Catching Babies Blog Series: Fear, Faith and Perverse Incentives
A series of interviews with author J.D. Kleinke on topics raised in his new novel, Catching Babies.
When I heard that a medical economist had written a novel about the business of childbirth, my first thought was, “That’s odd.” After reading Catching Babies, I thought it might be interesting to read your previous books and ordered Bleeding Edge (1998) and Oxymorons: The Myth of a U.S. Health Care System (2001) on Amazon.
Naturally, the main difference between the first two books and Catching Babies is the lack of sex scenes. Once I got over my feeling of being ripped off, I realized that Oxymorons is a pretty straightforward primer on our mess of a health care “system”, and that Bleeding Edge can stay on my nightstand as all-natural Ambien.
Several topics from the previous books bleed over into Catching Babies. The “thicket of paperwork” that welcomes those new to private practice, your no-so-veiled valuation of the CNM as cost-saving boon to the system and chart discrepancies that beg for a switch to EMRs.
The most salient connection between previous books and the new one that I noticed comes into focus when the hospital CEO points out the profitability of treating insured pregnant women.
Within the first few pages of Bleeding Edge, you had already named the arbitrary use of the cesarean section as an egregious example of one of the huge, inexplicable practice variations in our country. Specifically, you wrote:
Variations by region, physician type, and patient’s insurance status infest the entire spectrum of medical care: surgery versus drugs for the same condition; hospital admission rates; hospital lengths of stay; traditional versus leading-edge surgical technique; diagnostic imaging and lab testing frequency; specific drug selection; and the list goes on, ad infinitum. When viewed in the aggregate, such variations are far from just costly from a financial and human perspective; they border on scandalous.
And, of course, the patient’s insurance coverage is often cited as an explanation for the variation.
Naturally, arbitrary practice variations and profit as an incentive for which type of treatment to recommend are hardly exclusive to maternity care. In April 2010, a study was published in JAMA which examined the rapid growth in the use complex fusion surgeries (as compared to decompressive surgery or nonoperative treatment) in older patients with spinal stenosis. They found a 15-fold increase in the rate of the complex surgery, a trend that found its way to Medicare patients as well (1.4 per 100,000 to 19.9 per 100,000 between 2002 and 2007). Unfortunately, it’s a surgical trend that one of the the co-authors says has no “big advantage” that increases odds of comorbidity, particularly in older patients.
NPR’s coverage of the study showed the striking parallel between back surgery and the cesarean section, with one paragraph in particular driving the comparison home.
Deyo says there’s no reason to think people suddenly started developing the spinal deformities that justify the complex surgeries. He offers several possibilities for the upswing. “Many surgeons genuinely believe that the more invasive procedures offer some benefits,” he says. “But certainly there are important financial incentives at play as well.”
Substitute “pelvic” for “spinal” in the first sentence and this entire paragraph could apply to the rampant overuse of the cesarean section in recent decades.
So what is that something that raises hackles about the issue of extreme practice variations in maternity care and overutilization of the cesarean section, but doesn’t provoke the same vitriol when discussing unnecessary back surgery? It stands to reason that a patient should be able to exercise the same rights in refusing any complex surgery in favor of less invasive procedures or therapies… or none at all.
This is not just a great question - it’s the essence of why I inadvertently ended up enraptured by the issues I’ve encountered in obstetrics and maternity care, when there are maybe half a dozen other spheres in health care with bigger, even weirder problems. Maternity care has all those same problems, but they are amplified by the enormous gulf between what women expect to happen when they’re pregnant, and what the system is designed to expect and deal with on their behalf. We are all programmed by our culture, by human yearning, by whatever bedrock sense of belief we all have in a better future, to expect a normal pregnancy and a healthy baby. If not, no one would get pregnant in the first place. Having a child is the supreme act of human faith. That’s the perspective and presumption of the individual, or at least of most. This will be a perfect baby. I may not be perfect, but my child will be. That’s why when someone announces that they’re pregnant, the normal human impulse is to say “congratulations!” not “good luck.”
The traditional maternity care system, in starkest contrast, does not say “congratulations.” Instead, it braces itself for everything that can and might go wrong. It expects complications and the occasional disaster, and it is designed to accommodate those disasters, from the proliferation of testing and diagnostic technologies for prenatal care to NICUs in every other hospital. In the world of emergency medicine, we build in what we call “shock capacity,” or more collective ER resources than we need on any given day because, well, some days the emergencies will pile up, and our collective capacity is tested. Call it ‘epidemiologic clustering’ or ‘full moon syndrome,’ but it is really the ‘shit happens’ factor in all of life. The traditional medical system has been built deliberately to absorb full moon days, even as we as individuals hope to God we’re never unlucky enough to deliver on one of those days.
If that weren’t problematic enough, just add in money and stir. The entire health insurance reimbursement system is based on compensating providers for these normalized rates of complications and disasters. That’s the essence of insurance risk-pooling. So guess what happens to ‘normal?’ That’s right – we end up with a brave new ‘normal’ - one that is far more severe than the real ‘normal.’ That’s the real origin of phenomena like your excessive c-section rate. The logical end-product of a decades-old reimbursement system, one designed to compensate for complications and disasters, is a system that perversely rewards those providers who end up coping with the most complications and disasters. And finally, add in a few thousand lawyers and stir.
This is the world as the pregnant woman finds it, and guess what happens? It’s a collision course of almost diametrically opposed expectations. Women expect healthy pregnancies and perfect babies, and the entire traditional system is fortified, and rewarded, and legally girded, to expect messes. The culture of the OB/GYN is saturated with this opposing expectation. This is one more reason why Catching Babies morphed from cool-headed non-fiction into an overheated novel. Because the essence of all great drama is conflict, and while there is conflict throughout the traditional health care system, it is nowhere louder and angrier than in maternity care. To come full circle back to your question, we may have tolerances for other excesses in health care like spinal surgery, but we have zero tolerance for the imposition of this dysfunction on our newborns, on the our biggest hopes and dreams, on what is, for many, the essential meaning of their lives. Every Mama is a Mama Bear, or should be, and this is the first place she shows up.
Catching Babies Blog Series:
Consider the Source: A new voice for maternity care reform: J.D. Kleinke (March 14, 2011 on Science & Sensibility)
Catching Babies Blog Series: Tolerating Risk in the U.S. Maternity Care System (March 15, 2011 on Birthing Beautiful Ideas)
Catching Babies Blog Series: Fear, Faith and Perverse Incentives (March 16, 2011 on The Unnecesarean)
Catching Babies Blog Series: Birth Sense Interview (March 17, 2011 on Birth Sense)
Catching Babies Blog Series: Refusal, Rights and Balance (March 20, 2011 on Mom’s Tinfoil Hat)
Catching Babies Q&A with J.D. Kleinke (March 14, 2011 on The Health Care Blog)
Catching Babies (Kleinke, 2011)
Oxymorons: The Myth of a U.S. Health Care System (Kleinke, 2001)
Bleeding Edge (Kleinke, 1998)
Disclosure: I received a free review copy of this book.