Q&A: Covered California’s Dr. Lance Lang on the state’s high C-section rates, and what’s being done to curb them
C-section rates have risen in hospitals across the country, and the procedure often brings little benefit to mother or child in low-risk pregnancies. For the past decade, major health organizations throughout California have coordinated efforts to further understand wide variations in C-section rates between hospitals, and to develop a strategy to bring down numbers. Covered California, the state’s health exchange, has been one of several organizations in the state pushing for change. The Center for Health Journalism recently spoke with Covered California’s Chief Medical Officer Dr. Lance Lang to find out how the state is trying to curb C-section rates and what aspects of the story journalists should keep an eye on.
The following interview has been edited for length and clarity.
Q: How do California’s C-section rates compare nationally?
A: What’s important about California’s C-section rates is the variation. The point that matters most for an individual woman is not the state’s average, but what the rate is in the hospital she goes to. The problem is that the range throughout the state is still around 12 percent at the low end and 69 percent at the high end. That means that what happens during labor for an individual woman is determined more by what hospital she’s in than her actual health.
Q: What do you think is driving such wide variation in the number of cesareans?
A: A number of things, both economic and cultural, and mostly provider driven: It’s a lack of applying evidence in a systematic way. It’s a lack of knowledge that the C-section rate is as high as it is in a given hospital, because you’re not tracking it. It’s the fact that payments are higher for C-sections than for vaginal deliveries, at least for hospitals. It’s the fact that OB-GYNs have very busy lives and it’s much faster and more efficient for their schedule to do a C-section. And it’s a lack of back up: There’s nobody in the hospital during after-hours who can do a cesarean, so there’s often an artificial deadline to try to get done before a doctor has to leave for the weekend. Additionally, cesareans used to be thought of as an unusual event, but over time people have normalized the procedure.
Q: Could you describe how the California Health Care Foundation’s Maternal Quality Care Collaborative (CMQCC) and Maternal Data Center are working to reduce low-risk C-section rates in the state?
A: It’s been a coordinated effort that spans a decade. CHCF provided funding for the data center and CMQCC, a statewide organization that works to reduce disparities in maternal care, under the leadership of medical director Dr. Elliott Main. It’s remarkable how much improvement you can get just by collecting data on C-sections, comparing notes, and making sure every doctor and hospital knows their C-section rate.
It’s a huge intervention that’s being systematically done across the state, involving data, consumer engagement, quality improvement and payment reform. Millions have been spent collecting and validating maternity data through the Maternal Data Center, which has informed the development of evidence-based clinical interventions. Over the last few years, Dr. Main has also worked with national entities including the American College of Obstetrics and Gynecology to develop educational materials that are useful for all hospital staff who support natural delivery, not just doctors. They’ve been able to supplement collected data with a solid understanding of what the best practices are to support a natural delivery. In addition, data is now released publicly.
In the last year, we started working with Diana Dooley, California’s Secretary of Health and Human Services, to publish an honor roll of hospitals who’ve gotten their C-section rates under the national target rate of 23.9 percent. The media has begun calling hospitals in their community to praise them for their inclusion, or to ask why they weren’t able to make the cut. Both are terrific; hospitals that are doing a good job need recognition, and hospitals who haven’t gotten there need encouragement.
Also, the Robert Wood Johnson Foundation worked with the Pacific Business Group on Health (PBGH) and Disney to fund a pilot in three hospitals that showed that you can lower C-section rates in a hospital by 20 percent in one year, proving that these high rates are something that hospitals can change.
Q: Unnecessary C-sections impact health care costs. Could you describe the rationale for this?
A: If you separate cost and charges, then traditionally charges are greater for C-section. But when you take into account providing nursing through a long labor, not to mention the physician back up needed in case something goes wrong, supporting a high vaginal delivery rate is more expensive than defaulting to a high C-section rate, when it’s done right. So, if you pay more for a C-section when we know it costs more in terms of real overall expenses to support vaginal deliveries, that leads to perverse outcomes. You’ve got to align payment incentives with the quality goal that you’re seeking. It’s just that simple. If you’re paying more to just have episodic C-sections, then all the money is going there instead of where it needs to be — developing a system that supports the right kind of care.
The background on this is that for any number of cultural reasons in this country, we pay more and value more for doing things like surgery. We don’t always use good judgment to know when surgery is needed or to help people work through their other options. We pay more for surgery than we do for the nurturing support that’s necessary to help women through long labors. That’s just nuts, so we’re trying to reverse that trend. Surgeons make more than medical doctors, and there are a lot of people who think that causes perverse outcomes in our system.
Q: What has Covered California done to encourage lower C-section rates?
A: At Covered California, we used the results of the pilot led by the Pacific Business Group on Health to require that all hospitals in any network our 11 health plans provide must hit the national target of 23.9 percent by 2019. Any hospital that isn’t working towards this target will be questioned as to whether they should be part of our insurers’ networks. If you didn’t have the data, the guidelines, the educational support, and demonstrated proof that we can change rates from all the work that came before, then setting a deadline would be meaningless. Our goal is not narrow networks but rather quality improvement projects with a deadline.
We’re also aligning with all the major health care purchasers in the state through Smart Care California, a public-private partnership that includes Covered California, CalPERS, Medi-Cal, CHCF, PBGH, and many others, because variation is a problem not only at the hospital level, but also among purchasers. If all the payers coordinate to make this a priority, changes to the health care delivery system will follow.
Q: Are there any stories that journalists on the maternal care beat should keep an eye out for in the upcoming months?
A: In a recent meeting, we heard from Dr. Main, who also leads a national effort to look at how best to pay for maternal services. He reported to our group of stakeholders about the best payment methods to remove the financial incentive towards unnecessary low-risk C-sections, and about how some hospitals and payers have been experimenting with different economic models.
We plan to adopt a menu of options, and I imagine most of them will lean in the direction of a blended reimbursement rate, where you basically pay the same for all deliveries, whether vaginal or cesarean. There are some folks that have experimented with actually paying more for vaginal deliveries, but there are people who worry that you might actually create incentives that would cause some to avoid C-sections, even when they’re medically necessary.
[Photo by Kelly Sue DeConnick via Flickr.]