Day Two of Things That Work: Preventing Early Elective Deliveries

Today’s Managing Health Care Costs Indicator is 39

Something is broken with deliveries in the United States.  Our Caesarian Section delivery rate has increased to over 34% - and the VBAC rate (vaginal birth after C-section) has plummeted.  Caesarian sections are a major abdominal procedure, requiring significant recovery time, and raising health care costs.  Further, women who have had C-sections are more likely to have placenta previa complicating later pregnancies, which can threaten the life of the mom and the baby.

Early elective inductions – done for convenience of patient or physician without medical indications – are an important cause of preventable C-sections.  Attempting an induction when the cervix isn’t ready is more likely to result in failure of labor to progress –which can trigger the cascade toward C-section.  Early elective inductions also lead to premature births that require extra days to weeks in a neonatal ICU.   Again, this leads to higher costs and worse outcomes.

Here’s what’s working.  The Leapfrog Group began publicizing voluntarily-reported early induction rates earlier this year – and hospitals are taking notice. WBUR’s Martha Bebinger reported late last week that top Massachusetts maternity hospitals are prohibiting early elective deliveries.  In her report some expectant moms argued that they wanted ‘control’ over when to deliver their babies.  But excellent medical evidence suggests that early inductions increase adverse outcomes – and physicians shouldn’t offer patients options that increase the risk to them and their unborn babies. 

It’s important that the approach of hospitals is to administratively interdict unindicted early inductions.  Clark et al showed that a “hard stop” is substantially more effective than peer review or physician education.  These researchers also showed a 16% decline in NICU use associated with implementing this hard 

There are many other issues with organizational structure and payment methodology that drive increased C-section rate. These include lack of obstetrical practice integration and labor coverage, underuse of nurse midwives, and higher hospital payments for C-sections.  So – there is plenty more work to do.  Catalyst for Payment Reform recently published a tools for employers to promote maternity payment reform.   

For now, we can celebrate that many hospitals are doing serious work to prevent early inductions that are not medically indicated.

California to Mandate Maternity Coverage

Today’s Managing Health Care Costs Indicator is $12,320 to $17,093

The Los Angeles Times reports that the California Legislature has just passed a bill that would mandate that individual health insurance cover pregnancy-related expenses. 

California already mandates maternity coverage for health maintenance organizations and for state-regulated employer insurance, but until now insurers have been able to write individual policies that exclude coverage for pregnancy.

The $12,320 to $17,093 is the range of estimates of hospital and obstetrician costs is from the International Federation of Health plans in 2009.  This data is not trended forward from 2009, and does not include costs of anesthesia.  This is also for a vaginal delivery; cost is higher for Caesarian Section, which represents about 35% of deliveries in the US at this point.

Governor Jerry Brown has not yet announced whether he will sign the bill. Should he?

Pregnancy is often planned – so theoretically prospective moms could plan their finances to account for this expense.  However, delivery is just too expensive for most people to be able to pay this out of pocket.  It seems to me that pregnancy is exactly why we should have social insurance and share the cost burden across the larger population.

On the other hand, voluntary individual health insurance premiums will rise substantially if  pregnancy is covered.  Women could sign up after their positive pregnancy test – and thus deprive the insurance pool of their pre-pregnancy premiums.   Hence, the cost of the health insurance premium would need to be very high, to account for adverse selection, the selective recruitment of those likely to have the highest medical bills.  Health insurance which is unattractive to the healthy is unsustainable.

This is the problem of voluntary, ‘guarantee issue’ individual health insurance – it’s in each person’s individual best interest to sign up only when she needs benefits, but this limits the ability of the healthy to subsidize those with health care needs. 

The Affordable Care Act’s individual mandate addresses this issue, although it’s wildly politically unpopular to require that Americans purchase private health insurance to avoid a penalty.

Jerry Brown will find it difficult to veto this bill.  He’ll want to show solidarity with pregnant women, and make it easier for them to obtain proper prenatal care.  The maternity care needs to be paid for one way or another – we’re not going to force women to have their children on kitchen tables.   If Brown  does sign the bill, premiums will rise rapidly in the individual market, making it difficult for many to afford the health care insurance they currently have.  

It’s easy to see why policy experts are much more enthusiastic about the individual mandate than Americans filling out public opinion surveys!

Addendum: LA Times editorial supporting mandate

Hospital Improves Maternity Care and Lowers Cost

Today’s Managing Health Care Costs Indicator is $3.5 billion

Maternity care really matters.  Earlier prenatal care, prenatal vitamins, and cigarette, alcohol and drug cessation help us have healthier children – and prevent excess health care costs. Still, maternity represents 20% or more of hospital admissions for many employers, and sick newborns often represent a quarter of all catastrophic care cases. 

Caesarian section delivery is shockingly common in the US – about 1/3 of all deliveries at this point.  The World Health Organization has recommended an optimal rate of 15%.  C-sections increase the likelihood of complications of subsequent deliveries –and they decrease the new mom’s ability to immediately bond with the newborn.  Once a woman has an initial c-section, it’s unlikely she’ll have a future vaginal delivery, as VBAC deliveries are increasingly rare.

Induction (intravenous drugs to start the labor process) is also quite common in the US– and can start the cascade toward C-sections – since if induction is begun before the cervix has started to dilate, it’s likely to lead to prolonged labor that is ended by Caesarian section.

The variation in elective induction is dramatic across different institutions – here’s a link to the Leapfrog Group’s website , where you can see elective induction rates by hospital. 

Health Affairs just published an article from Intermountain Health describing its focus on system variation (not merely variation of individual clinicians).   Intermountain’s efforts began over a decade ago – and cover a range of medical care.  I’ll focus here on the results of their maternity process improvement.

Intermountain recognized that 28% of their elective inductions in 2001 did not meet medical criteria –and imposed the following rule. 

When an expectant mother arrived at the hospital for an elective induction, nurses completed an electronic check sheet that summarized appropriateness criteria. If the patient met the criteria, the induction proceeded; if not, the nurses informed the attending obstetrician that they could not proceed without approval from the chair of the obstetrics department or from a perinatalogist—a specialist in high-risk pregnancies.

With the initiation of this rule, the percent of elective inductions which did not meet clinical criteria dwindled to 2%!  Intermountain’s c-section rate is 21% now – over a third lower than the national average.

The authors state that $50 million in annual medical costs have been averted through this simple program, and extrapolate that a national effort like this could save $3.5 billion per year.

This is a great example of making care better for moms and babies and saving money at the same time.  I often talk about how we have to make difficult choices to improve value in health care.  The only tradeoff necessary to lower inappropriate elective inductions, and thereby lower c-section rates and premature deliveries is a small decrease in physician autonomy.    Seems like a very good tradeoff indeed!