Welcome to the third in our series of blogs in which we examine the SMART Act’s changes to the Illinois Medicaid system. As a quick reminder, we think that truly smart health care policy has three components:
- Providing great outcomes and preventing bad ones.
- Caring for the whole person.
- Fiscal sustainability.
This blog will focus on a change we think does achieve smart health care policy—Illinois Medicaid will now no longer pay an extra amount for medically unnecessary, or elective, Cesarean (C-section) births, but instead will cover them only at the normal vaginal delivery rate. Hopefully, this change will decrease the number of parents choosing C-sections for non-medical reasons by creating impetus for parents and health care providers to have a serious talk about why they would like to schedule a medically unnecessary C-section. Even though C-sections are very common and comprise about one third of all births in the United States and a similar percentage in Illinois, a Cesarean birth is still a major abdominal surgery. This means that a C-section comes with all of the risks associated with other common surgeries, including adverse reactions to medications and increased risk of infection for the mother, along with health risks for the baby. To top it off, billing for an uncomplicated C-section birth is almost double that of a vaginal birth. The State of Illinois estimates that eliminating medically unnecessary C-sections will save about close to $3 million in the next year. All those health risks and more expensive, too? Sounds like a good place to start improving Medicaid.
So why are medically unnecessary C-sections a choice for some people? Parents and doctors might schedule medically unnecessary C-sections for a variety of reasons, including wanting to deliver with a particular doctor or on a particular day, desire to avoid prolonged labor pains, or desire to avoid the uncomfortable last few weeks of a pregnancy.
However, the World Health Organization strongly cautions against medically unnecessary C-sections. Medical professionals say that medically unnecessary C-sections are more likely to cause problems for both the mother and the baby. Scheduling C-sections for reasons of convenience often result in the surgeries occurring prior to the 39th week. Babies do better when their C-sections come no sooner than one week before their due date, if at all possible. This wait allows their lungs, brains and kidneys to finish developing. Babies born by C-section have, on average, more difficulty breathing after birth and have lower Apgar scores. Particularly at risk are those infants delivered before 39 weeks, a segment which includes one in three C-sections. These infants are at risk for eating and breathing problems, jaundice, and temperature instability and are at greater risk of being re-hospitalized for poor weight gain or failure to thrive. Mothers have a longer recovery time and a higher risk of complications from C-sections than from vaginal births. Complications can include blood clots, excessive bleeding, infections, and injury to the bladder, uterus, or bowel. Of course, all of these avoidable but serious complications cost the Medicaid program more money.
Some hospitals are already implementing procedures to cut down on their numbers of medically unnecessary C-sections. In Salt Lake City, Intermountain Hospital has implemented a program to encourage parents and health care providers to carefully consider the rationale for C-sections. This successful program has kept their C-section rate below the national average, thereby decreasing patient costs by more than $270 million over a 10-year period. The hospital states that $3.5 billion could be saved in annual medical charges if the national rate of C-section births was comparable to their own. In addition to saving money, Intermountain accomplished an even greater goal—better medical outcomes.
Of course, some situations will call for a Cesarean section for reasons of medical safety, like some births involving multiple children, risky situations or older mothers. Medically necessary C-sections will still be covered at the higher rate under Medicaid; it’s only the elective C-sections that will be covered at the less expensive vaginal birth rate. This should cut down on the numbers of elective C-sections, saving money and improving health outcomes at the same time. Healthier outcomes for moms and babies from a less expensive procedure? Sounds like it fulfils all the prongs of our test!