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Monday
Mar282011

All About the Benjamins? TennCare's Call for Lower Cesarean Rates

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By Emjaybee


Thanks to a tweet by @PushforMidwives I discovered this amazing story from the Tennessean.

Please read the whole piece, but for my purposes I will use the time-honored tradition of “fisking”, to take on each deeply-conflicted section of this article one at a time. Article text is in italics; some text bolded for emphasis.

Lower TennCare rates for C-sections upset obstetricians

Right off the bat, we know who is the subject of this story, and how it is being framed; as a battle between OBs and the force or forces driving lower c-section rates.

What’s even more interesting is that there’s a double meaning in the word “rates”—it might mean, at the beginning of the article, “number of c-sections” but also “what OBs will get paid for c-sections.”

But I will give the writer Tom Wilemon some slack here, because reporters seldom get to write their own headlines.

The state’s effort to reduce unneeded cesarean sections for TennCare patients may instead mean fewer doctors and hospitals willing to deliver babies.

That’s the assessment of obstetrics professors with Vanderbilt University and Meharry Medical College, who say the biggest losers could be hospitals, especially smaller ones with limited sources of revenue.


Now this is attention-getting. First of all, the assertion of the utter inability, in the face of c-section reform, of hospitals and doctors to handle any births whatsoever.

Remember: all c-sections are not being banned, but “unneeded” ones reduced. Yet apparently this change, which seems both medically sound and fiscally responsible, will shut down obstetrics departments across the state.

The buried assertion (and to me, the buried story) is this implication: it was only the fees from unneeded c-sections, those performed on poorer TennCare patients no less, that were keeping many obstetrics programs afloat in the first place.

In other words, we are being told that in order to preserve hospital access to all birthing women in Tennessee,  some percentage of the birthing population are currently acting as sacrificial lambs, and are having unneeded surgeries in order to keep the machinery running. And that this is necessary and unavoidable; in fact, no other type of action for changing this situation is even suggested.


We are also told that the biggest losers are the hospitals, not the women being threatened with having no place to birth, and certainly not those having admitted unnecesareans.

Under Gov. Bill Haslam’s proposed spending plan for next year, hospitals and obstetricians would get only half of what they now receive for C-sections. The change is projected to save $14.9 million, accounting for more than one-third of the overall cuts to TennCare.

“In my opinion, the state is just trying to save money on the backs of hospitals and doctors,” said Dr. Frank H. Boehm, professor of obstetrics and gynecology at Vanderbilt. “I don’t think there is any big medical reason to do this.”


I’m just going to bold this oddly casual statement, considering that Dr. Boehm is discussing surgery performed on thousands of women in his state. He either believes that all c-sections are necessary and the whole “reducing unneeded c-sections” thing is a crock and a cover for slashing payments, or he also wants to preserve the unnecessareans-as-financial-engine model. It is hard not to suspect he falls into the second group, because he expresses no concern whatever about womens’ health risks going up if c-section rates go down—once again, it’s about OBs and hospitals, not their patients.

Currently, the average reimbursement rate for a C-section is $6,623. That figure would fall to the same rate as a vaginal delivery, which would be about $3,300 under the proposal — a 5 percent increase from the current amount.


Here “rates” refers to OB/hospital reimbursement.

Dr. Wendy Long, the chief medical officer for TennCare, gave both financial and health policy reasons for the change during the governor’s budget hearings.

“C-sections are considerably more expensive than non-C-sections,” Long said. “In many cases, they are absolutely necessary, but in other cases the C-sections are more elective in nature, so we hope to see a reduction in elective C-sections.”

She pointed out that TennCare C-section rates, which stood at about 20 percent in the late 1990s, now account for about 30 percent of deliveries.

 

And we are back to “rates” as “number of c-sections.”  If we had not already been told that elective or unneeded c-sections were a financial necessity earlier on, it would be difficult to see how reducing this expensive form of surgery would be a bad thing for obstetrics departments and hospital access in general, which may be why Dr. Long doesn’t find it alarming; perhaps she did not get that memo.

Meanwhile, Dr. Janice E. Whitty has gotten a different memo, this one familiar to most Unnecesarean readers:

But that increase does not mean that the surgical deliveries were elective, said Dr. Janice E. Whitty, chief of obstetrics at Meharry.

“It is very true that the rate of cesarean deliveries is increasing, but it is not increasing just because of convenience. It is increasing because of the repeat cesarean deliveries that occur,” Whitty said. “Many doctors now don’t want to face the liability of doing a vaginal birth after a cesarean section.”


I continue to be amazed by doctors and hospitals who think it is ethical to perform unnecessary surgeries in order to protect themselves from lawsuits, and who will say so to anyone who asks. And who maintain that “done to prevent lawsuits” does not fall under “elective.” It would be hard to think of a more elective reason to expose a patient to surgical risks.


But wait…here’s a bit about medical necessity:

A vaginal delivery after a mother has previously given birth through a C-section carries the risk of a uterine rupture, which can result in death of the mother or the child.

“If a woman needs a cesarean section, the obstetrician has to perform a cesarean section,” Whitty said.

 

And here we have the standard uterine rupture talking point familiar to Unnecessarean readers, as usual not backed up with data, but it does bear the distinction of being a medical, and not a litigious or financial, reason to c-section a woman. Points for that.

The procedure involves extra costs, including anesthesia and surgical staff.


“You may find that some hospitals will give up the practice of obstetrics if they are not reimbursed at a rate that will cover their expense for a cesarean delivery,” Whitty said. “There are quite a number of expenses involved.”


But if shutting down obstetrics departments means there are no obstetricians close enough, will women giving birth face increased risks of death or injury? Another unasked question.

I will give them this; refusing to do *any* births if you can’t c-section is more consistent than refusing VBACs only because they might need c-sections, even though you are prepared to c-section non-VBAC births if necessary. Points for that too, I suppose, although “there are quite a number of expenses involved,” is so vague that it does not increase one’s faith that hospitals can actually justify what they were charging in the first place.


But let’s get on to the important stuff: money and politics.

$14.9M is biggest chunk

The other big cuts to the TennCare program included $12.7 million by reducing non-hospital reimbursement rates to doctors by 1.5 percent and $8.4 million derived by reducing payments to emergency room physicians when they perform triage procedures.

But those cuts do not approach the hits that obstetricians will take. The $14.9 million derived by halving what they receive for C-sections accounted for the biggest chunk of the $39.9 million in total cuts.

“It’s disappointing that obstetricians are being singled out here,” Boehm said. “Keep in mind we’re not getting a huge amount of money for this. It’s not like we are getting a huge fee for cesarean sections to begin with. Keep in mind this is the TennCare population. This is about half of patients in the state. I think about half of our OB population are on TennCare.”

 

It would be useful to know a few things here; how much revenue birth brings into a hospital, what the other doctors and ER physicians think about their cuts, and the politics behind cutting healthcare for so many Tennessee citizens. Again, though, I give the reporter some slack; this whole piece  has a slashy, edited feel, and his original article might have had more meat to it. Reporters get paid even less than TennCare OBs, after all.

The legislature will have final say on the proposed cuts. TennCare is not the only state agency that would get less funding. The average reduction Haslam seeks throughout state government is 2.5 percent.

But the change in C-section reimbursements surprised obstetricians.  Said Whitty: “I was stunned that such a proposal would be made.”


Throughout this article women remain completely invisible, except as dollars to be fought over/fees to be charged. Their health, and how it relates to more or fewer c-sections or to hospital access, remains almost entirely outside the discussion, except in ways that are disturbingly unrelated to medical necessity.


However, if you follow the article link, there is one place the women do show up in relation to this article; in the comments section, where they are accused of being illegal immigrants and having too many children at public expense.

 

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Reader Comments (116)

Heh. I knew that’s where you were going with this one, Amy.

I’m waiting for the segue from: “There's no question that the vast majority of people charged by the government ARE guilty.”

…to: There's no question that the vast majority of people who receive cesareans NEED them.

Then you wait until someone says “But most cesareans aren’t NEEDED.”

Than you say “Prove it.”

They quote the WHO, you say “the WHO, Amnesty International and every NCB advocate is wrong. QED!”

March 28, 2011 | Registered CommenterJill

And no, obstetrics is not exempt from analysis of and measures to reduce overutilization of procedures. The cesarean rate is one of the quality measures used to analyze utilization and efforts to reign in the use of the cesarean section are not 1) a mass attack on obstetricians personally or 2) a callous economic decision that kills babies.

Some form of these narratives pops up in the media from time to time and has for decades.

March 28, 2011 | Registered CommenterJill

Oh man. Amy, if you really believe the right to legal representation is a bad thing, that's unusual but your perogative, but...that's a pretty massive derail here. There are many, many legal blogs on the internet where you can argue about that. Perhaps you should start with those.

In response to your earlier question, my whole point rests on the description of the cesareans being cut as "unneeded". My point was also that it would be a simple matter for the OBs serving TennCare to take the positions that the state was risking women's health because all those cesareans *were* in fact needed. If the reporter had pressed, the smarter ones might actually have done that and come off looking better.

But astonishingly, they didn't even bother; they pretty much admitted that unnecessary surgeries=a good thing, a financial and legal necessity. The patients increased risks of infection and complications and death...who cares? There's bills to be paid!

Which, much like your position that anyone that can't afford a lawyer is guilty anyway so screw them, is neither ethical nor acceptable to a hell of a lot of us.

March 28, 2011 | Unregistered Commenteremjaybee

"Heh. I knew that’s where you were going with this one, Amy."

Not exactly. I used the legal example because it is comparable in many ways. There is no reason to provide trials for the guilty. And it is true that most defendants are guilty. However, some defendants are innocent and it is often difficult to tell in advance which ones are the innocent ones. We provide trials for everyone not so public defenders can profit from state money, but because we consider it more important to make sure that no innocent people go to jail.

Similarly, TennCare wants to claim that there is no reason to pay for "unnecessary C-sections." And it is true that there is no reason to pay for unnecessary C-sections and that many C-sections are unnecessary in retrospect. However, a substantial portion of C-sections are life saving and (because of the limitations of current technology) it is often difficult to tell in advance which ones are the life saving ones. We pay for all C-sections because we consider it more important to make sure that no babies die preventable deaths.

I also used the example, because I think emjaybee will understand it. Debates on the appropriate reimbursement of public defenders have nothing to do with whether the guilty are getting trials that they shouldn't get. Similarly, debates on the appropriate reimbursement for the care of poor women have nothing to do with whether poor women are getting C-sections they don't need.

The real point, which I haven't made up until now, is that rather than illustrating some elaborate evil conspiracy, the issue at the heart of this is Economics 101. When you cut aid for poor people, whether it is legal aid or medical aid, poor people suffer.

Moreover, TennCare is an insurance entity just like any insurance company. They insist that various instances of care are "unnecessary" in order to avoid paying for that care. Why on earth should poor people trust TennCare to make decisions based on patient wellbeing when other insurance companies attend only to the bottom line?

I know you guys really, really, really want to reduce the number of C-sections. However, depriving the poor of high quality medical care is a rather cynical way to go about it.

March 28, 2011 | Unregistered CommenterAmy Tuteur, MD

The difference between representing the guilty is that we have a presumption of innocence until proven guilty. So, the representation is of the innocent, not the guilty, and yes, that is worth it.. If you want to use that analogy for childbirth, all pregnancies should be assumed healthy and normal until proven otherwise.

But, I guess that many doctors can't do that, and we wind up with all pregnancies being treated as high-risk and recieving many more interventions and procedures than needed, not just unneeded cesareans.

March 28, 2011 | Unregistered CommenterDianna

Amy, your legal "analogy" is a massive fail. How do you determine who is guilty WITHOUT a trial and the constitutionally-guaranteed right to counsel? And even if you know someone committed the act in question, how would you know, without a trial, whether there were mitigating circumstances or an affirmative defense? And even unquestionably guilty persons deserve counsel to insure that their rights (and even guilty people have rights) are being protected.

Would you just assume everyone was guilty and then provide them no means of showing otherwise? And you want to apply this to birthing women? Yikes, yikes, and double yikes.

March 28, 2011 | Unregistered CommenterLiv

Amy, we saw the argument about reducing the cesarean rate depriving poor people of needed medical care used in the late 80’s. We saw it more recently in a different form… they called them “death panels.” Wouldn’t want to deprive Grandma of her heart medication!

Emjaybee’s post had as much to do with some of the underlying narratives that pop up in media coverage as it had to do with what’s happening in Tennessee. Your comments provide examples of these conspiracy-theorist narratives that have been batted around for decades to scare the public into equating economic analysis of obstetric practice patterns with dead babies and suffering families. The notion of systematically changing obstetric practice patterns is such an emotional sore spot… such an Achilles heel. Why?

Your argument that Economics 101 is at the heart of this is right on… but not in the way that you are conceptualizing it (or spinning it). We could let Health Economics 101 speak for itself. That’s where I assume you would be introduced to discussion of utilization, the nature of the typical U.S. relationship between hospital and physician which gives little hospital control of practice patterns, unjustifiable extremes in practice variation, the difference between non-profit and for-profit hospitals, etc. Are there economic disparities in access to quality health care? Absolutely. Are they caused by an insurance company wanting to save costs by reducing the rate of a particular procedure for economic reasons? Probably not. Who knows… maybe the funds saved from unnecessary procedures in this case will be used to fill in the gap between underutilization and needed care in a different area.

Any chance you want to try again and come up with something fresh?

March 28, 2011 | Registered CommenterJill

As a practicing OB in Middle Tennessee who servesTN Care patients, let me put the money references in perspective. Doctors are not getting anywhere near the $6400 figures mentioned- the bulk of that is what the hospital gets. For antepartum care (typically 12 office visits), a vaginal delivery and all associated hospital care, and a 6 week postpartum visit, as well as being available 24-7 for phone calls and emergencies, I get about $1200. For a Cesarean delivery, it's about $1400. This is about 1/3 of what a private insurer would pay, and that is about 1/5 of my monthly malpractice insurance premium alone.

March 28, 2011 | Unregistered CommenterMid-TN OB MD

" How do you determine who is guilty WITHOUT a trial and the constitutionally-guaranteed right to counsel?"

The same exact way that you determine a C-section is unnecessary BEFORE the baby is born. In other words, you can't determine it.

Emjaybee, I'm still waiting for that step by step explanation. Are you really resting your entire piece on an insurance entity claiming that something is "unnecessary" because they don't want to pay for it? Do you have information on how they decide whether the C-section was necessary? If you don't know how they decide, then you don't know that their criteria are valid.

March 28, 2011 | Unregistered CommenterAmy Tuteur, MD

Hi Mid-TN OB MD,

Thank you for your comment.

The International Federation of Health Plans cites an average physician payment for cesarean delivery as $3,505 and vaginal delivery as $2,997 in the U.S. in 2010. (http://ifhp.com/documents/IFHP_Price_Report2010ComparativePriceReport29112010.pdf)

Here are average facility charges (2007-08) - http://transform.childbirthconnection.org/resources/datacenter/chargeschart/

Anecdotally speaking, I've heard from other doctors that they are closer to your range.

March 28, 2011 | Registered CommenterJill
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