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Consider the Source: A new voice for maternity care reform, J.D. Kleinke

March 14th, 2011 by avatar

I get a particular kind of delight when I learn about someone who is willing to speak out about U.S. maternity care and yet isn’t the typical stakeholder. You might know the type I’m talking about: not a midwife or a doctor or an activist for any agenda, not someone who was harmed or transformed by their birth, not a spokesperson for a particular agency or professional society – just someone willing to look at our system, intelligently analyze its shortcomings, and be bold about how we could transform it into a system that reliably delivers humane, high-quality care.

A few months ago, I was introduced to J.D. Kleinke. It didn’t take me much time on Google to figure out that J.D. is exactly this kind of non-stakeholder. Turns out he’s a non-stakeholder with tremendous insight and influence. A health economist and health IT pioneer, he’s well known in health care reform and technology circles. He’s also an accomplished and prolific writer, with two health economics text books and articles in just about every major health care publication under his belt. But none of those publications has taken on maternity care specifically – until now.  And instead of writing a health economics text, he’s delivered a drama-packed, beautifully crafted novel, Catching Babies, published this month by Fourth Chapter Books. (Disclosure: I received a complimentary review copy.) I know the readers of this blog will be interested in the book. Even more so, I think you’ll be eager to hear more from this new voice for maternity care system reform.

Fortunately, there are plenty of opportunities to do so. J.D. will be making the rounds on the blogs this week – visiting The Unnecesarean, Birthing Beautiful Ideas, Birth Sense, and Mom’s Tinfoil Hat to discuss the themes in his book and the lessons it holds for “real life”. And next week, J.D. and I will be tackling the issues on stage together at the Health 2.0 conference. Watch for tweets, blogs and videos coming out of that meeting.

Let’s kick things off with an interview.

Amy Romano: J.D., in the author’s note at the beginning of Catching Babies, you say that you set out to write a non-fiction collection of case studies addressing conflicts and controversies in the field of women’s health. Instead, you ended up writing a novel about the personal and professional drama of a cadre of ob-gyn residents near the end of their training. How did this process unfold?

J.D. Kleinke: I was living among a group of OB/GYNs as they were going through their residency, right when the non-fiction rudiments of Catching Babies were coming together in my mind. As with many residents in any specialty, they would talk incessantly about their workloads, especially about their weirder cases. As they did, I could not help but notice that the most dramatic and interesting elements of each story were not the specific clinical details, but the emotional reactions of the physicians themselves. Fascination, revulsion, contempt, pathos, cynicism, wonder, ridicule, dread. The wide variety and raw intensity of their responses to what they were dealing with in the hospital every day were often counter-intuitive, sometimes shocking to me, and I noticed how these reactions started to pattern around the personalities and family histories of the physicians themselves. Some OBs tended to respond to the most emotionally difficult cases with fascination and compassion, others with a cynicism or blitheness that bordered on cruelty. After enough watching and listening, I started to notice a strange binomial distribution among the ones I knew most personally: one group were deeply empathic people making enormous sacrifices – they were what we would call heroes and, in a couple cases, martyrs. Another group were cold, mean, vindictive, really nasty – the sort of people who were plenty smart and technically capable – but I wouldn’t want them delivering my dog’s puppies. Oddest of all, there was no middle ground. This is the exact opposite of the bell curve of personality and temperament you tend to find within almost all other groups of professionals, including most other medical, if not surgical, specialties. And people who tend toward the extremes of heroism and callowness make for good drama!

Amy: Your novel begins during the main characters’ final year of residency and ends after they’ve all dispersed into private practice, fellowships, and other post-residency adventures. Why did you choose this particular time frame for your story?

J.D.: Great question. This precise year is the key inflection point in the life of any physician. It’s the moment of truth for everyone leaving years of school and facing their options out there in the big bad world. You’ve been studying, training, amassing debt, living on subsistence wages, and solidifying your ideals for 12 or more years – and now it’s go-time. And your competing choices are hugely different. Are you going to try to cash in as big as you can? Hunker down and try to advance the field? Try to take your already rarefied skills to the next level? Teach? Agitate? Or are you going to endure still another round of academic medicine to help the poor and desperate patients who stream without end into your teaching hospital? This is also the inflection point for doctors personally. Many have been postponing marriage, their own pregnancies, homeownership – in short, all the hallmarks of “growing up” – well into their 30s. And most of the OB/GYNs I’ve observed personally were hellbent on playing catch-up, often making terrible decisions and compromises in the process. This is also ripe for great drama: smart people with some of the most profoundly adult responsibilities in society who are, in a way, still arrested adolescents, thanks to 12 or more years of intense schooling and training.

Amy: One of your characters is an ob-gyn who wants to collaborate with home birth midwives to better integrate care during transfers. Just last month, ACOG released a new Committee Opinion that urges the development of integrated systems to optimize home birth outcomes. What do you see as the major opportunities or barriers when it comes to realizing the vision of integrated systems of care across birth settings?

J.D.: Let the record show – I thought of it first and I have drafts from Catching Babies going back to 2003 to prove it! Actually, it’s an idea whose time has been a long time coming. There is a groundswell of demand among American women to deliver at home – thanks in part to the hair-trigger interventions and often brutalizing processes I portray in Catching Babies – but thanks also to the same ethos emerging around the country regarding green energy, vegetarianism, organic food, recycling, local food sourcing, and generally trying to live a less toxic, less industrialized life – an enormous collective backlash against the technocratization of society. There is a growing number of women who believe that the traditional maternity care system has pathologized childbirth, and they want no part of it. Right or wrong, this is what they believe. There is, therefore, not just an opportunity, but an enormous responsibility for all of us to find ways to cope with their flight to homebirths, because homebirths are going to happen whether we like it or not. The barriers of course are enormous: medical, organizational, financial, legal, even criminal in some situations. Why? Because all elements of what is essentially not a health care system, but is really an “illness care system,” are elemental to the system for profound reasons, most of them ultimately economic. And they will not go away without an especially good fight because, in the home birth setting, the simple fact of the matter is that babies will die – a small number of babies who would not otherwise die had they been delivered in the hospitals, a few feet away from ventilators and the NICU. These cases are of course extreme outliers, as are those babies who die during delivery in the hospital. But we have a better safe than sorry system and culture, and that’s why homebirth will always be fighting a steep uphill battle. I am also just as aware of the thousands of other suboptimal birth outcomes of babies who are rushed through to delivery in the hospital who would have been just fine delivering at home. Unfortunately, the loudest sirens in our society – the lawyers, reporters, and politicians – don’t trade in population statistics, they don’t acknowledge trade-offs. They focus on the outlier, the tragedy of that one dead baby delivered at home – and probably would have died from the same problem in a hospital setting. But still, they focus on the reckless midwife, the random disaster that couldn’t have been prevented anyway. The biggest barrier to homebirth is the difficulty recognizing that the collective outcomes profile for homebirth – delivery complications, infection rates, rates of postpartum depression – is definitely different, and perhaps better for the population as a whole, but it will include an occasional travesty that a hospital setting may have avoided. Would the homebirth family have consented that? Will they honor their waiver of their right to sue? Doesn’t matter. There will always be an ambitious reporter, grandstanding local politician, or gutter-crawling attorney ready to re-write everyone’s intentions, and all the facts, when tragedy strikes.

Amy: You have been called “an advocate for a smarter, data-driven, post-partisan health care system.” What might this look like in the context of maternity care?

J.D.: Smarter and data-driven is easy, or at least easier than the “post-partisan” part! As applied to maternity care, a smarter, data-driven system would be fully armed from end-to-end with good clinical decision support systems specific to pregnancy, labor, delivery, and post-partum care. These systems would mobilize accurate, clinically detailed, risk-adjusted normative data about what works and doesn’t work for a very specific type of pregnancy – actually beginning with pre-pregnancy fertility, genomic and family data – and they would be parsable and analyzable up against accurate, clinically detailed, granular data about the pregnancy at hand. Hard as all that sounds to create and implement, we have now have systems like it in the ICU and for several medical specialties. Why not for maternity care? The “post-partisan” part – well, that is actually harder to imagine – because it would run headlong into much bigger problems than health care system problems. Look no further than the mindless screaming about birth control, abortion, gay marriage, or stem cell research, and you’ll realize that maternity care will never be free from the intrusions of partisan politics. This is actually one of the reasons I find the subject so interesting, and one of the reasons I wrote Catching Babies. Women’s health stands at ground zero for the entrenched ideology, zealotry, fear, and unconscious loathing of women’s sexuality that so clearly enrages many of America’s politicians and preachers. It is what drives people who otherwise claim to be “anti-Big Government” into all of our bedrooms, our marriages, and women’s health clinics, and they are not going to be off minding their own business any time soon.

Amy: Let’s close our eyes and imagine a time in the (hopefully not too distant) future when we can declare that the U.S. has achieved the 2020 Vision for a High Quality, High Value Maternity Care System. What was most critical to our success? What role did childbearing women themselves play in the transformation?

J.D.: I’m only a novelist – I don’t know if my imagination is that good! Everything that stands between us and that vision are precisely the same things standing between the rest of the American health care mess and a truly reformed, functional system. Maternity care is American health care in miniature, and fixing one on the most fundamental level is as hard as fixing the other. I suppose this is because, ultimately, the problems shared by the two are exactly the same. With childbirth, its just that much more maddening, because pregancy is not a disease, and yet the illness care system presumes that it is, and treats it like it is, and lo and behold, we end up with bad birth outcomes, many of which stem from nothing more than this erroneous orientation. That orientation is wrong in and of itself, whether it’s heart disease, mental illness, or maternity care, but that’s how the non-system was non-designed decades ago, when hospitals were places you went to die, not get better. Consistent with that tradition, our reimbursement is all wrong: providers are paid for more interventions, not better outcomes. And except in a few closed systems like Kaiser or Intermountain – and for only limited periods of time – we have no access to useful patient information, so many birth providers are either going on what the patient was able to report, or they are flying completely blind. What else? The tort system is a disaster and regardless of its actual direct impact, the perception of the size of this impact is caustic, divisive and counterproductive. And the evidence base for some of the most important things in maternity care is not great, and even where the evidence is great, findings are poorly disseminated or ignored. Certain practices are followed by birth providers for years – like the immediate cutting of the umbilical cord postpartum – when common sense and research has shown that delayed cutting is much better for the baby. Nonetheless, providers still do what they always did – because that’s how they always did it. The best ways to realize the vision you’re asking about is to stop treating maternity care – all medical care actually – like a folk art, arm all providers with better information, measure what they do, and radically realign the payment system to reflect those measurements. All else will fall into place. And to answer your last question, the single best way to make all that happen is to arm pregnant women with the same information. This is 2011 – we have the Internet now – no more excuses for paternalistic decision-making on behalf of passive patients. Patients should be encouraged to research and understand their bodies, pregnancies, birth choices, and intervention decision points – without interference, biases, or pressure from providers. Which brings us back to the home birth issue. This is a grassroots rebellion by women who are seeking to take back precisely this kind of control. Maybe they have over-corrected, if only because they felt so little control inside the traditional system, but their actions speak louder about maternity care in America than I ever could!

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Data: Come out, come out, wherever you are!

February 2nd, 2011 by avatar

Data can transform how maternity care is organized, delivered, and experienced.  I’ve written this before, and I think most of the readers of this blog would agree.

But data can’t do anything if it’s hiding.

Last year, I watched DHHS Secretary, Kathleen Sebelius, announce the Community Health Data Initiative and saw the results of the pilot phase. In just six weeks, developers took newly released or already available public data and created apps and visualizations that utterly transformed how I saw the future of health and public policy. I literally sat at the edge of my seat watching some of the demos.

Take, for example, this app from Palantir (prepare to have your mind blown)

With this tool, state and local policy makers can visualize the scope and intensity of the child poverty problem, see how child poverty relates to health conditions (in this example, teen pregnancy rates), map that data with the availability of services such as Boys and Girls Clubs, see what federal funding is available and where it has been targeted, identify the leaders on the ground, and see what they’re doing to address the issues. The tool, developed in just a matter of weeks and demoed in 11 minutes, “hopefully stops us from doing a 2 year survey of the area before we make any decisions.”

Then there’s Bing Health Search:

Just a few of the features: a patient searches for a hospital by name and quality and patient satisfaction data come up as part of the search results; a policy maker maps how food deserts correlate with diabetes rates (“a complex study is now reduced to an easy exercise”); or a person looking for real estate checks out local health indicators along with schools, taxes, and other data they might use to decide where to live.

(Interested in seeing more? Check out the Health 2.0 Gallery.)

Now it’s our turn.

Childbirth Connection has just partnered with Health 2.0 to issue the first challenge dealing with maternity care, with hopes of using this opportunity to translate the consensus vision of high-quality, high-value maternity care into action.

Our challenge:

Create a data visualization tool that demonstrates geographic variation in access, procedure use, outcomes, and/or costs in maternity care to galvanize state and regional action for quality improvement.

The winning team gets a cash prize of $2,500, a meet and greet with health economist and author J.D. Kleinke (whose remarkable blog post on induction was making the rounds yesterday), and the opportunity to demo their data visualization at the Health 2.0 meeting in San Diego in March.

The expected user is a state or local policy maker or advocate. What kind of visualization would you like to see?  What kinds of problems that might normally prompt policy makers to embark on a “2 year study” could be boiled down to an “easy exercise” with the right app? Share your wildest ideas in the comments. Or better yet – sign up to join a team!

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“Except When Medically Necessary” : Making informed choices about induction of labor

January 27th, 2011 by avatar

It’s not hard for women to find advice and recommendations to avoid induction of labor “except when medically necessary.”  But what do those words mean and who decides when an induction is medically necessary?

Lamaze’s Healthy Birth Practice Paper cites ACOG Guidelines that define medical induction of labor as necessary in the following circumstances:

  • your water has broken and labor has not begun.
  • your pregnancy is postterm (more than 42 weeks).
  • you have high blood pressure caused by your pregnancy.
  • you have health problems, such as diabetes, that could affect your baby.
  • you have an infection in the uterus.
  • your baby is growing too slowly.

Yet a systematic review of the highest quality research found evidence only to support the first three. Even in these three cases, differences in important health outcomes were small, study methodologies have been criticized, and some important questions remain unanswered.

For the rest of this list and other so-called “medical” reasons for induction, we simply lack scientific evidence that induction offers any clear health benefits, and for other conditions the available evidence suggests induction is more likely to harm than help.

When trade-offs are uncertain for a proposed course of treatment, that treatment is known as “preference-sensitive care.”  According to the Dartmouth Atlas of Health Care, a leader in studying practice variation, “Decisions about these interventions — whether to have them or not, and which ones to have — should thus reflect patients’ personal values and preferences, and should be made only after patients have enough information to make an informed choice, in partnership with the physician.”

As the Dartmouth Atlas has demonstrated for many types of medical and surgical interventions, however, decisions are more likely to reflect local practice patterns and the preferences of individual providers than the preferences of patients themselves. While the Dartmouth Atlas does not track induction rates, a 2004 study in New York State found that risk factors (at least those documented in birth certificate records) explained just 12.6% of the four-fold variation in induction rates across hospitals.

But what of the variation in the use of interventions when clear evidence suggests is harmful? Shouldn’t rates of those interventions be stable at or near 0%?  Take, for example, the rate of elective (non-medically indicated) deliveries before 39 weeks. In a landscape where clinical consensus is hard to come by, all of the major players from ACOG and ACNM to the March of Dimes, the National Quality Forum, and the Joint Commission, have gotten on the no elective deliveries before 39 weeks bandwagon. Yet this week a major hospital watchdog group, The Leapfrog Group, partnering with Childbirth Connection and the March of Dimes, released for the first time hospital rates of elective deliveries before 39 weeks and the results are all over the map (pun intended). Some hospitals are in the low single digits, rates we know are possible when quality improvement efforts are taken seriously, while others report up to half or more of all births between 37 and 39 weeks are electively delivered.

Women need individualized, evidence-based information about the likely benefits and harms when considering induction of labor in the face of complications or significant risk factors. Childbirth Connection has launched a new web resource dedicated to Induction of Labor to help fill this need. But evidence is just one piece of the puzzle. Women also need information about maternity care practice patterns in their communities, since this factor seems to affect their likelihood of induction more than any other. Leapfrog’s voluntary database of elective early delivery rates stands to drive significant quality improvement. Let’s hope it’s just the first step toward full transparency of maternity care quality.

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Bending the Curve, Beginning with Birth

December 9th, 2010 by avatar

As I prepare for next week’s webinar on payment reform to align incentives with quality, I have been thinking a lot about how we pay for maternity care in this country, and the opportunities to rein in costs while improving the quality of care. I have concluded that we face both an unprecedented opportunity and an unprecedented responsibility to get serious about maternity care payment reform.

Pregnancy, childbirth, and newborn care are collectively the most common and expensive hospital conditions billed to both Medicaid and private insurers.  The national hospital bill for maternity care totaled $98 billion in 2008 – and no other condition came close to this figure. (See more facts about costs on Childbirth Connection’s updated Facts and Figures page.)   With states across the country facing budget crises, strategies that responsibly reduce the Medicaid bill for births ought to be on the table, especially if we can do so while simultaneously improving quality.  (More on that in a minute.)

What are the arguments for payment reform? They fall into a few categories:

  • We’re paying too much
  • Incentives and idiosyncrasies built into the current system virtually guarantee that we’ll continue to pay too much
  • The payment system offers no accountability whatsoever for providing high quality care. In fact, it incents poor quality care.

Although maternity care seems to have been off the radar of those debating strategies to bend the cost curve, that seems to be changing.  A flurry of recent articles and reports have demonstrated the points above:

We’re paying far more than other countries for maternity care: Citing the data in the Annual Comparative Price Report prepared by the International Federation of Health Plans, The Incidental Economist shows that average combined hospital and physician payments for a vaginal birth are nearly twice as high in the United States as they are in the next most expensive country (Australia).

We’re paying more and more each year. Facility charges for maternity care leapt from $86 billion in 2006 to $98 billion in 2008, according to data Childbirth Connection has obtained from the Agency for Healthcare Research and Quality.

The response of insurance companies thus far has been to reduce their coverage for maternity care, a move that puts families at risk of bankruptcy. Several blogs (including Midwife Connection and Better Health) have covered the persistent practice of considering pregnancy a preexisting condition and denying insurance claims for pregnant women, a reality that childbearing women will face until provisions of the health care reform law go into effect in 2014. On the Costs of Care blog, essay finalist Tarcia Edmunds-Jehu shares a story of an insured pregnant woman seeking public assistance for the first time because she faced out-of-pocket expenses for just two prenatal ultrasounds that her insurance failed to cover.

Market forces don’t reward value: Over on Running a Hospital, hospital CEO, Paul Levy, borrows some slides from David Morales, Commissioner of the Massachusetts Division of Health Care Finance and Policy, showing that the highest paid hospital receives nearly double the payment for a normal vaginal birth than the lowest paid hospital and that hospitals that charge the most are rewarded with more business – the 10 hospitals being paid the most did four times the number of births than the 10 hospitals being paid the least. And these data don’t take into consideration the proportion of births that were c-sections, a rate that ranges from 17-44% in hospitals across the state. (C-sections cost more than vaginal births.)

C-sections drive profits: In California, where a 2006 study showed that most of the variation in c-section rates among low-risk first time mothers is attributable to practice patterns, not patient characteristics, for-profit hospitals have significantly higher rates than nonprofit hospitals, according to a recent investigative report by California Watch.

Women have caught on to these perverse incentives, and are opting out in search of better care. In an opinion piece in the Washington Examiner, E.D. Kain talks about why he and his wife chose to have their second child born at home with midwives even though their insurance didn’t cover one penny. “The pre-insurance costs of a home birth ended up being pretty close to the post-insurance costs of having a baby in the hospital,” he writes, largely because “you don’t pay for the room, the bed, the doctors, or the drugs.” Kain and his wife also appreciated the personalized attention, house calls before and after birth, and the fact that they would know the midwife who would care for them in labor, “amenities” that shouldn’t be the purview just of home birth.

Aligning Incentives with Quality

So, can we reverse these trends and improve quality at the same time?  A new bill introduced in Congress last month will, if passed, establish demonstration projects to evaluate alternative payment structures for covering maternity care.  The bill requires that tested payment mechanisms measure and improve health outcomes and forbids denial of services. Tuesday’s webinar will feature a national expert who has studied payment reform models that drive quality improvement while lowering costs. Harold Miller, President and CEO of the Network for Regional Healthcare Improvement, and Executive Director of the Center for Healthcare Quality and Payment Reform, has been an active member of the Transforming Maternity Care Project. He’ll bring his insights to the issue of maternity care and present the most promising models to use payment incentives to drive improved quality. Having had a sneak peak at his slides, I’m confident that transforming how we pay for care will transform how care is delivered and experienced – for the better. I hope you’ll join us. You can register here.

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Introducing Science & Sensibility’s New Community Manager

November 15th, 2010 by avatar

As regular readers know, Lamaze has been searching for a new Community Manager for this blog. It’s been a rigorous process with many fantastic applicants, each of whom would have brought the blog in great new directions. But we had to make a choice and we are thrilled to introduce officially our new Science & Sensibility Community Manager, Kimmelin Hull, PA, LCCE.

Kimmelin has been a regular contributor to Science & Sensibility since earlier this year, offering up memorable and thoughtful posts on the effects of noisy maternity wards, and whether breastfeeding products help or hinder breastfeeding, among other topics. She has also maintained her own blog for more than two years.  She is the author of A Dozen Invisible Pieces and Other Confessions of Motherhood and contributes regularly to Montana Parent Magazine. Perhaps most importantly, she is a Lamaze Certified Childbirth Educator who has educated hundreds of couples through her private childbirth education practice in Bozeman, Montana. Prior to becoming a Lamaze educator, she worked as a Physician Assistant in surgical and urgent care settings for five years.

It has been a real pleasure to work with Kimmelin and I feel very confident that the blog is in excellent hands. Kimmelin’s vision for the blog is one that I have been gestating for a while myself: to create a multi-contributor community featuring perspectives from across the maternity care disciplines.  Kimmelin will share more of this vision in an upcoming post, but she and I are actively reaching out to people who have expressed an interest in contributing, making a conscious effort to increase the diversity of voices on the blog to include such perspectives as high risk pregnancy and addressing disparities in maternity care, among others. We want to maintain the intellectual rigor and emphasis on evidence and normal physiological birth that have become hallmarks of our blog while also increasing the scope of what we cover.

As for my own contribution to the blog, I will be sharing news from the Transforming Maternity Care Partnership including monthly posts exploring in depth each of the focal areas of the TMC Blueprint for Action, to coincide with Childbirth Connection’s webinars on these topics. The next webinar will be on Payment Reform Aligning Incentives with Quality with one of the leading thinkers in this area, Harold D. Miller. (See his landmark paper, From Volume to Value.) You can find out more about the webinars and sign up for the Payment Reform program at Childbirth Connection’s webinars page.

Please join me in giving Kimmelin a very warm welcome! And many thanks for the intensely gratifying experience of having this platform to connect with each of you, for reading this blog, and for all of your thoughtful comments along the way.

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