VBAC article from NY Times

[egoldber]

Talks about how many women are having a hard time finding doctors and hospitals that will allow them to attempt a VBAC.

http://www.nytimes.com/2004/11/29/health/29birth.html?oref=login

[dowlinal]

This article was so disturbing to me. I am adament about at least attempting a VBAC for my next baby and I know my doctor is fine with it so I think it is so wrong that I need to make sure that the hospital will allow it.

Did you notice that at the end of the article the author kindof hinted that you could get around the policy by just refusing to consent to a C-section?

A

[hez]

Blech. Makes my scar hurt just thinking about it. My doc ASSURED me I could try a VBAC as she was trying to comfort me when we made the choice on the c/s. I don't know 100% what I want to do whenever baby #2 comes along, but it p*sses me off royally that I might not get to make the choice.

[ddmarsh]

My sister who lives in FL is leaving her doctor primarily b/c he does not have med mal insurance - yes, none. Apparantly in FL you are required to only have some minimal sort of personal insurance. At any rate, in addition to this sending me through the roof on her behalf he has also completely refused to consider a VBAC. This after he was probably the cause of her first section (completely unnecessary induction).

[calebsmama03]

On the issue of no malpractice insurance, I actually think it's becoming a trend. One of my father's docs ended up leaving his practice and moving from IL (I forget to which state) to open a small practice that accepts NO insurance, but charges fair prices out of pocket and he carries no malpractice ins - states it very clearly in a sign in his waiting room and has patients sign something. I don't know how I feel about it. On the one hand I think I'd never go to a doc w/o malpract ins -esp not an OB - but on the other hand I think "good for him" since the insurance (malpractice and health)industry is really making medical care ridiculously expensive. It's an interesting ethical issue....
Lynne
Mommy to Caleb 3/3/03
http://www.gynosaur.com/assets/ribbons/ribbon_emerald_18m.gif[/img][/url]
Oh my!! #2 5/05

[kfcboston]

I saw this piece, and had been hearing about these trends. I had been thinking more seriously about VBAC before I found out about the twins, although I have yet to COMPLETELY rule it out. But I am most certainly one of those women who feels she had surgery, not gave birth. And a disappointing thing about my multiple pregnancy is that I'm assuming my odds of a VBAC just shot through the floor. But my OB certainly hasn't ruled it out, so I guess we'll see.

[JacksMommy]

I'm with Kaiser in the Bay Area and they are very pro-VBAC still, which is great. In my VBAC class the midwife said that the reason a lot of doctors/hospitals are refusing VBACs is because over the last year or so, insurance companies have started to require that the 1999 ACPG guidelines referred to in the article be followed in order for the insurance company to cover a VBAC, meaning that a doctor has to be available the entire time the laboring woman is at the hospital. Thsi is simply not practical for a lot of medical practices/hospitals (since you can labor for ages as many of us know), hence the decrease in allowing VBACs - how sad! I am hoping to have a VBAC with #2 and feel lucky to be with a hospital that gives me the choice.

Laurel
WOHM to Jack, 6/4/02
EDD baby girl 12/24/04

[MegND95]

I feel so fortunate that I was able to VBAC twice. The first was in a military teaching hospital, where the climate was more "liberal." The second time was in a regional hospital with midwives who worked in conjunction with OB's. And I know that the second time around, there was an OB present the entire time I was in labor.

It simply enrages me that women who want to avoid surgery are being denied that opportunity!

"In my VBAC class the midwife said that the reason a lot of doctors/hospitals are refusing VBACs is because over the last year or so, insurance companies have started to require that the 1999 ACPG guidelines referred to in the article be followed in order for the insurance company to cover a VBAC, meaning that a doctor has to be available the entire time the laboring woman is at the hospital. Thsi is simply not practical for a lot of medical practices/hospitals (since you can labor for ages as many of us know), hence the decrease in allowing VBACs -"

I have heard this argument too. But what about non-VBAC women who have problems during labor? As many women know, there are situations that come up during labor that necessitate immediate surgery. Shouldn't the OB be available for them too??

[ddmarsh]

"carries no malpractice ins - states it very clearly in a sign in his waiting room and has patients sign something. I don't know how I feel about it. On the one hand I think I'd never go to a doc w/o malpract ins -esp not an OB - but on the other hand I think "good for him" since the insurance (malpractice and health)industry is really making medical care ridiculously expensive"


The problem even with having patients sign a waiver is that I think most, or many, people do not *really* understand what they are waiving. Sure, they understand in theory that the doctor does not have insurance. What they likely do not understand is, in the event something occurs, they have virtually no recourse. Many also probably assume that nothing will happen to them and therefore do not give it a second thought.

I have wondered about the type of physician who would practice without insurance. IOW, is there some sort of lack of concern or regard for care in this area that might somehow also be present in their care of patients. I'm not saying there is or is not, just have wondered if that might be the case.

[egoldber]

I think that many physicians are doing this in response to pressure from their malpractice insurers. They are literally being told the types of treatments or procedures they can and cannot do for patients (like VBAC) by their insurers. And in some states malpractice insurance (especially for OBs) is becoming so prohibitively expensive that they are being forced to drop their malpractice insurance or leave OB. Its complicated stuff.

For example, the OB practice I used to use would not do a VBAC for me unless I signed a liability waiver. This was per their malpractice insurer.

[Rachels]

I agree. It's not as simple as it seems. The insurance companies are NOT paying attention to medical evidence-- if they were, they'd be paying for VBACs and homebirths as a matter of course. It's entirely based on litigation, which is a poor reason for major medical decision-making.

It's not entirely parallel, but the same thing is becoming more common in clinical psychology. I know that if I were to start a small private practice now, I would likely not accept insurance. The reason, at least in the case of psychology, is that I've far too often been asked to disclose WAY more details about people's personal lives than they realize. I've been forced to diagnose people with mental disorders when they were struggling with the normal painful experiences of life. I've been told to provide inadequate treatment simply because insurance didn't wish to pay. I've found many insurance companies to so badly compromise patient care that I'm simply not sure I'd be willing to have them dictating my course of action if it were entirely up to me. I imagine that there are a good number of physicians who feel the same way.

-Rachel
Mom to Abigail Rose
5/18/02


"When you know better, you do better."
Maya Angelou

http://www.gynosaur.com/assets/ribbons/ribbon_sapphire_24m.gif Two years and counting!

[cuca_]

I think it is awful that women are not given a choice. I had a c-section with DD, and don't know yet what I'm doing this time around, but at least I am happy that I have a choice. In fact, my doctor seems to be encouraging a VBAC rather than a repeat c-section.

On another note, I think the discussion is a bit confusing, in that it seems that malpractice insurance and health insurance are getting mixed up. I believe that the refusal to perform VBACs stems from the fact that malpractice insurance will not cover any incident that takes place during the procedure. On the other hand, I do not think that health insurance comes into play in the doctor's determination to perform a VBAC or not. As far as I know, health insurance companies do not care if it is a VBAC or not. In fact they usually pay the same rates for c-sections and vaginal births, so it really does not make a difference to them. Plus, there is no liability issue for them, should something occur during the procedure.


Carmen
DD May 2003
#2 expected in May 2005!

[DDowning]

"As far as I know, health insurance companies do not care if it is a VBAC or not. In fact they usually pay the same rates for c-sections and vaginal births, so it really does not make a difference to them. Plus, there is no liability issue for them, should something occur during the procedure."

Speaking as someone who worked for a national healthplan and negotiated contracts with hospitals and doctor groups in my pre-SAHM life, this is not the case in my experience. Very few of my contracts if any had the same rate regardless of type for OB deliveries. Even my base rate PPO contracts had a discount % off clause but didn't dictate the payment limit for services needed. I can also honestly say that there were many heated discussions involving the differences in cost for Vaginal versus C-sections, not to mention the minutia of details put into the "extras" related to delivery - additional day, Border babies when mom is sick, multiple birth rate, etc.

[cuca_]

Deidra,

That's interesting. My DH has been working in the health insurance industry for years, and has worked for several major plans. He has always been involved in contract negotiations. We were talking about this a few days ago, and he said that they pay the same rate for vaginal and c-sections. I double checked with him and he confirmed that this is the case in the companies he's worked for. He also said that in his experience they do not care if it's a vbac or not. I guess there's not a general policy, and it varies by company.

Carmen
DD May 2003
#2 expected in May 2005!

[cuca_]

Deidra,

That's interesting. My DH has been working in the health insurance industry for years, and has worked for several major plans. He has always been involved in contract negotiations. We were talking about this a few days ago, and he said that they pay the same rate for vaginal and c-sections. I double checked with him and he confirmed that this is the case in the companies he's worked for. He also said that in his experience they do not care if it's a vbac or not. I guess there's not a general policy, and it varies by company.

Carmen
DD May 2003
#2 expected in May 2005!

[HGraceMom]

My sis and BIL are both young (30) general medicine docs in IL and are job hunting as I type - their insurance costs, and the "politics" of working within hospital contracts are making it cost-prohibitive for them to continue their practicies. They're looking into starting an investment research group, becoming consultants, etc. instead of continuing to serve their communities. Currently they both work in very poor, urban hospitals / clinics where their services are desparately needed, but combined have over $400,000 in school loans they have to pay off, plus every day living expenses - it's a shame because they love their jobs, just can't afford to continue in them.

[HGraceMom]

My sis and BIL are both young (30) general medicine docs in IL and are job hunting as I type - their insurance costs, and the "politics" of working within hospital contracts are making it cost-prohibitive for them to continue their practicies. They're looking into starting an investment research group, becoming consultants, etc. instead of continuing to serve their communities. Currently they both work in very poor, urban hospitals / clinics where their services are desparately needed, but combined have over $400,000 in school loans they have to pay off, plus every day living expenses - it's a shame because they love their jobs, just can't afford to continue in them.

[Rachels]

It does. Hospitals often make a good deal more for c-sections, and it's one of the things that has contributed to the enormous, medically-unjustified rise in c-section rates. More money plus getting home earlier rather than waiting through a woman's long labor is a powerful, if inappropriate, motivator.

-Rachel
Mom to Abigail Rose
5/18/02


"When you know better, you do better."
Maya Angelou

http://www.gynosaur.com/assets/ribbons/ribbon_sapphire_24m.gif Two years and counting!

[Rachels]

It does. Hospitals often make a good deal more for c-sections, and it's one of the things that has contributed to the enormous, medically-unjustified rise in c-section rates. More money plus getting home earlier rather than waiting through a woman's long labor is a powerful, if inappropriate, motivator.

-Rachel
Mom to Abigail Rose
5/18/02


"When you know better, you do better."
Maya Angelou

http://www.gynosaur.com/assets/ribbons/ribbon_sapphire_24m.gif Two years and counting!

[cuca_]

That's amazing. My DH even told me that one of the reasons that they pay the same is because they don't want to encourage c-sections, so they come to a price point in between vaginal and c-section and that is what they pay for births. (I assume the hospital still gets money for the longer stay with a c-section, but I didn't ask) This makes much more sense to me, but I guess money talks. In fact he just told me yesterday that they try to promote prenatal care awareness among their members, as many times this is the cause of unnecessary c-sections. But then, he is currently at a medicaid/family aid company, so that might makes things different.

Carmen
DD May 2003
#2 expected in May 2005!

[cuca_]

That's amazing. My DH even told me that one of the reasons that they pay the same is because they don't want to encourage c-sections, so they come to a price point in between vaginal and c-section and that is what they pay for births. (I assume the hospital still gets money for the longer stay with a c-section, but I didn't ask) This makes much more sense to me, but I guess money talks. In fact he just told me yesterday that they try to promote prenatal care awareness among their members, as many times this is the cause of unnecessary c-sections. But then, he is currently at a medicaid/family aid company, so that might makes things different.

Carmen
DD May 2003
#2 expected in May 2005!

[chrissyhowie]

I wasn't going to post anything, but realized that I was still thinking about this issue several days later after reading this thread. So I'm resurrecting it :).

As a whole, insurance plans do not reimburse the physician more for different modes of delivery. There is a global fee that is given for prenatal care plus delivery, regardless of if that delivery was vaginal, VBAC or c-section. There are some modifications of that global fee for more complicated pregnancies requiring more prenatal visits, etc., but again delivery mode does not factor in. A decade ago this was not the case (c-sections did get more in the past), but today reimbursements have been made equal to the health care provider because it should not play a role in the decision-making for delivery.

Yes, the actual hospital does get more reimbursement for c-section deliveries, but more resources are used for a surgical delivery mode (operating room time, more nursing staff, surgical supplies, etc.). The hospital does NOT influence or decide delivery mode, nor does it pressure physicians to choose certain delivery modes for lucrative benefit. So the rate of reimbursement for c-sections is not what is influencing this disturbing trend of banning VBACs.

What is driving the VBAC ban is malpractice. In July 2004 the American College of Obstetricians and Gynecologists issued a new practice bulletin regarding VBAC. Their selection criteria for choosing VBAC candidates included immediate availability of the physician or anesthesia throughout active labor. Because of liability issues, this pretty much made it impossible for many smaller, rural hospitals and many solo private practioners to offer VBAC to their patients. Even if they do have the access to immediately available obstetricians and anesthesia for emergency c-section, many providers have stopped offering VBAC to their patients, again due to this malpractice fear. It is just not worth it to them.

It is becoming more and more difficult to find a doctor and institutions who are VBAC-friendly, and I personally believe it to be driven by the litigation risks that occur with the rare catastrophic outcomes that have been associated with VBAC. Unfortunately, fear of malpractice litigation influences much of medical practice these days. It is the sad reality of a system once designed to help assure good medical care, now twisted to often cause poor medical decision-making.

Okay, getting off my soap-box now :). Thanks for listening.

[egoldber]

Thanks for chiming in Chrissy! I was hoping you would. :)

[cuca_]

Thanks for posting Chrissy. I guess my husband's explanation was correct, then, in that they pay the same amount for deliveries and do not care if it is a vbac or not. It appears logical that the issue behind the unavailability of vbacs is malpractice litigation. That is what I was trying to state in my previous post, however, I did not do it as eloquently as you did. Your obviously much more knowledgeable about this!

Carmen
DD May 2003
#2 expected in May 2005!