Less is More

Jennifer Block has written an article on an obvious solution to part of the “health care problem” — midwife-attended birth. We as a nation are spending entirely too much on birth without getting enough of the good results we ought to be able to expect, were money the sole solution.

In Orange County, Florida, where Jennie Joseph practices, one in five African-American babies were born premature in 2007. In response to these disparities, Joseph also runs a prenatal clinic that turns away no one and coordinates care with the local hospital. Among the women who got prenatal care “The JJ Way” in 2007, less than 1 in 20 gave birth preterm, and there were zero disparities. “It’s not rocket science,” Joseph told me. “It’s really just about practitioners being willing to have conversations with women.” Joseph is perhaps being coy, but whatever she’s doing, we should be studying it very closely.

In short, we don’t have a “wellness model,” but a “sickness model.” And that doesn’t seem to be working very well. In fact, I know it doesn’t work well at all, because pregnancy is not a sickness; and when treated like sickness, all sorts of problems crop up that are not inherent, and could be avoided.

Presto! Change-o!

A recent article in U.S. News and World Report, titled “Rate of Unnecesary C-sections Far Lower than Thought“, discusses an article in January’s Obstetrics and Gynecology which finds that “the real rate of unnecessary C-sections is 4%.” Huh?

First, I don’t have the study, so I can only go by this article, which was brought to my attention by The Unnecessarean Blog. My first thought is, define “necessary.” It appears that the study looked at women who were planning a vaginal birth and ended up with their first Cesarean (whether this was the woman’s first baby or not, I can’t tell). Now, it says, “The CDC researchers sifted through data on 565,767 births from women who were considered at low risk for needing a C-section.” So now, define “low risk.” How was their risk status determined? Would it not be determined by pre-labor factors known to her doctor and presumably herself? The article says that going on birth certificate data alone, 58.3% of these women had no risk factors for a C-section; but that based on hospital discharge data, nearly 90% had a risk factor listed. Ok, define “risk factor.” How is it that over 40% of “women who were considered at low risk for needing a C-section” actually had at least one risk factor for a C-section? Doesn’t having a risk factor move you from “low-risk” to moderate or high risk? Maybe not. Maybe you can have one risk factor for a C-section and still be considered low-risk, but that two or more risk factors bumps you out of “low” risk.

Besides, having a risk factor for a condition and having the condition are two widely different things. A man may “have risk factors” for a heart attack, but that doesn’t mean that he will definitely die from a heart attack if he is not hospitalized from now until he’s 80; nor does it mean that a bypass operation is necessary.

Kahn said there are several possible reasons for this discrepancy. One is that the main purpose of a birth certificate is simply to record the birth. Birth certificates aren’t completed by physicians, but instead rely on worksheets filled out by the mother. And, she said, hospital discharge data is used to bill the insurance companies and doctors must be very detailed on these reports to get paid, which might make them more accurate.

“Doctors don’t touch birth certificates,” said Dr. Miriam Greene, an obstetrician at New York University Langone Medical Center and author of the book Frankly Pregnant. “The person who writes up the birth certificate might not be knowledgeable about all the risk factors for C-section, and they see the baby is fine and may think there was no issue.”

Now here is an interesting factor — doctors rely on discharge data to get paid by the insurance companies. I used to work for a pharmacy, and I know some of the hoops we had to jump through to get a medication approved for a patient. A friend of mine also went through months and months of hassle trying to get her husband’s various treatments approved (or pre-approved) by the insurance company; and some of the rejections were because the pencil-pushers (at either the doctor’s office, hospital, insurance company, or anyone else involved in getting data from one person to another) wrote or typed the wrong code. As an example of a type of false rejection (which also happened to this same friend), her second son (who was named Andrew, obviously a masculine name) was entered as a “female” into the insurance company’s database; and then they refused to pay for his circumcision (this is years ago, when it was still covered by most insurance companies) because their insurance policy didn’t cover pregnancy-related expenses for dependent daughters. In other words, because of the mix-up, the insurance company people and/or computers considered that newborn Andrew had just given birth to her first child.

So, doctors and everyone else in the health-care field have to be careful about how they code things and how they enter data into the various computer systems because their livelihoods depend on it. Doctors who don’t get paid for attending C-sections won’t be very happy campers. It makes me wonder if they are, um, getting creative with women’s risk factors when it comes to hospital discharge data so that they will get paid. Insurance companies — like every other company — don’t 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 won’t let them attend VBACs, so they force women to have “elective” C-sections; while women’s health insurance won’t let them have “elective” C-sections — what happens then? Does she have a medically unnecessary repeat C-section or a VBAC? If she has the surgery, and her insurance company won’t cover the surgery because it’s elective, will she have to pay the doctor out-of-pocket for her unnecessary surgery, or will he just “eat” the cost?

Is this scenario actually happening now? Are doctors “discovering” risk factors for women after the surgery so that they can be sure that they’ll be paid for the surgery?

Consider the following story, which actually happened to someone I know. A woman gave birth to her 4th child (planned hospital birth — she loves epidurals), and the doctor came in, ready to discharge her, and asked if she was ready to be home, and she replied quite honestly that she was rather enjoying the respite she had from the demands of being at home with her older children, and enjoyed being able to focus on the new baby. So, the doctor looked at the thermometer he had just taken her temperature with and said, “Hmm, it looks like your fever is a little high [it wasn’t — it was perfectly normal], so I think you should stay in the hospital an extra day, just to be on the safe side — to make sure you aren’t getting an infection.” Presto, change-o, she suddenly “qualified” for an extra day of R&R in the hospital, courtesy of her insurance company. Think this doesn’t happen every day in every hospital in the country?

This study presumes that hospital discharge data is accurate, while birth-certificate data is deficient. It may be. I certainly have read numerous things (studies, mentions in other studies, articles that talked about studies) that have shown that birth-certificate data is not very reliable when making certain judgments. But to go from “nearly 60% of women have no risk factors” to “just less than 4% of women have no risk factors”?? At what point do you start questioning the hospital discharge data’s accuracy? Especially when doctors have a monetary interest in making sure they and the hospitals get paid for everything that was done, so that they don’t lose any money.

I remember a joke Abraham Lincoln was reported as telling: How many legs does a dog have, if you call its tail a leg? Four — calling a tail a leg doesn’t make it one!

In a similar way, suddenly discovering (after the birth) that a woman is obese, or has high blood pressure (you remember — that one time in that prenatal visit when her bp spiked?), or gained too much weight (we know how women lie about their weight), or had protein in her urine, or had edema, or had a headache (we’ll just forget it was because she knocked her head on the car door), or had a small pelvis (let’s just erase the previous “adequate pelvis” notation in her chart), or whatever the “risk factors” were that the doctors charted in order to get paid by the insurance company, doesn’t make them real.

Did the researchers take a cross-section sampling of these women to find out if the discharge data was accurate, or was it just assumed to be so? In the Johnson & Daviss CPM home-birth study published in the British Medical Journal, they said that in addition to the data gathering from the midwives and the birth certificates, that they took a sampling from the mothers and had them verify the details of what they had been told about the births, to make sure that there weren’t any errors. Was something like this done here? It might be interesting what women remember being told before the birth, and what they found out afterwards — like the woman who had a C-section for breech, only to find out that the baby had flipped sometime between the last ultrasound and the surgery, so she could have had a vaginal birth… but then the doctor came in and tried to justify the C-section by saying that “the baby was big [8 lb. something] and your pelvis was small [although it was previously noted to be the best pelvis shape], so you likely would have ended up with a C-section anyway.” That was bull. The parents didn’t buy it (but what could they do?); yet the doctor still got paid for his “necessary” C-section.

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?