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« Can I Change Care Providers While Pregnant? | New York Cesarean Rates, 2008 and 2009 »

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)

I agree with the majority of your analysis. However I read the first part differently. Being friends with several OBs and CNMs, I understand the concern about lower compensation rates means the hospital/practice costs aren't being covered or are being covered with less room for "profit". This means doctors will end up being paid less and hospitals will get out of the less/unprofitable business of birthing babies and into more profitable forms of surgery like orthoedics. Doctors will follow. Cesareans do cost more than vaginal births and I don't know that cutting reimbursement for them is the right way to go either. That could affect lower income women negatively, too.

I agree that this piece creates more questions than it answers.

March 28, 2011 | Unregistered Commentervanessa

"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."

Could you explain your reasoning process step by step to show how you arrived at this assumption?

I don't see anything in that article, or your analysis of it, that justifies your assumption.

Let me give you a legal example as a parallel. Suppose public defenders protested about government cuts in reimbursement for "unneeded" representation of the guilty. Would you assume that "unneeded" representation of the guilty, poor Tenneseans no less, are keeping many public defender programs afloat in the first place?

March 28, 2011 | Unregistered CommenterAmy Tuteur, MD

Normally I don't go for government solutions. They usually flop badly with unintended consequences. Maybe this one will too, I don't know. If the c-sections were NEEDED, I agree that OBs would stop practicing and hospitals would have a difficult time covering costs of care, as vanessa pointed out; however, since we know that all 30+% of women who get c-sections now DON'T need them, I think the only result will be fewer c-sections. After all, they really are more expensive to perform, but bring in more profit (which isn't a dirty word, by the way. I feed my family with profit, and so do you)...sorry, as a die-hard capitalist I digress. Ahem, they bring in more profit because doctors can get women in and out of the hospital quicker and on a schedule. So even though they're more expensive to perform, they make that money back in volume. However, if they know their compensation with not cover the cost of the procedure, they'd need a LOT more volume to make a better profit. That's not a number that's likely to increase, so more likely than closing their doors, they'll probably just think twice before eviscerating a woman out of convenience or fear of litigation.

But again, government solutions usually have unforeseen and unintended consequences. I'm interested in seeing how this plays out.

March 28, 2011 | Unregistered CommenterHeather

@Amy. There's no such thing as "unneeded" representation of the guilty, unless we're assigning each person 5+ lawyers, so your point is moot. However, if we WERE assigning each person 5+ lawyers, then yes, I would assume that was keeping those lawyers afloat at the public's expense. In fact, that would be painfully obvious.

March 28, 2011 | Unregistered CommenterHeather

Let me give you a legal example as a parallel. Suppose public defenders protested about government cuts in reimbursement for "unneeded" representation of the guilty. Would you assume that "unneeded" representation of the guilty, poor Tenneseans no less, are keeping many public defender programs afloat in the first place?

This analogy is unhelpful, because legal representation is needed, and is in fact guaranteed by the Constitution, in every case. But look at the other side and you are proving emjaybee's point: unneeded prosecutions are keeping the DA's office afloat. Maybe cutting budgets to reduce criminal prosecution would be a great thing too.

March 28, 2011 | Registered CommenterCourtroom Mama

I would like to think that funding cuts would mean less invasive care. Will it though? Cutting paychecks doesn't make for a more holistic doctor. OB's won't leave, they will just stop serving people with TennCare. It seems to simply be another midterm election "we have the power now and the poor people are going to be sorry" agenda.

Reform is great, but this isn't reform.

March 28, 2011 | Unregistered CommenterClaire

Amy, let’s use an actual legal/political example instead of a hypothetical.

To garner public support of Prop 12 in Texas, a picture was painted of physicians fleeing the state, leaving underserved/unserved patients in their wake. This was total B.S. with evidence to back it up. According to Texas Watch, “Researchers can find no evidence that limits on patient rights have had an impact on the number of physicians providing direct patient care.” (http://www.texaswatch.org/wordpress/wp-content/uploads/2010/10/MedMal-Fact-Sheet-2010.pdf)

Emjaybee found a similar vein in this media portrayal of the martyred physician, which is very much not the case here. It makes a great story, though.

March 28, 2011 | Registered CommenterJill

Heather wrote: "however, since we know that all 30+% of women who get c-sections now DON'T need them, I think the only result will be fewer c-sections."

How do we know that?

March 28, 2011 | Registered CommenterJill

" legal representation is needed"


Why do the guilty need representation? If they did it, why should we waste time and money on trials that cost thousands or tens of thousands of dollars on people we know are guilty? There's no question that the vast majority of people charged by the government ARE guilty. So why are we wasting money on them?

March 28, 2011 | Unregistered CommenterAmy Tuteur, MD

oh please. I'm not going to derail this thread; here's a resource that might help clarify: http://www.constitutionalcriminalprocedure.com/

March 28, 2011 | Registered CommenterCourtroom Mama
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