Perfect Babies and C-Section Complaints
Tom aka Rusty Rustbelt
Perfect Babies and C-Section Complaints
Some issues are like spring flowers, always returning.
The “too many C-Sections” debate is recurring again, raising issues of cost and clinical judgment (some women want sections for cosmetic reasons).
Problem is, Americans expect perfect babies, and if babies are not perfect it is time to call the lawyers.
(John “lover boy” Edwards became very rich filing junk science Cerebral Palsy cases against Ob-gyns.)
The last time I did a cost study on an Ob-gyn practice, all of the contribution margin from Ob was going to malpractice premiums, most of the expenses and all of the physician incomes were derived from gyn services (as I remember the premiums were about $140,000 per physician). So why deliver babies?
Certainly there is malpractice, and it is (in my opinion) malpractice not to do a quick section on a distressed baby (as one of my doc friends said, “we were all trained in the 2 minutes C-section drill). Proper compensation for legitimate cases is important.
Ob-gyns are becoming employees are a means of shifting risk and cost to hospitals and integrated networks. Difficult cases are referred up the specialist chain, often to academic centers (often many miles from home). Medical students are avoiding OB as a specialty.
This is no way to run a health care system, and the plans moving through Congress do not address these issues.
Tom aka Rusty Rustbelt
I have a friend in the US whose child has severe CP because the OBGYN didn’t recognize that there was a serious impediment to birth, and the resulting vaginal birth was so traumatic the child lost oxygen for far too long. There were a number of standards to have been followed, checkpoints that should have been hit– they weren’t, and a tragedy needlessly happened. They sued. Is that a junk lawsuit? Or should they just have accepted a baby that wasn’t perfect? (Why sue? Partially to stop it from happening again, partly because the extra care their beloved son needed represented a staggering financial burden.) Which cases count as junk if your child is disabled for life due to a preventable error?
The whole intervention thing is a difficult question. I live in the Netherlands, where home births are common and where doctors are *extremely* reluctant to do c-sections. Sounds nice, right? Except that the Netherlands has one of the highest levels of infant mortality as a consequence. I’ve met a woman here whose child died in breech because the doctors were reluctant to switch to a c-section until it was too late. The non-interventionist position accepts some ‘acceptable’ losses. Acceptable if it isn’t your baby…
I tend to agree with most of what you have in your post. What rusty fails to mention is the caps on lawsuits for reasons other than loss of future income and care. The courts in most states limit the amount to be received for such issues to a range of $250,000 – $500,000. Where this becomes an issue is in the cases of babies and the elderly. How does one estimate loss of income for a baby and the elderly are screwed because they are on the back end of life. Perhaps universal coverage would take care of much of the issue? But it appears, many do not want this type of medical healthcare either and much of the disagreement comes from the medical sector also.
“The proportion of surgical and obstetrics payments as a part of all payments was virtually unchanged between 1991 and 2005. In 1991, 9.7 percent of all payments were for obstetrics cases; in 2005, the figure decreased to 9.0 percent. Surgical cases accounted for 26.0 percent of payments in 1991, and 26.2 percent of payments last year. Claims that surgeons and ob/gyns face a growing threat of litigation are simply not borne out by the facts. (Figure 9)” Page 9 from here : http://www.citizen.org/documents/NPDB%20Report_Final.pdf Medical “Malpractice Payment Trends 1991 – 2005”
In 1999 The institute of Medicine reported ~ 99,000 deaths occured because of medical error in hospitals. A similar report in 2006 by The Medical Institute reported deaths reported medication errors as being common and costly to the nation (same report as above). Errors appear to be common in hosspitals and the numbers of preventable growing. What is not occurring is the AMA policing its own ranks for doctors who have the highest incidence of error. Again from the same report and in the same period of time, 33% of all doctors who had 10 or more malpractice payments were disciplined by the state boards (NPDB data). The other 67% were not sanctioned. Inmproving patient safety could start here with little cost to patients or hospitals.
Michigan protects doctors who admit to mistakes to patients by disallowing the use of the conversation in court. While this doesn’t alleviate the mistake or take care of the patient in severe cases, it does allow doctors to tell patients what went wrong and in many cases being told the truth results in the patient and/or family not suing. There is room for improvement in patient safety for both hospitals and doctors. Unfortunately much of this conversation is never heard due to the hype on Malpractice Lawsuits.
Run, unfortunately, “Unfortunately much of this conversation is never heard due to the hype on Malpractice Lawsuits.” The more correct term for many of us is defensive medicine. The medicine practiced to help protect Drs from malpractice lawsuits.
Does anyone have an issue with a DR having to pay $140,000 in malpractice insurance????
And rusty your correct the real problem is everyone wants perfect babies. Until we get to the designer babies built in test tubes I don’t think that will happen…at least we don’t have problems like China and INdia with infantcide and gender-based abortions.
Islam will change
Sorry that this comment will have too much uncertainty, but… Just the other day I heard an interview on either NPR or WBAI with a physician who was describing the need for a “:check list” approach to all operative procedures. As noted above, no I can’t recall the details other than that physician was part of a group that was instituting such a check list approach at several hospitals with which the group was associated. He claimed a dramatic reduction is bad results. he gave some anecdotals of what happens in the absence of a check list approach. He also noted that in other technically complex professions the check list is common practice. He used commercial piloting as an example. That’s a written, pre-established list of things to do and check at each step of the procedure including the follow-up care. He argued that the absence of such a detailed check list approach to surgical medicine was a significant factor in the number of bad results and in large measure due to ego issues of surgeons in general. An interesting take on the issue. Sorry I can’t recall who and where, but I’m trying to track it down. Check list surgery!! An essential step forward?? It’s amazing to me that it isn’t common practice, according to the interview.
If the doctor has to give up OB, or move to another state, or most of our OBs go to work for big city hospitals, this causes severe problems.
Try driving 50 miles with a women in labor…….
Buff, what do you think the doc’s net income was for that year?
Protocols and best practices have been around for a long time.
Sometimes they work. If there is an aberration in the profile (say a diabetic coma in the middle of labor) then we need docs with good and quick judgment.
Here’s a bit more on this. http://scienceblogs.com/principles/2009/01/checklist_check.php
One thing I also read was about a survey of surgeons about using check lists. Even surgeons who answered that they were not inclined to use check lists, when later asked if they had surgery would they want check lists used during the surgery, they answered yes. 🙂
In reality all surgeons use checklists, all surgery staffs use checklists and all anesthesiologists use checklist. Two questions..
1) is the checklist written or “between the ears”
2) has the checklist been updated for best practices and increased safety procedures
I have no knowledge about whether C-sections are overused here in the US or not. I do know that there are perverse incentives beyond the “defensive medicine” incentive to perform C-sections here in the US. A C-section will get the hospital more money from the longer hospital stay, and will get the doctor more money from the additional procedure performed.
Does that make a difference in how quickly the doctor performs a C-section? I have no way of knowing. But one thing that McAllen, Texas makes clear (see the New Yorker article) is that in the presence of such perverse incentives in the case of heart care, doctors can make the choice to cut while saying both to themselves and others that the real reason is something else. I.e., even when doctors explicitly say that profit is *not* causing them to perform too much of a procedure (heart bypass surgery in the case of McAllen), the surgeons who had more of a financial stake in the surgery (part-owner of the hospital etc.) performed more surgeries.
The problem is, how can we disentangle all these factors? Well, I suppose we could look at HMO’s and see if they work (I mean *real* HMO’s, like Kaiser, where the insurer and the provider are the same entity and doctors are on salary). Do the doctors there perform fewer Caesarians than fee-for-service doctors? That would be an interesting piece of data to know… Kaiser has the same defensive medicine incentive as an individual ob-gyn, but the docs have no financial incentive to perform procedures. And if Kaiser does perform fewer Caesarians than fee-for-service doctors, does that affect the outcomes (in terms of the health of the baby) in any way? Again, that’d be interesting information to know. Unfortunately I don’t have that information — and I don’t know anybody who does, other than perhaps Kaiser themselves (who regularly do cost and outcomes analyses internally).
Bad Tux: good thinking except that the hospital (in my experience) has almost nothing to do with the decision – the OB department does what the physician and patient decide
In Rusty’s world, the fact that he feels superior to some public figure is reason enough to reach any conclusion he wants. Note the sneer at Edwards’ career and the reference to his private behavior.
Rusty is an accountant who has worked with hospitals. He routinely relies on that background to claim knowledge of the practice of medicine, to claim expertise in national health care issues beyond that of people with expertise on national health care issues, and to claim greater understanding of how the economy works than anyone who has not studied…accounting.
You’ll note that Rusty has a diagnosis – a highly conventional diagnosis, I might add – having to do with the desire for perfect babies. Let you in on a secret. I wanted my girls to be perfect. The midwives wanted my girls to be perfect. Anybody who doesn’t want their babies to be perfect needs to take a good hard look in the mirror. If a perfectly natural state of affairs is what’s Rusty diagnoses as the major problem with an area of medicine, then, well then the real cause of obesity is that we like food, and the real cause of old age is that we don’t like dying young.
AB readers have long been fed the notion – by Rusty and through the fact that the editorial board here allows Rusty to publish here on policy, medicine and culture with a small “c” – that Rusty has some expertise outside of accounting. The reality, to the extent that we can know it, is that Rusty has picked up some strong opinions about policy, culture and medicine during his career as an accountant. His expertise is in accounting.
So when Rusty offers expert opinion that seems at odds with your own experience, feel free to grab for the salt shaker.
May I suggest, since we are discussing variability in medical practice, that we might want to rely on, or at least examine, the work of John Wennberg. Wennberg spent decades studying what is termed “unwarranted variation” in medical practice, and found that supply – how many doctors in a medical “market” were qualified to perform a particular procedure – has a very large impact on how much that procedure is done. Hysterectomies go up when there are more gyn-surgeons in the market.
This is not to say that supply is the only factor working, or that it is the cause of any recent variation in the rate of C-sections. But when offered an evaluation of the rate of C-sections which is essentially an assertion that a single cause – the US culture of malpractice litigatino (leaving out the desire for perfect babies) – from a guy who makes his living doing something other than medicine, litigation, policy analysis or statistical research, it seems worth pulling in other possible factors just to see what they might do to the discussion.
For those interested in having a few facts about the causes of variation in medical treatment, poke around for some of John Wennberg’s writing (look for “Jack” as well).
Personal Foul. Unnecessary Roughness!
Whatever the limitations of Rusty’s experience, he has about 20X more experience in Health Care than you or I or any other poster on AB, so I value his insights. The only thing “wrong” with his expertise is that YOU don’t agree with his opinions. Not exactly the gold standard of critical thinking.
Thanks for the Wennberg stuff, kharris. I was also wondering about the claim upthread that the Netherlands has one of the “highest infant mortality rates”. Checking that claim seems to show it isn’t so.
The doctor who spoke about checklists on WBAI is Dr. Atul Gawande who wrote a book called “The Checklist Manifesto” — and I agree, this is very relevant to health quality and cost controls. Might try it with education, too. Here’s a link to Dr. Gawande speaking on Democracy Now!
Actually, at least half of what you said about me is wrong, for example, about 2% of my work the past 35 years has been with hospitals
And about 20% of my work would be strictly classified as “accounting” althought that is certainly where I started. The part about being a health care executive and working on public policy and legislative issues you missed. REad a little closer.
Everyone wants a perfect baby. If the result is not a perfect baby, what are the alternatives? And what of the costs and attendant risks of a few million extra C-sections per year?
There are serious questions here – sorry you missed them.
Thanks for the citation and the link.
The chcklist suggestion was also a subject on the NPR podcast I listeded too today. It was actually about Radiaiton treatments and their inherent dnager and the fact is the speaker felt like technology has progessed much farther thant the Dr’s ability to monitor at this point.
But note my reference to the McAllen, Texas, case study. A number of hospitals are doctor-owned. Are more Caesarians performed at these hospitals than at non-doctor-owned hospitals? I don’t have an answer to that question, but it’d be a good question to find an answer to, in order to see whether financial incentives actually do come into play.
kharris, this reality about health care costs being inversely responsive to competition is something I noted about payday loan vendors. You would expect that when there are more payday loan vendors in an area, they would compete and cause interest rates to go down. But in fact, that does not happen, according to a paper published by the Denver Fed… in fact, there is a mild correlation between higher interest rates and a higher number of payday loan vendors in an area. The explanation is simple: a vendor has high fixed costs that must be divided across however many customers he has in order to stay in business, and if he has fewer customers due to competition, he must charge those fewer customers higher rates in order to pay his fixed costs, or else fold up and go out of business. So more payday loan vendors dividing the same number of customers means higher interest rates charged to those customers.
Now, in the payday loan situation you would expect a Walmartization of payday loan outlets, i.e., more customers means lower per-customer fixed costs meaning that the big would tend to get bigger and the smaller would eventually fold as they went into a price spiral, and I am baffled as to why that has not happened in the markets studied by the Denver Fed, neither the authors of that paper nor I have any reasonable rational explanation for the lack of consolidation in that industry. But in the case of health care that Walmartization doesn’t — can’t — happen, because there is a natural upper limit to the number of patients that a doctor can serve, not to mention that price isn’t a factor for most customers of doctors — they want the best medical care they can get, not the cheapest, because their health is more important to them than the cost. The net result is that more doctors beyond what is needed to provide services for the population results in higher costs, exactly the opposite of what the followers of the Free Market Fairy claim when they state that somehow the Free Market Fairy will wave her (his?) magic wand and somehow make doctors’ fixed costs lower just because there’s more doctors in an area.
CoRev, the notion that defensive medicine is a major cause of high medical costs in the United States does not survive actual study. The CBO did a study and found that yes, states with tight limits on medical tort do have lower healthcare expenses than states with no limits on medical tort… but that the difference was minimal (less than 2% price difference between the two). Various people have second-guessed the CBO on this subject, but that is right now the definitive data that we have on the subject — that yes, defensive medicine does exist, but no, it isn’t a significant cause of high utilization of medical procedures. See the McAllen Texas situation for another example — McAllen has the same demographics as El Paso, is in the same state with the same tort-unfriendly laws, yet has much higher costs than El Paso and doctors in McAllen are much quicker to jump into more invasive and expensive treatments. When asked to justify the greater number of procedures they did, doctors in McAllen said “defensive medicine”. But that just did not pass the laugh and giggle test when El Paso had the same demographics and legal system, especially since none of the doctors in McAllen interviewed by the New Yorker could remember ever being sued or any of their fellow doctors in McAllen ever being sued. So why the difference? Read the article in the New Yorker and see if you can figure that one out, my basic surmise was that there were financial incentives that doctors in McAllen had that doctors in El Paso didn’t have, but I’d need more information to say that definitively.
There is some data but on various procedues (particularly cardiology and imaging) but I can;t lay my hands on any direc and reliable data.
Suppose medical malpractice costs suddenly dropped for whatever reason. Maybe due to tort “reform”, maybe due to smaller jury awards, maybe due to better doctors. Whatever. Is there any reason to believe that lower malpractice costs would reduce the costs of healthcare overall? The fight between doctors and malpractice insurance companies is a fight…well, between them and not between the patient and the doctor. The doctor and the insurance company are fighting over who is going to keep that share of the pie. There is no reason to believe that lower medical malpractice insurance rates would translate into lower healthcare costs. Doctors’ fees are determined by the demand for medical services and the supply of doctors available to meet that demand. That’s why the AMA likes to make sure the supply of doctors is very constrained. So if malpractice insurance rates drop, that just puts more money in the doctor’s pocket, not mine. If the medical market were competitive this higher income for doctors should increase the supply of doctors, but since medical schools work very hard at making sure very few doctors enter the market each year, there’s not much hope that the market will fix the problem.
And to further support this line of reasoning:
we find that increases in malpractice payments made on behalf of physicians do not seem to be the driving force behind increases in premiums. Second, increases in malpractice costs (both premiums overall and the subcomponent factors) do not seem to affect the overall size of the physician workforce, although they may deter marginal entry, increase marginal exit, and reduce the rural physician workforce. Third, there is little evidence of increased use of many treatments in response to malpractice liability at the state level, although there may be some increase in screening procedures such as mammography.
The effect of malpractice on medical costs is large relative to its share of medical expenditures, but relatively modest in absolute terms—growth in malpractice payments over the last decade and a half contributed at most 5.0% to the total real growth in medical expenditures, which topped 33% over this period. On the other side of the ledger, malpractice liability leads to modest reductions in patient mortality; the value of these more than likely exceeds the cost impacts of malpractice liability. Therefore, policies that reduce expected malpractice costs are unlikely to have a major impact on health care spending for the average patient, and are also unlikely to be cost-effective over conventionally accepted ranges for the value of a statistical life.
You are correct. BTW, the second paper referenced, the one by Lakdawalla and Seabury, also showed a 0.2% rise in mortality, when medical liability costs dropped by 10%.
Tort Reform is currently being used as the shiny object over in the corner of the room…”OH, look over there”. And it works, because physicians and providers are great at assigning blame for rising costs to everyone else. It must be those evil insurance companies, it must be those awful lawyers, it must be the dreaded pharma industry.
I say that many of them need to stop, and look in the mirror.
If the medical market were competitive this higher income for doctors should increase the supply of doctors, but since medical schools work very hard at making sure very few doctors enter the market each year, there’s not much hope that the market will fix the problem.
And if you look at Wennberg (mentioned above), you’ll note that the magic market fairy doesn’t seem to result in lower costs either. The notion that more doctors would mean lower costs seems like a pretty theory. But the reality is that when we track costs on a doctors-per-capita basis in a given specialty, there is a small but positive correlation between medical costs and the number of doctors in that specialty in a given geographic region — i.e., the more competition, the higher the medical costs. Free market competition does not appear to work here, probably because a) people don’t shop for health care because they want the best doctor, not the cheapest doctor, because they value their health more than they value money, and b) doctors have fixed expenses and if they have fewer patients, must charge more per patient (or do more unnecessary procedures) in order to pay those fixed expenses, so more doctors means a higher amount of fixed expenses in a market means higher overall medical expenses.
At some point somebody needs to point out that the free market fairy is in fact a grumpy transvestite with hairy legs and a beard whose day job is as a knee-capper for the Mafia, i.e., not someone who’s looking out for you and me, but, rather, someone who’s looking out for the big guys (the providers in this case). But everybody seems to be distracted by the frilly pink dress and the sparkly magic wand. Siiiiiigh!
Finally, btw, you guys have gotten to something I can become endlessly verbose on, my research focus is on Medical Workforce Supply, and specifically, Primary Care. Which BTW, is a much bigger problem than OB, not diminishing OB at all.
Throw aside the “perfect baby” comment. Of course expecting parents want to have happy, healthy babies. That’s the same kind of red herring as “those people want to live on the streets!” or “the reason fewer women than men are university professors is that they don’t want to.” In reality, chances are that that assumption just won’t hold water (as in the case of university professors and gender, where women seeking tenure are strongly disadvantaged compared to men largely because of maternity and child care issues).
Here’s a link with some research on the subject–scroll a third of the way down to the blue text box. This was from a study published in 2009:
In other words, not using a common intervention technique (Pitocin) reduced the number of emergency birth methods (C-section, forceps, vacuum). As the cost of doing emergency abdominal surgery is much greater than observing a vaginal birth, it stands to reason that not following a Pitocin protocol will save money in the long run. But…inducing or augmenting labour is a business generator for hospitals. Going in to the hospital to be induced (for whatever reason) means that the doctor and hospital will be paid for performing a service, even though it has been shown that induction/augmentation is not generally in the interest of the woman involved.
Another article: http://www.sltrib.com/parenting/ci_13644948
Note the paragraph “After Magee began strict enforcement — requiring that a mother’s cervix be nearly ready for natural labor, and limiting the beds available for elective inductions — too-early inductions dropped to 4 percent by 2007 and are “effectively zero” today, Fisch says. Overall, elective inductions dropped 30 percent.” (emphasis mine)
In other words, by limiting the use of a procedure, the costs associated with too-early induction (cesearean section, neonatal ICU, infection, maternal hospitilizations) fell like a rock.
Moving along, there’s a persistent belief that once a cesearean, always a cesearean. Maybe 30 years ago that was true, but techniques have been improved to the point where the chance of uterine rupture–the greatest source of worry for vaginal birth after cesearean–is lower than the chance of fetal distress during a normal labour. (source: http://www.childbirth.org/section/CSFact.html) There are several well-documented studies and meta-studies about VBAC, one of which is this one: http://tinyurl.com/yk7n6wq
And the sentence that jumps out at me most was:
“For a [Trial of Labour (aka VBAC)] success probability of 76 percent or greater, TOL is more cost-effective and provides higher quality of life.”
So for you to say that people want perfect babies and therefore they’re suing and getting more c-sections is pretty stupid. There’s a host of reasons and perverse incentives going on, and unless I miss my guess, this is the kind of thing the medical review panels in the health care reform bill are designed to do. Say, “this outcome costs less and is better.”
Thank you for making the argument to CoRev who is relatively intelligent but parrots the standard Fox News litany of quackery. Along similar lines on Defensive Medicine, you may appreciate this: http://roanoke.injuryboard.com/medical-malpractice/the-myth-about-defensive-medicine.aspx?googleid=266220 “The Myth of Defensive Medicine”
Pay attention to the links which give greater detail. Maggie Mahar on Health Beat also does a fine job of debunkingthe Defensive Health Practices also.
Run, Badtux, Run thanks for the backhanded compliment. But, what you two are asking is for me to disbelieve my own experience. As you probably know I am older. I do see several Drs, and can tell when one is practicing defensive (overly cautious) medicine, and when they are not.
The more visits the more often an experienced patient learns to say, NO! It is obvious when a Dr says, well I am going to write in the file “patient refused …” Why did he have to do that? Defensive medicine in action!
So if defensive medicine is such a huge issue, why can’t we ever directly measure it in terms of dollars and cents? Why can’t anybody ever find a significant difference in cost between states with strict tort limits and those without? By “significant” I mean more than 2%. And you do know that malpractice insurance accounts for less than 1% of the costs of healthcare here in the USA, right?
The fact of the matter is that every statistic we currently have says that we could ban malpractice lawsuits altogether (thereby eliminating the common law right to be made whole when damages are done against you, but hey, us right-wing radicals love eliminating rights dating back to the Magna Carta, right?) and it’d make less than 2% difference in healthcare costs. Your anecdotal evidence otherwise is worth about as much as any anecdotal evidence — i.e., nada, because a sample size of 1 is worthless for making any probabilistic determinations about a subject (see: Statistics 101). Indeed, your anecdote could just as easily support the assertion that your doctor is trying to bluff you into allowing additional useless procedures in order to pad his pocket. That’s just how useless anecdotal evidence is — a single anecdote can be used to support practically *anything*.