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.