117 Budget impact analysis of aCTG in primary midwife-led care 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, taskshifting 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 5
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