Steve Calvin M.D. on pregnancy care, health care reform, and innovation

Has paying for your pregnancy left you with a bundle of bills? Next time try the BirthBundleTM.

Pregnancy is a big enough physical and emotional challenge for mothers (and to a much lesser extent fathers) without the additional complications of how to choose, arrange, and pay for care.   It is difficult to decide on the various options for care and some parents are not able to tie up all the loose financial ends until their little one starts to walk.   For many families a pregnancy leaves them with a bulging folder holding insurance and billing letters from a long list of professionals and facilities that had a hand in the 9 months of care.  This is the bundle of pain that a disjointed fee for service system delivers.   There is a better way.

The better way comes from designing a system of perinatal care starting with the way that care is paid for.  It requires a new system covering the entire maternity and newborn care episode with one comprehensive payment.   This basics of this concept are described in a September 2013 paper from the Integrated Health Care Association:

http://www.iha.org/pdfs_documents/bundled_payment/Maternity-Issue-Brief-September-2013.pdf

Here at the Minnesota Birth Center we are building a new model that we call the BirthBundleTM.   True change will only come by starting with the foundation of primary maternity care and then building upward and outward to provide the necessary safety net.  Our foundation will be independent midwife-led birth centers integrated with obstetrical facilities and providers.   The BirthBundleTM is designed and provided by the Natal Network Inc., an entity that we have formed to coordinate all the moving parts.  We will be testing this model as a pilot with insurers and provider partners here in Minnesota.  Stay tuned for updates.

Catching Babies?

Attending birth is a

better description than

“catching babies”.

 

Attendance denotes

invitation

catching suggests

trespass, pursuit, and even violence.

 

Who is this about anyway?

The baby catcher or the

one giving birth, or

the one born?

 

They both require (and deserve) an

honest answer.

Evidence-based maternity care

If you want to understand labor and its variations I highly recommend reading the excellent comprehensive summary by Rebecca Dekker PhD RN APRN from the University of Kentucky:

http://evidencebasedbirth.com/friedmans-curve-and-failure-to-progress-a-leading-cause-of-unplanned-c-sections/

When we admit the error of our obstetrical ….

Cesarean section rates have doubled over the last 25 years.    This has occurred without evidence of benefit to mothers or babies.  In fact, the increase in rates has been physically and financially detrimental.    There are some key causes of the increased resort to the surgical delivery of babies.  One is the belief that there is an ideal pattern of labor and delivery and that deviation is dangerous.   Since the 1950s obstetrical care has been guided by a faulty understanding of normal labor.  Emmanuel Friedman gave us the Friedman labor curve as a template that we have imposed on all mothers giving birth.

My little part in this perpetuation of error included teaching medical students that all mother’s should have their labor progress plotted on the curve and that deviation required “active” management of labor.  This led to unnecessary Pitocin and cesarean sections when progress didn’t fit the curve.  We should have known better.   Over the last few years academic medicine has started to recognize the error of our ways.   A great recent summary of this comes from my medical school alma mater, Washington University in St. Louis.  Alison Cahill does a nice job summarizing the information:

http://dbbs.wustl.edu/curstudents/Documents/Markey/Tuuli_Paper_Markey_2013.pdf

This is why I am so happy to be involved with a new model of pregnancy and birth care.  At the Minnesota Birth Center our great midwives recognize that most labors are normal – even those that don’t follow the Friedman curve.  When abnormalities occur it is important to recognize and intervene, however it is often a good idea to just give a mom and baby a new position, a warm tub of water, and some time.    It helps to recognize that the current conventional wisdom isn’t always current (or wise).

A New Inspiring Primary Care Model

A week ago I heard a couple of speakers at an Ashoka Fellows symposium in St. Paul.  One was Dr. Rushika Fernandopulle, founder of Iora Health  (http://www.iorahealth.com/).   Rushika is a talented and articulate physician who is starting from scratch with a new primary care model.   It is a team approach that moves beyond the fee for service payment system.   It is a model that is long overdue.  He has been at this for a decade and is getting real traction with successful clinics in four locations across the country – with plans for many more.

I was inspired by Ruskika’s passion and tenacity.  I’d recommend listening to some of the online videos featuring him.  He is improving primary care in the ways that we envision improving maternity and newborn care.   Just tweaking the current broken system gets us nowhere.  In late September and early October I presented our vision to the American Association of Birth Centers conference (with Amy Romano) and to the University of Minnesota Nurse Midwifery program symposium (with Tanya Muller, our midwife director at the Minnesota Birth Center).  It was very encouraging.  There are many fired up folks ready to make big changes to improve the care of mothers and babies.

I am excited to see what comes next.

The godmother of US midwifery

At a lunch four years ago in Savannah, GA the godmother of US midwifery catalyzed my desire to help improve the maternity and newborn care system.  I saw her again this week.  The American Association of Birth Centers is holding its 30th annual meeting here in Minneapolis.  Fortunately the weather is beautiful for the visitors.

For two days before the meeting a “How to start a birth center” course was taught by my friend Kathryn Schrag CNM.  More than 65 attendees learned a lot from Kathryn and each other.    Near the end of day 2, much to everyone’s delight, Kitty Ernst CNM MPH made an appearance.

Kitty is the aforementioned godmother of midwifery.   I hope to be even 10% as active and effective as she is when I reach my ninth decade.   She holds the Mary Breckenridge Chair at Frontier Nursing University and is passionate about educating and encouraging certified nurse midwives:  http://www.frontier.edu/alumni/message-kitty-ernst

Her remarks to the gathering were the usual mixture of wisdom and humor.  She combined them in her assertion that improvement of the pregnancy care system will happen if we facilitate the conversion of all labor and delivery RNs to CNMs.  Those who refuse the transition she would exile to the orthopedic surgery service….

The transition to a high value maternity and newborn care system is gaining momentum.  It won’t be a smooth ride but it will be exciting and a great opportunity for those who are as bold as Kitty Ernst.

 

Excitement at the Minnesota Birth Center

Just over a year ago mothers started having babies at the Minnesota Birth Center (MBC).  Tanya, Martha, and Mary-Signe provide great midwifery care along with their talented nursing colleagues.   More than one hundred mothers and fathers have welcomed their new daughters and sons in the birthing rooms.  We are now at capacity and have a waiting list.  Two of the little newborn girls were my granddaughters Hazel and Sigrid.   Their moms chose the MBC without any pressure from me and they were both birthing champs.

As medical director I  am not supposed to play a role in the birth of babies at the MBC.  That is the natural domain of the midwives.   They do it really well.   I have only been present for one of the births at the center.  It was very exciting and had a happy ending.   It started with an urgent late night call to come down to the center ASAP.  A second time mother was very close to delivery and after the membranes ruptured it became clear the the baby was in a breech presentation.

This was one of those OB surprises that sometimes happens.  Since she was completely dilated the baby was coming very soon and transfer to the hospital was not an option.  It took me 10 minutes to join the crowd at the center (another mom was giving birth at the same time).  Over the last decade in the US  breech births have almost exclusively been accomplished by cesarean section.  This is due to a slight (though real) increase in risk to the baby – because the head is the largest and last part of the baby to be born.  The pros and cons of vaginal breech delivery will have to wait until another post.

Anyway, this baby was arriving any minute.  I thought through the situation and (as always) contemplated the worst possible outcomes.  Being certain that preparation will ward off disaster I asked if someone could run across the street to the Mother/Baby Hospital to get a pair of Piper forceps for use if the head got trapped.  Fortunately the forceps remained wrapped on the foot of the bed, unused.  A healthy little boy came out backwards, gently and easily.  He was immediately placed in his mother’s arms.

This episode reminded me of at least two things.  The power of prayer is one.  When I took off out the door I didn’t tell Cindy where I was going and our daughter Christie only knew that the birth center needed me for an emergency.  They had an (answered) telephonic prayer time for a good outcome in an unknown situation.  The other thing is that this is how things are supposed to work at a midwife-directed free-standing birth center.  We aim to be safe, satisfying, and seamless.  I am privileged to be part of a team that recognizes situations and rapidly responds.

The next morning I decided that the best way to prevent a recurrent unexpected breech presentation would be to buy our own pair of Piper forceps.   My first search turned up a pricey ($700) pair on a surgical instrument website.  Doctor Cheapskate then looked on ebay and found some for $42.40.  Even if it turns out that I get only one blade I can probably afford to buy the other one.  The pair will be placed in the bookcase with the natural childbirth books as a good luck charm.

The Most Expensive Pregnancy Care in the World

Today’s New York Times has a front page article that lays out the reasons why pregnancy care needs reform:

http://www.nytimes.com/2013/07/01/health/american-way-of-birth-costliest-in-the-world.html?pagewanted=all&_r=0

The solution is  a comprehensive package of pregnancy and newborn care for a single price.  We are building this new model here in Minnesota.

Paying for and delivering pregnancy care – the case for a Pregnancy Care and Delivery Home model

Things have been really busy at the Minnesota Birth Center – we have the happy problem of reaching capacity.   We are making plans for expansion.  More on that another time.  It has been a while since I’ve put up a post.   I think that this one is worth the wait.  Amy Romano CNM co-authored an article with me on how we pay for and deliver pregnancy care:

http://www.minnesotamedicine.com/Portals/mnmed/April%202013/Payingforanddeliveringpregnancycare1304.pdf

It is in the April 2013  “Minnesota Medicine” – an issue focusing on how we pay for care in public programs.   We are grateful for the chance to make our case.  We always welcome comments.

The cost of having a baby in the United States

We are never going to get anywhere in improving the value of healthcare without knowing specifically what the costs are for those paying the bills.  Harold Miller is one of the most persistent and perceptive advocates for real positive change in healthcare.  A very important new study on pregnancy care costs was commissioned by his organization, The Center for Healthcare Quality and Payment Reform, along with Childbirth Birth Connection and Catalyst for Payment Reform.  It is available here:  http://www.chqpr.org/

This study reveals the real dollar amounts PAID for care by employers/insurers, government programs, and from patients out of pocket.  This information cuts through the “confusopoly” I have mentioned before.  It even shows that the insurers and the providers are as confused as anyone else.  The average total commercial insurer payments for all maternal and newborn care for vaginal and cesarean section delivery were $18,329 and $27,866 respectively.   The numbers for Medicaid were $9,131 and $13,590.  With four million births per year in the US more than $50 billion dollars are spent on pregnancy care.

From my perspective there are four major highlights of the study.  First, is the finding that facility fees make up well more than 1/2 of the total cost.  Second, is that 3/4 of the total cost occurs at the time of delivery.    Third, is that normal newborn care averages $4400.  Fourth, and probably most important, the high cost of cesarean birth for mother and baby is amplified by the fact that we have an unnecessarily high cesarean section rate (of 33%).  Besides hand wringing over these numbers there are some things that can be done.

Harold has been a mentor and advocate for the work that we are doing here in Minnesota to develop and test what Amy Romano CNM and others from Childbirth Connection call a “pregnancy care and delivery home” (PCDH).   With an insurance company partner we will soon be testing a PCDH model for low-risk mothers on Medicaid.  It will be for mothers who choose midwife-directed birth center care and it includes continuity of care with basic CNM and OB physician professional services in the hospital – all for a single price.

We will be studying the outcome of our pilot with our insurance partner and colleagues at the School of Public Health at the University of Minnesota.  Our model is designed using the recommendations of Childbirth Connection (childbirthconnection.org).  Their Transforming Maternity Care Partnership and Evidence-Based Maternity Care resources lay out a clear path to pregnancy care that is higher quality, more satisfying, and less costly.