Friday, August 07, 2009

CSx2 (Carrots, Sticks & C-Sections)

There are a lot of ideas about how to reduce the cesarean rate (current figures are 31.8% in the US and over 26% in Canada):
  • increase the rate of out-of-hospital births (freestanding birth centers and home births, both of which have cesarean rates under or around 4%)
  • encourage hospitals and birth attendants to follow evidence-based medicine, such as the Mother-Friendly Childbirth Initiative
  • increase access to VBAC
  • decrease the primary cesarean rate
  • encourage healthy pregnant women planning hospital births to seek care from CNMs rather than obstetricians
  • educate pregnant women and couples about practices that facilitate normal birth, such as Lamaze's 6 Care Practices that Support Normal Birth
  • decrease physician liability--or fear about liability that drives up the cesarean rate
Washington State has implemented a new policy that creates strong financial incentives to bring down the cesarean rate. Starting next month, Medicaid will reimburse hospitals the same amount for cesareans as for vaginal births. Before this change, hospitals were reimbursed much more for cesareans than for vaginal births. From an article about taking away the incentives for too many c-sections:
On average, Medicaid pays $5,000 more for a C-section than for a vaginal birth, and private insurance pays a far greater premium. You don’t have to be a cynic to wonder if that could have something to do with the rise in unnecessary C-sections.

[Dr. Jeff Thompson, the state’s chief medical officer for Medicaid] explains that there’s no good way for the state to pick out which C-sections are unnecessary. “Medicaid won’t pay for an unnecessary C-section, so hospitals have to code every section as necessary,” he says. But equalizing the amount hospitals get paid for vaginal and C-section births eliminates a financial incentive to perform C-sections. That should mean that the only reason for a doctor to perform a C-section will be that it is medically necessary, and in fact doctors and hospitals will have every financial reason to avoid C-sections — letting money sort out the necessary from the unnecessary. Policy wonks call this “realigning incentives."

“We are choosing to improve quality mostly by using carrots rather than sticks,” says Dr. Dimer.
So will this work? And how?
The size of the financial incentive is crucial, he says. That’s because there are such powerful incentives pushing for C-sections. Dr. Dimer [a Group Health obstetrician who chairs the regional ACOG chapter and co-chairs Washington's perinatal advisory committee] explains that the incentives for C-section go beyond money. “In nature, labor can go on for hours and is highly unpredictable,” whereas a C-section delivery is highly predictable and far shorter. “In American culture, where time is money, having something that is finite and predictable is highly desirable,” she says.

[Dr. Elliott Main, chair of obstetrics at California Pacific Medical Center and principal investigator for the California Maternal Quality Care Collaborative] says that financial incentives for vaginal birth have to be enough to counteract those factors, enough to command attention. He thinks Washington’s cuts in C-section reimbursement may just be that big. The state has slashed Medicaid reimbursement for uncomplicated C-sections from about $3,600 to around $1,000. Hospitals with high C-section rates are in for a rude awakening. Thompson says that since the change in reimbursements took effect he has already received calls from hospitals asking for help revising the protocols they use to decide when a C-section is called for.
Washington State has already implemented another cost-saving and cesarean-lowering initiative: providing Medicaid reimbursement for licensed midwives who attend out-of-hospital births. From the article:
Washington has a history of bucking the national tide when it comes to childbirth. It has a rate of out-of-hospital birth double the national average, and the state is one of only nine states in the country where Medicaid will cover out-of-hospital birth attended by a licensed midwife. In 2008 the Department of Health funded a cost-benefit analysis of the practice. It found that paying for home birth resulted in good outcomes for mothers and babies and yielded a net savings to the government of about $250,000 per year from the reduced numbers of C-sections. (Licensed midwives have every incentive for their patients not to have C-sections, including the obvious: Licensed midwives don’t do C-sections. They get paid next to nothing when their clients transfer to a hospital and have C-sections.)

Currently, midwives from Washington state are lobbying in the other Washington for legislation to push all states to cover out-of-hospital births with licensed midwives through Medicaid. Amber Ulvenes, a lobbyist for the Midwives Association of Washington State, recently used the state’s cost-benefit analysis to come up with an estimate of how much money this would save nationwide. She says if 1 percent of Medicaid-covered births were attended by certified midwives, at least $71 million would be saved annually.
If this new financial incentive works, all the better. It seems like nothing so far has been able to turn the tide of rising cesarean rates, except for a brief period in the 1990s when VBACs were actively encouraged. Perhaps money speaks the loudest language of all.


  1. I'm not sure I'm all that supportive of these types of incentives. From a nursing perspective, all it does is create a hospital that is obsessed with cutting costs, which typically results in staff lay-offs. And that decreases labor support for women, and increases the pressure for a faster turn-over.

    It also creates a situation where fewer and fewer hospitals are willing to accept "Medicaid" clients, which can than lead to a two-tier system of hospitals.

    I have yet to see an OB make a decision based on financial incentive--convenience, impatience, sleep deprivation, personal prejudice, litigation fears--yes, but not a c/s because it pays more.
    So I think that the only people that this will influence will be hospital management, and their first instinct is not going to be to encourage vaginal births.

  2. What about the people without Medicaid? I wonder if there will be a backlash of impatience for those people who have insurance but who have not educated themselves about their options.

    As in, Dr. A has spent the last two nights waiting around on a couple of moms with Medicaid. When it gets close to five pm on the third day and his patient with private insurance can be scared into a c-section (thanks to pitocin and a few decels), will he be more even more likely to jump at that chance?

  3. Wow, I was in the process of writing about this very same article. GET OUT OF MY HEAD! My take on it was slightly different (though I don't disagree with your points at all).

    Better get cracking . . .

  4. I'm hopeful about these incentives.

    I disagree with midwives not making any money when their clients get C-sections. A small portion of their fee comes from the birth itself. The majority of it is for the prenatal and postpartum care. And if the midwife transfers with the woman and acts as her support person - which she should, given that midwifery is about continuity of care - she should still be getting paid for that work, as well.

  5. I would have slight concern over doctors refusing to perform a C-section even when necessary. However, that possibility is likely going to be what is splashed all over the news in huge headlines -- "Washington State's new reimbursement fees hurt the poorest, neediest moms, by taking away their access to C-sections" or some such. Some doctors insist that vaginal births are easier, because you basically show up to catch and maybe sew some stitches and you're done, whereas with a C-section, you have a definite post-birth surgery to complete. *However*, that doesn't take into account any amount of labor-sitting a doctor might do, nor the fact that the doctor might urge a C-section for less-than-medical reasons.

    But this article brought to light something I'd postulated about previously -- some article I read months ago talked about how that the rate of "unnecessary C-sections" was something like 4%, because the researchers looked at the doctor's billing codes. Oh, puh-leeze! The researchers claimed that the billing codes were more accurate than the patient's notes, because "the doctor's reimbursement depended on accurately reporting the reasons for the C-section" so he would spend more time on them, making sure they were correct, while the same level of care might not be taken over the notes. Um, yeah. Hey, brainless! You think, just perhaps, the doctors might **come up with** codes to claim the C-section was necessary *so that* they would be reimbursed for it? Duh. Not saying all doctors do this, but if they're afraid of not being reimbursed for unnecessareans, *boom* change the paperwork and there are none. Simple. Yet false.


  6. Wow! I hope this incentive spreads so that unnecessary c-sections are greatly reduced. I highly doubt NECESSARY c-sections will be ignored because of the incentive.

  7. As a woman who just had a home birth in Washington, I am grateful I live here! I didn't realize how good we have it until I started learning about the laws and regulations in other states. It will definitely be interesting to see how this changes things.

  8. I live in Washington also. Two of my kids were born at home here. We are indeed lucky.

  9. Hopefully, the other 49 states will follow in Washington's progressive position on home birthing.

  10. Perhaps?!?! I think if we take a good, long look at our culture we would all come away with the same knowledge: Money Talks.


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