The Maternity Unit Dilemma

More have closed, costs are rising and there’s no answer in sight.

Maternity care across the Delaware Valley continues on a crisis course, even beyond the economic problems of Philadelphia and other population centers.

The problem is particularly severe in Philadelphia and its four Pennsylvania suburban counties, where since 1997, 18 hospitals have ceased providing maternity care and Mercy Suburban Hospital in East Norriton has announced it will end obstetrical services after June 10, 2010. Between 2004 and 2006, the number of obstetricians/gynecologists practicing in Pennsylvania decreased 11 percent. In southeastern Pennsylvania, the number of OB-Gyns has dropped about 30 percent since 2001.

Meanwhile, the rate of premature births — with their heavier use of medical and financial resources — has been increasing across Delaware, New Jersey, Pennsylvania and in the nation as a whole. The infant mortality rate in Philadelphia is increasing and is significantly higher than the national rate. These factors further pressure those hospitals and professionals still providing maternity care and raise additional issues about prenatal care.

Problems remain long and deep, with significant impact on providers, the way maternity care is provided, and on taxpayers, mothers and families.

Problem 1:  Reimbursement Rates

If 41 percent of the time, you’re reimbursed for only 82 cents of every dollar of your costs, how long will it take you to go broke? These numbers reflect the average Medicaid reimbursement rate and the percentage of births covered by medical assistance in Pennsylvania. Two-thirds of the births in Philadelphia are covered under medical assistance. Nationally, Medicaid reimburses an average of 88 cents on the dollar for births.

Hospitals are often reimbursed for less than two-thirds of their maternity care costs. Experts analyzing insurance data conclude that hospitals in this area lose $2,000-$4,000 per birth.

Of services that hospitals provide, maternity services are disproportionately dependent upon Medicaid. In Pennsylvania, medical assistance pays for approximately 16 percent of all hospital discharges, but accounts for 41 percent of newborn discharges. So to stay in the baby birthing business, hospitals must find a way to cover their losses.

For example, Hahnemann University Hospital passes along its costs to tuition at Drexel University College of Medicine, with which it’s associated. Cooper University Hospital in South Jersey tries to provide services with “better insurance mix” in order to afford to care for the large Medicaid population in Camden.

Problem 2:  Liability Costs

Even though the overall number of medical malpractice suits in Pennsylvania has dropped in the past five years, Lloyd’s of London calls Philadelphia “the worst liability market in the world,” according to Owen Montgomery, MD, Chief of OB-Gyn service at Hahnemann. The cost of malpractice insurance is an 800-pound gorilla, he says.

Ironically, the costs of lawsuits and legal insurance are not closing other high-risk specialty units such as neurology and cardiology, he notes. Nor are they dramatic factors in markets such as New York City or Boston.

It means few obstetricians in this region remain in private practice. Most, like Robin Perry, MD, Chief of OB-Gyn at Cooper University Hospital, have become hospital employees. Another recourse is for institutions to “self-insure,” an approach taken by Drexel and the University of Pennsylvania.

Liability issues have increased discussion within the profession about designating only certain “laborists” or “hospitalists” to perform births in order to decrease the number of high-risk specialists to insure.

“Defensive medicine” has become reality. One of the most troubling examples is the upward trend of births by surgical Caesarian section. C-section rates “are going nuts,” according to Dr. Perry.

C-sections in New Jersey have reached 40-45 percent. Some circumstances call for surgical intervention, she explains, but nowhere near half. In the short run, birth by Caesarian surgery suggests a sense of control, especially among busy practitioners who are not necessarily experts in fetal monitoring. But looking forward to a decade of this trend, Perry predicts the overall statistics will reveal increased post-operative maternal complications as a result, adding further to costs and liability.

Problem 3:  Preterm Births

Another troubling trend is the rise in rate of premature births and increased need for neonatal intensive care units (NICU) across the country. It isn’t clear to what extent the increase in premature births results from inadequate prenatal care and poor lifestyle choices, from improved interventions in problem births and neo-natal care, or from other factors.
Whatever the reasons, prematurity adds costs and risks to care, contributing to hospital expenses, as well as exposure to liability, even though the medical personnel and hospital may have performed according to best practices.

A 37-week fetus is not mature, according to Richard Derman, MD, Chair of OB-Gyn at Delaware’s Christiana Care Health System. Waiting until the 39th week for induction or a C-section (unless medically necessary) reduces NICU admissions, he says. “Even one day matters” in improved health for the baby and reduction in costs of care and liability, says Dr. Derman.

Christiana Hospital in Newark, DE delivered 7,100 babies last year and has a high-risk level 3 nursery with 70 NICU beds. As one of the largest maternity units in the country, it is a leader in research. Christiana has been actively collecting data and tracking outcomes to determine best practices of care.

Research helps identify specific procedures that are most successful and can reduce errors and liability. For example, Dr. Derman says a program of injectable progesterone for women with pre-term labor in prior pregnancies is one important way Christiana improves patient outcomes and helps lower liability costs.

Christiana also requires all of its 88 OB-Gyns to be re-trained in the latest protocols for unpredictable events such as shoulder dystocia (when the baby’s shoulder gets stuck on the mother’s pelvic bone during delivery) and post-partum hemorrhaging. “Sticking to strict protocols results in more favorable outcomes,” Derman says. And favorable outcomes are less expensive and less risky, as well.

Additional Issues

Areas with high birth rates do not always coincide with providers of maternity care. For instance, South and Northeast Philadelphia have no maternity units, whereas three hospitals with maternity care are clustered within walking distance of each other in Center City, Dr. Montgomery points out.

This poor geographic distribution of hospital-based maternity care increasingly coincides with inadequate availability of prenatal care in the underserved communities. It results in fewer options for care, longer delays for appointments and increasing difficulty in obtaining healthcare for pregnant patients, according to the Maternity Care Coalition.

Furthermore, when these patients show up for delivery without medical records, hospitals perform costly extra tests. Some existing maternity departments experience overcrowding as they absorb patients affected by the closure of units close to their communities. As providers stretch their capacity, the likelihood of error or “near misses” increases. Inadequate healthcare in the short run compromises outcomes and also becomes more expensive in the long run.

Looking Ahead

As with other complex problems, solving the maternity care crisis requires new approaches on multiple fronts. Some groups advocate for changes in public policy and insurance, some focus on maternal education and others look at research and the delivery of care. Here are some samples.

Licensed nurse midwives have joined the maternity practices of Drexel obstetricians at Hahnemann, resulting in high patient satisfaction, says Dr. Montgomery. Their services cost less than obstetricians, though he explains that’s not the reason they’re integrated into the team.

Practicing in collaboration with obstetricians, nurse midwives “expand the pool of practitioners and access,” says Pamela Clarke, a vice president of the Delaware Valley Healthcare Council. They help to ease the strain on obstetric practices and hospital maternity units.

Some advocates hope birthing centers and prenatal clinics may also help fill in gaps in maternity care. Better prenatal care and healthier mothers can lead to fewer complications — and decreased costs of maternal and newborn care. The Maternity Care Coalition (www.momobile.org), headquartered in Philadelphia, offers services to improve maternal and infant care in southeastern Pennsylvania.

Christiana Hospital is one of the principal sites in a huge new federal study, the National Children’s Study, which will follow babies through adolescence in order to determine specific factors associated with healthy outcomes. Information from this research could identify new ways to improve care, while reducing risks and costs.

Ann L. Rappoport, PhD is an educational consultant and a contributing writer to MetroKids.