Between a Rock and a Hard Place

This is a prediction, not a fact, so I could be totally off-base here, but bear with me. It’s possible that some women have already had to face this.

In 5-10 years, women will be caught between battling insurance companies over elective C-sections and elective repeat C-sections.

Insurance companies, like every other company in a free-market society only survive when they bring in more money than they spend. This is true of grocery stores, convenience stores, department stores, and every other company from the local mom-and-pop to the giant Microsoft.

Health insurers charge a certain amount of money per month from their customers, based on actuarial tables of how costly their health care will be. This is why they do not want to accept clients with pre-existing conditions — they know up-front that these people will be more expensive than average. If they do have to spend more than the average on these or any other person, premiums go up and benefits go down. That’s life. Insurance companies don’t exist as a hobby or a charitable organization. They, like every other company in this country, exist to make money. And that’s not a bad thing.

Malpractice insurers do the same thing, but from the opposite perspective. They charge their doctor-clients a set amount, also based on actuarial tables, and how expensive a claim against their client will be for them. Obstetrics has one of the highest malpractice premiums of any class of doctors, and this is quite simply because sometimes birth doesn’t go as everyone wants, and some babies get damaged; and when a baby gets damaged, parents sue, and doctors settle; if they try to fight it, a sympathetic jury will see the damaged baby and stick it to the doctor and insurance company — even if the doctor did nothing wrong. In today’s society, there is no excuse for a less-than-perfect baby. So, doctors perform C-sections way too often, as a sort of “get out of court free” card. It’s hard to justify to a jury (especially a non-medical jury that often has no clue about the ins and outs of obstetrics and surgery) that a C-section wasn’t necessary when a baby ended up dead or damaged. It’s much easier to do 1000 unnecessary C-sections, and then be able to say, “Hey, I did everything I could, and it still didn’t turn out right, but it wasn’t my fault!”

But what happens after a C-section? This is truly where women will be squeezed between a rock and a hard place.

If a woman has another baby after having had a C-section, she will have to choose whether to have an elective repeat C-section or attempt a vaginal birth (unless she has placenta previa or some other condition which makes a C-section medically necessary). I foresee that health insurance companies are going to start balking at paying for elective C-sections, just as they already refuse to pay for other elective surgeries, like breast augmentation. After all, if surgery is not necessary, and a cheaper, natural alternative exists, why pay for the artificial and expensive way?

But doctors are refusing to attend VBACs — not because the evidence shows them to be riskier than any other pregnancy necessarily — the rate of uterine rupture and subsequent emergency surgery in attempted VBACs is about the same as the rate of other catastrophic things happening in an average woman, like umbilical cord compression or cord prolapse — but rather because their malpractice insurance companies are dictating to the doctors that they will not insure them if they attend VBACs. I’m assuming that the idea is that although the overall risk of uterine rupture in an attempted VBAC is very small, it is a known risk, and if it happens, the plaintiff’s lawyers can argue that the doctor was somehow at fault. If, however, cord prolapse happens, then the doctor’s defense is more easily made — “it was just one of those things that happened; it was unknowable beforehand, and we did everything we could to prevent a bad outcome.”

With 30% of American women giving birth by C-section for the most recent statistics, that number is likely to rise as the rate of VBACs fall. I’ve read of a hospital being built in Michigan, scheduled to open in another few years, I think, which is being built with many more operating rooms in the L&D floor, in anticipation of a 50% C-section rate. At the time I first read it, I thought that was laughable; now I’m not so sure. Even if it’s not 50% nationally, some hospitals or areas are already at that rate. The number of women having their first C-section keeps going up; and if they are not allowed to have vaginal births afterwards, then repeat C-sections will also increase.

So, what will these women do, when their doctors insist on an “elective” repeat C-section, but their insurance companies refuse to pay for it?


2 Responses

  1. Hmm, that is a very interesting thing to ponder.

  2. […] like spending money, and especially don’t like spending it unnecessarily. I’ve previously blogged about a hypothetical future scenario in which doctors’ malpractice insurance […]

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