All of the great leaders have had one characteristic in common: it was the willingness to confront unequivocally the major anxiety of their people in their time. This, and not much else, is the essence of leadership.
- John Kenneth Galbraith
A Clarion Call
Kudos to Dr. John Queenan for his candid editorial “How to Stop the Relentless Rise in Cesarean Deliveries,” published in the August issue of Obstetrics and Gynecology. We applaud his candor as an obstetric leader willing to confront the serious problems associated with the steadily rising cesarean section rate now approaching 34%.
Dr. Queenan predicts that the significant increase in primary cesareans coupled with the sharp decrease in the VBAC rate will soon result in a 50% cesarean section rate in the U.S.
There’s no doubt that the relentless rise has been a source of anxiety for maternity care stakeholders for at least a decade as the rate has increased year after year. Women feel pressure to accept interventions including major surgery they’re not sure they’ll benefit from, driving a small but rapidly growing group of women to opt for home birth instead. Medicaid programs face severe financial constraints and are set to accept millions of new enrollees in 2014. Given the price tag, Medicaid simply can’t afford a 50% cesarean rate, nor even to sustain the current rate. Obstetricians are now seeing more and more patients with sometimes life-threatening consequences of too many c-sections at unprecedented rates. As Dr. Queenan warns, “the rising cesarean rate is a threat to the profession and there’s no time for complacency.” His editorial ends with a clarion call for concerted action by his profession to confront the problem and commit to action before policy-makers and payers step in and force change.
What kind of action? The editorial poses what Dr. Queenan calls “a simple question”, “How can we curtail the runaway increase in cesarean deliveries?” and offers two “complex” solutions: “make VBAC more accessible and more desirable,” and “prevent primary deliveries in the first place.” He offers many specific strategies, among them:
- implementing hospital quality improvement programs,
- increasing utilization of midwives,
- addressing problems in the liability system, and
- improving shared decision making.
Hospitals and Quality Improvement
Dr. Queenan highlights the important potential of hospital quality improvement programs, but successful models have just begun to emerge and face barriers to widespread replication. That’s because hospitals charge as much as double for cesareans than for vaginal births. One of the practices contributing to soaring cesarean rates - elective induction before 39 weeks – has dramatically increased admissions to newborn intensive care units (NICU) generating even more hospital revenues. Lowering the c-section rate will reduce NICU admissions and revenue.
Despite this disincentive, some hospital systems have implemented effective quality improvement programs. For example, the Hospital Corporation of America (HCA) has reduced elective inductions and cesareans and improved other outcomes by implementing better data systems and focusing on eliminating variation in care processes and procedures. This resulted in significant reductions in malpractice claims and loss rates. However, as long as the overall fee-for-service system rewards volume and poor outcomes, hospital led quality improvement projects like HCA’s will be limited. Case in point: Intermountain Healthcare’s quality improvement program reduced elective inductions and cesareans saving Utah taxpayers more than $50 million per year through reduced payments, while Intermountain’s costs fell only by about $41 million, resulting in a loss of more than $9 million per year in operating margins.
So what can we do?
This is where comprehensive payment reform comes in. It’s time to align care provider incentives with those of hospitals, and reward providers and facilities that provide high-quality maternity care that improves the health outcomes of mothers and babies.
Restructured payment models such as bundled payments for the full episode of maternity care and value-based purchasing should be tested through regional pilots and demonstration projects that are carefully evaluated and refined to ensure they meet intended objectives. Effective models should then be disseminated for replication and widespread uptake. (Promising models of payment reform are addressed in the multistakeholder consensus “Blueprint for Action”, and were elaborated upon by Harold Miller in his 2010 webinar, Transforming Maternity Care: How Payment Reform Can Lower Costs and Improve Quality.”)
A critical factor for success in payment reform is the development of a robust performance measurement and reporting system. They go hand-in-hand, because payers cannot reward good performance if it is not measured. Although we’ve made good progress on the maternity front, we must keep working to fill existing measure gaps to assess processes, outcomes, and value of maternity care; care coordination; shared decision making; and experiences of women and families. Planned expansion of NQF-endorsed perinatal measures is a welcomed next step, but many more provider and facility measures are needed to allow comparison, and public reporting of data is crucial for leveraging results to improve maternity care.
Harnessing the Collective Anxiety for Needed Change
Anxiety about the quality and value of maternity care is growing. As the situation has worsened, we’ve seen the typical symptoms of rising anxiety – avoidance of the problem, anger, and blame – among all stakeholders. But science tells us that anxiety also can have an adaptive function: it helps humans identify danger, problem solve, and learn from mistakes. We need leadership from all stakeholder groups to harness our anxiety for the good, and reduce the maladaptive responses that have become the hallmark of the cesarean debate. Thanks to stakeholder leaders already engaged in successful maternity quality improvement programs for paving the way. We are hopeful that others will heed the call.