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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)

Personally, I consider truth more important than "freshness."

OK. Then give me the truth while you're at it. Fred Phelps thinks he bears the truth, too, and he likes to run around and tell everyone.

March 28, 2011 | Registered CommenterJill

Jayn, there is a large body of literature on perverse economic incentives in medicine. It's also a touchy subject.

March 28, 2011 | Registered CommenterJill

By the way, there's a very similar topic over on Stand and Deliver; Rixa had a local hospital close its maternity department; she cites low Medicaid reimbursement as a cause.


I do think the topic of "how much should a practitioner be paid" is a valid one; my beef here has been with the idea of increasing surgery rates to make up numbers. That is not an acceptable bookkeeping move, and as Jill said, goes back to the larger discussion of perverse incentives.

What's interesting too is the hospital Rixa refers to did have a high c/s rate but went under anyway.

March 28, 2011 | Unregistered Commenteremjaybee

"She is saying that it is acceptable to section a third of women because doing so saves some babies. Not the babies of all 33 of 100 women...but of how many? I think this is a value judgment which needs to be more in the open and not assumed. How many surgeries are justified to save one baby?"

Susan has gotten to the heart of the matter. How many C-sections are justified to save one baby?

To a large extent, society has answered that question. The societal judgment is that not even one baby can be lost. That's certainly the message of both the courts and parents, and society expresses its viewpoint through the law. When a baby dies a potentially preventable death, neither the courts, nor parents consider efforts to lower the C-section rate to be a justification for forgoing a C-section.

This is the reality that all obstetricians must acknowledge. Unfortunately, birth activists refuse to acknowledge this reality. Even worse, they have no practical suggestions for how to lower the C-section rate without sacrificing babies' lives.

March 28, 2011 | Unregistered CommenterAmy Tuteur, MD

"my beef here has been with the idea of increasing surgery rates to make up numbers"

Whether intentional or not, that was one of the take-home messages in the Tennessean article.

March 28, 2011 | Registered CommenterJill

"This is the reality that all obstetricians must acknowledge. Unfortunately, birth activists refuse to acknowledge this reality. Even worse, they have no practical suggestions for how to lower the C-section rate without sacrificing babies' lives."

I will hold you to a higher standard than your typical joke of a conclusion because I know you can do better. All you are doing here is perpetuating the same narratives as discussed earlier in the thread. On one hand, you can keep going with it... it's all the same to me. I just think you could kick it up a notch and drop some of the Westboro Baptist "you're all callous baby killers!" rhetoric.

Don't go for the low hanging fruit. You tried to invoke Economics 101 earlier. I'd love to hear what you have to say within that framework. Are you up for it? (Please and thank you)

March 28, 2011 | Registered CommenterJill

As a first but possibly minor point, the fact that any risk at all now justifies a C section is a very effective cover for doctors who do C sections at times for their own convenience when they really don't sincerely believe there is a threat. Statistics about the times of day and times in the year when the most C sections are performed tend to validate women's experiences that this happened to them.

Second, natural birth advocates HAVE made practical suggestions which would lower C sections without "sacrificing babies' lives.". Don't do those things which either put babies under greater stress or which make it more difficult for women to push their babies out. Don't induce women too early. If you feel you have to induce past a certain point because some babies die in utero past that gestational age, at least don't push the pitocin past the point necessary to get the woman into labor. When she is in labor, see if her body will take over. A typical uninduced first labor could easily take 24 hours, so don't push your induced first time mothers to deliver in 12! Very hard and long lasting contractions stress babies right? If you don't push them into distress you won't have to rescue them with C sections.
Let mothers eat and drink during labor. Nourishment is important to babies as well as mothers. Glucose IV's are not the same as food.
Let the mother walk around and choose her own positions in labor. (Use a saline lock instead of a running IV. Use telemetry monitoring.) This does enable babies to get themselves into a better position to be born. I think I have read that you deny this. But have you ever struggled to get a large piece of furniture through a narrow doorway ? Didn't you wiggle it around, try it from this angle and then from that angle? But if you won't believe this, at least believe that the mothers will be less stressed, and in less pain, and their stress hormones will therefore not be affecting the baby. Try to keep things calm and quiet and not too bright as mother moves towards birth. Keep your monitoring of the woman unobtrusive. All of this is not just about the experience of the woman, it also makes the birth move along better resulting in less stress for babies.

I am not someone who thinks that birth always works, or that a woman's body will never grow a baby she can't birth, or any of that. But we are mammals, and we pretty much need the same conditions for birth as other mammels, who seek out a quiet dark place to give birth and will often outright stop the process if people, or unknown people, disturb them. I agree that birth is more problematic for humans as a whole because we are large headed and stand upright. But that doesn't make us not need what other mammels generally need.

I know you will say that these things haven't been proven in scientific studies to help babies. However, it is difficult to study what isn't happening! It is not easy to rule out confounding factors in studies of birth, and it takes large samples to have valid results. It also hasn't been proven that these things harm babies. So as long as monitoring can be done while providing this kind of birth environment, why not do it.

At the very least, stop pushing the pitocin so hard.

Susan Peterson

March 28, 2011 | Unregistered CommenterSusan Peterson

I personally liked this curious tidbit by Dr. Wendy Long, the chief medical officer for TennCare,:

"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."

non-C-sections- HA! you mean a vaginal birth?
and elective c-sections from Tenn care- clientele- so the people who are receiving their health insurance from TennCare are marching into their OB's office looking to schedule c-section?

March 28, 2011 | Unregistered CommenterSaanenMother

"I just think you could kick it up a notch and drop some of the Westboro Baptist "you're all callous baby killers!" rhetoric."

I'm not accusing anyone of being a baby killer. I am agreeing with what Susan said; it comes down to how many C-sections are "worth it" to save one baby. There is no right answer. There's only the answer that society agrees upon and that obstetricians have to abide by.

Pretend for the moment that you are in a class at a school of public health. If someone in the class were to make the same point that I did, would you respond by accusing them of labeling everyone "baby killers'? Or would you actually think about the issue and try to 1. articulate a point of view, and 2. support that point of view with evidence?

March 28, 2011 | Unregistered CommenterAmy Tuteur, MD

Oh, Amy. You and I have been down the same road on this topic so many times. Same song, 4567th verse.

I really do think that you can do better than this. We can pretend that you're in an econ class refusing to discuss overutilization of a particular procedure by sticking your head in the sand and pretending that there's no way to ever know whether or not it's overused, then invoking dead babies. What kind of response to you think you would get?

I'm actually being selfish. I'm working on something and was hoping you could come up with something new. And, yes, I'm only being a turd to you right now. Sorry about that.

I'm not kidding about that guest post, though.

March 28, 2011 | Registered CommenterJill
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