Birth is universal, and because of this fact, it is also a big health care issue. Childbirth is the number-one reason for hospitalization in the United States. The stakes are high, both healthwise and costwise. It is the only instance that begins with one patient and ends with at least two. And at about $15,000-$20,000 per birth, it is an expensive proposition. Additionally and importantly, birth is a compelling Medicaid issue, because nationwide, Medicaid pays for half of births.
Within the topic of maternity care, cesarean section ("C-section") figures prominently, especially in the United States, where the rate is one of the highest among industrialized nations. The US C-section rate has risen by 50 percent over the past fifteen years, according to the California Maternal Quality Care Collaborative (CMQCC). (The CMQCC is "a multi-stakeholder group that drives improvement in maternal and infant outcomes through rapid-cycle data analytics and collaborative action," according to its website.) Now, one-third of all babies born in this country enter the world via surgery—a significant departure from the federal Healthy People 2020 goal of 23.9 percent for low-risk mothers.
So what?
Why should we care about C-section overuse? Overuse matters because, while C-sections are critical and often life-saving in limited circumstances, they bring serious risks for both mothers and babies.
For the baby, C-sections are associated with higher rates of infection, respiratory complications, and neonatal intensive care unit stays.
For mothers, C-sections often mean higher rates of hemorrhage, transfusions, infection, blood clots, and postpartum depression. Mothers having undergone a C-section also have a longer recovery and will almost always (a greater than 90 percent chance) have a repeat C-section in subsequent births—leading to higher risks of major complications (for example, hysterectomy, uterine rupture). Also, to the detriment of both mother and baby, breastfeeding rates are lower following C-sections.
On the cost side, C-sections are on average $5,000 more than vaginal births, not including associated costs (for example, hospital readmissions, home care, subsequent C-sections), according to the CMQCC. When one considers overall US health care spending, that may not seem like much. But with tight Medicaid budgets, and about 4 million total US births annually, it adds up. The bottom line: C-sections are an important tool—but one that should be used sparingly.
Moving toward a solution in California
In California, where 500,000 babies are born each year—one-eighth of all US births—an effort is afoot to lower the C-section rate. Focusing on first-time, low-risk mothers (another way of saying "low-risk" is "NTSV" or nulliparous, term, singleton vertex), many stakeholders across the state are recognizing the importance of this issue and are starting to take action. These stakeholders are spurred on by the fact that there is striking, unwarranted variation in the C-section rates of low-risk mothers. These vary from 12 to 70 percent across California's 251 hospitals providing maternity care. This variation means that a woman's method of birth can be very different simply because of the hospital at which she delivers (that is, for no evidence-based reason at all).
Figure 1. First Time, Low-Risk C-Section Variation In California Hospitals
Source: California Maternal Quality Care Collaborative (CMQCC), 2014.
Although troubling, this variation also signals an opportunity: while 60 percent of California hospitals need to improve to hit the national target, 40 percent of hospitals already meet that goal—showing that achieving the goal is possible. Additionally, a recent successful pilot in three Southern California hospitals led by Pacific Business Group on Health (PBGH) underscores cause for hope. These hospitals lowered their low-risk C-section rates by about 20 percent in six months and, notably, have maintained their lower rates since.
How was this reduction accomplished? It took pulling several key levers (depicted below). Through the innovative, low-burden, low-cost Maternal Data Center run by the CMQCC, these hospitals were able to obtain their hospital rate and also "drill down" in the data to get physician and patient information, which is very helpful in understanding the drivers of the overall hospital rate. The CMQCC also showed providers how to change (achieve "quality improvement").
Purchasers—such as Disney—signaled dissatisfaction with their employees' high C-section rates. The contract requirements and payment methods that followed suit aimed to put in place one "blended" payment for a delivery of either type versus paying more for C-sections, which is now often the case.
Likewise, patients helped the cause: negative social media about high C-section rates at one hospital got the attention of administrators.
In the background, public policy was hinting at change: legislation was being considered to allow midwives—whose goal is supporting normal birth—to practice at the top of their license.
Figure 2: Levers To Lower The C-Section Rate
Source: California HealthCare Foundation (CHCF)
What happened in these pilots serves as a good model. Not all of the levers have to be pulled, but several are certainly needed. And the more levers pulled, the more accelerated and sustained the change can be.
Building on Success
As part of its emphasis on high-value care, California HealthCare Foundation (CHCF), a nonprofit philanthropy based in Oakland, has launched an initiative to lower the state's C-section rate for low-risk women to 23.9 percent in five years. CHCF is funding projects to pull as many levers as possible, as simultaneously as possible, to bring about change—building on statewide momentum by working with many engaged partners such as, but not limited to, CMQCC, PBGH, California Department of Health Care Services (DHCS/Medi-Cal), Covered California (state exchange), Integrated Healthcare Association, California Public Employees Retirement System (CalPERS), the Hospital Quality Institute of the California Hospital Association, and both state and national specialty provider societies. Notably, the Statewide Workgroup on Reducing Overuse—a multistakeholder group (led by CalPERS, DHCS, and Covered California) that purchases and/or manages care for 15 million Californians—recently selected C-section reduction as one of its three goals.
Building on CHCF's early investment in the data center, CHCF is providing continued support for this critical transparency lever, as well as for development of a C-section toolkit for providers and a statewide quality improvement initiative to implement the toolkit in at least sixty hospitals. CHCF also anticipates funding projects to engage patients and support payers.
It is possible to lower the C-section rate. And knowing what we know about the health risks and costs, we have an imperative to eliminate overuse. With strategically placed funding, CHCF aims to contribute to "moving the dial." We hope to be reporting success in a few years, thus giving California more reasons to celebrate its 500,000 annual births!
from Health Affairs Blog http://ift.tt/1OjLpuA
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