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Sunday, June 27, 2010

Should OBs be investigated for insurance fraud?

It's no secret: our economy (and our healthcare system, as a matter of fact) are in the crapper. Companies and insurance carriers are looking for ways to cut costs and save money. I remember back several years ago when, while driving on the turnpike, I would always see the same sign: a jail cell and something accusatory about committing insurance fraud and how it can drive up everyone's premiums.

Perhaps the finger of guilt is being pointed in the wrong direction. It's not really the consumer who is defrauding the insurance carrier; in the case of a typical hospital birth, maybe it's the physician.

The standard of care in obstetrics is to perform the same excessive battery of tests, monitors and other expensive interventions - that normally would be performed only on a high-risk patient - on every pregnant woman, often whether they need it or not. Suddenly everyone is high-risk. And I'm sure those interventions come with a hefty price tag.

And correct me if I'm wrong, but don't some OB's balk at attending Medicaid-covered patients because a government payor is less likely to pay for certain procedures than a traditional insurance carrier? Wait a minute ... maybe I do want the government running my pregnancy healthcare after all...

I switched OB's for my third pregnancy, and typically under my health plan, all prenatal visits are covered. On three separate occasions, I was billed a copay: once during my first visit (I don't remember ever having to do this with the old guy) and again when my doctor and I had a "conversation" about a VBAC - which basically consisted of her lecturing me in a nice way and feeding me inaccurate information. I considered this part of my pregnancy care and planning, together, the birth of my child; she considered it a consultation.

The third time, they noticed some swelling in my lower extremities and that my blood pressure was elevated. Nothing new from my last pregnancy (and I wasn't billed for it then, either), and apparently not that uncommon in the rest of the pregnant population. But no - this was considered "outside of the scope of prenatal care" and I was again billed. (But apparently that brief hospitalization for observation was considered part of regular prenatal care, because I never saw a bill for that one. I mean, isn't everyone admitted briefly for observation during their pregnancy??)

After awhile I was beginning to wonder if my doctor was nickel and diming me to death just to eke out as much money from me as he could in addition to what the insurance company was paying out. I realized later that, because they were so overbooked, she had charged me a copay because I had questions. And actually wanted answers. Which was much more than I got from the other guy (Me: "I wondered about why I never had the urge to push during my last labor." Him: "Oh, don't worry about that. We'll help you with that when the time comes."). If he talked any more to me, he'd have to charge me for it. Because, when you're herding a dozen or more pregnant women through the door every day, time is money, you know!

I can't imagine if I had been completely new to pregnancy and birth, with no information whatsoever, trusting my doctors implicitly and feeling like I had no need to question them. They basically have no time to tell you anything of consequence except weigh you, collect your pee, measure your belly and dismiss you.

Fast forward to the birth: again, no time to wait on things like slow labors, broken waters with no sign of labor in sight (one site, albeit an article published in 1999, suggested inducing if labor hadn't started within four hours), or first time mothers who are slow to dilate. You get the idea. The clock is ticking! As a result, the inevitable unnecessary induction is scheduled, often leading to the ubiquitous unnecesarean.

Enter insurance fraud.

Personally, I think doctors with high rates of induction and c-section should be investigated. Unless you're a high-risk doctor (and really, everyone is now, no doubt, because isn't pregnancy a risk?) there is no reason why doctors like the one mentioned on the Birth Sense blog (Aka "Jack the Ripper," God help us!) should get away with such abuse of their power and the tools to carry it out. Do you ever wonder if someone who is processing the claims these doctors submit thinks, "Wow, Dr. So and So induced nearly a dozen patients in X amount of time," or "Dr. So and So sure does a lot of c-sections."

We know that a c-section costs more to do than a traditional vaginal birth, as it should. But consider this: when you tally up the cost of anesthesia, the supplies, this that and the other that are all part of a claim, it is expensive. Multiply that by the number of women having c-sections these days (around 32 percent), and you have a booming "industry."

And since a vaginal birth tends to be cheaper, there are easy ways to quickly run up the tally: IV fluids. Induction of Pitocin, several doses. Epidural or similar anesthesia, several doses. Introduce complications such as shoulder dystocia or fetal distress, use of monitoring (which is pretty much done to everyone, regardless), drugs to revive or resuscitate the baby, etc. and that's more money that's ultimately tacked on to the bill. Some of it's warranted - saving your baby after a uterine rupture during a, let's say, non-induced VBAC, for instance. (i.e. something that inherently could not be helped and was not caused by either a medical error or unnecessary intervention)

Not to mention that in the case of a complicated vaginal delivery or c-section, you will probably require more monitoring from nursing staff, as will your baby, and usually a longer hospital stay. Perhaps even minor surgery to repair damage caused by such a traumatic, rushed birth. Multiply that "cascade of interventions" by the number of women who are induced - sometimes for real reasons, sometimes not - in this country, and again, you have a booming business. CaChing!

Not long ago The Unnecesarean posted about billing costs in pregnancy and delivery. Many readers who commented through the FaceBook link remarked how their c-section births were upwards of $45,000. (Yes, that's thousand.) Still others said they or their insurance companies were getting billed for procedures that never happened in their births:
After my DD was born, I received the actual itemized list of charges that the hospital submitted to my insurance company. I was at the hospital about two hours before she was born and left 23 hours later. The only intervention I had was a heplock. I was charged for pitocin I did not receive and I was charged for anesthesia I did not receive. I called my insurance company about this, and they just shrugged it off.
If this isn't insurance fraud, I don't know what is. And even more alarming is that her insurance company couldn't have cared less that she was attempting to save them several thousand dollars.

If more OBs were penalized for excessive interventions and surgeries that weren't warranted, perhaps it could open some eyes in this country about the abuses going on in maternal care. (Unfortunately, I realize the lines are blurred in what's considered truly 'necessary' and what isn't.) In a perfect world, it might help, in some way, to lower the c-section rate because now the people responsible for paying the bill are starting to pick up on how much over-billing is occurring. (I'm convinced that if it were any other division of medicine, this investigation probably would have already happened by now.) They've already been talking of 'de-incentivizing' certain maternity costs that mean the OB would get paid the same, regardless. While this might stop some abuse, I'm not sure how well it's working, and do think that surgery should cost more because of the level of skill involved. But it certainly shouldn't be used to the point that it is.

Monday, June 14, 2010

Birth as Art

I'm not even sure how to title this post, other than I've been seeing birth images in fascinating places lately.

I had the pleasure of finally making the trek to the Corning Museum of Glass this weekend and seeing some amazing work. A mixture of science and art, glass and its history have always fascinated me. You would expect to see sculpture and other artists' renderings on display in a museum, and this one is no exception. Except this particular work stopped me in my tracks and left me speechless for a moment.

I immediately wanted to know: who was this artist? Was it a man or a woman? Was it "cesarean art," as I have seen here and there? Cesarean art kind of used to disturb me because, before I had my second section, I couldn't fully comprehend the frustration, the exasperation, the sometimes empty feelings, or whatever the artist was trying to express, in her artwork. Whatever it was, I just didn't get it. Yet.

I then wondered, if it really was considered cesarean art, would the museum accept such a piece? Even though this particular exhibit featured modern art, were they really ready to open such a can of worms?

The piece is titled "Omagh," done by glass artist Clifford Rainey, who was born in Northern Ireland. At first I was perplexed, not knowing what to take this for. I had no idea whether it pertained to cesareans or birth and a feeling of desolation or violation in that sense, but when I went home, I googled it to get more information.

Omagh, which roughly translates into "the virgin plain," is the site in Northern Ireland of the IRA bombings in 1998 that killed dozens of people, including a mother of four who was pregnant with twins. I immediately realized that this statue must have been memorializing that tragedy and probably this woman in particular, I could guess, although I don't know for sure. Without having any sense of perspective - whether seeing it for what it was supposed to represent or for what it represented to me - I sensed that some people thought it bizarre, probably disgusting, and had no idea what they were looking at or why. The moment was lost on them and they simply moved on, probably in a hurry to catch up with their tour group.

Apparently the statue is part of a group of pieces he has done that feature the female torso. I don't know if Rainey has any idea of the profound effect his work has, albeit for completely different reasons than what he probably intended. This piece, titled "Hollow Torso," has more significance in name alone to some than most people would care to admit.

Another piece that has been on my mind for several years now is this simple glass flower. Sometimes they create them at CMOG as part of a class or public display of glass blowing and I believe you can even do it yourself. I saw one on display several years ago after the birth of my second child, and found it breathtaking - but for totally different reasons. To me, it looks like an umbilical cord, the flowering part where the cord attaches to the placenta. I wanted one, perhaps to somehow remind me of my VBAC and that beautiful, strong, amazing cord of life. (photo courtesy of

Once I realized what the Omagh statue probably really symbolized, I almost felt bad - as if somehow I was completely overshadowing the pain and tragedy of that event with my own situation. If ever there really was an appropriate time to say "at least you have a healthy baby," I suppose this would be it. But then I realized that art is subjective; obviously what means something to one person might mean nothing to someone else, or take on a completely different meaning than what the artist had intended. I realized that what the viewer took away from it transcended the true meaning of this piece, whatever that may be. Whatever the case, I realized that to some women, this is what a cesarean - or even a forced, hurried vaginal birth - feels like. Physical pain and scars, emotional pain, feelings of terror or trauma in subsequent births, all because of that one event, or series of events. To think - some women have never experienced a childbirth that wasn't like this.

Monday, June 7, 2010

What I've been doing instead of blogging ... (pics)

I can't believe it's been like two weeks since my last post. I think that with the onset of summer weather, my brain has checked out for the duration. Garage sales are top priority now that my husband's done with teaching, and I've spent so much time outside it's sickening.

It all started when I was mowing the lawn one day. I've been eyeing that Neglected Flower Bed for over a year, and gradually advanced over to it with the lawn mower. Just a clip here, a nudge there. Before I knew it, 75 percent of it was gone. What a liberating feeling.

The Neglected Flower Bed started out as a giant kidney-shaped monstrosity in our back yard that literally took up most of our lawn space. Together with Neglected Flower Bed #2, we had a strip about 6 feet wide in the middle and literally a six-foot wide bed around the entire back and sides of the garage. My poor son lamented that he missed our old house because of the yard. I reflected back on the poor lazy-#*% loser who used to live here and thought, Yeah, once you start a job you should really finish it, ya know? Instead of leaving it for the next guy.

Something more painful than childbirth:
digging out 10+ years of someone
else's crap.
Over the year my husband has dug up more invasive, ugly-looking perennials that I can think of. Entire beds of pachysandra, the most widespread crap ever. In fact, Neglected Flower Bed #1 and #2 had probably the top three invasive perennials - vinca, pachysandra and Solomon's Seal, all of which I see at roadside plant sales and think, "I want to pay someone to get rid of this stuff, not buy more of it!" My father-in-law thought we should leave it and that it looked nice; I wanted to hit him over the head with the shovel and hide the body in the weeds, but decided that would be wildly inappropriate. (After being 7 months pregnant and moody that one summer and letting him talk me into planting ugly evergreens, which I hate, never again am I letting him give me gardening advice.)

So, back to the mower. The stuff reminded me of - sorry, it's disgusting! - untrimmed pubic hair, and I could finally stand it no longer. I have yet to spray RoundUp or anything similar, and was under the insane impression that digging up clumps of carpet-like roots would somehow do the trick. After a good rain, the ground is nice and soft, but those roots are still there, waiting underneath the surface to sprout once again and choke the life out of my new plants. And those trees there? The big ones are ancient pines; the smaller ones with lots of leaves are, I'm pretty sure, weeds that have gone to seed. Lovely, no? That other one in the middle I'm hoping is not a walnut, which are notorious for killing just about anything planted next to them. (Well, not entirely; obviously vinca thrive next to them!)

Two years ago: The Yard from Hell. Pachysandra to the
left of me; vinca major to the I am, placing
an order for 10 gallons of RoundUp. 
I dug up an old picture from two years ago when we moved in: you can see the craziness and major weed trees and other unidentifiable ugliness going on in our midst. After looking at this photo, I'd forgotten just how heinous it looked. The picture's kind of dark, but I think you get the idea.

Ironically the campus that we live on decided the front corner and one side of the house looked bad, so they hired a landscaper to take care of it, but decided to leave this hot mess for us. WTH?!

And now ...

Sorry for the awful window screen in the way... You can barely see an outline of where the Neglected Flower Bed #1 and #2 used to be. It looks like we dug up a swimming pool or something. The brown spot in the bottom right corner is where I'm currently digging. But at least you can see - and get to - our garage now. Who knew there was a nice little brick and stone path under 20 years of crap?

So that's where I've been...just to prove to myself that I do have other interests besides birth. :D