Because most philosophies that frown on reproduction don't survive.

Thursday, August 21, 2008

A Case Study on Costs and "Basic Health Care"

One of the elements of discussion about health care from the perspective of Catholic Social Teaching that often bothers me is when someone states, "Basic health care is a human right" and then goes on to insist that this means we need a system by which the maximum range of health care paid for by the best insurance in the modern US is available to everyone via a government single payer system. (The which leaves aside the practical matter that virtually no single payer systems cover as much as cushier US private insurance plans do.)

Modern medicine has brought us incredible benefits, which we rightly want to make sure that everyone in society is able to share. But modern medicine has also make it possible to throw large amounts of money at a problem to achieve a return which is statistically pretty small. Should this be considered "basic healthcare"?

When we sit down to ask ourselves, "Why can some people not afford health care coverage in this country," it seems to me that one of the reasons is that we've raised our standard of "basic" so high that it becomes hard to afford.

We've been experiencing an applied study in this as we sort out our options in regards to BabyDarwin being breech. 3-4% of pregnancies are breech. BabyDarwin is in what is termed a Frank Breech position, which means his bottom is down, and his feet are up near his head. This is, according to most of the reading we've done, by far the safest form of breech positioning, and some medical authorities maintain that it's basically as safe to deliver a baby in a Frank Breech position as it is deliver a baby who's head down. Others maintain it's slightly more dangerous. The only actual numbers I was able to find were in the Wikipedia (with all appropriate provisos):
Umbilical cord prolapse may occur, particularly in the complete, footling, or kneeling breech. This is caused by the lowermost parts of the baby not completely filling the space of the dilated cervix. When the waters break the amniotic sac, it is possible for the umbilical cord to drop down and become compressed. This complication severely diminishes oxygen flow to the baby and the baby must be delivered immediately (usually by Caesarean section) so that he or she can breathe. If there is a delay in delivery, the brain can be damaged. Among full-term, head down babies, cord prolapse is quite rare, occurring in 0.4 percent. Among frank breech babies the incidence is 0.5 percent, among complete breeches 4-6 percent, and among footling breeches 15-18 percent.

There are also some other dangers that are more of an issue in other breech positions or with a premature baby -- in that if the legs and torso are delivered first and are much smaller than the head (which is usually only the case with premature babies -- at full growth the torso is large than the head) then the baby may be partly delivered while the mother is insufficiently dilated, and then the head gets stuck. This can cause damage to the head, loss of oxgen, and a range of injuries resulting from trying to pull the baby loose.

Because of the 0.4% versus 0.5% difference in risk between standard postion and Frank Breech, and because "breech" in general has a bad name as a result of the other issues (with premature babies and with other positions), the verdict we're getting is pretty much that if we can't get BabyDarwin to turn, we'll have to go the c-section root, because no doctor around here is willing to deliver a breech baby naturally. (And the home birth midwife is clearly not willing to touch it with the proverbial ten foot pole.)

We have solid insurance, so the c-section root will actually cost us less out-of-pocket than what the homebirth route (not covered by insurance, and unfortunately already paid for). But the overall health care cost issue is significant.

Googling around for costs on a c-section I'm seeing a "list price" in the ballpark of $20,000 (though I'm sure the insurance company manages to get it for less.) The prices I'm seeing for a normal vaginal delivery in a hospital are around $6,000. The home birth cost was $2,100 (though that was with an early payment discount -- and before they raised their prices, so apparently "list" is now $3,600.)

The difference in risk between normal delivery and c-section in our particular case is apparently around 0.1%. So comparing a c-section and hospital delivery, we as a society are spending just shy of $28 million on doing 1999 unnecessary c-sections in order to avoid one natural delivery that would have resulted in serious problems. Looking at the difference between a c-section and a home birth at list price, that difference grows to $33 million.

We're justly hesitant to put a dollar value on a human life, and obviously, if you're the 1 out of 1000 who sees your child die or severely injured as a result of the difference in risk between normal positioning and Frank Breech, knowing that the chances were low would do nothing to console you. However, aside from the question of how many lives could be saved if that $30 million were used in some other way than getting c-sections for all breech babies, there's another element to the incentives at play here.

This is primarily an academic discussion for us because we're middle class and well insured, and so we have no problem at all affording the c-section if we can't get the baby turned. (And no problem affording the multiple ultrasounds and consultations and such involved in trying to get the baby turned.) But imagine that we were poor an uninsured. Because the incentives and regulations for our medical system are built around the assumption that everyone worth thinking about has the deep pockets of an insurance company behind him, we'd still be faced with no doctor of midwife being willing to provide a normal delivery, so we'd be stuck going into $20k of debt that we had absolutely no way to pay off in order to get a c-section that we probably didn't need.

As it stands, our medical system is built around the assumption that cost is no object. And doctors are very heavily penalized based on any "avoidable" injuries or deaths that occur on their watch. The result is that instead of providing good, high quality "basic" health care, and using extreme (and expensive) measures only when necessary, we often require extreme measures "just in case". This makes it far, far more difficult to provide "basic" health care to all.

I don't know enough about health care to provide specific policy proposals, but just working through this example it seems clear to me that we are not discussing enough variables when it comes to making sure that "basic health care" is available to everyone. Instead, the only debate going on in our political arena is on how to provide everyone with the level of health care which is often provided under comprehensive insurance policies -- a level which we probably cannot afford to provide to everyone, and which is determined as much as a matter of tail-covering as medical need.

7 comments:

Cliff said...

Most often they turn head down on their own. Hope thats the case for you.

Jessie said...

We recently had a baby via C-Section and were uninsured. We chose that route because of the high cost of insurance that covers maternity here in KS. Fortunately, we had the cash. Negotiating pre-payment with providers, the OB was $3000 for the 9 months and delivery, and the Hospital gave us a $5000 covers it all option. Anesthesiology was around $1800.

We got the deal because we could prepay

This option was cheaper than buying the insurance ($500/mo with an 8/mo exclusion, $2,000 deductible, 80/20 copay).

Personally, I think general insurance is the worse thing to happen to the health care industry. It separates payer from the receiver of the benefit, generates reams of paperwork, and is so integrated that if you don't have insurance you are looked at like a leper (and please pay up front).

Anonymous said...

My sister with a Type 1 diabetic toddler diagnosed at 18 months sent me this:

http://www.dudleynews.co.uk/newsxtra/3610892.Caesarean_babies_more_likely_to_have_Type_1_diabetes/

Interesting in the unintended consequences department.

Good luck to you all, you will be in my prayers,

chris

CMinor said...
This comment has been removed by the author.
Derek said...

Interesting post. You touch on a major problem in medicine - the litigious atmosphere phsycians work in. It affects everything in medicine - often decisions are made not based just upon the right or best thing to do, but what is the most defensible thing to do. Usually, this means doing too much.

I think the other big part of the problem with health care costs is that individuals don't know how much insurance costs, since employers provide it. This is the major source of the "cost is no object" mentality - no one truly knows the cost. The system is a remnant from after WWII when wage caps were in place and employer-provided healthcare was a way to get around those caps and attract workers. Sixty years later, the system is hardly recognizable - it is dysfunctional and opaque. Analysis and cost-benefit decisions by indivuals is virtually meaningless b/c of the disconnect between the cost of services and the cost we pay for them. Many people have a sense that they shouldn't pay more than $20 or so to see a doctor, get blood tests, an MRI, whatever. I'm not sure why we can't shop for health insurance the same way we shop for car insurance, with the caveat that safeguards would need to be in place to ensure that everyone could be covered.

One more thought - you muse: "how many lives could be saved if that $30 million were used in some other way than getting c-sections for all breech babies..." This kind of constant sum analysis always makes me nervous - it has the whiff of rationing or rational (i.e. centralized) distribution of resources. Take another example: a 70 year old who develops a low-grade lymphoma. We can do a mini allogeneic bone marrow tranplant that will extend the person's life (until they die of something else). Should we be spending resources on this, then? They are expensive and the bang for the buck is low. But, we can do it, and in my opinion we should do it. Until serious attempts are made to rescue the current defective system we have, attempts at rationing will only make things worse.

Finally, it's very possible that OBs would do a c-secion for a breech even without the litigous environment. No one wants to be responsible for a child dying that could be easily prevented.

Darwin said...

One more thought - you muse: "how many lives could be saved if that $30 million were used in some other way than getting c-sections for all breech babies..." This kind of constant sum analysis always makes me nervous - it has the whiff of rationing or rational (i.e. centralized) distribution of resources. Take another example: a 70 year old who develops a low-grade lymphoma. We can do a mini allogeneic bone marrow tranplant that will extend the person's life (until they die of something else). Should we be spending resources on this, then? They are expensive and the bang for the buck is low. But, we can do it, and in my opinion we should do it. Until serious attempts are made to rescue the current defective system we have, attempts at rationing will only make things worse.

I'm glad you brought that up.

I do think there's a lot of danger in the "should we use that million here or somewhere else thinking", although at the same time it seems to me that cost should be more of a factor in how health care is provided. (At least to the extent that its possible for people to get good "basic" care as well as "no holds barred" care.

What makes me frustrated in this case is that we're hitting up very much against the requirement of a much more expensive, invasive procedure despite the fact that nearly everything I can find suggests that delivering this type of breech is not actually any more dangerous than a "normal" delivery -- though of course if the doctor has no experience, I'm sure it's less safe.

But at the same time, I don't want to see a system in which there's a reflexive, "It's expensive, let's not do it" approach.

One thing for sure we could use is some malpractice reform to try to take the lawyer out of the hospital room.

gillberk said...

Healthcare, though, is its own special world. Between the life-versus-death and quality-of-life type questions it poses, and the ever widening options for medical care, it is very hard to know and agree about what is the ‘right amount’ of health care.Health expenditures continue to grow very rapidly in the U.S. Annual spending on health care increased from $75 billion in 1970 to $2.0 trillion in 2005, and is estimated to reach $4 trillion in 2015. As a share of the economy, health care has more than doubled over the past 35 years, rising from 7.2% of GDP in 1970 to 16.0% of GDP in 2005, and is projected to be 20% of GDP in 2015.
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Gillberk

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