Inductions and Deductions

It’s almost the more-or-less official start of tax season — most if not all tax-related information must be given to wage-earners by Jan. 31, so that they can compute their taxes owed by April 15. Oh, yeah, I’m doing the happy dance. Not!

There are probably numerous inductions and C-sections performed in the last few days of December. Why? Tax deductions, of course! The way our tax system is set up, children are deductions (regardless of how little money they actually cost the parents) while fetuses are not (regardless of how expensive they are — prenatal visits, ultrasounds, quad-screen tests, etc.). So, babies who are born at 11:59 on Dec. 31 get their parents a tax deduction for the whole year of 2008, while those born at 12:01 on Jan. 1 only start their tax-deductible status the following year, 2009.

I’m sure many people say, “Why not?” Of course, there are numerous medical reasons why not to choose a medically unnecessary procedure, summed up in the following statement: if it’s not necessary, then it introduces unnecessary medical risks for no medical benefit whatsoever.

But I wonder how much money people actually save by forcing their babies to be born prematurely. (I use that term deliberately — they may not be “pre-term” but since they haven’t signaled full maturity by starting the labor process, who is to say that they are actually mature?)

I’m no CPA, but from what I can gather about current tax rules, most people will get a $500 tax credit for a child (this means that after everything is figured out, you take the total amount of taxes owed and subtract $500); and each dependent also garners the tax-payer a $3500 exemption for taxes (which means that if a man with a wife and two children earned $35,000 in 2008, he gets to subtract $3500 x 4 or $14,000 from his income, so instead of paying taxes on $35,000, he pays taxes on $21,000; so to make it simple, we’ll pretend that the federal government only wants to take 10% of the money you earned, so reducing your income by $3,500 reduces the amount of taxes you’d pay by $350). There may be other reductions in the amount of taxes paid; but then again, many people will earn too much to qualify for some of these deductions and credits, so their effective “savings” by having their babies unnecessarily early may be more or less.

So, what’s the big deal? Baby is born a few days before he’s totally ready — most likely everything will be okay, and we get a neat tax deduction — yippee!

Not so fast. As I said before, unnecessary medical procedures introduce medical risk for no benefit. Most likely everything will be okay, but a certain percentage of mothers and/or babies will be harmed or put at risk. Increased medical risks tend to cost more. Many people’s health insurance is set up so that they pay a percentage of the costs. So, every added “thing” (whether it’s the medication, extra hospital stay for mother or baby, infection, epidural made necessary by painful pitocin-contractions, C-section due to failed induction) will cost the mother probably 20% of the total cost of the entire bill. Now, if you don’t have any insurance, you’ll pay all of the added costs yourself. Now your “big” tax deduction may not seem quite so big. While many people have met their health insurance deductibles (if they have them) by the end of the year, some people have multiple deductibles for multiple types of health care, and may be surprised by how much they end up paying for their “insured” pregnancy and birth — for instance, there may be one deductible for obstetrician visits; another for medical tests including ultrasound; if other doctors are called in to consult (say for heart problems), you may have a separate deductible for that; and then another deductible for the hospital charges; and yet another for the use of the anesthesiologist. Even if you only pay a percentage, those costs add up.

Friends of mine had to pay 20% of a $25,000 total bill (all doctor’s and hospital charges) for their baby’s birth by necessary C-section, or $5,000. While I daresay that most births don’t cost the parents that much out-of-pocket, understanding that some births might end up being that much — especially if a C-section is performed, or if the baby ends up in the NICU with breathing problems — just might put a damper on some enthusiastic penny-pinchers who might be tempted to have an induction to create a tax deduction for the year.

One final note — here’s the kicker — if the baby is born at the end of the year and does create a tax deduction for that year, current tax law states that children who are 17 or above at the end of the year do not qualify their parents for a tax deduction for them for that year. So by gaining a tax deduction this year, you lose it some 17 years in the future. So it ends up being six of one and a half dozen of the other — unless, of course, you or your baby lose the statistical game and end up with a medical problem caused by an unnecessary induction or C-section. At which point money becomes more or less irrelevant.

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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.

Planned C-section vs. planned vaginal birth

Here is an interesting study from Canada, though not without fault. In brief, the authors took a group of (apparently otherwise low-risk) women who were having a planned C-section due to breech presentation, and compared the rates of maternal morbidity and mortality to low-risk women who planned a vaginal birth. Since many women who plan C-sections are at high risk, the authors did not include any other planned C-sections — there were no codes for C-sections performed without indications — that is, truly elective C-sections, so they selected the breech births as a comparable cohort. Many other women were excluded — the usual kinds — preterm birth, multiple gestation, etc. — to try to get two low-risk similar if not matching groups.

Outcomes of interest included maternal mortality (in-hospital deaths only) and severe morbidity (intra-and postpartum). Severe maternal morbidity was defined as the presence of one or more of the following complications: hemorrhage requiring hysterectomy, hemorrhage requiring blood transfusion, any hysterectomy, uterine rupture, anesthetic complications (including those arising from the administration of a general or local anesthetic, analgesic or other sedation during labour and delivery), obstetric shock, cardiac arrest, acute renal failure, assisted ventilation or intubation, puerperal venous thromboembolism, major puerperal infection, in-hospital wound disruption and hematoma. Length of hospital stay for childbirth was calculated by subtracting the hospital admission date from the discharge date.

Here is the table with all of the morbidity rates for the two groups: planned C-section for breech presentation, and planned vaginal births (although some of these ended in C-section).

Obviously, successful vaginal births (whether spontaneous or induced) had a lower rate of these problems than planned C-sections; and most of the problems in the “planned vaginal birth” group were in births that became unplanned C-sections. It wasn’t mentioned whether some of the problems led to an emergency C-section, or if the C-section led to the morbidity. For instance, if a woman has an amniotic fluid embolism, the mortality and morbidity rates for both mother and baby are very high; and about the only thing doctors can do is an emergency C-section and probably a hysterectomy. Also, if there is a placental abruption that manifests in a hemorrhage, the woman would be taken for an emergency C-section, and may need a blood tranfusion because of the initial blood loss, rather than due to the C-section itself.

Although no women died in the breech C-section group and some did in the planned vaginal birth group, the authors concluded that this was not significant. (The rate of maternal mortality in the “planned vaginal birth” group was less than 1/50,000, so even without statistical analysis, it is not difficult to see that 0 deaths out of less than 50,000 births in the C-section group is similar, especially when maternal mortality is relatively rare anyway.) The authors mentioned that the rates of morbidity were similar to other published rates of maternal mortality associated with planned C-section, implying that had the study been larger (although it encompassed over two million women over 14 years), it would have found similar results as other studies.

One medical problem that women in the planned vaginal birth group had at a higher rate than the planned C-section births was in hemorrhage requiring transfusion. This was offset by a reduction in rates of hemorrhage requiring hysterectomy. The authors concluded that what most likely happened is that if a woman who was having a C-section began to hemorrhage, the doctors simply removed her uterus to stop the blood flow. This resulted in less total blood loss and fewer transfusions, but in more women without wombs, when all was said and done. When a woman who was not having a C-section began hemorrhaging, the doctor tried different means of stopping the blood loss other than hysterectomy, using that as a last resort; this resulted in more blood being lost which led to more transfusions, but also in more women keeping their ability to have children.

As a footnote, I will point out that in this study, as in many others, the authors define any unplanned C-section as an “emergency”. I don’t like that division, since most of the C-sections I’m aware of personally have been unplanned as well as non-emergent surgeries. It’s not like the babies’ heartrates were crashing or anything; many C-sections are due to passing somewhat arbitrary timelines (FTP — “failure to be patient” or “failure to progress”) although both mother and baby are doing well. I just recently read a story of a woman whose obstetrician willingly let her push for something like 11 hours — yes, you read that right — she PUSHED for eleven hours, not just labored that long! — because the baby’s heartbeat was fine throughout. (The mother was also tolerating labor well — the doctor would have done a C-section had the mother wanted it — he wasn’t forcing the woman to labor. But as long as the baby was fine and the mother was fine, he wasn’t going to force or push a C-section.)