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When Tim Armstrong, CEO of AOL, cited the cost of “distressed babies” as the reason for cutting 401K benefits to AOL employees, he created a media storm by blaming sick babies for poor corporate governance.  Armstrong cited the million dollar costs of caring for two premature babies as the reason for needing to change employee benefits, essentially outing the private health information of a few of its workers (possibly against HIPPA regulations). He put the mother of one of those babies in a position of defending her daughter’s life and honor, and their family’s sizeable use of the benefits package they pay for through AOL’s employee insurance program.

It is much easier to blame babies and the women who bear them than it is to shine a light on selfish corporate leadership and our bloated, inefficient, for-profit medical system that often works on the rationale of doing procedures “because it can” instead of establishing criteria for action “because it should or should not.”  Extreme incidences such as this mask the underlying problems inherent in our “can do” medical system’s approach to caring for those who are ill, and hold a special lens for viewing maternity care.

I have not yet in the media coverage of this story seen a reference to the question of whether or not a “micro-preemie,” born barely at the age of viability, should undergo extensive lifesaving measures.  Some would call the procedures necessary to keep a five-month fetus alive outside of the womb “heroic measures,” but others could call those procedures “torture.”  Numerous needle sticks in veins that are so small they are barely visible to the eye, tubes in the nostrils and down the throat for months on end, electrodes and monitors attached all over the body, kept in a plastic box to maintain body temperature because the baby is unable to do that on its own, attached to a ventilator because it cannot breathe on its own, fed through a tube threaded through its nostril and down into its belly into an underdeveloped gastric system which is at high risk for painful and deadly infection, being so fragile that it cannot be held or touched for months are just some of the “heroic” measures that micro-preemies endure.

In addition to the efforts made to save the fetus, the mother often undergoes a cesarean section; a major abdominal surgery that puts her at risk for complications and infections and can jeopardize her health in future pregnancies.

Furthermore, the micro-preemies that survive into early childhood often suffer from ongoing health problems, learning disabilities, and behavioral problems.  Sometimes these problems are relatively minor and children grow to become healthy, productive adults.  Sometimes though, these children do not fare as well and demand constant, high-level care throughout their lives.  There is no crystal ball to tell the future and know which outcome will occur.

It is truly a miracle of modern science that a baby can be born so early and survive, but the doctors who make the decisions in the Neonatal Intensive Care Unit are not the same doctors who continue to treat the life-long illnesses and deficits from which micro-preemies often suffer, and they are not the doctors guiding the mothers through future pregnancies where they are denied Vaginal Births After Cesareans (VBACs) or suffer complications from the previous cesarean.  Previous cesarean has been linked to infertility, and by using surgical means to attempt to save a fetus with a 1 in 3 chance of survival, doctors put in jeopardy the very thing the parents may desperately want if their premature baby dies – a chance for another baby.  Pushing the envelope of viability is really a grand experiment on human subjects that sometimes seems to focus more on whether or not the doctors and medical teams can create miracles of life in the moment, but doesn’t take a long view of what those lives might look like in the days, months, or years ahead.

A surgeon’s tool is surgery, so it is the prescribed course of action for many who are confronted with illness and seek help through our current medical system.  There are numerous unnecessary and unhelpful surgeries performed every year to provide “healing” from heart disease and back problems, as well as other maladies.  Based on our doctors’ advice, we are optimistic to a fault, believing we can prolong life and cheat death without truly understanding the odds in each healthcare situation, believing we will be the one with the winning lottery ticket and consoling ourselves when failure occurs that “at least we did everything possible to save a life.”  What this system denies is the possibility of a more compassionate acceptance of fate, and tragic though it may be, there can be such a thing as a good death.

Maternity care is particularly vulnerable to over-action and heroic measures because birth, by its very nature, is the entryway into life.  Our modern system of obstetrics in the United States uses numerous interventions and takes every precaution to ensure a healthy baby which, ironically, leads to the highest death rates of mothers and babies of any country in the industrialized world.  Countries that treat birth as a normal, healthy process intervene less and get better outcomes.  Often, the families that are receiving this over-medicalized care are not even given enough information to make care decisions based on informed consent, nor are they given true choice in the medical setting.  Blaming the women, and without question, blaming the babies for costly care is the epitome of shit rolling downhill.

All this care, optimism, and desire to cheat death – this attitude of “life at any cost” does cost us dearly.  Our inability to grapple with these issues ends up being very expensive, and truly does lead to “million dollar babies.”  I don’t have the answers for many of the questions these dilemmas raise.  What I might choose in a life or death situation would be very different from what you would choose, I am sure. There are no simple solutions.  It seems to me though, if doctors want to advance medical science through human experimentation the subjects should be fully informed and not have to pay for it, and if we truly believe as a society in “life at any cost,” that should extend to everyone and we shouldn’t gripe about it when it comes time to actually pay.

If AOL had planned for the rising costs associated with the rollout of the Affordable Care Act, which strives to provide everyone in our country with access to healthcare so they too might have a chance to cheat death, it would not have made the news.  If AOL leadership had respect for and appreciation of its employees to the point of reducing management’s salaries in favor of buffering these unusual and short-term costs of healthcare and retirement for its workers, it probably would not have made the news.  If it made an effort to improve the healthcare system in our country to one that is evidence-based, efficient and affordable, that probably would not have made the news either.  That bad behavior gets highlighted instead of examples of how to move equitable, affordable, high-quality healthcare forward for our country; that makes me “distressed.”

 

Michal Klau-Stevens is The Birth Lady.  She is a Lamaze Certified Childbirth Educator and expert on citizen childbirth issues.  Her website is TheBIrthLady.INFO.

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When businesses offer healthcare packages as benefits to their employees, they take on the responsibility of having a direct impact on the health and well-being of their employees through the programs they offer.  There will be lots of changes to our healthcare system in the coming years as more aspects of the Affordable Care Act come online, yet as long as corporations continue to offer employee healthcare as a benefit, they have an influence on the quality of care and how it is delivered.  As stakeholders in the healthcare system, businesses have a responsibility and a financial imperative to ensure that the healthcare access they offer through their insurance programs is going to lead to high-quality care with the healthiest outcomes at the lowest cost.  To do this, they may have to use their best business tools and skills to engage unlikely corporate partners in the healthcare field.

My husband’s company offers us several healthcare plans to choose from as part of his corporate benefits package.  We choose the plan that best suits our needs, but even that statement is somewhat laughable based on the choices that are made available to us.  In the decade that he has worked for this company, our costs of participating in this benefits package have more than doubled, while our coverage has diminished.  We went from paying $400 out-of-pocket for our first birth to over $1400 for our third, and they were six years apart.  (The first birth was with an epidural, and the second two were totally unmedicated, yet cost more than twice as much – crazy, right?)  Costs of childbirth education and a doula were not covered, yet both services have been shown to improve outcomes and reduce costs.  I had low-intervention births because I prepared in advance and demanded it from hospital staff, not because that type of care was freely offered.  The nearest birth center is an hour and a half away, and homebirth is not covered by our insurance.  Of course, to go outside of this system and pay for maternity care without insurance is even worse.  A relative who did that got slapped with a $10,000 hospital bill that will take years for her to pay off.  We are forced into expensive, poor quality care partially because that is what our employers provide to us as our choice.

The insurance company that manages these benefits is making record profits, but my husband’s company is certainly not getting a great deal from this arrangement, as it is paying more for the service, giving less to its employees, and paying for the poor outcomes both in healthcare bills and lower employee productivity.  The hospitals that provide care in the community where my husband’s corporation is located deliver non-evidence-based services that have a direct impact on the corporation’s bottom line.  Participation in this system contributes to infant and maternal mortality rates that are some of the worst in the industrialized world, and are putting a huge financial strain on our country’s economy.  At what point does it become fair to say that corporations, as major stakeholders in healthcare, have a responsibility to force change within the insurance, hospital, pharmaceutical, and medical industries because they have the resources and the clout to do it in a way that nonprofits and individuals can’t?  I think the time is now.

This means that, for an example, my husband’s employer would have to invest time and money into learning about optimal maternity care.  A good place to start is with Childbirth Connection’s report “2020 Vision for a High-Quality, High-Value Maternity Care System.” Next, they would work with insurance companies to develop benefits packages which offer high-quality, high-value care.  I’m sure there is an insurance company out there that would be happy to work with a Fortune 50 company to develop an innovative maternity care package that provides high-quality, evidence-based care at reasonable costs, with good profit margins because it utilizes lower-cost practitioners.  His company could go to the hospitals that serve its employees and work with them to institute midwifery programs, redesign labor rooms to be more conducive to low-intervention birth, and provide training for nurses, midwives, and doctors on collaborative, evidence-based care practices.  It could send its lobbyists to advocate for change in payment for healthcare and tort reform, as well as laws that limit the powers of the hospital, pharmaceutical, and medical industries to influence research and the practice of non-allopathic care while increasing access to midwives and birth centers through legislation.  Also, his employer could support community-based resources such as birth networks, independent birth centers, and nonprofits that provide information and services to expectant and new families, and steer employees towards healthier options through education and improved access.

Through the tools and skills of negotiation, leveraging business relationships, utilization of resources, and government and community engagement, corporations can play a major part in quickly changing the quality of our maternity care system.  It is in their best interest to do so, and it is their responsibility to do so.  As long as corporations continue to take on the role of healthcare payers, it is reasonable for society to expect a high level of corporate engagement in ensuring the system they are paying for produces good outcomes at reasonable cost.

We know our maternity care system is broken, and there are many steps that will need to be taken to fix it.  Our regulatory, legal, and compensation systems will need reform.  We need to change our education system so that we have enough midwives and doctors coming through the learning pipeline to manage all the births that take place every year in our country.  We need to ensure that the information these students are learning about birth is accurate, evidence-based, and clinically appropriate.  Research must be unbiased and include qualitative evidence so that the psychological and emotional aspects of birth are understood as well as the physical aspects.  Women must have physical and financial access to normal, physiologic birth in hospitals, birth centers, and at home, which means that midwives and birth centers must be legal and accessible in every state.  In order for these changes to happen, the infrastructure our current system will have to undergo drastic changes that will reduce the number of hospital beds and displace obstetricians, who are surgical specialists.  It is not enough for advocates of maternity care reform to demand change; we must also work together with the existing systems to find creative, workable solutions which focus on having healthy women and babies as the primary result.

Evidence shows that midwifery care outside of the hospital setting provides comparable outcomes for babies and improved outcomes for mothers at much lower cost than hospital birth.  That is causing competition to grow with doctors, Certified Nurse Midwives, and hospitals, many of which are educational institutions, on one side and Certified Professional Midwives and independent birth centers on the other.  From a fiscal point of view, this is a David vs. Goliath fight.  Billions of dollars flow through the hospitals systems, while birth centers are small, independent businesses.  According to Salary.com, Obstetricians are paid a median income of $251,374, while Certified Nurse Midwives are paid $92,115, and SimplyHired.com puts the annual salary for Certified Professional Midwives at $50,000.  “Big Birth” is trying to eliminate its smaller competitors to maintain market share, even while the evidence and financials support the benefits of utilizing less costly practitioners.

Viewed through a lens of improving outcomes though, opportunities exist that might satisfy both sides.  Reducing malpractice cost is a primary concern, because that is what is driving the maternity care system currently.  Obstetricians can pay between $85,000 and $200,000 for malpractice insurance.  Rising payouts for non-economic damages and punitive damages drive the malpractice rates to dizzying levels.  The problem is that sick babies are expensive to care for, and even when doctors and hospitals are not at fault for poor outcomes, they have the deep pockets to cover the costs of ongoing care.  Many years ago, Suzanne Arms, an advocate for maternity care reform, suggested creating a superfund that would be used to support children born with birth defects, genetic illnesses, and other poor outcomes that are not due to negligence but are financially overwhelming to parents.  Having an option to care for sick children that is not tied to the legal system would go far in reducing the pressure on doctors and hospitals to provide perfect results in an imperfect world.  Implementing such a plan today would break the stranglehold that risk management has over giving appropriate care to pregnant women.

Furthermore, a common practice now is for hospitals to build new wings to accommodate more labor and delivery beds that accommodate patients who have Cesareans.  This creates the revolving problem of having more beds, so they need to be filled to pay for them.  Why not purchase or rent nearby existing buildings that could be converted into freestanding birth centers to accommodate the low-risk birthing women?  This would free the in-hospital beds for the small percentage of women who truly need to have surgical births, while offering the more appropriate level and style of care that most birthing women need.  These “flex spaces” would allow for changes in the needs of the community in terms of numbers of beds as populations ebb and flow.  More out-of-hospital births that are still connected with learning institutions would provide more opportunities for medical and midwifery students to learn about and research normal, physiologic birth in a way that they are not able to do now in hospitals.  Also, they would provide more access to safe, appropriate, cost-effective care to birthing women.  These freestanding birth centers that employ a mix of obstetricians, CNMs and CPMs would be models for collaborative care.

We know that money is major factor that drives decision-making, but outcomes must also be at the top of our list of priorities.  Right now, our outcomes are terrible – in fact, they are some of the worst in the industrialized world.  It is time that all the elements in the system work cooperatively to take steps to change this broken system.  There will be mid-points where compromise will be necessary on all sides, and the groups with less money and fewer, less influential voices must be allowed an equal seat at the table.  There are many bright, motivated people working to improve care for birthing women and babies, and there are many opportunities to employ creative solutions to the vexing problems within our maternity care system.

It would be simple to say that the problems in maternity care in this country, including high intervention rates, poor outcomes and high cost, are “women’s problems,” but it would be untrue.  Men are deeply affected by the crisis in maternity care now too.  On a personal level, as fathers, they carry the heavy burden of caring for their partners throughout pregnancy, birth, and the postpartum period.  Expectations of parental involvement in pregnancy are high now, and many men must juggle the daily demands of their jobs with medical appointments, prenatal testing, ultrasounds, which require time off during working hours and pull them away from their workplace.  Finances and job security are high on their list of concerns at the same time that they are called away to support their partner and participate in the pregnancy.  Managing childbirth classes and dealing with major life changes such as finding space in the house for the new baby, or having to purchase a bigger car or baby furnishings weigh heavy in men’s minds.  Stress is increased if their partner or newborn needs extra care, which can further affect their attendance and performance at work.  Their income is affected in the form of insurance premiums, co-pays, and deductibles when paying for care that is more expensive than it needs to be, and fosters poor outcomes that demand even more care. 

 

The psychological effects of managing the conflicts and dealing with the additional stresses of parenthood as a working father can take a toll in terms of productivity on the job.  This can create a vicious cycle of stress reducing productivity, which further increases the stress.  This level of high anxiety can affect a man’s health, his ability to do his job, his connection to his partner, and his connection to his baby.  Extended periods like this can ultimately even effect his partner and child if it leads to illness or abuse.

 

Businesses that provide family friendly work environments create programs that reduce these types of conflicts and stresses.  Flex-time, telecommuting, in-house support resources including financial planning and childcare can go a long way towards making a work/family life balance achievable for working fathers.  Men who are given the tools they need to manage the demands of both work and family are happier and more productive on the job.  Businesses that strive to go the extra mile to help their employees reach that balance will find that the costs associated with these programs are offset by lower healthcare costs, less absenteeism, and a more loyal workforce.

 

The ultimate program that businesses can work to implement though, is a reworking of our healthcare system so that the system is more efficient, less costly, and produces better outcomes.  That would reduce everyone’s stress levels.

 

In last week’s post we learned that businesses could save millions of dollars by reducing the number of cesarean sections their insured employees and dependents incur in their maternity care.  What are the downstream effects of avoiding those cesareans?  Are there more savings and benefits to be had?  Why yes, as a matter of fact, there are!

Women who have spontaneous vaginal birth experience fewer infections and readmissions to the hospital for complications.  To give an idea of the costs associated with hospital readmission, a 2012 report from the Northeast Business Group on Health states that preventable readmissions cost an estimated $25 billion a year and happen frequently in commercially insured populations.  Almost twice as many women who have cesareans are readmitted to the hospital than women who have had vaginal births.

A cesarean is major abdominal surgery.  By avoiding it there is a shorter recovery time with fewer problems relating to general health, bodily pain, extreme tiredness, sleep issues, bowel issues, the ability to carry out daily activities, and ability to perform strenuous activities which are common to women recovering from C-section surgery.  Furthermore, many women who have had cesareans develop long-term health problems relating to the surgery such as adhesions, chronic pain and numbness at the incision site.  To resolve these issues, women sometimes need physical therapy or sometimes even a further surgery, which can cost between $3,000 and $16,000.  The real cost and human capital savings come later, during subsequent pregnancies, by avoiding dangerous life-threatening complications such as hemorrhage and placental abnormalities, which can be deadly for mother and baby.

Babies born via the traditional route are less likely to be admitted to the Neonatal Intensive Care Unit (NICU.)  The Childbirth Connection report “The Cost of Having a baby in the United States” shows the “total average allowed payments for newborns that required an intensive care admission were $32,595 for newborns from vaginal childbirths and $47,429 for newborns from cesarean childbirths,” and the rates for NICU admissions for babies born via cesarean were 13% vs. 6% for normal births.

By not having to recover from surgery, breastfeeding is more likely to be initiated and maintained for longer periods of time.  This leads to healthier babies with fewer allergies and asthma, less likelihood of Type 1 diabetes and obesity, and fewer cases of breast cancer and diabetes in the moms. In fact, a 2010 study in Pediatrics stated that the U.S. could save $13 billion if breastfeeding for 6 months became the norm.

Better emotional health can be a result of avoiding an unexpected cesarean.  Women who have cesareans are more likely to suffer from postpartum depression, and that can have a serious effect on their ability to be focused and productive when they return to work.

Keeping all these numbers in mind, doesn’t it seem worthwhile to actively seek out opportunities in your workplace where you can steer the people you insure away from costly, unnecessary surgery?

How many cesarean sections does your corporate insurance plan pay for in a year?  If you work in an industry unrelated to maternity care, you may not think to ask this question – but you should.  Why?  Because the current cesarean rate in the U.S. today is over 30%, even though the World Health Organization estimates that 15% is the optimal rate for balancing the risks of this major surgery against the benefits. If your business were to achieve half the national rate (i.e. the optimal rate of 15%) it could save your company thousands, if not millions of dollars a year.

“The Cost of Having a Baby in the United States,” a recent report released in January 2013 by Childbirth Connection, states that maternity costs in the US have risen by 50% since 2004 and the “average total Commercial insurer payments for all maternal and newborn care with vaginal and cesarean childbirths were $18,329 and $27,866, respectively.”    By avoiding one employee’s cesarean section a year a small company could save more than $9,500.  Ten cesareans avoided saves $95,000, and 100 unnecessary cesareans averted by a corporation that currently pays for 350 births annually saves almost one million dollars in a year.

You may be thinking that cesarean surgery is necessary to save the lives of either the mothers or the babies who experience this type of birth.  It is true that cesarean, also called C-section, is a life-saving technique.  However, they are considered by many experts to be overused.  Our nation’s rising maternal death rates, which already put us at the bottom of the barrel compared with other industrialized nations, show that our high rate of C-section is not providing the lifesaving outcomes we desire from such a costly intervention.

Furthermore, a recent study released by the American Academy of Birth Centers shows that ”women who receive care at midwife-led birth centers incur lower medical costs and are less likely to have cesarean birth compared to women who give birth at hospitals.”  In fact, the cesarean rates for women transferred to hospitals from birth centers was 6%.  This shows that is possible for our maternity care system to do better.

Reforming our maternity care system is a David vs. Goliath fight.  Reform-minded underdogs such as midwives and consumer advocates who are armed with scientific and qualitative evidence and cost-saving practices are coming up against well-funded entrenched stakeholders like hospitals, medical societies, and insurance companies that are fighting to keep the status-quo to protect their bottom line.  Savvy businesses will recognize that because they are commercial insurers of their employees they already have a horse in this race.  It is time for corporations to learn about maternity care, the same way they have about other wellness issues and chronic illness control for their employees, to help bring about changes that will improve outcomes and save lives, and also save our nation billions of healthcare dollars in the process.

The first step for businesses to take to ensure they can realize cost savings in maternity care is to flex their economic muscles and let insurers, hospitals, and medical societies know that lowering the cesarean rate is a priority for your business.  Purchases of insurance products, benefits, and wellness packages should reflect that priority.  If the adequate products don’t yet exist, corporations can demand that they be created.  Healthcare improvement collaboratives can help smaller businesses leverage their power to demand these types of products.  Corporate gifts and grants to hospitals can come with the caveat that the hospital show annual progress in reducing their cesarean rates toward the 15% mark and poor results=no more money.  Push back against organizations that lobby for non-evidence-based care practices, the exclusion of birth centers, and the limiting of the practice of midwives as care providers.  Ensuring access at the state and national levels to birth centers and midwives for care will be an important pathway to economic savings in the coming years.

What can your company do to help employees reduce their chance of having a cesarean birth?

(Truven Health Analytics, Childbirth Connection, Catalyst for Payment Reform, Center for Healthcare Quality and Payment Reform, 2013)

(Susan Rutledge Stapleton CNM, 2013)

How easily can the women you cover with your benefits packages access low-cost, low intervention maternity care?  There is a lot of discussion around the internet these days about how the use of midwives and birth centers could save the government billions of dollars because it pays for almost half the births in this country through Medicaid.  Who pays for the other half of the births in the country?  American businesses, through their employee benefits packages.  The style of care that midwives in birth centers and out-of-hospital provide is low-intervention and lower cost, is beneficial for the majority of women giving birth, most of whom are considered at low risk for problems with their pregnancies, and leads to better outcomes with less morbidity.  That’s great, but if women can’t access it, then it doesn’t lead to cost savings.  Women can’t access midwifery care if state legislation does not support it.

In order to see the cost and performance benefits of midwifery care, out-of-hospital midwifery and birth center regulations, along with payment structures, must be aligned with the goal of providing widespread access.  These state-level regulations are set through legislation.  Every state has a different set of rules dictating what type of licensure midwives must have, how birth centers must function – if they are allowed at all, and whether or not payment is required through Medicaid or Medicare and private insurance.

The ideal legislation would:

  • Set clear guidelines for who may legally practice as a midwife out-of-hospital, and include all the pathways for licensure, including Certified Nurse Midwives, Certified Professional Midwives, Certified Midwives, and Licensed Midwives
  • Allow midwives who practice out-of-hospital to be regulated by midwifery boards, not medical boards and have no requirement for written collaborative practice agreements with obstetricians
  • Allow independent birth centers to operate unencumbered by onerous rules
  • Require that all types of licensed midwives be reimbursed by Medicaid, and also private insurance
  • Provide adequate funding and appropriate regulation of the educational system in order to train more midwives

26 states currently have legislation that regulates out-of-hospital midwifery.   10 states outlaw direct-entry midwifery, and 14 states have ambiguous regulations or licensure is unavailable.   82% of states have regulations regarding birth centers, and it is important to know if those regulations in your state favor them or not.  There are also regular pushes by medical trade groups, hospital organizations, and medical boards to alter legislation to favor hospital birth in order to maintain market share.  There is a lot of money at stake when it comes to maternity care, and hospitals and doctors are reluctant to allow the competition that midwifery creates in the marketplace.

If legislation doesn’t align to provide your employees with access to midwifery and birth center maternity care, your business will continue to pay top dollar.