Sunday, March 06, 2011

Better Maternity Care Can Reduce Healthcare Costs

Although many people blame federal and state government deficits on wasteful spending, one of the biggest factors driving deficits is rapidly growing health care costs. High healthcare costs not only cause higher government expenditures on Medicare and Medicaid, they also increase the costs of providing health benefits to government employees.

Moreover, during a time when we’re trying to recover from the recession, high and growing healthcare costs make it more expensive for businesses to hire new workers, and big increases in healthcare costs make tight family budgets even tighter.

The good news is that there are many ways to reduce spending on health care that actually benefit patients. For example, preventing the thousands of hospital-acquired infections that occur every year in our region would not only save millions of dollars but save hundreds of lives.

One of the biggest opportunities for reducing healthcare costs is improving the quality of maternity care. For most businesses, childbirth and newborn care is the largest or second largest (after heart care) category of hospital expenditures, and it’s by far the largest category of hospital expenditures for state Medicaid programs, so even small improvements can result in large savings.

The place to start is with the most common hospital procedure in America – the Cesarean section. A C-Section is a surgical delivery of a baby, rather than a normal, vaginal delivery. Not only does a C-section typically cost twice as much as a vaginal delivery, it is more likely to result in infections, injuries, and other complications for both mothers and babies.

Yet today, nearly one-third of all babies in the country are delivered by C-Section. Fifteen years ago, only 20% of babies were delivered by C-Section, and in the 1960s, the C-Section rate was under 5%. In southwestern Pennsylvania, rates of C-Sections vary widely. In 2008, the rate of C-Sections for low-risk first-time mothers in Allegheny County was 28.5%, but in Armstrong County it was 36.7%, while in Indiana County, it was only 19.8%.

A major reason that the rate of C-Sections is high and growing is not because they’re necessary, but because they’re convenient. Babies often take longer to arrive than their mothers or doctors might like, and C-Sections often are used to shorten labor or to make babies adapt to the busy schedules that their mothers and doctors have. Yet that temporary convenience can harm both babies and mothers, sometimes permanently.

C-Sections are particularly problematic when they’re used to deliver babies too early. The desire for convenience has resulted in a growing number of cases where doctors use drugs or procedures to induce labor rather than let the pregnancy take its natural course. About one-fourth of deliveries are now electively induced before the baby has reached full term (39 weeks). Yet research has shown that even babies born a few days too early are more likely to have problems such as developmental delays. Moreover, labor inductions before 39 weeks are more likely to result in expensive and risky C-Sections, and the baby is more likely to spend time in an expensive neonatal intensive care unit (NICU).

These unfortunate trends can be reversed. For example, a team of physicians and nurses at Pittsburgh’s Magee Womens Hospital, using “Perfecting Patient Care” training they received from the Pittsburgh Regional Health Initiative, reduced the rate of early elective inductions by 64% and reduced the frequency of C-Sections in elective inductions by 60%. They won the Fine Award from the Jewish Healthcare Foundation in recognition of their cutting-edge work.

There are additional opportunities for even greater savings in maternity care. For example:

•Birth centers are a safe option for healthy women with normal pregnancies who would rather deliver babies outside of a hospital setting, and they typically cost one-fourth as much as a hospital delivery. Pittsburgh is fortunate to have a nationally-accredited, free-standing birth center (The Midwife Center for Birth & Women’s Health) that provides this kind of choice.

•Fewer pregnancy complications and better birth outcomes could be achieved if more women received early and adequate prenatal care. Unfortunately, one in every five mothers (20%) in our region does not get adequate prenatal care, and the rate is shockingly poor in some parts of the region (more than 1/3 of mothers in Fayette, Greene, Indiana, Washington, and Westmoreland Counties did not receive appropriate prenatal care) and for minority populations (1/3 of African American mothers did not receive appropriate prenatal care).

A major contributor to all of these problems is the way health plans and Medicaid typically pay for maternity care. Hospitals are paid more for C-Sections than for vaginal deliveries, creating an incentive to do more C-Sections, and doctors are often paid similar amounts for both types of delivery, even though vaginal deliveries typically take longer and occur at inconvenient times. Doctors and hospitals make more money when mothers and babies have complications or when babies spend time in NICUs, rather than being rewarded for achieving better outcomes and reducing costs.

Some health plans and hospitals are changing this; for example, the Geisinger Health Plan in Central Pennsylvania pays for maternity care based on outcomes, and the Geisinger Health System has significantly reduced C-Sections and improved the quality of maternity care as a result. Health plans in southwestern Pennsylvania should also begin paying for maternity care in ways that enable physicians to deliver higher quality, lower cost care. We’ll not only save money, but have healthier babies and mothers as a result.

(To learn more about strategies for improving the quality and reducing the cost of maternity care, see the 2020 Vision Report and Blueprint for Action from Childbirth Connection, and the presentation on alternative methods of paying for maternity care on their website.

(A version of this post appeared as the Regional Insights column in the Sunday, March 6, 2011 Pittsburgh Post-Gazette.)


Anonymous Katy, co-leader ICAN of Southwestern PA said...

As co-leader of the Southwestern PA chapter of the International Cesarean Awareness Network, I was so excited to read your article in today's Post-Gazette! You bring up such an important conversation. Our group is working on a letter to the editor in hopes of continuing the discussion.

We're particularly interested, of course, in the climbing number of primary cesareans with the simultaneous plummeting numbers of vaginal births after cesarean (VBACs).

ICAN as a group aims to improve maternal-child health by preventing unnecessary cesareans through education, providing support for cesarean recovery, and promoting VBAC. ICAN strives for a healthy reduction of the cesarean rate driven by women making evidence-based, risk appropriate childbirth decisions.

We love how you critically point to the financial incentive for cesarean delivery, despite high risks for mother and baby, physically AND emotionally.

Please let us know if you are ever interested in speaking at or attending one of our meetings!

3:29 PM  
Anonymous Laura Harrison, AAHCC Bradley® instructor said...

I would also like to commend you on such a well-written article. The only thing I would add is that more access to prepared childbirth classes be included in routine prenatal care. Just being seen by a physician and having the routine tests done won't change statistics. Pregnant women need to be educated about birthing babies. As a natural childbirth instructor, I can see the difference in my student's births and statistics which are far better than the national average. When couples or moms are educated about the birth process, knowing how their bodies will work, what to expect, how to respond, knowing what will keep them low-risk and what their rights and options are makes for better outcomes and lower costs. As your article pointed out, doctors are not going to change the system when it will cut their throats, patients must. And right now, patients are listening to their doctors and counting on them because they don't have adequate information to make informed decisions. Classes, which only one or two insurance companies choose to partially reimburse parents, can make a huge difference in outcomes and costs.

1:41 PM  
Anonymous Elizabeth said...

Thank you, thank you, thank you for writing and publishing this piece! I live in Philadelphia, where we have watched 15 regional hospitals close their maternity units, leaving us mothers with fewer options for good maternity care--all due to the fact that maternity units do not make enough money for the hospital. It is a crisis here that needs to be reversed. Or, as you suggest, birth centers need to be opened in their place. Thank you again for this article!

8:48 AM  
Anonymous Anonymous said...

Well thought out article including great analysis. Hopefully your article and analysis gains more attention than it is actually getting. The cost savings alone is enough to warrant a discussion on the subject. If one insurer pays on outcomes, I can imagine more could follow.

2:03 PM  

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