Evidence-based care takes a back seat
By Shelley Burns
I read this article with dismay last month. Why, in a profession that prides itself on evidence-based care, does the C-section rate continue to increase?
The increasing C-section rate is *almost* a microcosm of what is happening in many areas of healthcare. This overutilization of a medical procedure is driven by misaligned incentives for nearly everyone involved – except, perhaps, the baby. Like other causes of overutilization, the drivers of C-section rates are complex and intertwined. And while the scientific evidence is clear, it’s the cultural and market issues that make reducing the C-section rate more like a wild game of whack-a-mole.
Medical advances have lowered the attendant risks of C-sections, a great boon for those mothers and newborns who need them. Mothers who don’t require a C-section understand that the risks are lower, and consequently aren’t as wary about having a C-section as they used to be. They also understand that sometimes, to prevent risks to mother and or baby, a C-section is necessary. AND you can schedule baby arrival to the minute. Mothers don’t want to add the increased risks mentioned in the article to themselves or their babies. Yet, they are faced with work deadlines and short maternity leaves, and so don’t have much time to cobble together a support network after the birth. So, many mothers feel some slight increased risks are worth it. After all, they know plenty of other women who had a C-section and everything turned out just fine.
C-sections are attractive to physicians, too. One source claims that C-sections can eliminate six of the nine most common reasons for obstetrician lawsuits. Faced with declining reimbursements and increased litigation, where is the incentive for the physicians to advocate strongly for a vaginal delivery? C-sections make their paychecks and schedules more amenable; the likelihood of litigation is reduced; and, their patients want C-sections. If the consumer is supposed to drive the care, and the physician has explained the risks, what’s a physician to do when an expectant mom wants a C-section?
Hospitals, as well, are caught in the consumer-driven care trap. Their customers, physicians, and mothers want C-sections and hospitals deliver (pun intended) what the market wants. Hospitals get additional benefit because accommodating C-sections gives them more control over delivery volumes and schedules, and they can forecast their costs and staff requirements more accurately. C-sections also generate more services from the hospital, and our reimbursement system is service-based, not outcome based. Hospitals get higher reimbursements for C-sections.
So the primary participants in the C-section decision are today incentivized to increase C-section utilization. Each person/entity in this scenario faces undesirable consequences if they do the right thing, according to evidence-based medicine. Until there are changes in the payment system, legal system, and our overall business culture, evidence-based care will continue to take a back seat to societal and market forces. And this example of overutilization typifies many of the other conundrums present in our current healthcare system.
At the beginning of this post I said that the C-section trend was *almost* a microcosm of healthcare utilization issues overall. For many other medical activities, the gorillas in the room are the drug, implant, and medical device companies. These companies’ presence in the C-section microcosm is very small; in this instance, they aren’t driving increased utilization. But for those procedures where they have a stake, add another market force incentivized to increase utilization. Another conundrum for another day.
Shelley Burns is head of knowledge management at HMC.
