General Business Issues

Featured Health Business Daily Story Nov. 17, 2009

Health Plans Work to Reduce the Health Risks and Costs From Elective C-Sections Before Full Term 

Reprinted from HEALTH PLAN WEEK, the industry's leading source of business, financial and regulatory news of health plans, PPOs and POS plans.

By Angela Maas, Contributing Editor, (amaas@aispub.com)

A combination of quality-of-care and cost issues has prompted some health plans to take steps to reduce the number of scheduled, medically unnecessary premature Caesarean section deliveries, mainly through a focus on education of both women and physicians.

Various studies show that a growing percentage of women is having C-sections, many of which take place before the 39th week of gestation. According to the CDC, between 1990 and 2005 there was a 20% increase in babies born before the 37th week of gestation and a 29% increase in births occurring at 37 to 39 weeks of gestation. Many studies show heightened risks to both babies and mothers when the babies are delivered before 39 weeks.

Although there are certainly medically necessary reasons for some of these C-sections, newborns delivered prematurely are at risk for more medical complications than those born at full term. Many of these infants are admitted to the neonatal intensive care unit, which can be much more costly for health plans than a C-section or vaginal birth without NICU admission.

There were more than 1.3 million C-sections in 2006 in the U.S., up from less than 800,000 in 1996, according to the most recent data available from the American Congress of Obstetricians and Gynecologists (ACOG). For a while now, plans have asked what they can do about this growing rate, says Marjorie Schulman, M.D., a neonatologist and senior medical director at Aetna Inc. “This is not the important question, but it’s the one everyone asks,” she maintains. Rather, she says, the focus should be on what these high C-section rates represent, which is a quality issue mainly with babies and the impact of neonatal costs. “The real quality issue has more to do with the infant than the mom,” she explains, adding, “We don’t tease apart issues of quality and cost; they are in lock step.”

“This is both a quality-of-care and a cost issue,” agrees Tina Groat, M.D., national medical director of women’s health at UnitedHealthcare. “A baby should not be born electively before 39 weeks unless there is a clinical indication” to do so. This type of delivery “is a driver of NICU costs,” she says. And while NICU costs “are not the No. 1 issue [overall in terms of cost to a health plan], they are in the top couple of issues,” she explains. Average costs for a vaginal delivery are between $5,000 and $6,000, while costs for a C-section delivery are in the $8,000 to $9,000 range. But for births resulting in a NICU stay, those costs jump to the $20,000 to $30,000 range, according to Groat.

The issue is particularly important to plan sponsors because many of them have a large number of women in their child-bearing years. “Productivity is as much of an issue as cost,” Schulman says. One-third of inpatient stays are for maternity-related issues, she explains, and premature scheduled C-sections are “low-hanging fruit” within the bucket of maternity care.

Data Show Increase in Premature C-Sections

A study in the June 2008 issue of Clinics in Perinatology showed that there was an increase of almost 60,000 single-baby preterm births from 1996 to 2004. Of these, 92% were delivered by C-section. “While maternal and fetal complications during pregnancy may result in the need for a C-section, we’re concerned that some early C-section deliveries may be occurring for non-medically indicated reasons,” said March of Dimes Medical Director and Senior Vice President Alan R. Fleischman, M.D., when the data were released.

This year, the New England Journal of Medicine published a study that looked at repeat C-sections that were done electively before 39 weeks of gestation. Researchers found that among the women surveyed, these early scheduled deliveries were “common.” In addition, “the rates of adverse respiratory outcomes, mechanical ventilation, newborn sepsis, hypoglycemia, admission to the neonatal ICU, and hospitalization for 5 days or more were increased by a factor of 1.8 to 4.2 for births at 37 weeks and 1.3 to 2.1 for births at 38 weeks.”

The March of Dimes notes that late preterm babies — those born between 34 and 36 weeks gestation — are six times more likely than full-term babies to die within their first week of life and three times more likely to die within their first year. Groat says that babies born within the 37- and 38-week time frame “have twice the likelihood of going to the NICU” than babies born at 39 weeks.

Lack of Understanding Can Be Issue

Sources queried by HPW cited several reasons why the rates of scheduled premature C-sections continue to rise.

“I think there is a lack of understanding of the importance of the last couple of weeks of pregnancy with the baby’s development,” asserts Groat. “Many women think a normal, healthy pregnancy is 36, 37 weeks.” Schulman explains that “37 weeks is technically term,” with gestation of 39 to 40 weeks being full term. But she points to various surveys showing that at least half of the women surveyed think that full term is 34 to 36 weeks. “It’s not nine [months] times four [weeks in a month],” she says. “It’s 277 days, which is a big difference.”

If women have already had a C-section, they can safely have a vaginal birth after Caesarean (VBAC) later, but ACOG notes that there is a risk that the C-section scar may rupture, as well as the uterus. For those reasons, “some hospitals have adopted a policy that they will not allow VBACs at their facilities,” explains Samantha Meese, a spokesperson for The Regence Group, which operates Blue Cross and Blue Shield plans in Utah, Washington state, Oregon and Idaho. “These are usually smaller hospitals with fewer resources, where they are concerned about the higher risk should delivery not progress appropriately.”

Convenience is certainly a factor for many women and physicians, sources tell HPW. For example, many women want to have babies delivered by their own physician, Groat asserts, so if an obstetrician is going on vacation at 39 weeks, a woman may opt for an early delivery. “This is an issue of women who are empowered, insured and have a relationship with their obstetrician,” says Schulman.

Plans Educate Women, Doctors, Hospitals

Many plans are taking steps to help reduce the amount of scheduled premature C-sections. Schulman tells HPW that Aetna has just started a partnership with the March of Dimes in which the plan will be “acting as a consultative matchmaker between larger plan sponsors and the March of Dimes.” In that role, she says, Aetna will introduce some of its clients to people at the March of Dimes “who can customize programs for women of child-bearing years.” The insurer, says Schulman, is hoping to “deliver messages directly to employees of these companies” and “develop quality educational outreach for women through the workplace. This is a no-brainer quality message.” So far, she says, “several plan sponsors have expressed interest,” and Aetna is continuing to reach out to other plan sponsors. “The discussion about the mode of delivery is generally held between a woman and her doctor behind closed doors,” she says. Because of this, education at several levels — pregnant women or ones considering getting pregnant, physicians and hospitals — is critical, she explains. “The only interventions that seem to have worked are quality interventions with teeth at hospitals” such as audits or quality-assurance programs, she adds. “We have pretty active data sharing and educational outreach.”

United has a two-pronged approach directed toward both physicians and members that it developed after a review of 2005 data, Groat tells HPW. The plan looked at selected markets in the Southwest and found that 48% of babies admitted to the NICU were born to mothers who had scheduled deliveries, many of which were before 39 weeks gestation. After the plan shared its data with the hospitals and physicians in those areas, there was a 46% decrease in NICU admissions within the first three months, a statistic that has remained consistent. Groat says the plan now does data sharing not just with physicians but also with hospitals that perform a lot of deliveries among its members. “We’re taking some of the best practices and sharing them with hospitals,” she explains. United is also reaching out to members to let them know that “the last few weeks of pregnancy are important to the baby,” says Groat.

CIGNA HealthCare spokesperson Mark Slitt tells HPW that the plan uses ACOG guidelines on elective delivery prior to 39 weeks in its outreach to health care professionals. It also offers members a 24-hour health information line that includes mortality and morbidity information affecting both mothers and babies with elective delivery before 39 weeks.

“This helps educate the mother if her doctor suggests early delivery,” he says. CIGNA’s Healthy Pregnancies, Healthy Babies program, as well as its high-risk maternity case management program, provide the same information as the health line “if the mother’s delivery plan indicates the possibility of an elective early delivery,” he adds.

The Regence Group has a maternity management program, Special Beginnings, designed to promote a healthy pregnancy and delivery. “Through Special Beginnings, we work to educate expectant mothers about the potential incremental risks to mother and infant” when the baby is delivered by C-section electively before the 39th week of gestation, explains Meese. “Through this program, we educate expectant mothers on the benefits of full-term, vaginal delivery to help encourage a healthy pregnancy and delivery. We also educate them about when it may be medically indicated to not have a vaginal birth.”

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