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After insurance reform, fewer pregnant women have scheduled deliveries
March 7, 2017 / 9:17 PM / 10 months ago

After insurance reform, fewer pregnant women have scheduled deliveries

(Reuters Health) - Low-income pregnant women in Texas were up to 14 percent less likely to deliver babies unnecessarily early after the state’s Medicaid insurance program stopped paying for preterm elective births in 2011, a new study shows.

Babies were born five days later and six ounces heavier in Texas on average than in a group of comparison states that continued to pay doctors and hospitals for scheduled, or elective, early deliveries, according to a report released Monday in Health Affairs.

Infants born after a full 39-week term are more likely to thrive, previous studies have shown. But doctors deliver 1 in 10 American babies early - either by inducing labor, performing a cesarean section, or both - in cases that fail to justify early intervention, the authors write.

“Payment reform was an effective tool in reducing early elective deliveries,” lead author Heather Dahlen said in a phone interview.

Reducing elective early deliveries could potentially yield important gains in newborns’ outcomes, said Dahlen, who is a health economist and a research fellow at Medica Research Institute in Minnetonka, Minnesota.

The high rate of preterm births in the U.S. has been a major factor in its infant mortality ranking, which is near the bottom of industrialized nations, the authors write.

Researchers analyzed birth certificate data for all Medicaid-financed single births in Texas as well as in comparison states from before payment reform in 2009 until afterward, in 2013.

Refusal to pay for medically unnecessary early deliveries appeared to have the largest impact on minorities in Texas, with rates falling more than twice as much for Latinos as for whites, mirroring differences seen in previous research.

Dr. Lisa Hollier, an obstetrician who has championed reductions in early elective deliveries, was pleased about the study’s finding of a 10 to 14 percent drop in unnecessary early elective deliveries, she said in a phone interview. A professor at Texas Children’s Hospital in Houston, she was not involved in the new study.

But she expressed concern about another of the study’s findings - a small reduction in the number of early deliveries that were deemed medically necessary.

“We don’t want to see doctors avoiding appropriate deliveries,” she said. “As a clinician, I really have to balance the risks of waiting versus the risks of delivery now for this mom and baby.”

Before pronouncing the new law a success, she wants to see additional data on the number of medically necessary early deliveries and the number of newborns admitted to intensive-care units.

In 2011, Texas became the first state to eliminate Medicaid payment for medically unnecessary early elective deliveries before 39 weeks gestation. Five other states - Georgia, Michigan, New Mexico, New York and South Carolina - followed suit in 2013.

Because Medicaid pays for about half of all U.S. deliveries, similar policy changes in other states have the potential to significantly lower rates of early elective deliveries, the authors conclude.

But Dr. Elliott Main of Stanford University in California, one of the leaders in the movement to reduce early elective deliveries, is skeptical.

Main, who wasn’t involved in the current analysis, criticized it as “messy” because it relied on birth certificate data, which can be inaccurate.

Like most physicians, he prefers to see doctors, not lawmakers, regulating his trade.

“There are lots of tools you have to try to change practice,” he said in a phone interview. “If these don’t work, then you have to resort to a law.”

Collaborative efforts have significantly cut early elective delivery rates in every state over the past 10 years, Main said. California’s rate has plummeted, he said, but doctors in a few private, independent hospitals have continued to deliver babies unnecessarily early.

Main sees the bulk of the problem outside the Medicaid population. “It’s not nearly as big an issue nationwide in Medicaid patients as it is in commercial patients, white college-educated women who want to schedule their deliveries and also doctors who take care of those women,” he said.

Some private-paying expectant mothers bond with their obstetricians and want them to deliver their babies, rather than another doctor who might be on call at the time. Consequently, Main said, “there’s a lot of tendency to fudge the rules.”

SOURCE: Health Affairs, online March 6, 2017.

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