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Monday, July 18, 2011

Seeing dollar $igns

With all this talk about President Obama raising the "debt ceiling," you have to wonder where the spending cuts are being made (or if they're being made). Politics aside, I can't help but think of one way the government could definitely save money: reduce the cesarean rate.

It's estimated that the US could save $3.5 billion a year in healthcare costs if the number of medically unnecessary cesareans were reduced. I don't know if that's just for the surgery alone, so perhaps the figure is much higher when you account for everything that takes place up to the cesarean. Think about the way a typical birth unfolds in the US:
• Mom is approaching 39 weeks in an otherwise normal pregnancy. Since her doctor is telling her it's "dangerous" to go past her due date, she decides to go ahead with an induction. After numerous doses of Cervidil and Pitocin, her labor finally starts, but is slow and very painful. Perhaps pain relief from the epidural is spotty, or they just need to keep giving her boluses because her labor is so long. They finally agree to do a cesarean for fetal distress. After birth, they decide the newborn must spend time in the NICU because her dates were off and the baby is showing signs of prematurity. He spends a week in the NICU and then goes home. Oh, did we mention this mom was giving birth in a military hospital? 
• The mother has already had a prior cesarean, and is scheduled to have another "elective" repeat cesarean. 

(This is just based on some of the stories I hear from mothers. While it obviously doesn't always go this way, it's not that uncommon, either.) 

While it's been said that Medicaid won't pay for unnecessary cesareans, I'm sure they can find other reasons to do them. When you don't even know what constitutes "necessary" anymore, it's probably not all that hard.

As of 2009, certain states were working hard to eliminate any financial incentives for doing cesareans. Washington State was one of them, and saw a 14-48 percent c-section rate, which obviously alarmed some. Before the policy change:
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.
Because of that lack of incentive, there is probably more accountability when you are receiving money from a government agency. I won't say there still isn't some form of fraud going on, but it's no doubt easier to get away with if your patient is privately insured. Additional health care costs probably come from extra items tacked onto your bill. Didn't receive an epidural but it's on your bill? Your health insurance company will probably pay for it anyway, even though you've called to complain. One West Virginia OB faces up to 340 years in prison for her part in billing patients for things they never received. Those little "extras" can really add up.

Statistics have also shown that you are more likely to get a cesarean if you give birth in a for-profit hospital than a non-profit one. They have to make their money somehow, right?

While it's glaringly obvious, at least to birth advocates and those who simply want a choice in their births, lowering healthcare costs in this way would require the obstetrical community to basically change the way they practice medicine, which I don't think is going to happen anytime too soon. Our health care industry is increasingly moving away from focusing on the patient and rather seeing dollar signs every time you hop up onto the exam table, for a number of reasons. They have to make their time "worth it," both because of their own personal pursuits and because of rising insurance costs for them that otherwise wouldn't justify them continuing to practice medicine. You are just the little fish - albeit probably one of the most important ones - in the food chain.

More reading:
Take away the incentives for too many c-sections - Crosscut Seattle
"Whatever you try is just going to end in a cesarean section" - My OB Said What?!
"If a baby hasn't engaged by 37 weeks, we need to do a cesarean section" - "My OB Said What?! (same doctor)
Should OBs be investigated for insurance fraud? 
All about the Benjamins? TennCare's call for lower cesarean rates - The Unnecesarean 


Anonymous said...

This is something that really irks me. Our state, like every other state these days, is trying to figure out ways to cut costs. One of our state representatives (who is unfortunately my representative) made the asinine suggestion that to cut costs Medicaid should no longer pay for epidurals or pain medication for laboring mothers. Oh, unless they are having a c-section of course. Let's ignore the fact that OB's are doing unecessary c-sections, along with a myriad of other expensive, unecessary tests and interventions such as elective inductions that are time consuming in the L&D unit and very costly. The $300-$400 per delivery that Medicaid pays for an epidural is what is going to save us. Sheesh.

How about Medicaid not paying for elective c-sections or elective inductions? I can't even to begin to imagine how much money that will save... pretty sure more than $400 a delivery, seeing how it's really big here to be induced at 39 weeks regardless of your Bishop score. I only know a handful of women who have declined induction and gone into labor on their own.

Grrrr. Thinking about this again makes my head hurt... lol. (In case anybody is wondering this guy pretty much got his manhood ripped off by his female constituants and backed down pretty quick.)