Million-dollar babies

ITIJ 201, Cost Containment Review, October 2017
Whether through educational wellness plans or smart policy language, international health insurance providers have a chance to limit their exposure to increasing maternity costs
Since 1985, according to the World Health Organization (WHO), the international healthcare community has considered the ideal rate for caesarean sections (C-sections) to be between 10 and 15 per cent. Since then, C-sections have become increasingly common in both developed and developing countries. When medically necessary, the procedure can effectively prevent maternal and newborn mortality – in fact, two new HRP studies show that when C-section rates rise towards 10 per cent across a population, the number of maternal and newborn deaths decrease. When the rate goes above 10 per cent, there is no evidence that mortality rates improve. A 2015 WHO statement into caesarean rates also found that they ‘represent a significant expense for overloaded – and often weakened – health systems’. 
Where in the world?
A report entitled The Increasing Trend in Caesarean Section Rates: Global, Regional and National Estimates: 1990-20141 considered the variations between geographic regions. It found that Latin America and the Caribbean has the highest C-section rate with 40.5 per cent of births, followed by North America (32.3 per cent), Oceania (31.1 per cent), Europe (25 per cent), Asia (19.2 per cent) and Africa (7.3 per cent). Another study published in 2015 in the BJOG journal took in C-section rates in 26 European nations and found wide variations – 25 per cent of births in the UK are C-sections, while in Cyprus the figure is 52 per cent and in Sweden it is 17 per cent. When narrowed down to take into account C-sections planned before labour started, Cyprus still took the top spot with 38.8 per cent, followed by Italy with 25 per cent.
A report from Aetna International (Striking the right balance: Global caesarean delivery rates in an era of controversy) has highlighted how the lack of effective pre-natal guidance is impacting global caesarean rates. Data from Aetna International’s Beginning Right International Maternity Program revealed that in 2015, the rate of caesarean delivery amongst insured members in Dubai, for example, was 25-per-cent higher than the average of 19 per cent recommended by a recent Journal of the American Medical Association (JAMA) article. Factors such as medical liability law and the medical malpractice environment, financial incentives and scheduling convenience have contributed to this global surge in caesarean deliveries, according to Aetna. 
“Regional differences in caesarean rates highlight a medical imperative – to give expectant mothers consistent guidance on when surgical delivery is necessary,” said Dr Lori Stetz, Aetna’s senior medical director. “For this reason, Aetna International’s Beginning Right International Maternity Program provides expectant mothers with information and counselling on caesarean sections to ensure that any decision is made for the right reasons.” Dr Stetz noted that the Middle East, India and China are seeing greatly increased rates of C-sections. The increased availability of the procedure is certainly one aspect of why this change is taking place.
It’s vital that pregnant women are getting the information and advice they need, and from the right sources, Dr Stetz added: “Women need comprehensive prenatal and maternity support, and that can only be achieved when medical professionals listen to their needs, outline various birth options, and explain the risks and benefits so that the most suitable approach is identified. With this kind of respectful support, women can understand when recommendations are driven by medical necessity and when they are influenced by hospital, practitioner or other cultural factors.” 
The hospital, for instance, could have a certain vested interest in encouraging its patients to have a C-section. For the physician and facility, a C-section means that a birth is controlled, timed and risk-managed, not to mention the benefits of the procedure being significantly more expensive. Cultural factors, though, also have a role to play. Dr Stetz noted that a colleague in China had told her that in their hospital, the C-section rate stands at around 50 per cent of all births. While this is partly due to a rising middle class income and higher levels of medical care and thus availability of the procedure, Dr Stetz also suggested that the former one-child policy could have a part to play. One of the downsides to having a C-section for a first baby is that it is recommended by physicians that a woman has the procedure again if she has a second or third child, as it can be more difficult for a woman to carry a baby safely to term and have a normal delivery if she has had a C-section. However, China’s past one-child policy means that now, culturally, there is an expectation that there will only be one child, so this aspect of a C-section would not act as a deterrent to women considering this procedure.
First, do no harm
Dr Stetz was keen to highlight that ensuring appropriate caesarean section rates around the world are achieved is vital, as it avoids unnecessary harm to mothers and babies and lessens the impact on the wider healthcare community – not just on cost, but also on social care needs afterwards. “As it stands,” she said, “caesarean births [in the US] cost the healthcare system two-thirds more than vaginal births, and the increased recovery time from the surgery has a greater impact on wider society – for example, [in terms of] social care.”
Denise Buckland, senior vice-president of operations at International Medical Group (IMG) and a former obstetrics nurse, told the Cost Containment Review: “The costs of a caesarean vary worldwide and are relative to the cost of all medical care in a particular geographic location, but it remains that a C-section is more expensive than a vaginal delivery.”
And the cost can be seriously high, no matter what kind of cost containment practices are employed, or what kind of agreement an insurer has with a hospital. A five-night pre-booked C-section package in Matilda Hospital in Hong Kong starts at HKS$31,500, and can climb as high as $100,500. A straightforward vaginal delivery with an epidural costs $7,300. Little wonder, then, that health insurance providers are keen to offer women every opportunity to avoid an unnecessary C-section. 
So what are they doing to this end?
“Countries and healthcare partners need to look at how to provide high-quality care in all settings and achieve the right proportion of intervention, resulting in healthy mothers and babies,” said Aetna’s Dr Stetz. “We believe the key to this is working at a local level with the needs of individuals in mind, encouraging the appropriate development of emerging healthcare systems, and fostering the safe and effective use of medical technology all over the world.”
Insurance measures in place
Addressing the development of healthcare systems in emerging economies and changing cultural perceptions are enormous tasks, though, and ones that will take many years to implement and come to fruition. So what can insurers do now to minimise the costs incurred by medically unnecessary C-sections?
“To avoid the costs of paying for a planned C-section that in many cases is scheduled for convenience, insurance providers could implement a precertification process in which coverage for a caesarean is evaluated based on medical necessity,” said Denise Buckland. “Everybody considers the review of medical necessity as red tape, but it’s a key component in containing costs. This practice may not be popular, but it’s the only way to mitigate the cost of scheduled C-sections. IMG has this precertification in place under our long-term IPMI products that provide maternity benefits.” 
Dr Stetz told the Cost Containment Review that while Aetna’s IPMI policies didn’t used to contain any exclusions relating to C-sections, they do now, as the general policy language used previously meant that there was some room for abuse by a medical professional or a client. Now, the medical necessity of a C-section has to be justified by the treating doctor. The company has a list of medical conditions that must be met for a pregnant woman to be approved for a C-section. If the insured doesn’t meet with the requirements, then the company will pay for the cost of a vaginal delivery, but should the client choose a C-section anyway, then they will meet the cost difference.
Buckland added: “Our long-term IPMI products that include maternity benefits offer prenatal advice that encourages a healthy lifestyle during pregnancy. We also offer case management for members who are experiencing a complicated pregnancy and need more assistance in managing their health. In theory, good prenatal advice could help decrease the rate of C-sections. For example, by providing prenatal advice regarding appropriate levels of weight gain and dietary habits during pregnancy, a woman can more appropriately control her blood sugar and eating habits, allowing the foetus to develop at a normal size and decreasing the need for a planned C-section.”
Small print, big impact
At the end of the day, insurance companies are not going to deny coverage for a medically necessary C-section for anyone. However, there is little doubt that the rate of medically unnecessary procedures is increasing, and the cost to insurers is high, hence the introduction of policy language that will minimise abuse of benefits and encourage women to get the right education about the choices they face during their pregnancy and birth. All surgical procedures come with some risk, but major abdominal surgery is not to be taken lightly. By engaging early on with their insureds, as well as their treating physicians, insurers can make sure that their clients are treated appropriately and according to their best interests while ensuring policy guidelines are adhered to. n

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