June 2018 Letter from the Deputy Director: Meeting Safety and Quality Targets
Nancy Guinto is on a well-deserved vacation, so this month’s letter is from the Alliance’s deputy director, Susie Dade.
Just a couple of states away, Covered California – the state’s health insurance marketplace under the Affordable Care Act – announced it will exclude hospitals from being “in-network” if the hospitals haven’t met targets for safety and quality. They include several targets and one of them is performing fewer unnecessary cesarean sections (C-sections).
When medically necessary to protect the life and well-being of mother or child, a C-section is a good thing – a very good thing. But it’s major surgery and with it comes longer recovery times, significant risks and potential serious complications for both mother and baby. Not only are C-sections riskier, they cost considerably more and with high deductible health plans, women and families may end up with much higher bills than they anticipate or can afford. And let’s not forget that purchasers get a big bill as well. For many purchasers, the total cost of maternity care for their covered population represents a significant burden and is a priority to manage.
Bottom line: Women shouldn’t have a C-section unless absolutely necessary. Health care providers have an essential role to play in providing patient education and shared decision-making – and having systems in place to ensure C-sections ONLY occur when medically necessary. But far too often, C-sections occur for other reasons, such as patient or physician convenience or efficiency, common labor interventions that make C-sections more likely (e.g., inducing labor among first-time mothers), and casual attitudes about surgery.
Let’s delve into the data a bit. According to the Centers for Disease Control and Prevention, the national C-section rate is 32 percent (CY 2016). In Washington, the state average is 24 percent (CY 2017).
We know from our work at the Alliance that rates vary considerably based on where people live in the state and by hospital. For example, in the Alliance’s recent Different Regions, Different Care series that looks at how care differs based on where people live, we reported the percentage of all deliveries that were by C-section, relying on claims data from mid-2015 to mid-2016. Women who live in Yakima had a lower C-section rate: 21 percent for commercially-insured women and 16 percent for women insured through Medicaid. On the high end of the range, we saw 39 percent for commercially-insured women and 35 percent for women insured through Medicaid in Pullman and Omak, respectively.
By hospital, we see just as much variation. According to the latest Community Checkup report, some hospitals have rates less than 10 percent (e.g., Mason General Hospital & Family of Clinics) while a number of others are 30 percent or higher (e.g., Grays Harbor Community Hospital, Overlake Medical Center, Providence St. Mary Medical Center, Providence St. Peter Hospital, UW Medical Center).
The good news is that Washington’s average is well below the national average and the California state average. But at 24 percent, our state’s overall rate of C-sections is still too high. The World Health Organization states that the ideal rate for C-sections is between 10-15 percent, while a recent Journal of the American Medical Association study showed optimal C-section rates may be as high as 19 percent. So, the bad news is that regardless of which target we look to, Washington state has room to improve overall and some hospitals have significant room for improvement.
Fortunately, in Washington we have a State Hospital Association that works hard to get out in front of important quality improvement opportunities. According to Jennifer Graves, senior vice president for quality and safety at WSHA, they’ve been leading a Safe Deliveries Roadmap initiative for several years to improve maternal and infant outcomes including the reduction of unnecessary C-sections. Jennifer says, “Our efforts have included partnering with multiple stakeholders to develop best practice bundles, robust monthly virtual education for hospital staff, in-person Safe Table conferences, hospital site visits and quarterly data reports. Collectively, our efforts have demonstrated a reduction in the state-wide C-section rate and our focus is now to assist those hospitals who are still struggling with higher rates to identify possible challenges and opportunities.”
From our vantage point at the Alliance, the topic of C-sections lies squarely at the intersection of lower and higher value health care. Hospitals get paid more to perform C-sections and they usually take less time, so there’s an incentive there that is not well-aligned with the outcome we’d like to see. Excessive use of C-sections as a birthing option – for whatever reason – simply means that far too many women are undergoing major abdominal surgery without medical necessity. This poses a significant patient safety concern for mom and baby and a cost issue for purchasers and consumers. It is undeniably low-value health care with a potential for harm. In California, they have clearly said “times up.” The California marketplace’s position on C-sections may well be a harbinger of what’s to come as public and private purchasers in Washington and elsewhere seek higher value for their health care dollar. Tick tock.
Washington Health Alliance