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.
