Evaluation of Hospital Cesarean Delivery-Related Profits and Rates in the United States

Rie Sakai-Bizmark, Michael G Ross, Dennys Estevez, Lauren E M Bedel, Emily H Marr, Yusuke Tsugawa, Rie Sakai-Bizmark, Michael G Ross, Dennys Estevez, Lauren E M Bedel, Emily H Marr, Yusuke Tsugawa

Abstract

Importance: A high cesarean delivery rate in US hospitals indicates the potential overuse of this procedure; however, underlying causes of the excessive use of cesarean procedures in the US have not been fully understood.

Objective: To investigate the association between the probability of cesarean delivery at the patient-level and profit per procedure from cesarean deliveries.

Design, setting, and participants: This observational, cross-sectional study used a nationally representative sample of hospital discharge data from women at low risk for cesarean birth who delivered newborns between 2010 and 2014 in the US. Data were gathered from the Nationwide Readmissions Database from the Healthcare Cost and Utilization Project, compiled by the Agency for Healthcare Research and Quality. Data cleaning and analyses were conducted between August 2019 and May 2020.

Exposures: Hospital-level median value of profits from cesarean deliveries, defined as the difference between the charge and the cost for cesarean delivery calculated for each hospital.

Main outcomes and measures: Our primary outcome was the individual-level probability of undergoing a cesarean delivery. We examined the association with the hospital-level median value of profits per procedure for cesarean delivery (defined as the difference between the charge and the cost for cesarean delivery) using hierarchical regression models adjusted for patient and hospital characteristics and year-fixed effects.

Results: A total of 13 215 853 deliveries were included in our analyses (mean [SE] age, 27.4 [0] years), of which 2 202 632 (16.7%) were cesarean deliveries. After adjusting for potential confounders, pregnant women were more likely to have a cesarean birth when they delivered at hospitals with higher profits per procedure from cesarean deliveries. Women cared for at hospitals with the highest (adjusted odds ratio, 1.08; 95% CI, 1.02-1.14; P = .005) and second-highest profit quartiles (adjusted odds ratio, 1.07; 95% CI, 1.02-1.13; P = .007) had higher probabilities of a cesarean delivery compared with those cared for at hospitals in the lowest profit quartile.

Conclusions and relevance: In this cross-sectional study of US nationally representative hospital discharge data, hospitals with higher profits per cesarean procedure were associated with an increased probability of delivering newborns through cesarean birth. These findings highlight the potential influence financial incentives play in determining a high cesarean delivery rate in the US.

Conflict of interest statement

Conflict of Interest Disclosures: None reported.

References

    1. Kozhimannil KB, Law MR, Virnig BA. Cesarean delivery rates vary tenfold among US hospitals; reducing variation may address quality and cost issues. Health Aff (Millwood). 2013;32(3):527-535. doi:10.1377/hlthaff.2012.1030
    1. Little SE, Orav EJ, Robinson JN, Caughey AB, Jha AK. The relationship between variations in cesarean delivery and regional health care use in the United States. Am J Obstet Gynecol. 2016;214(6):735.e1-735.e8. doi:10.1016/j.ajog.2015.12.023
    1. Martin JA, Hamilton BE, Osterman MJK, Driscoll AK. Births: Final Data for 2018. Natl Vital Stat Rep. 2019;68(13):1-47.
    1. Osterman MJ, Martin JA. Trends in low-risk cesarean delivery in the United States, 1990-2013. Natl Vital Stat Rep. 2014;63(6):1-16.
    1. Menacker F, Hamilton BE. Recent trends in cesarean delivery in the United States. NCHS Data Brief. 2010;(35):1-8.
    1. Martin JA, Hamilton BE, Osterman MJK, Driscoll AK, Drake P. Births: Final Data for 2017. Natl Vital Stat Rep. 2018;67(8):1-50.
    1. Blondon M, Casini A, Hoppe KK, Boehlen F, Righini M, Smith NL. Risks of venous thromboembolism after cesarean sections: a meta-analysis. Chest. 2016;150(3):572-596. doi:10.1016/j.chest.2016.05.021
    1. de la Cruz CZ, Thompson EL, O’Rourke K, Nembhard WN. Cesarean section and the risk of emergency peripartum hysterectomy in high-income countries: a systematic review. Arch Gynecol Obstet. 2015;292(6):1201-1215. doi:10.1007/s00404-015-3790-2
    1. Deneux-Tharaux C, Carmona E, Bouvier-Colle MH, Bréart G. Postpartum maternal mortality and cesarean delivery. Obstet Gynecol. 2006;108(3 Pt 1):541-548. doi:10.1097/01.AOG.0000233154.62729.24
    1. Kainu JP, Halmesmäki E, Korttila KT, Sarvela PJ. Persistent pain after cesarean delivery and vaginal delivery: a prospective cohort study. Anesth Analg. 2016;123(6):1535-1545. doi:10.1213/ANE.0000000000001619
    1. Keag OE, Norman JE, Stock SJ. Long-term risks and benefits associated with cesarean delivery for mother, baby, and subsequent pregnancies: systematic review and meta-analysis. PLoS Med. 2018;15(1):e1002494. doi:10.1371/journal.pmed.1002494
    1. Leth RA, Møller JK, Thomsen RW, Uldbjerg N, Nørgaard M. Risk of selected postpartum infections after cesarean section compared with vaginal birth: a five-year cohort study of 32 468 women. Acta Obstet Gynecol Scand. 2009;88(9):976-983. doi:10.1080/00016340903147405
    1. Lydon-Rochelle M, Holt VL, Martin DP, Easterling TR. Association between method of delivery and maternal rehospitalization. JAMA. 2000;283(18):2411-2416. doi:10.1001/jama.283.18.2411
    1. Rossen J, Okland I, Nilsen OB, Eggebø TM. Is there an increase of postpartum hemorrhage, and is severe hemorrhage associated with more frequent use of obstetric interventions? Acta Obstet Gynecol Scand. 2010;89(10):1248-1255. doi:10.3109/00016349.2010.514324
    1. Tarney CM. Bladder injury during cesarean delivery. Curr Womens Health Rev. 2013;9(2):70-76. doi:10.2174/157340480902140102151729
    1. Temming LA, Raghuraman N, Carter EB, et al. . Impact of evidence-based interventions on wound complications after cesarean delivery. Am J Obstet Gynecol. 2017;217(4):449.e1-449.e9. doi:10.1016/j.ajog.2017.05.070
    1. Belfort MA, Clark SL, Saade GR, et al. . Hospital readmission after delivery: evidence for an increased incidence of nonurogenital infection in the immediate postpartum period. Am J Obstet Gynecol. 2010;202(1):35.e1-35.e7. doi:10.1016/j.ajog.2009.08.029
    1. Marshall NE, Fu R, Guise JM. Impact of multiple cesarean deliveries on maternal morbidity: a systematic review. Am J Obstet Gynecol. 2011;205(3):262.e1-262.e8. doi:10.1016/j.ajog.2011.06.035
    1. Silver RM, Landon MB, Rouse DJ, et al. ; National Institute of Child Health and Human Development Maternal-Fetal Medicine Units Network . Maternal morbidity associated with multiple repeat cesarean deliveries. Obstet Gynecol. 2006;107(6):1226-1232. doi:10.1097/01.AOG.0000219750.79480.84
    1. Sondgeroth KE, Wan L, Rampersad RM, et al. . Risk of maternal morbidity with increasing number of cesareans. Am J Perinatol. 2019;36(4):346-351. doi:10.1055/s-0038-1673653
    1. US Department of Health and Human Services . Maternal, Infant, and Child Health, 7.1: reduce cesarean births among low-risk women with no prior cesarean births. Updated 2019. Accessed October 24, 2019.
    1. Maternal Safety Foundation . NTSV Rate Dashboard. 2018. Accessed October 24, 2019.
    1. Betran AP, Torloni MR, Zhang JJ, Gülmezoglu AM; World Health Organization Working Group on Caesarean Section . WHO statement on caesarean section rates. BJOG. 2016;123(5):667-670. doi:10.1111/1471-0528.13526
    1. Molina G, Weiser TG, Lipsitz SR, et al. . Relationship between cesarean delivery rate and maternal and neonatal mortality. JAMA. 2015;314(21):2263-2270. doi:10.1001/jama.2015.15553
    1. Foo PK, Lee RS, Fong K. Physician prices, hospital prices, and treatment choice in labor and delivery. Am J Health Econ. 2017;3(3):422-453. doi:10.1162/ajhe_a_00083
    1. Alexander D. Does physician pay affect procedure choice and patient health? evidence from Medicaid c-section use. Working Paper 2017-07. Federal Reserve Bank of Chicago ; 2017.
    1. Keeler EB, Brodie M. Economic incentives in the choice between vaginal delivery and cesarean section. Milbank Q. 1993;71(3):365-404. doi:10.2307/3350407
    1. Grytten J, Monkerud L, Hagen TP, Sørensen R, Eskild A, Skau I. The impact of hospital revenue on the increase in caesarean sections in Norway: a panel data analysis of hospitals 1976-2005. BMC Health Serv Res. 2011;11:267. doi:10.1186/1472-6963-11-267
    1. Healthcare Cost and Utilization Project . HCUP Nationwide Readmissions Database, 2010-2014. Accessed August 5, 2019.
    1. Clapp MA, James KE, Melamed A, Ecker JL, Kaimal AJ. Hospital volume and cesarean delivery among low-risk women in a nationwide sample. J Perinatol. 2018;38(2):127-131. doi:10.1038/jp.2017.173
    1. Federspiel JJ, Suresh SC, Darwin KC, Szymanski LM. Hospitalization duration following uncomplicated cesarean delivery: predictors, facility variation, and outcomes. AJP Rep. 2020;10(2):e187-e197. doi:10.1055/s-0040-1709681
    1. Kuklina EV, Whiteman MK, Hillis SD, et al. . An enhanced method for identifying obstetric deliveries: implications for estimating maternal morbidity. Matern Child Health J. 2008;12(4):469-477. doi:10.1007/s10995-007-0256-6
    1. Asch DA, Nicholson S, Srinivas S, Herrin J, Epstein AJ. Evaluating obstetrical residency programs using patient outcomes. JAMA. 2009;302(12):1277-1283. doi:10.1001/jama.2009.1356
    1. Easter SR, Robinson JN, Carusi D, Little SE. The US twin delivery volume and association with cesarean delivery rates: a hospital-level analysis. Am J Perinatol. 2018;35(4):345-353. doi:10.1055/s-0037-1607316
    1. Armstrong JC, Kozhimannil KB, McDermott P, Saade GR, Srinivas SK; Society for Maternal-Fetal Medicine Health Policy Committee . Comparing variation in hospital rates of cesarean delivery among low-risk women using 3 different measures. Am J Obstet Gynecol. 2016;214(2):153-163. doi:10.1016/j.ajog.2015.10.935
    1. Anderson GF. From ‘soak the rich’ to ‘soak the poor’: recent trends in hospital pricing. Health Aff (Millwood). 2007;26(3):780-789. doi:10.1377/hlthaff.26.3.780
    1. Healthcare Cost and Utilization Project . Cost-to-charge ratio for inpatient files, 2020. Accessed August 6, 2020.
    1. Healthcare Cost and Utilization Project . Cost-to-charge ratio files, 2018. Accessed August 14th, 2019.
    1. Silva J, Tenreyro S.. The log of gravity. Rev Econ Stat. 2006;88(4):641-658. doi:10.1162/rest.88.4.641
    1. US Department of Labor, Bureau of Labor Statistics . Consumer price index. Accessed May 8, 2015.
    1. Clapp MA, Little SE, Zheng J, Robinson JN. A multi-state analysis of postpartum readmissions in the United States. Am J Obstet Gynecol. 2016;215(1):113.e1-113.e10. doi:10.1016/j.ajog.2016.01.174
    1. Fridman M, Korst LM, Chow J, Lawton E, Mitchell C, Gregory KD. Trends in maternal morbidity before and during pregnancy in California. Am J Public Health. 2014;104(suppl 1):S49-S57. doi:10.2105/AJPH.2013.301583
    1. Janakiraman V, Lazar J, Joynt KE, Jha AK. Hospital volume, provider volume, and complications after childbirth in US hospitals. Obstet Gynecol. 2011;118(3):521-527. doi:10.1097/AOG.0b013e31822a65e4
    1. Xu X, Gariepy A, Lundsberg LS, et al. . Wide variation found in hospital facility costs for maternity stays involving low-risk childbirth. Health Aff (Millwood). 2015;34(7):1212-1219. doi:10.1377/hlthaff.2014.1088
    1. Nguyen PL, Gu X, Lipsitz SR, et al. . Cost implications of the rapid adoption of newer technologies for treating prostate cancer. J Clin Oncol. 2011;29(12):1517-1524. doi:10.1200/JCO.2010.31.1217
    1. Matlock DD, Groeneveld PW, Sidney S, et al. . Geographic variation in cardiovascular procedure use among Medicare fee-for-service vs Medicare Advantage beneficiaries. JAMA. 2013;310(2):155-162. doi:10.1001/jama.2013.7837
    1. Thomas MP, Parzynski CS, Curtis JP, et al. . Percutaneous coronary intervention utilization and appropriateness across the United States. PLoS One. 2015;10(9):e0138251. doi:10.1371/journal.pone.0138251
    1. Medicaid and CHIP Payment and Access Commission . Medicaid payment initiatives to improve maternal and birth outcomes. MACPAC Issue Brief. April 2019. Accessed August 9th, 2019.
    1. TennCare . 2017 episodes of care results. Created 2017. Accessed August 9th, 2019.
    1. Kozhimannil KB, Graves AJ, Ecklund AM, Shah N, Aggarwal R, Snowden JM. Cesarean delivery rates and costs of childbirth in a state Medicaid program after implementation of a blended payment policy. Med Care. 2018;56(8):658-664. doi:10.1097/MLR.0000000000000937
    1. Ayres-De-Campos D, Cruz J, Medeiros-Borges C, Costa-Santos C, Vicente L. Lowered national cesarean section rates after a concerted action. Acta Obstet Gynecol Scand. 2015;94(4):391-398. doi:10.1111/aogs.12582
    1. Dranove D. Pricing by non-profit institutions. The case of hospital cost-shifting. J Health Econ. 1988;7(1):47-57. doi:10.1016/0167-6296(88)90004-5
    1. Woodworth L, Romano PS, Holmes JF. Does insurance status influence a patient’s hospital charge? Appl Health Econ Health Policy. 2017;15(3):353-362. doi:10.1007/s40258-017-0308-z
    1. Muhlestein D. What types of hospitals have high charge-to-reimbursement ratios? Health Affairs blog. Posted July 15, 2013. Accessed February 12, 2021. doi:10.1377/hblog20130715.033072
    1. Bai G, Anderson GFUS. US hospitals are still using chargemaster markups to maximize revenues. Health Aff (Millwood). 2016;35(9):1658-1664. doi:10.1377/hlthaff.2016.0093

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