This article is being reprinted on The CHCF Blog with permission from the Health Affairs Blog, where it first appeared on October 31, 2017.
In 2015 the California Health Care Foundation earmarked up to $5 million to tackle c-section overuse in the state. Here, I provide an update to a blog post I wrote in 2015.
A Vexing Problem
Each year, California welcomes 500,000 new babies — one-eighth of all born annually in the United States. And each year in California — as in the United States — almost one-third enter the world via cesarean delivery (c-section). This is substantially higher than Healthy People 2020’s goal of 23.9% for low-risk, first-birth deliveries by c-section. A c-section can be lifesaving in certain circumstances, but it is major surgery with risks.
For the baby, these include higher rates of infection, respiratory complications, and neonatal intensive care unit stays. For the mother, the risks include higher rates of hemorrhage, transfusions, infections, and blood clots. And once a mother delivers by c-section, she faces a 90+% chance of having others for subsequent births, leading to higher risks of major complications like hysterectomy and uterine rupture.
Unnecessary c-sections also drive up costs of care. The total average payment for c-sections is nearly 50% higher than for vaginal births. Given that Medicaid pays for half of all births in California and many other states in the United States, the cost of c-section overuse is increasingly borne by government at a time when budgets are squeezed.
No Silver Bullet
There are many reasons for the current overuse. So, we took a multipronged approach. Here are some of the key problems and how we are tackling them:
No Routine Performance Tracking
The low-risk, first-birth, c-section rate at California hospitals ranges from 11% to 77%. Such extreme variation signals something is wrong. Until recently, there was no widespread routine tracking of performance data. This means providers had no idea how they were doing, consumers had no way to make more informed choices, and purchasers lacked information to guide decisions.
Most providers want to do the “right thing,” but sometimes they don’t know how. The CMQCC developed a suite of improvement toolkits to address key drivers of maternal morbidity and mortality. CHCF funded one such toolkit on c-sections, which provides evidence-based guidance on how to support vaginal birth. The guide, which is free and supported by the American College of Obstetricians and Gynecologists, has been downloaded more than 4,000 times to date in all 50 states and in 61 countries.
The toolkit forms the basis of the c-section quality improvement (QI) collaborative, which CHCF is also funding. Via a mentor model (better-performing hospitals partner with ones that have not yet hit the 23.9% goal), staff at poor-performing hospitals meet regularly with mentors and the CMQCC’s team to discuss improvement strategies. The first of three cohorts of hospitals launched in May 2016, the second in January 2017, and a third will begin in November 2017. Across the three cohorts, a total of 105 (76%) of the 139 hospitals with baseline rates above 23.9% will be involved.
Money Talks . . . and It’s Saying the Wrong Thing Right Now
Historically, many purchasers have reimbursed providers more for a c-section than a vaginal birth, and doing so sends the wrong signal to providers.
California’s statewide effort aims to align payment with desired outcomes. CHCF provides support for Smart Care California (SCC), a public–private partnership working to promote safe, affordable health care. SCC, the cochair organizations of which collectively purchase or manage care for more than 16 million Californians (40% of covered lives in the state), has developed a menu of payment and contracting options for purchasers. This menu includes approaches that purchasers could use in paying for births—like paying the same rate whether a baby is born vaginally or by c-Section (“blended payment”) and requiring hospitals in their networks to meet the goal or have a QI plan in place. The idea is that one size may not fit all purchasers, so flexibility is needed, and adopting better-aligned payment policies in unison can send a powerful message. SCC has just approved the menu and will be tracking the progress of its adoption by purchasers.
Lack of Consumer Awareness
Most women are unaware that one of the main risks for having a c-section is the hospital where they give birth. Now, hospital maternity care measures in California are shared on Yelp. The CHCF-Yelp partnership provides a bigger megaphone for the clinical quality data. We also are gearing up for the second year of the C-Section Honor Roll, a collaboration of SCC and California’s secretary of health and human services to call out publicly the hospitals that are at or below 23.9%. The intent is to get the attention not only of consumers, but also of providers, too. A little local competition in a race to the top is a good thing.
Another consumer challenge is that our society has developed a cavalier attitude toward what is major abdominal surgery, likely because everyone now knows someone who has had a c-section. CHCF, the CMQCC, and Consumer Reports are developing patient education materials for distribution by SCC and others. The products will be a set of animated videos and print materials in English and Spanish. They are the consumer companion to the provider toolkit and will hopefully spur expectant mothers to talk with their providers about partnering to support labor and avoid an unnecessary c-section. The materials will be free. Release is expected in the first quarter of 2018.
Finally, CHCF has partnered with the USC (University of Southern California) Annenberg School for Communication and Journalism’s Hollywood Health and Society (a program of the Norman Lear Center) to educate television writers about maternity care so that accurate messaging about this topic is embedded in the programming. If successful, we could reach millions of women and families—way more than we ever could on our own. There’s no guarantee a TV writer will pick up the c-section topic. Time will tell if this gamble pays off.
What We’ve Learned So Far
With systemic change, you must take the long view. Here are a few things we’ve learned so far:
Change Is Possible
Overall, according to the CMQCC, there has been a decrease in the average low-risk, first-birth c-section rate from 2015 (baseline) at 28.3% to the first half of 2017 rate of 25.5% for all the hospitals participating in the collaborative. The statewide average for all California hospitals that deliver babies also has dropped from 26.5% to 25.1%. It’s the first time in twenty years that we are seeing a downward trend. That’s progress!
Partnerships Are Everything
Achievements would not have been possible without the engagement of partners—all working statewide toward a common goal. The entities linked to here are just some examples of the many partners statewide that are engaged in this work: providers, payers, professional organizations, and government.
Providers and labor and delivery units have distinct cultures. To learn how to drive better outcomes, the CMQCC (funded by the Yellow Chair Foundation) is surveying clinicians to understand provider attitudes about birth and the role they play in labor and delivery.
Payment Reform Is A Slog
Payment needs to be aligned with desired outcomes, but getting that to happen is hard, especially in California’s fractured health care market. It is a huge lift, and it takes an average of three years for purchasers to renegotiate contracts. Payment change must be pursued, but it’s daunting sometimes.
The Work Is Never Done
True, we are starting to see a downward trend, but results of the first cohort of hospitals are mixed when you look below the surface. Some hospitals have had dramatic (10%) decreases. Others have stalled. And one hospital from the initial pilot, before the collaborative started, has seen its rate creep back up. Per Elliott Main, the CMQCC’s medical director, this work requires “constant gardening.” We need to keep tracking the data, educating clinicians and consumers, and pushing for aligned payment until we build a new culture and create a new expectation. And even after all of that is done, we will still need to pull weeds and prune from time to time!
Stephanie Teleki is CHCF’s director of learning and impact. She partners with the foundation’s program teams to support organizational learning, evaluate the foundation’s investments, and optimize impact. Stephanie also leads the foundation’s portfolio in maternity care as part of CHCF’s focus on high-value care. This maternity portfolio includes a statewide initiative to lower the rate of unnecessary low-risk, first-birth c-sections; work to improve maternal mental health care; and work exploring the advancement of midwifery care in California.
Previously, Stephanie led CHCF’s transparency-focused efforts to establish and then expand both the California Maternal Data Center and the California Joint Replacement Registry. She also developed projects to track cancer care quality and costs in the state. Prior to joining CHCF, Stephanie was a policy analyst in the health unit of RAND Corporation, where she conducted health policy research and evaluations for such clients as the Agency for Healthcare Research and Quality, the Centers for Medicare and Medicaid Services, the Assistant Secretary for Planning and Evaluation, and private-sector health plans. She has also held research and management positions at Kaiser Permanente, MD Anderson Cancer Center, and the UCLA Center for Health Policy Research. Stephanie received a bachelor’s degree in English and history from Amherst College, a master’s of public health in health services research and policy from the University of Texas at Houston School of Public Health, and a doctorate of philosophy in health services research and policy from the University of California, Los Angeles, Fielding School of Public Health.