Members of the U.S. Senate Finance Committee suggest that Farzad Mostashari, MD, the National Coordinator for Health Information Technology, has little or no idea of the challenges rural healthcare providers face as they grapple with Meaningful Use requirements.
With all of the fighting, delays, and splashy headlines surrounding the Patient Protection and Affordable Care Act, the evolving status of meaningful use and the adoption of electronic health records often take a back seat.
Yet, the Health Information Technology for Economic and Clinical Health (HITECH) Act of 2009 and the $33 billion that came with it are leading and funding the development of the complex HIT infrastructure that will make possible key components of PPACA.
There are rumblings, however, that rural providers are falling behind with HITECH implementation. For example, only one-third of rural hospitals have electronic medical records systems, compared with half of all urban hospitals.
Members of the U.S. Senate Finance Committee Wednesday sought answers on the status of meaningful use in rural America from Farzad Mostashari, MD, the National Coordinator for Health Information Technology. "I'm concerned about the digital divide may only get larger as rural hospitals are expected to take the leap into the more rigorous requirements of [Meaningful Use] Stage 2," Sen. John Thune, (R-SD), told Mostashari during the hearing.
"They have already expressed great concerns about Stage 2. I am of the view that [Office of the National Coordinator] and [Centers for Medicare & Medicaid Services] ought to develop a way for rural hospitals to achieve Stage 2 while allowing more advanced healthcare systems and providers to move on to Stage 3 if they are ready. The question would be will you commit to giving rural providers more time to achieve Stage 2?"
Mostashari replied that federal officials "have been quite open to dialog with the rural community and how we can help them achieve success and not necessarily accept that they are necessarily going to be further behind."
While challenges remain, Mostashari says that rural providers have made tremendous progress in adopting electronic health records. In fact, Mostashari says he is so confident in the advances that smaller hospitals are making, that deadlines have been moved up, not back.
"We set a goal of getting 1,000 critical access hospitals to meaningful use by 2014. We are going to revise that goal to get 1,000 critical access hospitals to meaningful use by the end of this year," Mostashari says.
"We think we are making good progress with those hospitals through the technical assistance and coordination that is possible. So, we are open to dialog. But I would much rather see the rural hospitals be able to keep up rather than me acknowledge that they are going to fall behind."
An independent review appears to back up Mostashari's claims that rural America is making progress on the electronic medical records front. A report from the Robert Wood Johnson Foundation, co-authored by Mathematica Policy Research and the Harvard School of Public Health, finds that the proportion of rural hospitals with at least a basic EHR increased from 9.8% to 33.5% from 2010-12. During the same time urban hospitals saw EHR adoption rates rise from 17% to 47.7%.
"The inpatient divide between rural and smaller hospitals compared to better resourced urban hospitals, particularly teaching hospitals, remains, but it is closing," says study co-author Michael Painter, MD, senior program officer at Robert Wood Johnson Foundation.
"The other thing we are finding is that the rate of adoption seems to be accelerating among the small and rural hospitals compared with the larger better resourced urban hospitals. That makes sense because the better-resourced urbans accelerated early on and now that is leveling off. The more-challenged small and rural hospitals are accelerating. Where this all plays out is hard to see. We will keep monitoring it in the coming years."
Painter says the percentages of hospitals that have achieved meaningful use actually could be significantly higher than what his report found because it uses data from 2012.
"Those numbers are a moving target. When we looked at 2011 data, only 4% were meeting Stage 1 Meaningful Use. From that dipstick to the next year it went to 44%. So we would expect that when we looked at who is close to pushing over on the Stage 1 criteria there is a huge number there."
"You can't get that mired down in what those snapshot-in-time numbers mean. What we are seeing is a trending all in the right direction, with some ongoing small and rural gaps, although that seems to be closing. But we are not out of the woods yet," Painter said.
Back in Washington, several members of the committee, including Sen. Pat Roberts, (R-KS), made jokes about Mostashari's trademark bow tie and suggested that he and other federal bureaucrats have little or no idea of the challenges that rural providers face as they grapple with meaningful use.
"My concern is I don't think we are getting the word west of Highway 81 in Kansas…," Roberts said. "It's like Paul Harvey used to do with Page 1 and Page 2. Page one and I will be back in just a minute. Well you've got Phase 1 and Phase 2. If we could just pause and make sure that most of the rural providers know what is going on."
"I get two sides of the story. I talk with the people in Topeka and they say everything is going as best as it possibly can. But I get a lot of calls from providers saying this is the proverbial wet horse blanket. My suggestion would be [to] take this show on the road. I would recommend Hayes, KS or Dodge City, KS. That is my hometown. I'm not sure I would recommend wearing a bow tie in Dodge City. But if you could go out and sort of take this digital show on the road that would be helpful. Or maybe have these folks come in because I know you are extremely busy."
That sentiment was shared by Committee Chairman Max Baucus, (D-MT), who urged Mostashari to "get out… of your offices and out to rural America. See it. Smell it and taste it, and know what it is. It is one thing to conceptualize it. It is something else to experience it."
"I mention you, Dr. Mostashari. I don't know why. I sense you are a Philadelphia guy, an eastern guy, a big city guy. There is a huge difference. Eighty percent of life is just showing up, just getting out there, being there, seeing it. Get out from behind your desk. It is well worth it. You're going to make fewer mistakes with respect to rural providers if you get out and see it."
The most well-known of a series of hospital rankings is a powerful marketing tool, but one observer says he is troubled that none of the various "rating schemes" use state and federal inspection data in their evaluations.
U.S. News & World Report released its much anticipated 24th annual Best Hospitals ranking Tuesday with familiar hospitals holding the coveted top spots.
The only drama came when Johns Hopkins Hospital reclaimed the No. 1 spot on the magazine's honor roll, a distinction it had held from 1991 through 2011, but which it lost last year to Massachusetts General Hospital. Mass General had to settle for silver this year, dropping to No. 2 on the list. The Mayo Clinic in Rochester, MN came in third.
Johns Hopkins Hospital officials were positively giddy with the news and issued a press statement crowing that the Baltimore hospital was "back on top."
"Given the competitive, rapidly changing health care environment and the realization that U.S. News evaluated more than 4,806 hospitals, we hope you share our incredible pride in achieving this top-tier ranking among the best hospitals in the United States," said a joint letter to employees and staff from Paul B. Rothman, MD, dean of the medical faculty and CEO of Johns Hopkins Medicine, and Ronald R. Peterson, president of The Johns Hopkins Hospital and Health System and executive vice president of Johns Hopkins Medicine.
Mass General officials took solace in noting that the Boston hospital was ranked No. 2 in the nation, No. 1 in New England, and placed highly in all of the 16 specialty areas identified by U.S. News.
"Of the nearly 5,000 hospitals evaluated, Mass General has consistently placed among the top hospitals on the Honor Roll since the survey began in 1990," the hospital said in its media release.
U.S. News ranks up to 50 hospitals in each of 16 medical specialties. Just 147 out of nearly 5,000 hospitals earned national ranking in one or more of the specialties, the magazine said.
"The mission of Best Hospitals is to help guide patients who need a high level of care because they face a particularly difficult surgery, a challenging condition, or added risk because of other health problems or age," Avery Comarow, U.S. News Health Rankings Editor said in a media release.
"Patient survival and safety data, the adequacy of nurse staffing levels and other objective data largely determined the rankings in most specialties." Comarow said another factor was a national survey that asked physicians in each of the 16 specialties to name the hospitals they consider best for the toughest cases in their specialty.
More impartial observers say that the U.S. News rankings are simply the most well-known of a series of hospital awards, all of which have their good and bad points.
"The problem is there are a number of awards given out to hospitals. There is Health Grades and U.S. News, and LeapFrog [Group] and Consumer Reports and they don't always match with one another," says Charles Ornstein, senior reporter at ProPublica, the nonprofit news organization, and president of the board of the Association of Health Care Journalists.
"Oftentimes they strongly disagree with one another and there are a number of cases where they recognize hospitals that are in serious violation of federal and state regulations related to quality of care. It is a concern that there is such a proliferation of rankings that they have almost become hard to decipher."
Ornstein says the U.S. News rankings in particular present "a great marketing tool for hospitals that are recognized."
"It is a name consumers recognize. And hospitals are looking for independent validation of their quality. So, this is something which, even though they may criticize the methods and especially criticize it if their ratings go down, they definitely want to make the list of top hospitals in their area or in the country," he says.
Ornstein says he is troubled that none of the various "rating schemes" use state and federal inspection data in their rankings.
"They certainly use quality measures from Hospital Compare and other places. But they aren't taking into account the findings that regulators have when they go into a facility and use their five senses to identify problems with quality of care, medication errors, wrong side surgeries, and other types of mistakes," he says. "So, it is really important that these rating systems figure out a way to include regulatory findings in the reports."
"Also, whether we like it or not, a lot of the numbers are self-reported by the institutions," Ornstein says. "There are places that have been found to have up-coded their billing to make their patients look sicker than they are, or provided unnecessary surgeries, whether they are stents or back surgeries. And the rating systems don't have a mechanism to take into account those types of things."
Ornstein says the various ranking surveys would better serve consumers if they started using independently verified measures available on Hospital Compare and other Web sites, such as Why Not The Best?, which provide historical information on quality metrics.
"They should look at our Web site, HospitalsInspections.org, which incorporates information about federal deficiency reports against hospitals. There is also information available in every state on state inspections of those hospitals," he says.
"So, if you have an acute condition you are not going to do a ton of research. You are going to call 9-1-1 and be taken to the nearest hospital. But if you are looking for a hospital for a knee replacement or a hip replacement or some elective procedure, there is an array of sites that are trying to draw attention to patient safety at hospitals. That has to be something that is very much in the mix as you think about what hospital you want to go to."
Richard "Buz" Cooper, MD, a healthcare economist at the University of Pennsylvania, calls the U.S. News list "an old game, but it has some merit for what it actually measures."
"It lists the hospitals in which various specialties are highly regarded nationally, and the one with the most is #1. These are places where specialists elsewhere in the country trained, and they hold them in high regard. They are also places that specialists and generalists refer their most complex patients. So, they deserve recognition," Cooper said in an email exchange with HealthLeaders Media.
"But other hospitals are just as good in the vast majority of circumstances. Yet even there, there is a pecking order. For a serious problem, the highly developed community hospital is a better place to go than the 20-bed rural hospital."
Tenet Healthcare's deal to acquire Vanguard Health strengthens Tenet's ability to make acquisitions of not-for-profit hospitals and "might prompt smaller, stand-alone hospitals to consider some sort of alignment," Moody's Investors Service says.
Tenet Healthcare Corp.'s $4.3 billion acquisition of Vanguard Health Systems, Inc. is a credit negative for not-for-profit hospitals, particularly for smaller, stand-alone hospitals that will have to compete within the service areas of the soon-to-be much larger for-profit company, Moody's Investors Service says.
"The reality is this just puts a very effective competitor in their back yard or their front yard, potentially," says Beth Wexler, vice president and senior credit officer at Moody's. "Bigger picture, these smaller hospitals that might have significant capital needs don't necessarily have great leverage with payers or alignment with physicians, particularly when you are talking about markets that are more secluded or rural or difficult to recruit to. They are going to be more and more challenged to have an operating platform that is sustainable."
A Moody's analysis notes that the planned acquisition "consolidates two large and powerful systems into a bigger company with pro forma revenues of $15 billion as of 31 March that will increase competition, particularly for smaller standalone NFP community hospitals that operate in the Tenet and Vanguard markets."
When the merger is finalized, Tenet will operate 77 hospitals in 30 markets, which includes Tenet's 49 hospitals in 24 markets and Vanguard's 28 hospitals in six markets.
Moody's says that "the potential shared savings and combined resources will allow Tenet to engage in new and enhanced competitive endeavors that could threaten NFP hospitals, especially those with fewer resources. In recent years, Tenet has diversified its business with financial consulting services to hospitals and other healthcare-related businesses. Both Tenet and Vanguard have aggressively expanded their outpatient presence and often compete with similar ambulatory strategies as NFP hospitals."
Moody's also notes that the merger "strengthens Tenet's ability to make acquisitions of NFP hospitals. Such acquisitions are typically credit positive for target hospitals, particularly distressed institutions, as the acquisition typically results in 100% redemption of the target's outstanding bonds."
Wexler says the Tenet/Vanguard merger might prompt smaller, stand-alone hospitals to consider some sort of alignment, "whether it is clinical alignment or strategic alignment around certain services, or just looking for the protection of a deeper pocket."
"Each market is different and will somewhat dictate what is needed but it is more and more challenging," she says. "Reimbursements are declining. Volumes are declining. To the extent that these are not really high-acuity hospitals to begin with they are going to be more challenged to keep the volumes, the heads on the beds, which is not the game anymore. Having an effective competitor in the market with deeper pockets and a greater expanse, taking that leveraging power of the two for-profit companies and having them come together, just makes these for-profits more effective competitors in these marketplaces where these independents are already feeling pressures and challenges."
HMA Fixes July 18 as Record Date for Shareholders in Glenview Vote
Health Management Associates, Inc. has fixed July 18 as the record date for Glenview Capital Management's consent solicitation, which gives shareholders of record on that date the chance to choose whether to replace sitting HMA directors with the nine nominees put forward by Glenview.
Glenview, which owns 14.6% of HMA common stock, issued a notice to shareholders that any shares on loan on July 18 will not be eligible to consent.
Glenview, HMA's largest shareholder, filed documents with the Securities and Exchange Commission calling for the replacement of its board of directors.
In the SEC filing, Glenview says, "…[W]e are setting forth a path that we believe creates the strongest future for HMA's patients, employees, and investors while minimizing the risk to each vital constituency. We suggest HMA shareholders consent to fully reconstitute the Board…"
Glenview recommended replacing the board with "highly qualified, independent, newly elected directors" which it dubbed the "Fresh Alternative."
Headquartered in Naples, FL, HMA operates 71 healthcare organizations in 15 states. The fight for control of the company comes as Reuters reports that rivals of HMA, including Community Health Systems, are discussing a potential deal to buy the $4 billion hospital operator.
Carolinas HealthCare System to Buy Stanly Health Services
The board of directors at Stanly Health Services has agreed to sell the Albemarle, NC-based health system to Carolinas HealthCare System after negotiating a deal that includes $70 million in upgrades and other investments over the next 12 years, the two systems announced.
If the deal is approved by state regulators and the Carolinas HealthCare board, the existing management services agreement between the two health systems that has been in effect since 2009 will be cancelled and the transfer of ownership will become effective Oct. 1.
Financial terms of the deal were not disclosed, but Carolinas said it will spend $70 million over 12 years to improve patient care services and facilities within Stanly. Targeted investments include an upgrade of the information technology systems, expanding the intensivist program at the 119-bed Stanly Regional Medical Center, expanding the emergency department from 18 to 28 beds, patient room improvements, and building an urgent care center in Albemarle.
"As board members, our top priority is to ensure the long-term sustainability of our organization so we can continue to provide healthcare services of the highest quality well into the future," Stanly board chairman Larry Baucom said in prepared remarks.
"Extensive due diligence and evaluation went into this decision and the board believes that formally becoming a part of Carolinas HealthCare System is in the best interests of our patients, our employees, our physicians and our community. In this time of tumultuous change in healthcare we are now aligning our two systems to meet future challenges and opportunities."
Carolinas HealthCare System will assess medical staff needs and recruit physicians to Stanly County. Two members of the Stanly Health Services Board of Directors will be appointed to a new SHS board, and the remainder will be appointed by Carolinas HealthCare System to a newly created advisory council.
St. Joseph's to Align with CHE Trinity Health
St. Joseph's Hospital Health Center will join CHE Trinity Health – the nation's second-largest Catholic healthcare system -- following the signing of a non-binding Letter of Intent by their boards, the two organizations announced.
Financial terms were not disclosed.
If the deal is finalized, it would change ownership of Syracuse, NY-based St. Joseph's from the Sisters of St. Francis of the Neumann Communities to Catholic Health Ministries, the entity that sponsors CHE Trinity Health. CHE Trinity Health was formed in May 2013 when Catholic Health East and Trinity Health merged operations in 21 states.
"When CHE and Trinity Health consolidated, we saw a new organization of which we wanted to be a part because of the promise its new ministry offers," St. Joseph's CEO/President Kathryn Ruscitto said in prepared remarks. Ruscitto said the sale will give St. Joseph's to access the resources and economies of scale provided by a large health system while retaining some sense of autonomy.
"Most importantly, St. Joseph's will retain its governance structure and continue to operate locally, while gaining additional support from the breadth of CHE Trinity Health's combined strength, educational opportunities and best practices," Ruscitto said.
Sister Roberta Smith, general minister of the Sisters of St. Francis, said "the Sisters of St. Francis fully support St. Joseph's decision to align with CHE Trinity Health. We strongly believe CHE Trinity Health will provide a strong vision, bound by faith, for the future of St. Joseph's and the benefit of the Central New York community. We remain committed to the mission of St. Joseph's and will continue to lend our spiritual support for the compassionate good works of the institution."
The two systems said they will work together during a due diligence period over the next several months before finalizing the sale.
St. Joseph's Hospital Health Center includes a 431-bed hospital and healthcare system that provides services to patients in 16 counties in Central New York State. CHE Trinity Health is in 21 states across the nation with 82 hospitals, 89 continuing care facilities and home health and hospice programs that provide nearly 2.8 million visits annually. It employs more than 87,000 people, including 4,100 employed physicians.
A report commissioned by the Parkland Health & Hospital System board of managers in Dallas makes a score of recommendations for improving governance practices at the troubled safety net health system.
The Parkland Health & Hospital System board of managers this week made public an outside consultant's report whose 20 recommendations include expanding the seven-member board to 11 members.
The report also recommends that board members at the Dallas-based public safety net system serve three-year terms instead of the current two-year terms, receive more training to better understand and perform their board duties, and that a "visitors committee" of outside observers serve as advisors to the board.
"These recommendations, taken together, provide a comprehensive road map for the board as we develop a sustainable governance model that is appropriate for a complex billion-dollar plus public safety net health system in the 21st century," Parkland Board of Managers Chair Debbie Branson said in prepared remarks.
The report was commissioned in May 2012 by the board, which hired The Saranac Group LLC consultants. Saranac issued the report in March, but the Parkland board put the report on its agenda this month, at which point the board voted to accept the report. The next step will be to start discussions on the individual recommendations, none of which have yet been implemented or rejected, Parkland officials said.
Some of the recommendations, such as the reorganization of board committees can be done through board action alone. Others, such as expanding the size of the board, will require legislative approval because Texas state law limits the size of governing boards for publicly financed hospital districts to no more than seven members.
"A great deal of research and reflection went into these thoughtful recommendations, and the board is committed to raising the governance bar for large and complex public safety net health systems," Branson said.
"It is about our professionalism, performance and accountability in fulfilling our oversight responsibilities. We will be more responsive to the needs of Parkland and its patients, as well as the expectations of the Dallas County community, that's the end-game here. We want to create a governance system that will serve Parkland well for generations to come."
The report comes as Parkland braces for a rigorous inspection this summer by surveyors from the federal Centers for Medicare & Medicaid Services, which was prodded into action after the February 2011 death of a patient in the hospital's psychiatric emergency department. The health system has been under a corrective actionfor more than two-years for myriad quality and patient safety concerns.
In 2011, CMS placed Parkland under a systems improvement agreement that allows it to continue to receive Medicare reimbursements as long as a third party is onsite to monitor and facilitate changes that need to be made.
The administrative burden of being a physician continues to fuel discontent among doctors. More than a third report having a negative outlook for the profession, and the majority would not recommend it as a career choice.
Nearly 60% of physicians wouldn't recommend the profession to young people, a survey shows.
The various sources of the doctors' discontent include decreased autonomy, lower reimbursements, administrative and regulatory hassles, corporate medicine, litigation fears, and longer work hours, much of which has meant that they're spending too much time away from patients.
Looking ahead, 36% of the 3,456 physicians who responded to a survey conducted this spring by Atlanta-based physician staffers Jackson & Coker reported a negative outlook for the profession, while 16% were favorable and 48% cautious.
"What we have begun to find is that pretty much across the board the physicians are becoming a little disenchanted with the business of medicine," says Edward McEachern, vice president of marketing Jackson & Coker.
"Not the practice of medicine, but the business of medicine, because of this overwhelming administrative burden that is very difficult for them to work through and still practice good patient care medicine. It's to the point where we ask 'would you be willing to recommend the medical career as a position to the younger generation' and for the first time we've really begun seeing them not recommend it."
"They are saying 'with all the investment I have to have in my education and all of that is the outcome really worth it?' They are telling these young people 'Hey this isn't the place to go. Stay in healthcare. It's a great industry. Just don't become a physician.'
If you look at (Certified Registered Nurse Anesthetists) versus anesthesiologists the money is almost the same, but the risk for the CRNA is dramatically less in terms of liability, the cost of the education, etc. So all of a sudden when you are looking at the balance you think 'I will just become a CRNA and I won't have those sleepless nights, but I am making a large percentage of what the doctor is making.'"
>>View report
Source: Jackson & Coker
McEachern says the movement toward employed physicians may ease some of the concerns about paperwork and haggling with insurers, but that it also creates its own sets of problems.
"One of the motivations for physician relocation at one point was dealing with immediate income versus potential income," he says. "What happened is 20 years ago, when we did this survey, potential income was among the highest ranking motivators. Now it is immediate income and the reason is doctors aren't building equity in a practice anymore like someone building equity in a home they plan to sell in 20 years from now. Even though employment model has less overhead and risk, you also aren't building any equity in your own future. So you have to take all the money on the table now as opposed to building a practice."
Scott M. Manning, director of HR/Provider Recruiting at District Medical Group, the largest physician group in Phoenix, AZ, with more than 300 providers, says he senses a lot of job dissatisfaction among physicians although the levels cited by the Jackson & Coker survey "sound a little high to me."
"But I am not at all surprised that there are a percentage of docs who don't see medicine to be as good a career today as they did 20 or 30 years ago," says Manning, who is also president of the Association of Staff Physician Recruiters.
"It is kind of a generational thing. If you were to talk to docs who came out of training 25 or 30 years ago the vast majority of them would go out and join a small group of two or three docs, they would hang a shingle and open their own practice. For those folks things like Obamacare and expanded Medicaid or more government rules are a definite dissatisfier. They result in lower rates of reimbursements. They also result in less control over how you decide to run your practice. But it is not like it is any one thing such as Obamacare. This has been going on for many years. If you went back a few years, you'd see the same thing although the percentage wouldn't be this high but that is probably true of the docs who are older and heading towards retirement age."
Manning says dissatisfaction among older physicians will not necessarily affect the decisions of younger people to enter medicine.
"The folks who are coming into the business today know what they are getting into," he says. "Most of them tend to lean towards employment instead of being out on their own. You see the numbers of physicians who prefer to have someone else run the business so they don't have to worry about the overhead."
Even with all the carping by physicians, Manning says it remains a good living. The key is to ensure that would-be doctors understand what they are undertaking from the onset.
"You have to educate the people on what the career is today, not what it was 30 years ago, and emphasize the positive things about being a doctor today which are still very much what they were before," he says. "If you are going into the business because you want to take care of people and make a difference it is still a great business. If you are going into it because you want to make a good living it's still a great business. Will you make as big a percentage difference over the norm than maybe you did 30 years ago? Maybe not. Maybe the gap is closer. But physicians still make a very nice living."
McEachern acknowledges that disgruntled physicians could be more inclined to answer questions about happiness and job satisfaction and that their responses could be a way of venting the frustration and uncertainty that comes with healthcare reform and other fundamental shifts in care delivery, employment, and reimbursement models.
"That is the blowing off steam part. That is our theory. There seems like a lot of frustration tied to that uncertainty," he says. "What we have found is that autonomy and satisfaction seem very closely linked. What does that mean? We really don't know the answer yet. We are still waiting to get a few years down the road to see. As more and more doctors choose employment they are still going to relinquish some autonomy. Are we going to see an increase in satisfaction and employed physicians over the years or is it going to flame out just like it has with private practice doctors?"
Surgical residents who completed a year in rural practice were more likely to enter general surgery practice than those who did not. They were also more likely to practice in areas with populations of less than 50,000, an Oregon Health and Science University study shows.
Evidence suggests that a good way to lure young physicians into rural practice is to provide them with that experience while they are medical residents.
A new study out of Oregon this month in JAMA Surgery, for example, finds that exposing fourth-year surgery residents to rural practices increases the likelihood that they will practice general surgery in a similar location, even if their initial plans were to further specialize or settle in more-urban areas.
Karen Deveney, MD, program director for OHSU's Department of Surgery
The study reviewed the records of 70 surgical residents Oregon Health and Science University in Portland who completed the general surgical residency at OHSU and entered practice since the rural rotation began in 2002. The numbers are small, but the study found that residents who completed the rural year were more likely to enter general surgery practice (10 of 11) than those who did not (28 of 59). They were also more likely to practice in a site of population less than 50,000.
Most residents who completed the rural year (6 of 11) entered residency with a desire to practice general surgery. Of the residents who entered training with a specialty career in mind, four of five who completed the rural year are practicing general surgery, while 13 of 45 who stayed at OHSU's university program for the entire five years are in general surgery practice.
The study's lead author, Karen Deveney, MD, program director for OHSU's Department of Surgery, says a rural rotation exposes medical residents to a "sense of community" that often isn't as well defined in urban areas.
"You have a more long-term relationship with a lot of your patients than is often the case in the higher-urban areas, particularly in a specialty where you have brief encounter to take out the gallbladder and you see them a couple of times and they are gone," Deveney says.
"In a small community you take care of them. You take care of their mother and father. You take care of their kids. You see them in the grocery store. You see them when you're getting your car fixed. You end up having this sense of community and people kind of seek that. A lot of our whole hectic life, particularly in urban centers has become fairly isolated and so, this combats that."
"The other thing is that you feel comfortable with a greater variety of procedures and diseases and things and that gives a sense of accomplishment. Sometimes in the urban academic medical centers we are sort of—brainwashed is too harsh a word—but influenced that you can't know it all and so you should focus more and more on a smaller and smaller area."
"Then you get such fragmentation of care that you become an expert in a small thing but that over the long term is less satisfying because it also gets confining. If someone goes into a rural area to do training and practice they see you really can perform at a high level and have a good capability of taking care of a broad range of problems capably."
Many of the nation's taxpayer-funded medical residency programs, most of which are located in urban settings, have come under fire for their failure to expose residents to rural rotations. Even though 20% of Americans live in rural America, a recent study from George Washington University School of Public Health and Health Services found that only 4.8% of new physicians said they planned to establish a practice in a rural area.
The GW study examined the career paths of 8,977 physicians who had graduated from 759 medical residency sites from 2006 to 2008. The researchers found that 198 of 759 institutions produced no rural physicians during the study period. And 283 institutions graduated no doctors practicing in the Federally Qualified Health Centers that serve low-income or destitute patients in underserved urban and rural areas.
Deveney says the nation's residency programs are creating "such a geographic mal-distribution that the urban areas are saturated and the competition of specialists in urban areas is fierce."
"It's counterproductive, particularly in Midwestern and Western states where there is a large expanse of rural towns and people. The urban programs really need to pay attention to the needs of their state. That is kind of why they were set up in the first place," she says.
Even if new general surgeons practice in exurban or smaller cities, that is still preferable to having a glut of physicians practicing in urban centers. "We used towns of 50,000 as the cutoff in our study but there are some who went out to general surgery practice in smaller towns that are between 50,000-100,000," Deveney says. "Those are still closer to where the real need is than in the middle of Portland or Chicago or Seattle."
Deveney readily concedes that the numbers of residents in the Oregon study who gravitated towards rural settings come nowhere near meeting demand. Even so, every little bit helps, and she says the Oregon rural residency rotation could be a model for other states.
"Our program only produces a small number but if you multiplied that by 250 training programs that each produced a couple that would increase the number," she says.
"Increasing the number of trainees entering general surgery practice in rural areas won't take care of the shortage entirely because we don't produce enough general surgeons every year in the entire country—even if all of them went into rural surgery—to do the job. But between our model within a training program and one or two existing programs that have carved out an actual rural track residency program we're mostly saying 'hey if you do this it will work and here is how you do it.'"
"Anything we can do to give greater exposure to the joys of a more generalized practice will have an effect on redistribution."
University Hospitals announces its intent to acquire one of two of the last independent hospitals in northeast Ohio while consolidation continues in Massachusetts and New York City.
The number of independent hospitals in northeastern Ohio continues to dwindle with news that University Hospitals has signed a letter of intent to acquire Parma Community General Hospital.
Terrence G. Deis, president/CEO of Parma Hospital
"We went through a thorough process and we think we selected the very best partner," says Terrence G. Deis, president/CEO of Parma Hospital. "It was the right combination of commitment to us and the community, a quality footprint, and culture, so we feel pretty good about it. The medical staff maybe even more importantly feels good about it. There is a lot of work to be done between now and a definitive agreement but I feel a lot better about it than I felt I would have even a few months ago."
Healthcare analyst Allan Baumgarten says the UH/Parma deal comes just weeks after UH announced a similar merger with EMH Health in Elyria, which had left Parma as the largest hospital in Cuyahoga County that wasn't already part of UH or Cleveland Clinic.
"UH and Cleveland Clinic have established northeast Ohio as a two-system market and these deals further cement that," Baumgarten said in an email exchange. "Except that Catholic Health Partners (Cincinnati HQ but several hospitals in northern Ohio) has emerged as a possible third system in the region with its partnership with the Summa Hospitals and health plan in Akron."
Although he called Parma "fiercely independent," Deis says it became time to acknowledge the realities that independent hospitals face in a consolidating market.
"We have a shrinking demographic in Northeast Ohio and the competition has stepped up. We just weren't able to compete in that environment. In the last year especially it has been our feeling that it was really inevitable," he explains.
"We have a three-hospital collaborative and last month they announced that they are merging with UH. That left us as one of two of the last independent hospitals in the Northeast Ohio area. If that didn't reek of inevitability, then nothing did."
"For us, the sequester was a big deal. We are a large Medicare facility and a 2% reduction doesn't seem like a lot, but in a decent year 2% is our whole bottom line. It's tough to make that up. The job went from getting more difficult every month to more difficult every week to more difficult every day. The money was needed to attract and retain physicians and the more we were fighting to hang on, the more difficult that became because the first thing people want to know is where are you going to be in five years."
In a media release announcing the acquisition, UH said it would bring investments and new services as a major benefit to the agreement including expanding the presence of UH Rainbow Babies & Children's Hospital that provides neonatal care at Parma Hospital. UH Case Medical Center, an academic medical center, will provide clinical research, and new technology and other innovations.
"Parma Hospital is a vital anchor institution in the communities that they serve," Thomas F. Zenty III, UH's CEO said in a media release. "We are honored to have the opportunity to support and share in their mission to provide the highest quality patient-centered care and to join with them and their physicians in advancing the vision of value-driven, affordable care."
Parma employs 2,000 people and has more than 500 physicians on its medical staff, for a service area that extends beyond its six founding cities of Parma, Parma Heights, Brooklyn, Brooklyn Heights, Seven Hills and North Royalton.
UH employs 18,000 people and its health system includes 10 hospitals and 20 outpatient health centers.
Deis says he isn't sure what his role will be when the deal is finalized later this year or if he will stay on as part of the new hospital management. "That is not going to be my decision, but I would hope that would be the case," he says.
Still, the adjustment will take some getting used to. "Once you are at the top of the organization, whatever sized organization, it is a little bit tough to adjust to not being the last say in things," he says.
Other recent hospital consolidation announcements:
Winchester (MA) Hospital to Affiliate with Lahey Health
Winchester Hospital's board of directors has voted to pursue an affiliation with Lahey Health in a service area that includes northeastern Massachusetts and southern New Hampshire, the two hospitals announced.
"This is an exciting step forward," Kevin Smith, president/CEO of Winchester Hospital said in prepared remarks. "We believe that by joining Lahey Health, Winchester Hospital will be better positioned to continue to fulfill its mission of serving the health needs of our patients. An affiliation with Lahey Health will make Winchester Hospital an even more effective partner in maintaining and improving the health of the communities we serve."
Howard Grant, MD, president/CEO of Lahey Health, said the deal would bring together "two innovative organizations are aligning to create a comprehensive network of locally respected primary care physicians and nationally recognized specialists."
The announcement comes nearly one year after Winchester Hospital formed a steering committee to review potential partners. After completing the affiliation agreement, Winchester Hospital will join the Lahey Health Board of Trustees as part of a shared governance model. The Lahey Health Board of Trustees will have an equal number of representatives with full partnership from Winchester Hospital, the former Northeast Health System and Lahey Hospital & Medical Center Boards of Trustees.
The organization will continue to be called Lahey Health, and Grant will remain as president/CEO.
Winchester Hospital services the northwest suburban Boston region with 20 clinical locations in nine towns throughout northeastern Massachusetts. Winchester Hospital also provides an extensive range of outpatient services as well as integrated home care.
In 2012, Lahey Hospital & Medical Center affiliated with Beverly Hospital, Addison Gilbert Hospital and other Northeast Health System entities to form Lahey Health, a health system that provides a full continuum of integrated health services. Lahey Health includes Lahey Clinic Physician Group with practices in Burlington, Peabody and other locations throughout northeastern Massachusetts and southern New Hampshire; Lahey Health Senior Care and Lahey Health Behavioral Services as well as more than 30 primary care physician practices and multiple outpatient and satellite specialty care facilities.
NY Downtown Hospital Merges with NY-Presbyterian
New York Downtown Hospital has been acquired by New York Presbyterian, the two hospitals announced. Financial terms were not disclosed.
The 180-bed community hospital, now renamed NewYork-Presbyterian/Lower Manhattan Hospital, remains the only hospital south of 14th Street in Manhattan.
Steven J. Corwin, MD, the CEO of NY-Presbyterian said NY-Presbyterian/Lower Manhattan plays a critical role in the healthcare of the community. "As the only acute care hospital serving lower Manhattan, this campus is vital to meeting the healthcare needs of many populations," Corwin said in a media release. "We are working closely with the community, as well as with Weill Cornell Medical College and Weill Cornell physicians, to create a first-class campus that provides the highest quality, most compassionate care and service for patients and their families."
NY-Presbyterian/Lower Manhattan joins the five other campuses of NY-Presbyterian: NewYork-Presbyterian/Weill Cornell Medical Center, NewYork-Presbyterian/Columbia University Medical Center, NewYork-Presbyterian/Morgan Stanley Children's Hospital, NewYork-Presbyterian/The Allen Hospital and NewYork-Presbyterian Hospital/Westchester Division.
Illinois' Edward Hospital and Elmhurst Memorial Finalize Merger
Naperville, IL-based Edward Hospital & Health Services and Elmhurst (IL) Memorial Healthcare announced that they have finalized their merger and made new leadership appointments.
The merger creates one of the larger integrated health systems in the state comprised of three hospitals: Edward, Elmhurst Memorial and Linden Oaks at Edward, with revenues of about $1 billion and more than 50 outpatient locations across a service area of 1.7 million residents. The system employs nearly 7,700 and has more than 1,680 physicians on staff. System naming/branding will be determined and communicated in the coming months, the new system said in a media release.
"This is an historic day for residents of our communities because it brings together and strengthens important community-focused institutions with long histories of serving the western and southwestern suburbs,"Pam Davis, CEO of the new system, said in prepared remarks.
"While Elmhurst Memorial and Edward are already nationally recognized for quality and patient satisfaction, our collaboration will lead to even higher quality, and improved services and efficiencies for our patients as we meet the challenges of healthcare reform."
The new system will work with Illinois Health Partners, which includes DuPage Medical Group and its more than 400 physicians and many independent physicians, to jointly manage the care of more than 100,000 HMO patients in the region.
In May, Mary Lou Mastro was named president/CEO of Elmhurst Memorial Healthcare effective July 1. Gina Sharp was promoted to president of Linden Oaks at Edward, replacing Mastro. Also, Chris Mollet was named system executive vice president/general counsel, and Vince Pryor, was named system executive vice president/CFO.
Try to imagine the ripple effect of punching a $4 billion hole in the economy of a state whose lawmakers refuse federal Medicaid subsidies. It's not just hospital jobs that will disappear. Ancillary support jobs in healthcare and other businesses will wither, too.
Despite the nasty rhetoric, it seemed illogical that 14 states would reject billions of dollars in federal subsidies to pay for the expansion of Medicaid just to make a political point. There was a sense that political leaders in these recalcitrant states were bluffing to save face, but would eventually find a way to expand the program when they realized what they were giving up and who they were hurting.
Wrong!
And now that most state legislatures across the nation have adjourned for the summer with no intention of returning until next year, this is the reality we're left with at least for the next year or so.
A recent RAND study in Health Affairs estimates that the decision not to expand Medicaid in 14 states means that 3.6 million fewer lives will be covered, federal "transfers" to those states will drop by $8.4 billion, and those states' spending for uncompensated care will increase by $1 billion in 2016.
It would be easy enough to write off the decision to reject Medicaid money as just plain dumb. Unfortunately, it's more complicated than that because innocent people are going to be hurt by this ideological line toed in the sand by lawmakers who really ought to know better.
Two predictions: First, the people hurt by the refusal to expand Medicaid will be the sickest, most vulnerable and poorest in these states. And make no mistake about it: People will die when cash-strapped hospitals are forced cut back on services, personnel and access. This is not hyperbole. This must be understood.
David M. Zechman, CEO and President of Ozarks Medical Center
Second: All of these states that are now so boldly rejecting Medicaid expansion money will eventually fold when the public comes to grasp how much this ideology is costing them. It might take a year. It might take longer. Bank on it.
Even vociferous Texas, with close to 30% of its population uninsured, will join the expansion in some way, shape, or form. That much was made clear earlier this month when Dallas-based Tenet Healthcare Corp. acquired Vanguard Health System and its considerable holdings in the Lone Star State.
Like hundreds of his colleagues, David M. Zechman, CEO and President of Ozarks Medical Center, in West Plains, MO, finds himself caught in the middle of an ideological war between state lawmakers who are hostile to the Patient Protection and Affordable Care Act and federal bureaucrats charged with implementing its reforms.
The Missouri General Assembly has declined to expand the Medicaid roles until state Senate and House review panels can issue a report. Zechman says he doesn't see that happening for at least six to nine months. As a result, hospitals in Missouri are bracing for a triple-whammy:
They're the recipients of a 2% reduction in Medicare reimbursements owing to the mandatory cuts brought on by sequestration.
Because their Medicaid roles won't expand, they will continue to treat a significant uninsured and indigent population with little hope of reimbursement.
The disproportionate share payments that are designed to offset charity care costs for hospitals such as OMC are being eliminated on Oct. 1 when the Medicaid expansion goes into effect.
"We are going to get that cut anyway even though Medicaid expansion is not happening in Missouri," Zechman says. "The disproportionate share cut was made and it was anticipated that the hospitals would recoup that money back through expanded Medicaid and the insurance exchanges. The exchanges might get a little back, but we aren't going to get anything from the Medicaid expansion."
It's not just the hospitals and the vulnerable who will be hurt.
A University of Missouri analysis commissioned by the Missouri Hospital Association estimates that the Show Me State will be shown that it could lose more than 9,000 jobs, $1.9 billion in reduced capital investment, or $1.1 billion in cost shifting to private plans with the decision not to expand Medicaid.
Those cuts, which are included in the ACA and the Budget Control Act, combine to reduce Missouri hospital reimbursements by $4 billion through 2019. Another study from Mizzou found that Medicaid expansion would create more than 22,000 jobs.
Try to imagine the ripple effect of punching a $4 billion hole in the state's economy. It's not just hospital jobs. It's ancillary support jobs in healthcare and other businesses. It's less money spent in the supermarket in town, or the local café, or the hardware store, or the car dealership. It's money taken out of circulation that otherwise would have been spent locally.
So how will this all play out?
"Hospitals will reduce some services, there will be jobs eliminated and the worst-case scenario is some hospitals are going to close," Zechman says. "They will be the only providers in those rural communities and generally speaking they are the No. 1 employer in those communities. From an economic perspective it is going to kill those local communities."
Skeptics will point out that the MHA and Zechman have an interest in painting as bleak a picture as possible. That's a fair point. But what if we cut their estimates in half? See what happens when you take $2 billion out of the local economy. The effect is still daunting. Zechman calls the case for Medicaid "overwhelmingly compelling." He's right.
"The state legislators don't want to listen to us because they think the CEOs have a vested interest in this thing. Yeah, we do have a vested interest because we are responsible for making this place work," Zechman says. "But the legislators will perk up when they start hearing from constituents that they have lost their job and/or they can't access services anymore. Then it will start resonating."
"It is highly politicized and that is what is so sad about it. It hurts the most vulnerable and the poor and at the end of the day that is where we'll end up," he says. "I personally lean to the right more than the left, but I am thinking 'my gosh,' sometimes at the end of the day you have to realize this is it. Let's go!' I have to put on my CEO hat and do what's best for the community."
Zechman says resistance to the Medicaid expansion will eventually crumble "but there will be blood on people's hands first."
"They are going to have to live with that," he says. "I am going to do everything I can to save peoples jobs and to save services but there will come a point when we are not going to be able to do that and I know that. I am not trying to blame anybody else. I take total responsibility for what I have to do here. But honestly, there is going to be blood out there before this thing caves and that will be the tragedy of this thing."
Employers have an additional year—until Jan. 1, 2015—before reporting requirements mandated by the Patient Protection and Affordable Care Act go into effect. The unexpected policy decision comes in response to employer concerns about the complexity of data reporting requirements.
In a surprising announcement Tuesday afternoon the Obama administration said it would delay until Jan. 1 2015 a key provision of the Patient Protection and Affordable Care Act that requires mid-sized and large employers to provide health insurance for their workers or pay a fine.
Mark J. Mazur, assistant Secretary for Tax Policy at the U.S. Department of the Treasury, said on a blog posting that the decision to roll back the implementation date for businesses with 50 or more employees was made after "several months" of negotiations with businesses.
"We have heard concerns about the complexity of the requirements and the need for more time to implement them effectively," Mazur said in the blog. "We recognize that the vast majority of businesses that will need to do this reporting already provide health insurance to their workers, and we want to make sure it is easy for others to do so. We have listened to your feedback. And we are taking action."
"The Administration is announcing that it will provide an additional year before the ACA mandatory employer and insurer reporting requirements begin. This is designed to meet two goals. First, it will allow us to consider ways to simplify the new reporting requirements consistent with the law. Second, it will provide time to adapt health coverage and reporting systems while employers are moving toward making health coverage affordable and accessible for their employees. "
As unexpected as news was, the responses from key stakeholders and critics in the healthcare reform debate were predictable.
House Speaker John Boehner, (R-OH) said in prepared remarks that "this announcement means even the Obama administration knows the 'train wreck' will only get worse. I hope the administration recognizes the need to release American families from the mandates of this law as well. This is a clear acknowledgment that the law is unworkable, and it underscores the need to repeal the law and replace it with effective, patient-centered reforms."
Business groups cheered the news.
"We commend the Administration's wise move to delay the employer reporting and penalty obligations under the Affordable Care Act. This one-year delay will provide employers and businesses more time to update their healthcare coverage without threat of arbitrary punishment," said Neil Trautwein, with the National Retail Federation.
"The National Retail Federation has worked hard to engage and educate our diverse membership on the upcoming ACA requirements and consistently and empathetically called on the Administration to delay these specific regulations. We appreciate the Administration's recognition of employer concerns and hope it will allow for greater flexibility in the future."
Robert Zirkelbach, spokesman for America's Health Insurance Plans, said the insurance lobby "appreciates that the administration is being responsive to the concerns employers and insurers have raised about the workability of the reporting requirements related to employer healthcare coverage."
In a separate blog posting Tuesday afternoon, Valerie B. Jarrett, a senior White House advisor, said the administration would also cut red tape and simplify reporting processes for employers. "We have heard the concern that the reporting called for under the law about each worker's access to and enrollment in health insurance requires new data collection systems and coordination," Jarrett wrote.
"So we plan to re-vamp and simplify the reporting process. Some of this detailed reporting may be unnecessary for businesses that more than meet the minimum standards in the law. We will convene employers, insurers, and experts to propose a smarter system and, in the interim, suspend reporting for 2014."
Brian Haile, senior vice president for healthcare policy at Jackson Hewitt tax consultants said the delay should alleviate concerns raised by employers, particularly those with significant seasonal and part-time worker
"The federal approach acknowledges the challenges with implementing a policy that will affect so many employers—and strikes the right balance between speedy implementation and thoughtful policymaking," Haile said.
Haile, in an email exchange with HealthLeaders Media, identified several potential effects of the implementation delay for employers:
Fewer employers may cut employee hours in 2014. This one-year respite may make employers (e.g., restaurant and retail establishments) less likely to reduce employee hours below 30 hours per week.
Many families with children will have an unexpected benefit. For employers who offer employee but not dependent coverage, this one-year delay may also cause employers to postpone any offer of coverage to dependents. Interestingly, this may have a positive effect on such families for two reasons. First, children without an offer of employer-sponsored coverage may be eligible for the Children's Health Insurance Program if they meet the state-specific income and other eligibility requirements. Second, children without an offer of employer coverage may be eligible for the new premium assistance tax credits in 2014 even if their incomes are above the state-specific CHIP limit. Indeed, employers may be more likely to cooperate with enrollment efforts to get uninsured employees and their uninsured dependents covered under various ACA programs because they know with certainty that they will not face a penalty in 2014.
States may face less pressure from business interests to expand Medicaid. Jackson Hewitt had released a report earlier this year estimating that American employers would incur $876 million to $1.3 billion in penalties in 22 states that were refusing to expand their Medicaid programs as contemplated under the ACA. Today's decision effectively removes that penalty liability for 2014. However, employers will continue to face such penalties in 2015 and thereafter in states that do not expand their Medicaid programs.
The Treasury action today addresses anxiety among employers about the lack of final regulations from the IRS. While many employers with large part-time and seasonal employees embraced the flexibility afforded to them by the IRS' proposed approach, they voiced increasingly loud concerns that the IRS had yet to finalize this approach in a final rule. Indeed, the IRS has not publicly pledged to finalize these proposed rules before the major provisions of the ACA take effect in 2014. In an unexpected development late Tuesday, though, the Treasury Department effectively moots this issue for 2014.
Formal guidance from the White House is expected within the next week.
The rate of U.S. births by cesarean section is holding steady at 31%, says the CDC. But "we are seeing an increase in cesareans for longer gestational ages—for full term. That is very disturbing," says the head of a hospital quality watchdog group.
After more than a decade of alarming and persistent growth in cesarean sections, the procedure appears to have leveled off in the past three years, but still is used for nearly one-in-three deliveries, new federal data shows.
According to a report from the Centers for Disease Control and Prevention, the total U.S. cesarean delivery rate reached a high of 32.9% of all births in 2009, rising 60% from 20.7% in 1996. However, since 2009 the rate has held at 31.3%.
Leah Binder, president and CEO of The Leapfrog Group, an employer-supported hospital quality watchdog group, said in an interview that the CDC report contained "good news and bad news."
"The good news is the rate of cesarean sections for gestational age below 39 weeks has been decreasing. So we are seeing fewer and it's consistent with the trend Leapfrog has noted in the reduction of early elective deliveries. That is very positive," Binder says.
"The bad news is we are seeing an increase in cesareans for longer gestational ages, for full term. That is very disturbing. It's part of an overall trend of increased use of cesarean sections for normal births and that trend has obviously been rising significantly since the 1990s from 20% back in 1996 to the current 31%. It is a very steep increase."
The CDC report does not suggest what an acceptable rate of cesarean section births should be, but Binder says the World Health Organization has stated that cesarean section rate should be about 15%.
"It is extremely disturbing to see increases in the rates of cesarean after 39 weeks. It is masked by the overall numbers of cesareans because there has been this successful effort to reduce them at the early stages. They ought to be reduced at all stages," Binder said.
"One-in-three women do not need major abdominal surgery to have a baby. That is not how it works. It doesn't make sense. None of the literature supports it and it suggests that when a pregnant woman walks through the hospital door someone is holding a knife. Women's bodies are built for child birth and we can do a lot better than this."
The CDC study found that:
After 12 years of consecutive increases, the preliminary cesarean delivery rate among singleton births was unchanged from 2009 to 2011 (31.3%).
Cesarean delivery rates decreased more than 5% among births at 38 weeks of gestation, but increased 4% among births at 39 weeks.
Decreases in cesarean delivery rates for births at 38 weeks occurred for non-Hispanic white, non-Hispanic black, and Hispanic women, as well as for all maternal age groups.
Increases in cesarean delivery rates for births at 39 weeks occurred among non-Hispanic white, non-Hispanic black, and Hispanic women, as well as for all maternal age groups.
The cesarean delivery rate at 38 weeks decreased in 30 states; the cesarean delivery rate at 39 weeks increased in 23 states.
Asked for comment, the American College of Obstetricians and Gynecologists did not provide anyone to speak about the report. However, ACOG spun the findings slightly differently and said in a media release that it was "encouraging" that C section births had leveled off since 2009.
"The College believes that its ongoing efforts to reduce non-medically indicated deliveries before 39 weeks' gestation has helped to achieve this plateau," ACOG said.
"The College is also encouraged that the cesarean delivery rate decreased by more than 5% for singleton births at 38 weeks' gestation from 2009 to 2011. This decrease in cesareans occurred for women of all races and maternal ages, and in more than half of all states. However, the encouraging news is offset by data showing the cesarean rate at 39 weeks gestation has increased by 4%. More research is needed to find out the reason(s) for this increase."
Binder says that a recent survey from the Childbirth Connection [PDF], a non-profit maternity care advocacy group, found that only 1% of new mothers said they requested a C section.
"They also found that a lot of women were given C sections or inductions for reasons that are known not to be medically indicated," she says. "For example many women were told that they had big babies. That is not in and of itself an indication for a C section but 80% of those women were either given the induction or a C section. We know that based on that study and other and literature we know that there is a high prevalence of unnecessary C sections and certainly the increase over the last 20 years is a very disturbing phenomenon."
Binder says ACOG has listened to critics and taken some steps to address the overuse of cesareans. "For example, ACOG now does not now automatically recommend a cesarean section when a woman has had a cesarean in the past," she says.
"There has been a major push and frankly Leapfrog was the first domino to push on this. We launched a campaign on early elective deliveries that are scheduled without a medical reason either by C section or induction prior to 39 weeks gestation. That is too early. If you have a delivery at that gestational age, 37 to 39 weeks, babies end up on respirators and in (neo-natal intensive care units) and it's not safe."
Even with the support of the March of Dimes and decades of warnings from ACOG, Binder says the early elective deliveries were occurring "at a very high rate."
"Finally, in 2010 Leapfrog put out rates of early elective deliveries by hospital. That really galvanized things very quickly. We got a lot of attention," Binder says.
"The March of Dimes was very excited by the amount of attention we got for this announcement and they were able to use it to accelerate their own campaign against these deliveries. There has been a real movement around reducing early elective deliveries and these results do reflect that."
