On The Quick
Covered California Takes Aim at High Rate of C-Sections
Are we normalizing childbirth as a surgical procedure?
Hoping to reduce unnecessary C-sections, the state’s health insurance exchange, Covered California, is laying down the law: California hospitals that don’t reduce their low-risk cesarean section rates by 2019 may be dropped from insurance networks.
In 2016, almost one-third of all births in the U.S. — 31.9 percent — were via cesarean section. That’s substantially more than many experts feel is necessary or appropriate. Back in 1985, a World Health Organization (WHO) panel declared bluntly that “there is no justification for any region to have a [C-section] rate higher than 10–15 percent.”
The Healthy People 2020 target for first-time, low-risk, single-birth (abbreviated NTSV, for nulliparous, term, singleton, vertex) C-sections is 23.9 percent. According to Cal Hospital Compare (calhospitalcompare.org), California’s current overall rate is 25 percent, which isn’t far off the target. However, this overall figure belies huge variations from facility to facility.
At L.A.’s Martin Luther King, Jr. Community Hospital, for example, the NTSV C-section rate is only 14 percent, an excellent figure. At other California hospitals, over 70 percent of NTSV deliveries are cesarean.
Covered California Chief Medical Officer Lance Lang, M.D., FAAFP, says that “it’s the culture of the hospital that really determines whether or not [a patient] gets a cesarean section, not so much her own health.” Covered California Chief Medical Officer Lance Lang, M.D., FAAFP, says that “it’s the culture of the hospital that really determines whether or not [a patient] gets a cesarean section, not so much her own health.”
Two years ago, Covered California warned that, starting in 2019, meeting the Healthy People 2020 target rate for NTSV C-sections will become a contractual requirement for health plans participating in the exchange.
Covered California will allow some leeway for hospitals that are actively working to reduce their rates of low-risk C-section. Ultimately, however, if a hospital fails to meet this or other quality targets, insurers may have to drop that facility from their networks to continue participating in the exchange.
“We’re saying, ‘time’s up,’” warns Lang. “We’ve told health plans that by the end of 2019, we want networks to only include hospitals that have achieved that target.” The question Covered California’s approach poses is who will bear the brunt of the penalties for noncompliance. For patients in medically underserved areas, the removal of hospitals from health networks may mean traveling even further for care or else facing much higher out-of-network costs — even if the patient isn’t having a C-section.
Cost and Risk
C-sections can save lives, but even where they’re medically appropriate, they can present many risks to both mother and child, ranging from anesthesia complications and longer recovery times to increased risk of asthma and obesity in children delivered via cesarean.
Having a C-section also makes future vaginal deliveries more hazardous, which has prompted some hospitals to avoid or even ban vaginal birth after C-section in hopes of limiting their malpractice liability.
Nonetheless, C-section can be a tempting option for providers and hospitals even where it’s not appropriate care. Scheduling a C-section is more straightforward and predictable than a vaginal delivery. It can also mean greater reimbursement for the hospital. According to the California Health Care Foundation (CHCF), the average cost of a cesarean delivery is almost 50 percent greater than for a vaginal birth.
CHCF Director of Learning & Impact Stephanie Teleki, Ph.D., says an additional factor is the normalization of low-risk, first-birth cesareans. CHCF Director of Learning & Impact Stephanie Teleki, Ph.D., says an additional factor is the normalization of low-risk, first-birth cesareans. “All of us have become very used to C-sections — everyone knows someone who has had one,” she says. “So, they are often now taken lightly when they are in fact major surgery.”
If you’d like to learn more about reducing the NTSV C-section rate in your institution, the California Maternal Quality Care Collaborative offers a publication entitled Toolkit to Support Vaginal Birth and Reduce Primary Cesareans. You can find this comprehensive 159-page resource, which includes clinical evidence and strategies for changing the organizational culture surrounding birth, at www.cmqcc.org.
This article is from workingnurse.com.