Newtown, CT – January 11, 2013
With all the talk of medical homes, better care coordination, higher quality and lower cost, why are C-section rates in the US twice as high as recommended by the WHO, causing excess harm to moms and babies, and $5 billion in excess spending? What in the world are these medical homes doing if they're not even taking care of the basics? Some will argue that it's not about the medical homes, it's about the OB/GYNs and the moms. Others will argue that this is a too highly charged issue for plans or employers to take on. Yet others will surely try and convince us that the answer lies in simply slapping on more ACOs to "manage" patient care. Really? As President Obama stated in Newtown in mid-December, if we can't even take care of our children, how badly have we failed. And there's really no excuse because we know the solutions. In fact, they're addressed broadly in a recent NEJM Perspective by Emily Oshima Lee and Zeke Emanuel – shared decision-making tied to better incentives. These solutions are more specifically addressed by our friends at Childbirth Connections, Catalyst for Payment Reform and the CHQPR. We all need to take note and do some introspective review of individual actions and inactions in light of these reports and the increased risks to moms and babies that have become so pervasive.
What this means to you – The C-section rate has gone back to what, a little over a decade ago, was decried as a serious public health problem. What happened? Is it just apathy, laziness, ignorance? Yes, partially, but it's also a very good example of reversion to the mean – what happens to processes when there are temporary fixes and no structural and fundamental change. The light shined on this issue for a while, moms and physicians were having conversations, and C-section rates went down. The light moved off the issue and the prior mean performance reestablished itself. Of course, that reversion was also fueled by a number of bad incentives. First off, C-sections are more lucrative for providers. As reported in The Cost of Having a Baby in The United States, the total bill for a C-section is about $9,500 more than a vaginal birth. How's that for a perverse incentive? And then there are preferences, which, without full and complete disclosure of the risks for both the mom and the baby, can lead to the wrong decision. These bad behaviors are easily reversible if payers have the guts to act. Unfortunately, our history has extensively demonstrated that their intestinal fortitude is in short supply. So it's up to all of us to force through the change that we want to see happen. Patients need to seek out information on the risks of treatments, and employers have to stop accepting to pay for treatments that harm instead of healing. And make one more resolution this year. When someone tells you they can't do something, draw a yellow streak over their name and move on to the next until you find someone that will stand to the ready, say yes, and mean it.
Francois de Brantes
Health Care Incentives Improvement Institute, Inc.