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The Unnecesarean on Bloomberg.com



Alex Nussbaum has an article up at Bloomberg.com called Aetna Urges Moms To Avoid Cesareans Births To Reduce Risk. The title appears to be inaccurate, as Aetna has actually renegotiated maternity payments with 10 hospitals in the country and “moms” don’t appear to be involved in any of it.

Here is the excerpt in which Nussbaum covered my interview with him. We talked for at least 45 minutes, but he distilled it down due to space constraints to something that really went straight to the heart of why the blog came into existence.

‘Epidemic Proportions’

The U.S. isn’t alone in bending Mother Nature to modern medicine. Cesarean levels have reached “epidemic proportions” in many countries, the World Health Organization said in a report two years ago. The U.S. rate is on par with some Latin American nations and Australia but well ahead of the U.K., France and Norway, all with cesarean rates at 22 percent or less, the WHO said.

The backlash against the procedures has spawned its own website, The Unnecesarean, where San Diego mom Jill Arnold shares tales of women who felt pushed into C-sections.

Arnold, 38, was persuaded by doctors to schedule a cesarean in 2005 after being told her baby might be too large, she said. She went into labor before the operation and delivered her daughter, Maggie, normally and without incident.

Two years later, she gave birth to a second girl, Molly, at an independent birth-center where she felt “more in control.” She started the website after hearing from other mothers who felt pressured while finding more research that questioned the approach.

Patients ‘Railroaded’

“They feel either lied to or deceived or that they were pushed really heavily in one direction and later found out the medical indication wasn’t there,” Arnold said. “They feel they were railroaded.”


Nussbaum asked me in the interview about insurance companies getting involved in trying to limit cesarean births. Besides the probable conflict of interest in trying to save money, there are most likely public health benefits. On top of that, it could pave the way, in theory, for a patient to be faced less of a brick wall when looking to give birth vaginally in a hospital. Not only would this have possible positive public health implications, but could lead to greater patient satisfaction because patients will be more likely to find care that is consistent with their values and preferences.

In the interview with Nussbaum, I shared what I think is a foreseeable problem that can be circumvented this time around. When VBAC became the standard of care in the 90’s, many women were told the complete opposite of what women in the U.S. are told today—sorry, we don’t do repeat cesareans. In my opinion, any proposed economic incentives should never prevent patients from seeking preference-sensitive care.

There is a lot to discuss here. Obviously, as Elliott Main addresses in the article, there are perverse incentives for expedience on the doctor’s part:

C- sections not only pay more; along with inductions they also allow doctors to cluster births and schedule other visits around them, he said. And they assure a physician will be on hand for a delivery — and get the insurance payment — when a baby arrives.

The gap to focus on here is that between hospital reimbursement and physician reimbursement. According to the article, hospitals are reimbursed twice as much for cesareans as they are for vaginal deliveries. Not in the article, however, is that physician reimbursement is about the same for vaginal and cesarean deliveries— $3390 versus $4086 on average in 2011.




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Reader Comments (5)

Aaron Caughey, a great OB out of OHSU in Portland spoke about this issue at a conference I attended this year. According to his data, hospitals are generally reimbursed $9-10K for a vaginal delivery and $13-14K for C-sections, obviously incentivizing C-sections. His thought was to change the reimbursement structure to pay the same (somewhere in the range of $11K for ALL births and let the OBs and hospitals sort out doctor payments. Evidently Medicare is already considering this as a way to both trim costs and remove the incentive for unnecessary surgery. He's done some really good work and has some fantastic ideas about reducing the C-section rate.

July 13, 2012 | Unregistered CommenterBree

I agree wholeheartedly with Bree! Or we should swing it even further towards vaginal birth and reimburse hospitals more $$ for vaginal birth than Cesarean. This would reward hospitals for taking the longer time needed to let a mom birth vaginally and reward hospitals for better outcomes. This would lead to reimbursement for birth based on quality, like Medicare is doing with heart failure reimbursement. For example, pretty soon if a HF is readmitted within 30 days, Medicare will not reimburse for the extra hospital admission, since they see it as an indicator of poor discharge care. I think the way things are headed eventually is that if you don't meet certain quality standards, you don't get the $$ from the insurance company. Unfortunately, you have to tie quality with $$ in order to get hospitals to change.

Another thing I would like to see is more insurance companies reimbursing for certified doula care. That would probably save them more money than anything else they could do by reducing costs for Cesareans. Would be super cost-effective.

July 13, 2012 | Unregistered CommenterRebecca

I agree with most of that, Rebecca, but I have to say that I don't think reimbursing more for vaginal birth is the right way to go about it. Practically speaking, it would be a tough sell because C-sections do cost more than vaginal births so it would be tough to get hospitals to go for it. However, I also think it could have negative consequences in that, being that we currently live and work in a system that turns a profit for healthcare, I would hate to see it go the other way and have OBs reluctant to do C-sections when needed because they are worried about reimbursement. I think reimbursing at one rate for all births is the most practical and safest way to go about things.

July 13, 2012 | Unregistered CommenterBree

I was so happy to find this article in the paper this morning. Having given birth to 4 children in a hospital setting, I am very familiar with the ways in which the medical field pushes unnecessary interventions in the name of convenience. read my accounts here: http://notanotherteenmommy.com/2012/07/12/271/. Thank you so much for this website...sharing now

July 14, 2012 | Unregistered CommenterC.Marie

Even when the physician is reimbursed the same amount regardless of delivery route, the vaginal delivery most likely takes up more of his/her time than the cesarean, so there is still financial incentive for ceseareans (especially scheduled ones), isn't there?

July 19, 2012 | Unregistered CommenterKK
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