Rant: Health Care Reform/Pregnancy

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Since Health Care Reform is a hot top­ic, let’s look at it from the per­spec­tive of preg­nan­cy and birth.

What revi­sions would most ben­e­fit preg­nant women, their off­spring, fam­i­lies and com­mu­ni­ties?

1. Reward healthy behav­iors. A sys­tem that pro­vides reduced pre­mi­ums for health care for women who exer­cise, eat well, do not smoke and are in a nor­mal weight range is evi­dence-based.

Yes! We could pro­vide finan­cial incen­tives for being healthy dur­ing preg­nan­cy. Why? Healthy moms have healthy babies; healthy babies cost the pay­er less mon­ey.

2. Review best prac­tices. Is a 40 or 50% cesare­an rate the best prac­tice?  Accom­pa­ny­ing the rise in cesare­an births is grow­ing infor­ma­tion that babies born by cesare­an are at increased risk for a num­ber of immune dis­or­ders. But the busi­ness mod­el of med­i­cine rewards cesare­an because it both pays the provider more and is defen­sive med­ical prac­tice.

Fetal mon­i­tor­ing to deter­mine if a cesare­an may be nec­es­sary, is wrong 3/4 of the time. In an effort to change this, guide­lines are chang­ing for the use of mon­i­tors dur­ing labor. What is the evi­dence that this change of prac­tice is ben­e­fi­cial? Will it lead to more or less mon­i­tor­ing, which may itself be an inter­ven­tion that can dis­rupt nor­mal labor?

3. Change the busi­ness mod­el for health care. When we make finan­cial incen­tives for care providers, base them on best prac­tice, not on enrich­ing the mid­dle man. Cur­rent­ly the pay­ers (insur­ance com­pa­nies) are mid­dle men, mak­ing mon­ey (i.e., con­duct­ing busi­ness) by charg­ing fees. They ration pay­ments for ser­vices in order to pay their own salaries and over­head. They do not actu­al­ly do any­thing pro­duc­tive. This is why sin­gle pay­er, gov­ern­ment, and health care coop options have been pro­posed. They elim­i­nate most of the cum­ber­some mid­dle lay­er.

Why does insur­ance pay for cesare­ans? Well, they will do it once. After all, the care providers have to prac­tice defen­sive med­i­cine. But, once you have a cesare­an, you become a risk for the insur­ance com­pa­ny (they know what the research says about cesare­ans and off­spring health prob­lems) and may be denied insur­ance. They can no longer afford you.

Because care providers are paid fee for ser­vice and must prac­tice defen­sive med­i­cine, preg­nan­cy and birth have become increas­ing­ly bur­dened with inter­ven­ing pro­ce­dures that do not nec­es­sar­i­ly pro­mote a healthy preg­nan­cy or birth process. How is this play­ing out? Increas­ing­ly, we see women giv­ing birth in what they per­ceive as a more sup­port­ive and health-induc­ing set­ting:  their own homes. Think of it this way:  many women now believe that it is safer to stay home than go to a hos­pi­tal to give birth.

Unless health care becomes about best prac­tices and healthy out­comes — not price, size, and get­ting paid for pass­ing mon­ey back and forth — the U.S. will con­tin­ue to have some of the worst maternal/infant out­comes in the devel­oped world.