria

Appendix A: Obstetric Hemorrhage Patient Safety Bundle Elements

Appendix B: Severe Hypertension Patient Safety Bundle Elements

Severe Hypertension Patient Safety Bundle Elements

1. Facility has rapid access to standardized medications used for severe hypertension/eclampsia.

2. Facility ensures accurate measurement and assessment of blood pressure for every pregnant and

postpartum patient, including: (1) notification of OB Provider if systolic BP ≥ 160 or diastolic BP ≥110 for two

measurements within 15 minutes; and (2) after the second elevated measurement, initiates treatment with

antihypertensive medication(s) that are recommended to be administered ASAP (preferably within 60

minutes of verification).

3. Performs multidisciplinary reviews for monitoring of outcomes and process metrics, which include (at least)

required reviews by the perinatal quality improvement (QI) committee for appropriate and timely treatment of

severe range blood pressure and/or Severe Maternal Morbidity (SMM) Indicator (as defined by Centers for

Disease Control and Prevention).

4. Provides trauma informed support program for patients, their identified support network, and staff for all

serious complications of severe hypertension.

5. Provides educational information, which includes (at least) warning signs/ symptoms of severe hypertension/

preeclampsia, and who to contact with medical/ mental health concerns about the patient

6. Initiates postpartum follow-up visits to occur within 3 days of discharge for individuals whose pregnancy was

complicated by hypertensive disorders.

Obstetric Hemorrhage Patient Safety Bundle Elements

1. Uses an evidence-based risk assessment tool for hemorrhage risk at defined stages of labor (prenatal, on

admission, pre-birth, and on transition to postpartum care) for all patients.

2. Measures cumulative quantitative blood loss on all patients.

3. Performs active management of the 3rd stage of labor (department-wide protocol).

4. Completes multidisciplinary reviews for monitoring of outcomes and process metrics (at least) for obstetric

hemorrhage (OBH) cases resulting in 4 or more units of blood products and/or Severe Maternal Morbidity

(SMM) Indicator (as defined by Centers for Disease Control and Prevention) in perinatal quality

improvement (QI) committee.

5. Provides trauma informed support program for patients, their identified support network, and staff for all

significant hemorrhages.

6. Provides educational information, which includes (at least) warning signs/symptoms of obstetric hemorrhage

and who to contact with medical/mental health concerns about the patient.

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BDCMC01_072523 23

Blue Distinction Centers for Maternity Care| Program Selection Criteria

Appendix C: Safe Reduction of Primary Cesarean Births Patient Safety

Bundle Elements

Safe Reduction of Primary Cesarean Births Patient Safety Bundle Elements

1. Implements standardized admission criteria, triage management, education, and support for women presenting

in spontaneous labor.

2. Offers standardized techniques of pain management, comfort measures, and labor support methods that

promote labor progress and prevent dysfunctional labor.

3. Uses standardized methods in the assessment of the fetal heart rate status, including interpretation and

documentation based on National Institute of Child Health and Human Development (NICHD) terminology, and

encourages methods that promote freedom of movement.

4. Upholds standardized induction scheduling, to ensure proper selection and preparation of women undergoing

induction of labor.

5. Utilizes standardized evidence-based labor algorithms, policies, and techniques, which allow for prompt

recognition and treatment of labor dystocia.

6. Adopts policies that outline standardized management of Category II Fetal Heart Rate patterns and uterine

tachysystole.

7. Monitors primary cesarean delivery rates (using both a sample of cases [as determined by the facility] and

individual physician cases) for compliance with standardized evidence-based algorithms for labor dystocia and

management of Category II Fetal Heart Rate patterns to discuss in perinatal quality improvement (QI)

committee.

8. Provides trauma informed support for patients, their identified support network, and staff if necessary for

patients impacted by primary cesarean deliveries.