For nearly 30 years, the American College of Obstetrics & Gynecology has recommended that doctors and hospitals wait until at least 39 weeks to perform elective inductions or Cesarean sections, except for justifiable medical causes. Despite this guideline, 10-15% of babies born in the US every year are delivered early. The reasons are plentiful – doctors (and hospitals) receive higher reimbursements for elective inductions, women do not know about the risks of early inductions and C-sections, and both doctors and mothers see early induction or C-section as a convenience to themselves.
However, early inductions and C-sections are not without risks. Babies born before 39 weeks gestation are more likely to have respiratory problems, difficulties with feeding, and developmental problems that can be long term. So the question is, how can we get elective induction rates to decline?
There have generally been two approaches to this problem. The first is to systematically review every single pregnant woman admitted to the hospital to see if she meets medical criteria for a necessary early induction. Intermountain Healthcare in Utah has been practicing this type of utilization review for years, requiring the head of the Department of Obstetrics and Gynecology to sign off on any elective inductions. Prior to instituting the review process, 27% of deliveries were by elective induction at less than 39 weeks. That figured dropped to 6% within 18 months. The end result? Healthier moms and babies… and the hospital lost a lot of money. But hospitals are increasingly jumping on the bandwagon to reduce elective induction rates, as reported by Kaiser Health News, including some of the most high-profile maternity hospitals here in Massachusetts.
It’s comforting to know that hospitals are at least beginning to realize that what may be good for their bottom line isn’t necessarily good for their patients. However, money in medicine does a lot of talking, and one of the most effective ways to reduce unwanted behavior in the medical community is simply to stop paying for it.
And that’s just what has happened. UnitedHealthcare, the nation’s largest private insurer, began rewarding hospitals for taking steps to limit early deliveries if they could demonstrate a drop in their rates. BlueCross/BlueShield of South Carolina stopped reimbursing providers altogether for performing early deliveries without a medical cause. The South Carolina Medicaid program followed suit; together, the two insurers pay for 85% of births in South Carolina. The Texas Medicaid program has a similar rule on the books, and New York and New Mexico are considering adopting this policy as well.
Time will only tell which strategy will be more effective, but I wouldn’t be surprised to see early elective induction rates fall faster in the states that stop paying for them.