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Will Vermont's H.3921 Lower the State's Cesarean Rate?

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By Jill Arnold


Gustavo San Roman posted an interesting link on the Birthrisk.com Facebook page to the new bill introduced in Vermont to lower the cesarean rate. Vermont is ranked 40th in the nation in frequency of cesarean delivery with a rate of 27.9%. Dr. San Roman’s comment read:


Vermont Bill H.392 (link below) seems to ignore the fact that labor is a physical process. The cesarean birth rate is determined by BOTH the physical characteristics of the women who labor AND the experience and skill of their obstetrical care providers. Policies that ignore this fact can actually INCREASE the cesarean birth rate.”


An expert on payment reform who preferred no attribution when commenting on Emjaybee’s recent post about TennCare’s proposal to lower cesarean rates (read: cut costs) by reducing reimbursement to the hospitals and physicians for cesareans. [Yes, you can yell at me in the comments for quoting an anonymous source and telling you it’s from an expert.]

This is a perfect example of how NOT to do payment reform. Paying less than costs for appropriate procedures because some procedures are done inappropriately is a prescription for disaster. Moreover, it’s also inappropriate to penalize the hospital for a decision the physician makes, particularly in those cases where the physician is independent of the hospital. Although I think the best approach would be shifting to a structure that has a single payment for delivery (adjusted by maternal/fetal risk), if one wants to stick with the current separate fees, a better approach would be to pay the doctor more for a vaginal delivery (reflecting both the longer time involved and as a statement about its desirability), and leave the hospital payments alone.


I asked if people on our Facebook page if they would share what they thought the positives and negatives of the bill were. What follows here is the text of the bill and the first replies on Facebook.


BILL AS INTRODUCED                                                         H.392

2011                                                                                   Page 1 of 2

VT LEG 266011.


1                                                                          H.3921


2    Introduced by Representative Weston of Burlington


3    Referred to Committee on


4    Date:


5    Subject: Health; Medicaid; maternity care; birth; cesarean section


6    Statement of purpose: This bill proposes to direct the department of Vermont


7     health access to reduce the amount it reimburses health care providers for


8     avoidable cesarean sections to the same level it pays for complicated vaginal


9     births. It would also direct the commissioner of health, in consultation with the


10   board of medical practice, to evaluate the rates of cesarean sections and labor


11    inductions in Vermont and recommend methods to reduce them.


12    An act relating to Medicaid reimbursement for avoidable cesarean sections


13    It is hereby enacted by the General Assembly of the State of Vermont:




15    Beginning July 1, 2011, the department of Vermont health access shall


16    reimburse health care providers for cesarean sections without complications


17    and comorbidities at the same rate as for vaginal births with complicating


18    diagnoses.



BILL AS INTRODUCED                                                             H.392

2011                                                                                       Page 2 of 2

VT LEG 266011.1




2.               CARE


3   (a) The commissioner of health, in consultation with the board of medical


4   practice, shall evaluate the rates of cesarean sections and labor inductions in


5   Vermont and identify how best to:


6        (1) reduce the nulliparous term singleton vertex cesarean birth rate to


7             less than 15 percent;


8        (2) reduce the overall cesarean birth rate to less than 20 percent;


9        (3) ensure vaginal birth after cesarean (VBAC) is available at all


10            Vermont hospitals;


11       (4) restrict inductions of labor at less than 39 weeks of gestation without


12            medical indication;


13       (5) publish publicly viewable data on cesarean, VBAC, and early


14             induction rates attributable to individual health care practitioners; and


15       (6) undertake additional steps to improve outcomes in maternity care.


16   (b) No later than January 15, 2013, the commissioner shall report to the


17   house committee on health care and the senate committee on health and


18   welfare recommendations on controlling growth in cesarean delivery and


19    labor inductions and improving outcomes in maternity care for women in


20   Vermont.



Opinions shared on Facebook page. Please add your opinions in the comments.

1. I’m not sure this will work. A vaginal birth with complications is going to be a lot more work, time and stress for an OB than a C/s without complications. I see it increasing the c/section rate, since there will be no real incentive to women birthing vaginally when it takes a long time or is difficult. It would probably be more effective if they reimbursed vaginal births with difficulties at a higher rate than uncomplicated c/s.

2.  I think it’s commendable that anyone in government is even attempting to tackle this issue. I guess my concern would be the way they define “avoidable” — I assume there would have to be very specific guidelines in place for the medical staff to follow.

3. Maybe I’m not reading it perfectly, but you still have the fact that a complicated birth doesn’t get the Doc home by 5pm every night. A state should not have to provide incentive to be a good doctor, but in this country it probably comes down to that. It’s a step in the right direction but I don’t think it counts as a “win.” It may open the door for better bills for VT and be a pilot for all 50 states.

4. avoidable leaves a BIG hole called judgement… But if it reduces unnecessary c/s that is a step in the right direction…

5. I think the definitions are quite vague (“avoidable ceseareans” and “cesearean without complications or comorbidities” - is that sequelae of the procedure or is that referring to the indication for the procedure?). I honestly think this may reduce the amount of elective cesareans that doctors are willing to perform, but we know that this is actually a small proportion of total surgical births. Otherwise, all they have to do is get more clever at coding. There is almost always, according to the physician making the call, a “complication.” My gut feeling is that this won’t change things in practice but may create some awareness.

The other issue is that since it is not a law, just a proposal to adjust state medicaid reimbursement, it has the potential to create disparity in care given to various socioeconomic classes. While in reality this may mean that more women on medicaid are allowed to labor longer in pursuit of a vaginal birth (so the disparity may actually be to their benefit), there may be backlash in terms of perceived quality of care. However, it may be an interesting trial to see if given the option of a c-section with shorter trial of labor vs. a longer labor followed by a vaginal birth with no difference in reimbursement, the free bed space and control of schedule may still be a benefit to the attending physician. It may help to tease out whether time or money is a bigger factor.

6.  What exactly is the reimbursement all about exactly? Does a doctor not get paid for both, helping a woman to deliver vaginally and through c-section? Is the reimbursement ‘compensation’ for choosing a vaginal birth over a c-section that can be prevented?

The fact that with this bill the commissioner of health would have the ability to evaluate c-section and induction rates may start to help give awareness to the unnecessary procedures that occur in hospitals that lead up to c-sections (like inductions)!

7.  I think WA did this last year. I haven’t heard that it has made any difference.

8. Who defines what ‘avoidable’ means? Will the insurance companies actually demand access to ctg tracings and nurses/midwives’ notes to make that decision before paying up? Won’t doctors just identify a C/S’s cause as one on ‘the list?’ I have doubts about women being treated fairly when money is on the line like this. Just not sure this is the way, but would need to know the background of the bill and what research was employed to come up with it.

9. Also, this involves Medicaid clients, so it raises questions about women of lower means being treated differently. Good that someone in power is looking at lowering the C/S rate and improving care but red flags are raised.

10. I would think there would be a more notable impact on quality of care if insurance companies required prior authorization to induce… how many women NEED pitocin… and how many extra c-sec’s are a result of overuse of pit, prepidil etc…

11. Who’s going to regulate the regulators? Hearts are in the right place but very little good will come from more government intervention. Education is the key IMO

12. This will simply lead more dead and injured women and babies. Docs are not trained in real vaginal birth. This is a piss poor bandaid on top of a real problem.






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