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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)

"How many C-sections are justified to save one baby?"

The problem with this question is the assumption that c-sections can do no harm to babies, that they ONLY save babies. That is a false assumption (even without addressing the increased risk to the mother, who may have other children who are already dependent on her). I would dare you to deny that c-sections can sometimes do more harm than good to babies (not to mention mothers), but your answer might put me into labor (at 39 weeks on Wednesday!).

March 28, 2011 | Unregistered CommenterHeather

Why do you guys insist on feeding the troll? :p

March 28, 2011 | Unregistered Commenterdana

"I would dare you to deny that c-sections can sometimes do more harm than good to babies (not to mention mothers), but your answer might put me into labor"

C-sections are much safer for babies than vaginal delivery. That's what the scientific evidence shows.

The harms from C-section are minor and self limited, like TTN. The harms from vaginal delivery include brachial plexus injuries, stillbirth and death. If all babies were delivered by elective C-section, the perinatal mortality rate would be lower than current rates. Only NCB advocates appear to be unaware of the scientific evidence on this point.

March 28, 2011 | Unregistered CommenterAmy Tuteur, MD

Dana, because sometimes she breaks free from the repetitive cut-and-paste points and says something really interesting.

March 28, 2011 | Registered CommenterJill

And then we move on to talking maternal morbidity and the negative consequences of early elective deliveries to babies, which returns to discussions of perinatal mortality.

Freshness. Let's find it.

Oh well. If this is a new experience for people here, enjoy. Keep on being respectful and such.

March 28, 2011 | Registered CommenterJill

"C-sections are much safer for babies than vaginal delivery. That's what the scientific evidence shows."

Well, sometimes I do like to dance to the same ole song. ("September" by Earth, Wind and Fire."

This statement above Dr. Amy, cannot be true.

Or using one of your best and my favorite lyrics, Dr. Amy: "You simply made this (that) up."

Please, please please watch this video below with our fellow Massachusetts resident Dr. Gene Declerq- Dr. Amy then tell me alllllll about how c-sections, elective, routine or otherwise is what is SAFER for mothers and babies:


I am not talking about a quote, un-quote, natural birth. I am talking about a vaginal birth. Please and I earnestly mean it- explain how surgery is safer than vaginal birth.

March 28, 2011 | Unregistered CommenterSaanenMother

Neonatal Morbidity and Mortality After Elective Cesarean Delivery by Signore and Klebanoff appears in the June 2008 special issue of Clinics in Perinatology focussing on the epidemiology and neonatal effects of C-section. The authors conducted a decision analysis
modeling the probability of perinatal death among a hypothetical cohort of 2,000,000 women who had uncomplicated pregnancies at 39 weeks, half of whom underwent ECD and half managed expectantly. After taking multiple chance probabilities into account, the model estimated that although neonatal deaths were increased among women delivered by elective cesarean, overall perinatal mortality was increased among women managed expectantly, because of the ongoing risk for fetal death in pregnancies that continue beyond 39 weeks.

The authors found:

Elective cesarean
at 39 weeks Expectant management

Perinatal deaths 804 1496
Stillbirths 0 1118
Neonatal deaths 804 378
Respiratory morbidity 11,000 2524
Intracranial hemorrhage 490 1007
Brachial plexus injury 410 787
PPH 3700 1488
Suspected sepsis 20,000 33,211
Confirmed sepsis 0 2635
Laceration 8000 2464

In other words, if 1 million women underwent C-section at 39 weeks instead of waiting for onset of labor and attempting vaginal delivery, 692 more babies would be saved, 517 cases of intracranial hemorrhage and 377 brachial plexus injuries would be prevented. In exchange, there would be 8476 additional cases of short term respiratory problems, 5536 neonatal lacerations, and 2212 additional cases of postpartum hemorrhage.

The authors conclude:

"... Elective repeat CD rates have been increasing steadily since the late 1990s, and there may be a growing trend in CDs on maternal request... [E]xisting data suggest that ECD is associated with greater risk for neonatal respiratory morbidity and fetal laceration and potentially decreased risk for brachial plexus injury, neonatal sepsis, intracranial hemorrhage, intrapartum asphyxia, and neonatal encephalopathy. Although neonatal deaths may be increased among infants delivered via elective cesarean, overall perinatal mortality may be reduced because of prevention of antepartum stillbirths. To minimize potential neonatal risks in ECDs, these deliveries should not be undertaken before 39 weeks’ gestation. Patients considering ECD should be made aware of available data on potential risks and benefits to fetus and neonate. Further research is needed to inform these discussions."

So even C-sections WITHOUT a medical indication reduce perinatal death rates. Medically indicated C-sections reduce them even further.

NCB advocates need to avoid the "is-ought" fallacy, the belief that because something is a certain way in nature, that the way it ought to be. Childbirth is a product of evolution; it is not a perfect process. It is merely the most successful process in the absence of medical intervention. Medical intervention makes childbirth MUCH safer for both mothers and babies.

Labor is dangerous for babies. Indeed, it is probably the single most dangerous thing that occurs during the 18 years of childhood.

March 28, 2011 | Unregistered CommenterAmy Tuteur, MD

"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."

Obstetricians are part of society and participate actively in the answering of this question. They are not value-neutral, culture-free, un-socialized bystanders who are at the receiving end of such judgments and can't do anything but try to live up to it. I would wager that they actively participate in creating this standard of perfection. One example is the copious use of the dead baby card that is used to cajole, coerce, shame, guilt-trip and pressure pregnant women into agreeing to a doctor's proposed treatment. As a social scientist, I would have immediately had my doctoral research shut down if I had used such tactics to obtain 'informed consent' from my research participants -and that was just asking what language people spoke when they were children.

Maybe it would indeed be a lot more effective to efforts to lower the c-section rate if OBs actively contributed to a dialog that examines such standards of perfection, and examine their own role in perpetuating such a standard, rather than letting "NCBers" do all the dirty work and being labeled baby killers who care more about the experience of birth than the health and safety of the mother-baby dyad.

March 28, 2011 | Unregistered CommenterVW

hypothetical cohort ?

Please explain a hypothetical cohort. If we're just extrapolating results to support our arguments then what good is the data..I mean.... really!

Please note I wrote: VAGINAL not Natural, I am not talking about no interventions via vaginal- I am talking about the whole she-bang (no pun intended.) You name it- no holds barred vaginal births with pitocin, epidurals- you name it. Tell me how surgery is safer.

did you watch the movie Dr, Amy? I want to see you use that one to extrapolate data based on the ACTUAL study and number DeClerq provides.

March 28, 2011 | Unregistered CommenterSaanenMother

Let's not forget women go on to have other children. This article points out how repeat cesareans are what are driving the cesarean rates up. So, let's look at repeat cesareans.

Effect of prior cesarean delivery on neonatal outcomes
J Perinat Med. 2011 Mar 23

Conclusion: Having a prior cesarean delivery is associated with an increased risk of adverse neonatal outcomes. Adverse neonatal outcomes in subsequent pregnancies is additional evidence to suggest that unless specifically indicated, cesarean delivery should be avoided.

And, let's not forget higher maternal risk from even a primary cesarean:

Caesarean section without medical indications is associated with an increased risk of adverse short-term maternal outcomes: the 2004-2008 WHO Global Survey on Maternal and Perinatal Health

CONCLUSIONS: Caesarean sections were associated with an intrinsic risk of increased severe maternal outcomes. We conclude that caesarean sections should be performed when a clear benefit is anticipated, a benefit that might compensate for the higher costs and additional risks associated with this operation.

Hmm, what does that pesky World Health Organization know about medical indications for cesarean? Didn't Dr. Amy say there is no such thing?

Cesarean section is not somehow unique among all medical interventions in that there are no indications. It is not something we need to apply to all pregnant women in order to, retrospectively, claim it was needed in some. Clear benefits can be anticipated because of complications that arise in the prenatal or intrapartum course that indicate a cesarean section may be needed. It's no different than any other form of surgery. It's like saying we need to remove all appendixes to see which ones need to be removed. Not so much. There are indications for appendectomy, just as there are indications for cesarean section.

This article seems to disagree with neonatal health being improved by cesarean section:

Neonatal mortality for primary cesarean and vaginal births to low-risk women: application of an "intention-to-treat" model.

RESULTS: The unadjusted neonatal mortality rate for cesarean deliveries with no labor complications or procedures was 2.4 times that for planned vaginal deliveries. In the most conservative model, the adjusted odds ratio for neonatal mortality was 1.69 (95% CI 1.35-2.11) for cesareans with no labor complications or procedures, compared with planned vaginal deliveries.

CONCLUSIONS: The finding that cesarean deliveries with no labor complications or procedures remained at a 69 percent higher risk of neonatal mortality than planned vaginal deliveries is important, given the rapid increase in the number of primary cesarean deliveries without a reported medical indication.

Even though this conversation isn't as off topic as the ridiculous let's not follow the constitution and defend people accused of crime nonsense, it is still very off topic.

What is key to this discussion is if it is ethical to let compensation drive medical decision making, especially in the health care category of pregnancy and birth, which is as tied up in bodily autonomy as it gets.

March 28, 2011 | Unregistered CommenterMomTFH
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