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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)

OK, well now that we've moved the Overton Window of C/secs right past ACOG's own recommendations (even they don't say 100%=awesome) I feel compelled to point out that one particular commenter here may hold that fringe view, but the OBs in Tennessee did not make that particular argument, at least not explicitly.

That was actually part of my point--had they ever mentioned mortality risks (the writer did, but not any of the quoted doctors), they would at least have had the appearance of giving a shit about their patients. They did not.

It's one thing to have a completely blithe assessment of the risks of Surgery for All, it's another to simply see Performing Admittedly Unnecessary Surgery for Many as some sort of advanced form of bookkeeping trick.

If, for example, I was told I needed to have my kidney removed, only to learn later that the hospital sold it to the highest bidder to keep the staff paid, my outrage would not be due to the fact that I did not want the staff to get paid. Even if I had no complications and would be fine for the rest of my life down one kidney, it's still assault.

This is why I would recommend that the Surgeries for All/Most/Those That Lose the Dice Roll camp at least do their unwitting victims, uh patients, the courtesy of telling them this is what's happening. Here, I wrote a little script:

Dr. : Well Ms. Smith, how are you doing?

Smith: (winces) OK. I'm getting some good contractions going now.

Dr.: Well, we can take care of that for you. Ms. Smith, you may not know this, but obstetrics is a very expensive business. States aren't paying us enough to cover our expenses. But we've found a workaround that I hope you can help us with.

Smith: (panting)....I'm sorry?

Dr.: Well, you see we get a better return on our expenses when we do a cesarean section as opposed to a [makes finger quotes] "vaginal birth." And to be honest, if we dont' meet a certain quota of sections every month, this whole unit might get shut down. And then the women of [STATE REGION] won't have anyplace to have any kind of birth.

Smith: I'm sorry (wince) I don't understand.

Dr. Well, Ms. Smith, although your labor is progressing and the baby's doing fine, we have a lot of bills to pay here at [HOSPITAL NAME], and so, if you'll just sign here [presents form] we can get you prepped for your c-section.

Smith: But I don't want a c-section! You just said I don't need one! Isn't this illegal?

Dr. It's a gray area, but so long as you consent, we're good. Now, how about doing your part to help out the women of [STATE REGION]? It won't hurt a bit and you won't have to worry about being stretched out "down there."

Smith: [attempts to throttle Dr, is restrained by orderly]

Dr. [hurt and miffed] Well, Ms. Smith, I must say, I am disappointed in your lack of compassion! If no one in [STATE REGION] has anyplace to birth next year, you'll know it's because of women like you! [stomps out]


March 28, 2011 | Unregistered Commenteremjaybee

Oh, because I can't resist.


DETECTIVE FRANK TRIPP: Dammit, Horatio, how many c-sections do we have to do to save one baby??



March 28, 2011 | Unregistered Commenteremjaybee

right on emjaybee. right ON.

March 28, 2011 | Unregistered CommenterSaanenMother

@emjaybee, we all talk like that in Miami. And everything we say is punctuated by Roger Daltrey screaming. Also, have you noticed our cesarean rates down here? We don't need no stinking indications.

March 28, 2011 | Unregistered CommenterMomTFH

Do you also let CSI agents interview suspects and none of them ever asks for their lawyer? That's my favorite part. /derail

March 28, 2011 | Unregistered Commenteremjaybee


Surely you can do better than that.

1. What is the magnitude of the risk in future pregnancies? How does that compare with the saving of lives in current pregnancies? Citing that paper without detailed data is rather unprofessional.

2. Did you read the WHO paper? If you did, you would have learned that the lowest mortality rate was in the group that had C-sections for NO medical indication. The data in the paper shows the exact opposite of what the authors decided to conclude.

3. The MacDorman paper is a bunch of crap. The entire paper rests on the assumption that "no indicated risk" means no risk. You ought to know that there is a tremendous amount of research that shows that when the risk section of the birth certificate is not filled out, it does NOT mean that there is no risk. Most serious medical illnesses (heart disease, kidney disease, etc) are never mentioned on the birth certificate.

Moreover, that paper is an effort to correct the original paper from 2006 that was an even bigger piece of garbage since it didn't even take into account intention to treat.

You really have to read this stuff before you cite it, otherwise you are going to spend a lot of time being humiliated in front of your attendings.

March 28, 2011 | Unregistered CommenterAmy Tuteur, MD

Dr. Amy,
Surely I don't waste any more of my time arguing with someone who stoops to personal insults instead of arguing evidence. You know me better than that. I am not unprofessional because I limited my rather long comment by not copying any pasting more of an article. I did do better - better than you. None of this exists in a vacuum - yes, mothers have other risks. Surgeries have indications. Mothers go on to have other pregnancies. Any article you do not agree with is not "crap".  All of these studies have to make some adjustments in their methods, and these studies have a lot more generalizability than yours does.
And, I am doing just fine in front of my attending physicians. It has been a while since you left medicine and academics. Believe it or not, it isn't as acceptable to be dominating, blustering and arrogant to students anymore. I am doing just fine with evidence and thoughtful argument. But, thanks for being unprofessional yourself and fulfilling everyone's expectations of you by turning this personal.

March 29, 2011 | Unregistered CommenterMomTFH

in other words, you didn't bother to read and analyze the papers before you quoted them.

March 29, 2011 | Unregistered CommenterAmy Tuteur, MD

No, Dr. Amy, those aren't other words. Those are the same arguments you use every time. You call the studies I post "crap", accuse me of not reading them, throw in some personal insult like "unprofessional" (hello, kettle? Meet pot) and then make some rude comment about my future success as an obstetrical resident.

And, as usual, you completely ignore the substantive discussion.

I am on my way to the OR to be with an attending ob/gyn who knows how to instruct and is still in practice, so even if I was interested in continuing this waste of time with you I can't.

March 29, 2011 | Unregistered CommenterMomTFH

"And, as usual, you completely ignore the substantive discussion."

The substantive discussion is the CONTENT of the papers, not their titles or their abstracts. That was my entire point. What else could the substantive discussion possibly be about besides what the papers actually show and whether they are high quality papers with reproducible findings? You have ignored the substantive discussion because that doesn't support your personal beliefs.

Either you want to go through the papers or you don't. And, honestly, I hold you to a different standard than the other commenters. They throw around citations to papers they haven't read all the time, but many of them don't have a background in science, so they don't realize why that can't be done. You should know better.

If you cite a paper, you should be able to DEFEND what's in it. The flounce ("I am on my way to the OR") may work on lay people, but it doesn't work on me. You're dropping out of the discussion because you can't address my criticism.

If you want to be a doctor, you have to READ the scientific evidence, ALL the evidence, not just the stuff that you like. Your patients deserve treatment based on the sum total of the scientific evidence, not your personal beliefs masquerading as "science."

March 29, 2011 | Unregistered CommenterAmy Tuteur, MD
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