Issue 16 / 29 April 2019

IN its 2019–20 pre-Budget submission, Private Healthcare Australia (PHA), the private health insurance industry’s peak representative body, made the following statement:

“ … in 2015, between 42% and 60% of planned caesarean sections performed before 39 weeks’ gestation did not have a medical or obstetric indication, and between 10% and 22% of caesarean sections performed before 37 weeks did not have a medical or obstetric indication. This is harmful care for which benefits should not be paid.”

Who decides what constitutes harmful care? What right do insurers have to stand behind me in the delivery room and dictate to the woman in front of me that she must endure labour and vaginal childbirth because they will not cover the cost of an elective caesarean delivery?

Imagine the following scenario some time in our future:

I’m in the delivery suite. I call the anaesthetist to place an epidural for a woman having her first baby and screaming for pain relief. She is close to delivery but not ready for pushing and birth could still be 2 hours away. “Sorry, an epidural at 9 cm dilatation is a ‘low value’ procedure. There is no evidence that patients are more satisfied after delivery if they have an epidural for analgesia this late in the labour. Private insurance will not cover it,” says the anaesthetist. I hang up, incredulous. The woman cries out in pain for a full 90 minutes until exhaustion and fetal distress necessitate an immediate forceps birth. Her screams echo around the delivery suite as the head emerges in the next couple of contractions.

Ridiculous scenario? Apparently not if the private health insurers have anything to do with it.

The implication of PHA’s statement is, in my opinion, that doctors cannot be trusted to provide the best treatment for their patients – not when they are being paid for providing that treatment.

Of course, the imaginary scenario above is not real and there is no suggestion – yet – that epidurals constitute harmful care. However, if doctors stand by while financial stakeholders such as the private health care industry become self-appointed guardians of good quality medical care, where does it stop?

Managed care. That is where it stops.

It would then only be a matter of time until we see an American-style insurance system that dictates which investigations patients are entitled to have and which treatments they are allowed to have. As in the fictitious scenario above, one can argue that pain in childbirth is not harmful (at least physically). However, the (incredibly) rare complications of an epidural (eg, an epidural abscess) could certainly be construed as harmful.

Let’s be clear about one thing: this is about money. The private health care insurance industry is all about saving money, containing their costs and increasing their premiums and profits. Trying to exclude the “low hanging fruit” of medical treatment is the first step.

The lowest hanging fruit of all is the elective caesarean delivery. The extent of medical control over this physiological process is criticised and resisted, even in the face of overwhelming evidence that fewer mothers and babies die in childbirth than at any time in history (here and here). The contrasting, often evangelical, opinions for and against the legitimacy of patient-requested caesarean delivery allow health insurers to divide and conquer.

In the United States, the Institute for Healthcare Improvement has adopted the “Triple Aim” of lowered care costs, improved population health and enhanced patient experiences. Timothy Hoff, an Associate Fellow at Oxford University, who has worked in and made a study of the US health system for over 25 years, paints a dystopian picture of the future of primary health care in the United States. He states that the Triple Aim mantra has been “adopted by the (health) industry as its bumper sticker slogan to make health care better”.

“In theory, the Triple Aim has inherent appeal. Its system emphasises pursuits such as population health management, organisational integration, care standardisation, and disruptive innovation that lowers the costs of care. But it also de-emphasises the potential worth of the dyadic doctor–patient relationship. In its own concept design document, for example, the word ‘physician’ never even appears, and the more vaguely understood term ‘provider’ shows up only a couple of times.”

He outlines the insidious problem of the health industry aiming to improve and standardise health care by adopting a more retail model and, in doing so, this necessitates reducing the influence of doctors and traditional medicine. Hence, the private and nuanced decisions made between doctors and individual patients become subsumed by increasing power of the health care industry under the guise of improved care at reduced cost.

This should serve as a warning to Australian doctors. In spite of the political rhetoric, we have a very good system of health care in Australia that still provides good public care and affordable private care. In the list of OECD countries, our system is ranked second in the world in terms of balance between cost and performance.  At present, we still are able to offer patients some measure of individualised care.

All women will be disadvantaged. A legal right is a right that can be enforced. To remove the ability of women to make a choice regarding the mode of birth (even if only through financial coercion) is tantamount to removal of their human right to make choices over their own body.

Any new rules that act to subtly, or not so subtly, coerce women to make particular choices in relation to childbirth, act to oppress all women. They chip away at the freedoms of women to control their own bodies. They divide women into those who can pay for the delivery of their choice, and those who are financially coerced into vaginal delivery, unless there are overriding medical reasons or an emergency that medically justifies operative intervention. When any woman is coerced (socially, psychologically or financially) into having no real choice over her own body, then all women are diminished. To be sure, there are risks to mothers and babies with caesarean delivery. We are legally obliged to discuss those risks. We are not, however, obliged to advise women on the many short term and long term risks of vaginal childbirth.

Our colleges and universities guide standards of medical care and guidelines. The medical community acts globally to seek out and refine the best evidence-based standards of care. One problem with evidence-based medicine is that not all medical treatments can be assessed with a randomised controlled trial. Some areas of medicine do not lend themselves to this kind of analysis, pregnancy in particular. After all, who wants to be randomised to the thalidomide treatment group?

Another problem with an evidence-based approach is the difficulty in applying such evidence to the person sitting across from you. A patient’s specific medical issue, their family history, their psyche and their social circumstances are unique. To categorise all interventions without applying the circumstances of the individual patient reduces medical care to a mathematical equation rather than a human interaction. How can the intervention of caesarean delivery be marginalised as a luxury and optional procedure without understanding the woman requesting it?

All doctors need to be very worried about this submission from PHA and resist with great force. We have a flawed but highly successful medical system when compared on a global stage.

Now, it might be the “luxury” operation of elective caesarean section that is denied by insurers. Next it might be denial of cardiac surgery for former smokers. Later, it might be denial of “futile” chemotherapy for a dying 4-year-old.

Dr Amber Moore is an obstetrician/gynaecologist in private practice and a consultant gynaecologist at the Royal Women’s Hospital in Melbourne. She has an interest in medico-legal matters and has completed both a Bachelor of Laws and Masters of Laws at the University of Melbourne.

 

The statements or opinions expressed in this article reflect the views of the authors and do not represent the official policy of the AMA, the MJA or InSight+ unless so stated.

17 thoughts on “Elective caesareans in private health insurers’ crosshairs

  1. Mark says:

    This article neglects to discuss the harm caused by low value care. The harm is not necessarily to the patient receiving low value care. Instead, the harm falls on another person attempting to access the health system who is unable to access timely care because other patients have already used up the available health resources. In the short to medium term, health resources are finite, and expending them on low value care can result in too little being left for medium and high value care, resulting in harm to patients in other parts of the health system. I have yet to see medical professionals offer a reasonable response to this problem. In fact, I am not confident they are even the right people to ask.

  2. A/Prof Gino Pecoraro (Obstetrician & Gynaecologist Brisbane) says:

    Absolutely correct and succinctly described Amber!

    The spectre of managed care looms large in Australia, and as always, Obstetrics leads the way as obstetricians are seen by regulators and insurers as a soft target who generally won’t speak out.

    Imagine telling a group of orthopaedic surgeons or cardiologists that they can only provide the “high value care” that the patient’s health fund tells them is beneficial. Beneficial of course to the fund’s bottom line, rather than to the patient themselves.

    Our patients deserve the right to have clinical decisions made by doctors who know them and understand their individual (rather than collective) needs. Insurers employing administrators and accountants to decide whether these needs are “low value” is both inappropriate and and unnecessary.

    Managed care is what ensues when healthcare systems slavishly follow what external bodies tell clinicians what is the “best” treatment. Managed care is internationally accepted as causing worse outcomes and higher health costs in the long run although it may decrease costs (and patient choice) in the short term.

    it is unfortunately, also the natural progression and non surprising outcome of our current obsession with “protocol and hospital policy” based care.

    It is time for obstetricians (and all doctors working in the private sector) to engage the people power of their patients to make sure insurers don’t extend their reach. They must not underminin the doctor patient relationship and certainly should not enter into discussions around which particular treatment a patient can or cannot receive.

  3. Anonymous says:

    Dr Amber Moore seems to have missed the ” elephant in the room “, namely why are 42 – 60 % of planned Caesarians before 39 weeks being done WITHOUT A MEDICAL OR OBSTETRIC INDICATION ? Repeat ….
    ” without a medical or obstetric indication “. Sure sounds like over-servicing to me , a problem not confined
    to obstetrics, I believe.

  4. Anne says:

    Mark hits the nail on the head. The indirect result of low value care and the inefficient use of a finite health care resource is the restriction of access of other patients to higher value care, which has the potential to cause significant harm. Medical practitioners are probably not the right people to ask, but they are certainly the best ones to be educated about the potential harm resulting from their clinical decision-making process.

  5. Dr Kate Duncan says:

    “Medical or Obstetric indications” can vary widely. As a female Obstetrician I have a small but distinct group of patients who select me as their obstetrician on gender grounds. These women have ongoing difficulties in their lives resulting from past (or present) trauma. Childhood sexual abuse, rape and domestic violence survivors can have serious issues with trigger events and sexuality-linked experiences. Pregnancy, gynaecological examinations and (obviously) vaginal childbirth are all situations which set off fear and pain.
    To remove choice from these women would be further coercion (regulatory or financial) by a system which has already failed them.

  6. Greg the Physician says:

    Excellent article from Amber and excellent comments from Gino. The other comments have completely missed the point. Guidelines and protocols are based on statistical analysis of large numbers of patients, but appropriate medical care requires that each patient is assessed and managed as an individual. Each patient is different, with different health goals, co-morbidities, risks and benefits of any medical intervention under consideration. There are often also risks from taking a non-interventionist approach. Indications for, and contra-indications against, a specific treatment or intervention are often relative rather than absolute. The only people trained to make these difficult clinical decisions are medical practitioners; the bean-counters and bureaucrats should get out of the way and let us do our job, or go and retrain as doctors if they want to make clinical decisions.

  7. Dr Rachel David, Private Healthcare Australia says:

    This article is using an implausible ‘straw man’ scenario which is an illogical response to the very real issue of low value and possibly harmful care which occurs throughout the health system. There is strong documented evidence linking caesarian section without medical indication before the due date with poorer clinical outcomes. Women deserve to know this and it is our duty to inform them. This is not about apportioning blame, but recognising at a system level when the appropriate use of data has revealed a problem we can now work together to address. We should not be afraid of the emergence of new evidence in the health sector and remember – ‘first do no harm’.

    btw I am not a bean counter or a bureaucrat, but interested in advocating for a better, safer and more affordable health system on behalf of health fund members

  8. Anonymous says:

    so elective caesarians are offered and readily available for all public patients ?

  9. DrPhil says:

    It’s a hard road these days between “You’re the doctor, you decide” vs “Tell me everything so I can make an informed decision”. Amber’s “scenario” is a little contrived. A good anaesthetist will suggest alternatives to epidural, although a good obstetrician should know them anyway. Managed care is indeed an ominous spectre but too much “evidence” in Obstetrics is skewed by all sorts of confirmation biases, and the psychosocial aspects of good maternity care, which are echoed in the spectrum described above.

  10. Roger Graham says:

    I’ve been giving Anaesthetics for elective Caesareans for many years. I can remember about 2 patients in all that time who elected to have a Caesarean with only patient preference as the indication. All the others had a legitimate indication. Of course elective Cs is best done before pts come into labor but operating lists occur weekly or fortnightly so a Pt will be booked at 38 weeks rather than 40 weeks and risk coming into labor before surgery. The fact that the PHA can’t figure this out is really sad.

  11. Jean-Marie says:

    Great article Amber.
    I had an “elective” caesarean for a breach baby who, it turns out, could not have been born any other way. I chose to follow the advice of my doctor and put my faith in his medical judgment. To my mind this is preferable to taking the view of an insurer, or a utilitarian minded ‘commentator’.

  12. Allan says:

    The PHA rivals the Pharmacy Guild in having profit at the forefront of their advocacy while hiding behind statements such as “advocating for a better, safer and more affordable health system on behalf of health fund members”. With many insurers still flogging chiropractic, osteopathy and natural therapies, their hubris in trying to take the moral high ground is plain to see.

  13. Anonymous says:

    If “42% to 60% of planned caesarean sections performed before 39 weeks’ gestation do not have a medical or obstetric indication”, then private obstetricians should have a good think about why they are doing them and whether they are having honest discussions with their patients. Of course, it’s very hard to do so when your livelihood depends on it.

  14. Brian says:

    ” Missed the point completely ” says Greg the Physician , who may not have experienced first hand the joys
    of inevitable post-op complications , which those of us with an FRACS can live them with IF the procedure was
    undertaken with the best interests of the patient foremost, based on the best science available.

    The point is how much unnecessary surgery is taking place, and the PHA would seem to have a very legitimate
    interest in this question.

    I wonder how many of these patients undergoing elective Caesarian are told of the now documented significant
    increased risk of obesity for this child ( ? 20 – 40 % ). I suspect not many ….. so how honest are these obstetricians
    being about complications ?

  15. Emma says:

    I had an elective caesarean at 38 weeks. Why? Because my first vaginal birth was traumatic and resulted in PTSD (five weeks in a mental health unit) and significant pelvic floor injury (three-compartment prolapse, avulsion, incontinence – all career ending since I was a sports coach and athlete). Quite reasonably, I think, I wanted to avoid worsening both the next time around and, to this end, was happy to assume the clearly explained risks of a C-section.

    (It went better than I could have imagined and was a healing experience.)

    Yet, my operation is technically regarded as having no medical indication, and under this proposal, I would have been financially coerced into into an unwanted, traumatizing vaginal birth. (Incidentally, my waters broke the morning of the surgery so 38 weeks was absolutely the right timing).

    I’d genuinely like to know what the insurers make of my case.

  16. Dr Michael says:

    It is only in recent years that (some) private health insurance companies have become very vocal about what should and shouldn’t happen to patients under a private doctor’s care. I believe this coincides with a shift from the majority of the private health insurance market existing within not-for-profit insurers – like it was a few years ago – to the majority of people belonging to for-profit health insurers. This occurred when BUPA acquired MBF in 2008, when Medibank Private was privatised in 2014, and when NIB demutualised and listed on the ASX in 2007, leading to Medibank Private, BUPA and NIB having between them a large majority of the market and all being publicly listed and keen to maintain a good share price and deliver healthy dividends to investors.

    Prior to this shift towards for-profit health insurers, there was very little public complaining from health funds about what they should and shouldn’t be expected to cover. This leads me to believe that Australia’s private health system works well as it exists currently as long as private health insurance companies do not have to turn a profit and deliver to shareholders.

    All of us with private health insurance could stop this drive towards health funds dictating what medical practitioners are allowed to do by switching from a for-profit to a not-for-profit fund, from which there are dozens to choose. If the for-profit funds lost significant market-share they would also lose their clout when it came to pushing hospitals and doctors around.

    Finally, whilst I do believe in free markets in general, because private healthcare in Australia is already so highly regulated I believe we would be better served and have nothing to lose by allowing only not-for-profit health funds to operate in this country.

  17. Saul Geffen RACP says:

    Oh “Dr Rachel” from the PHA, so noble of you to be caring about your clients and the broader health system. Would that be the same industry group that sells “junk” health policies that you can only use in public hospitals? The same industry that claims to cover me for ambulance transport in Queensland despite Queensland legislation providing cover for all from electricity surcharge? The same industry that rings my patients after their total knee surgery telling them they can have “Rehab in the hone” but is unaware they live in multi-storey houses, alone and cannot drive for 3 weeks post op? Oh and there is no provider appointed to give that service in rural Queensland?

    Oh and Rachel would you mind telling my wife whose sister lost a child to an abruption at 38 weeks that there was “no medical indication” for the elective ceaser she and her extremely competent obstetrician decided on?

    Rachel do you have any children? How did you have them. Female doctors have the highest rate of EC of any professional group I believe

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