Re: Insurance Companies Won't Cover Cesarean Moms

[janasmama]

This article is linked to from Mothering's home page

http://www.denverpost.com/ci_9440838

I just wanted to pop in and say what I think....I don't think insurance companies, including medicaid, should cover elective cesareans or elective inducements.

[Poogles0213]

Originally Posted by janasmama

This article is linked to from Mothering's home page

http://www.denverpost.com/ci_9440838

I just wanted to pop in and say what I think....I don't think insurance companies, including medicaid, should cover elective cesareans or elective inducements.

But shouldn't every woman be able to give birth the way SHE wants to?? If we are going to argue that a woman has a right to choose how she births when talking about HB, why not for elective CS or induction? That seems kind of hypocritical to me....

[wombatclay]

Here's the thing... let's say that in your first pregnancy you have a complete previa and a cesarean delivery. That would be a medically necessary cesarean which saves the life of mama and babe and the insurance company pays for it.

Now you have a prior cesarean on your record. You get pregnant and learn that there are no VBAC birth facilities in your state. There are no care providers who can (openly, legally) attend a VBAC. There are certainly no VBAC providers or facilities covered by your insurance. However, you have a beautifully positioned placenta, the babe is lined up and good to go, your blood pressure is (amazingly given the circumstances) fine. You are not a candidate for a "medically necessary cesarean". So what do you do? You walk into a care provider's office and they say "We're sorry, but how do you plan to pay for your surgery? We don't offer vbac and your insurance wont cover a repeat cesarean. Would you like to look at our private payment options?" Then what? Your choices narrow to paying out of pocket for a seriously expensive procedure (my c/s with hopital stay topped 32K in rural upstate ny... we're not talking urban/spa hospital here), finding an underground homebirth midwife (whether or not you actually "want" a homebirth), showing up in an ER and depending on EMTALA for a vbac, having an "accidental vbac" either unattended or while traveling in a country where that is possible, or moving/reducing you income until you qualify for a federal/state based subsidized health program. And none of those options is healthy for mama or baby.

The crucial thing in my mind here is the use of "elective cesarean" at the heart of the decision. My records say "elective"... despite 32 hours of labor, despite being told by several dr's that a c/s was my only birth option at that point, despite everything I was told at the time, the record says elective. "The patient was informed of the risks and elected to deliver via cesarean section". There was time to do a spinal, time to call a full surgical team, time to do a low transverse incision, time for dh to get into scrubs. It was not an "emergency" and it wasn't even labled "medically necessary" despite what I was told at the time. Between transition style contractions, after more than a day of unmedicated back labor, I signed the papers they held out and so became an "elective cesarean".

And of course, why are there so few vbac providers? In large part malpractice insurance has gotten ridiculously out of control for vbac providers... so the provider can't afford to offer the service because their insurance company wont cover them if they do. And then the insurance company wont cover the patient when they are denied the vaginal birth option by that same provider. It's insane, it's not in the best interest of mothers, babies, or care providers but it's the mothers/babes who will "pay the most" in this scenario. The c/s rate continues to climb, vbac is harder than ever to obtain, and I truly believe that this sort of insurance ban is going to lead directly to maternal/infant death and injury. I hate c/s, but this sort of "insurance bottom line" baloney makes me sick to my stomach.

[janasmama]

Originally Posted by Poogles0213

But shouldn't every woman be able to give birth the way SHE wants to?? If we are going to argue that a woman has a right to choose how she births when talking about HB, why not for elective CS or induction? That seems kind of hypocritical to me....

Sure every woman should beable to give birth the way she wants but insurance doesn't always cover HB or midwives either so those people must pay for that service.

Originally Posted by wombatclay

Here's the thing... let's say that in your first pregnancy you have a complete previa and a cesarean delivery. That would be a medically necessary cesarean which saves the life of mama and babe and the insurance company pays for it.

Now you have a prior cesarean on your record. You get pregnant and learn that there are no VBAC birth facilities in your state. There are no care providers who can (openly, legally) attend a VBAC. There are certainly no VBAC providers or facilities covered by your insurance. However, you have a beautifully positioned placenta, the babe is lined up and good to go, your blood pressure is (amazingly given the circumstances) fine. You are not a candidate for a "medically necessary cesarean". So what do you do? You walk into a care provider's office and they say "We're sorry, but how do you plan to pay for your surgery? We don't offer vbac and your insurance wont cover a repeat cesarean. Would you like to look at our private payment options?" Then what? Your choices narrow to paying out of pocket for a seriously expensive procedure (my c/s with hopital stay topped 32K in rural upstate ny... we're not talking urban/spa hospital here), finding an underground homebirth midwife (whether or not you actually "want" a homebirth), showing up in an ER and depending on EMTALA for a vbac, having an "accidental vbac" either unattended or while traveling in a country where that is possible, or moving/reducing you income until you qualify for a federal/state based subsidized health program. And none of those options is healthy for mama or baby.

The crucial thing in my mind here is the use of "elective cesarean" at the heart of the decision. My records say "elective"... despite 32 hours of labor, despite being told by several dr's that a c/s was my only birth option at that point, despite everything I was told at the time, the record says elective. "The patient was informed of the risks and elected to deliver via cesarean section". There was time to do a spinal, time to call a full surgical team, time to do a low transverse incision, time for dh to get into scrubs. It was not an "emergency" and it wasn't even labled "medically necessary" despite what I was told at the time. Between transition style contractions, after more than a day of unmedicated back labor, I signed the papers they held out and so became an "elective cesarean".

And of course, why are there so few vbac providers? In large part malpractice insurance has gotten ridiculously out of control for vbac providers... so the provider can't afford to offer the service because their insurance company wont cover them if they do. And then the insurance company wont cover the patient when they are denied the vaginal birth option by that same provider. It's insane, it's not in the best interest of mothers, babies, or care providers but it's the mothers/babes who will "pay the most" in this scenario. The c/s rate continues to climb, vbac is harder than ever to obtain, and I truly believe that this sort of insurance ban is going to lead directly to maternal/infant death and injury. I hate c/s, but this sort of "insurance bottom line" baloney makes me sick to my stomach.

Sorry about your situation. I guess what really needs to happen is the insurance companies and the hospitals need to collaborate better. Insurance companies and hospitals/doctors do technically "work together" so they need to figure something out about this because although we hardly ever use our insurance (maybe once or twice a year for a office visit) our premium is super high because of what the insurance companies have to pay out for everyone else.

I understand your paperwork says "elective" but what I mean by "elective" is that the mother decides ahead of time before labor even happens to schedule a c/s for no apparent reason.

[wombatclay]

I understand your paperwork says "elective" but what I mean by "elective" is that the mother decides ahead of time before labor even happens to schedule a c/s for no apparent reason.

I know that's what you mean... but "elective" is the word used by the hospitals and by the insurance companies. This ban does nothing to encourage positive change... there is no incentive for care providers to offer vbac, no reason for birth sites to change their vbac bans. And no reason for a hospital to avoid doing c/s (they'll get their money one way or the other). The ONLY thing this does is save money for the insurance companies (trust me, premiums wont go down) while turning pregnancy into a nightmare for women.

The woman in labor who is told "hey, this isn't working, we need to do a c/s" is suddenly going to be paying out of pocket even if up to that point she was covered. The woman with a prior c/s who can't find a vbac provider is going to be paying out of pocket for a surgery she may desperately wish to avoid or she'll be birthing underground.

Sure, changing the terminology would help but... there is nothing in this insurance policy that addresses changing terminology and no reason at all for the medical establishment to change terminology to suit the needs of the patient. Thousands of women every month are being given "elective" cesareans and despite the media reports relatiely few of these are women who walked into an office and said "hey, I'd like to pick a date". More often they've been told by a care provider that a c/s is necessary (either before or during labor) and, right or wrong, they believe this.

If you'd like to see a reduction in rates (again, never gonna happen...best case scenario is they hold steady) there are plenty of things covered by insurance companies that cost as much or more than c/s and which don't have the same sort of implications for maternal/infant health. But that's a bit beside the point.

[Poogles0213]

Originally Posted by janasmama

Sure every woman should beable to give birth the way she wants but insurance doesn't always cover HB or midwives either so those people must pay for that service.

There is also a difference between "doesn't always cover" and NO insurance covering ANY "elective" CS.

There is also a big difference between the ~$35K it can cost for a CS and the ~$3-5K it can cost for a MW attended HB

[intorainbowz]

I think this ban is a negative. It is limiting the fertility options of women.

Why should I be forced to VBAC if I don't want to for whatever reason because my insurance company won't pay for what would be termed an Elective Repeat CS after my very medically necessary one? Why should women be forced down an emotional land mine path if it is not what they want? To please the bean counters at the insurance company, that's not a good enough reason for me.

I think this is very very wrong.

Limiting anyone's choices in birth is a very bad path. I don't agree with insurance company bans on hombirth, either, FTR.

[AlexisT]

"elective" does not mean "chosen". it means "scheduled". All CSes are classified as elective or emergency and it only relates to whether they are scheduled or not. A Caesarean may be scheduled for very good medical reasons. You can also have an "emergency" Caesarean that may have been preventable.

As it stands, insurers usually won't cover CS if you actually say "I don't want to have a vaginal birth". Doctors make up reasons when that happens. There is no way to prevent this from happening without also keeping women from getting a Caesarean when she actually needs one.

[applejuice]

Originally Posted by Poogles0213

But shouldn't every woman be able to give birth the way SHE wants to?? ....

Yes, and she should be prepared to pay for it also.

I had to. I elected to have four homebirths and I paid for them out of pocket. And there was no midwifery program in CA when I had my first two. All midwives were DEMs, uncertified or certified from out of state.

When a woman has group insurance, everyone is helping to pay for it; the $ comes out of everyone's pocket. If the surgery is elective, then she should elect to pay for it out of pocket. If hospitals and doctors had to fight to get paid for the caesareans they are doing unnecessarily from the mothers and their families rather than big insurance companies, they might think twice and three times before they go ahead with such a flagrant rate of surgery on one of three birthing women.

The obvious answer is to allow midwives to handle the 80% of women who have few problems delivering vaginally, and let the obs handle the 20% who have more problems. A line has to be drawn as the situation as it is is untenable.

[wombatclay]

I agree 100% that there are too many c/s. I agree that something should be done to encourage the US c/s rate to move down instead of up. I don't think this ban however is in any way motivated by the desire to improve maternal/infant care or even reduce insurance premiums. It is, plain and simple, a technique used by the insurance companies to increase their own revenues.

Cynical, maybe. But the truth. Hospitals and drs will, indeed, get their money. Insurance companies will keep theirs. But mothers and families will be stressed beyond measure.

In order to reverse the trends in surgical birth an insurance company could offer incentives to care providers who offer vbacs or natural births. They could reimburse fully for independent midwife care. They could offer incentives to hospitals that reverse the c/s trend. They could insure drs who attend vbacs at an affordable rate. But that isn't what they've chosen to do. Instead they've chosen a path that denies care to even more women. I can't respect the motives of a corporation that chooses to punish the victim instead of encourage change on the part of those in power.

And it is a denial of care... not all women have the option or ability to seek out providers "under the radar" in a non-vbac state. Not all can afford midwife care even when it's legal.

[janasmama]

I guess the best thing would be for the government to mandate that insurance and medical care be not-for-profit. I think it is unethical to make money on people's illnesses and medical emergencies. It kind of makes a vicious cycle of the suppliers keeping you "sick"

[intorainbowz]

Originally Posted by AlexisT

"elective" does not mean "chosen". it means "scheduled". All CSes are classified as elective or emergency and it only relates to whether they are scheduled or not. A Caesarean may be scheduled for very good medical reasons. You can also have an "emergency" Caesarean that may have been preventable.

As it stands, insurers usually won't cover CS if you actually say "I don't want to have a vaginal birth". Doctors make up reasons when that happens. There is no way to prevent this from happening without also keeping women from getting a Caesarean when she actually needs one.

I know from when I called to ensure everything was in place with my insurance company for my scheduled c/s, I was told they did not require any form of medical necessity for it.

As for making medicine non-profit, then why would drug researchers research new medications, and why would doctors go to med school if they could not expect a return on their investment of time and money into their training? I don't think most people are that altruistic.

[DHandDad]

When the Golden Rule Insurance Co. rejected her application for health coverage last year, Peggy Robertson was mystified.

From the article, it states that the insurance company refused to cover this particular woman AT ALL due to a previous ceserean.

Not that they refused to cover any future ceserean, but that they would not insure the woman AT ALL.

This type situation would come into play when a person is seeking health insurance outside of a group policy through their employer or their spouse's employer (i.e. self employed individuals without access to group coverage).

So we're not talking about a situation where they are forcing her to VBAC (as if that's even possible in most places anymore). They are saying 'We don't want you as a customer at all.'

Of course, around here, most private policies through Aetna/Cigna/BCBS/Humana don't cover maternity benefits AT ALL for anyone, so a prior ceserean wouldn't make a bit of difference in getting a policy. They aren't going to cover 'routine pregnancy and delivery' at all. Some policies have a rider you can buy that runs several hundred dollars per month, can't be used at all for 12 months from the time you start paying, and caps out at $5K or so for the lifetime of the policy.

[DHandDad]

Originally Posted by janasmama

I guess the best thing would be for the government to mandate that insurance and medical care be not-for-profit. I think it is unethical to make money on people's illnesses and medical emergencies.

I wonder what this would do to the quality and quantity of health care providers as a whole.

[Kitten]

I seriously doubt this could really be used to force a woman to pay out of pocket for a repeat c-section. A hospital would vastly prefer an insurance company to pay for a c-sec rather than try to get someone to pay out of pocket. The insurance company is a better bet. Doctors and hospitals would make sure that records indicate the c-sec was medically necessary. Frankly, I also suspect that the doctors of "too posh to push" women would make sure to come up with a medical reason for the scheduled patient choice c-sec anyway.

[Poogles0213]

Originally Posted by applejuice

Yes, and she should be prepared to pay for it also.

I had to. I elected to have four homebirths and I paid for them out of pocket. And there was no midwifery program in CA when I had my first two. All midwives were DEMs, uncertified or certified from out of state.

When a woman has group insurance, everyone is helping to pay for it; the $ comes out of everyone's pocket. If the surgery is elective, then she should elect to pay for it out of pocket. If hospitals and doctors had to fight to get paid for the caesareans they are doing unnecessarily from the mothers and their families rather than big insurance companies, they might think twice and three times before they go ahead with such a flagrant rate of surgery on one of three birthing women.

The obvious answer is to allow midwives to handle the 80% of women who have few problems delivering vaginally, and let the obs handle the 20% who have more problems. A line has to be drawn as the situation as it is is untenable.

There is a HUGE difference in cost between a HB and a CS though, like I mentioned earlier. I can't really imagine that the vast majority of families can pay for a CS out of pocket, even on a payment plan...it would take several years to pay off. FTR, I believe that all (or at least most) insurance should cover HB; at least some do cover it now, unlike the complete ban on CS coverage that the OP was suggesting.

Then there is, of course, the terminology that makes it about impossible to differentiate between a truly elective CS and one that was scheduled, for say, complete placenta previa at 39 weeks. They are both considered "elective" by the insurance company, but obviously one is medically NEEDED.

[DHandDad]

Originally Posted by Kitten

I seriously doubt this could really be used to force a woman to pay out of pocket for a repeat c-section. A hospital would vastly prefer an insurance company to pay for a c-sec rather than try to get someone to pay out of pocket. The insurance company is a better bet. Doctors and hospitals would make sure that records indicate the c-sec was medically necessary. Frankly, I also suspect that the doctors of "too posh to push" women would make sure to come up with a medical reason for the scheduled patient choice c-sec anyway.

I think the point you are missing is that there wouldn't BE an insurance company to bill. The insurance company is refusing to write a policy for a woman with a history of ceserean.

For those that get coverage through their job, it's a non-issue because typically open enrollment gives everyone the opportunity to sign up regardless of any existing or past health conditions.

But if you're self employed or don't work somewhere with access to group coverage, you're stuck trying to get coverage through a private policy. And if nobody will write a private policy for a woman with a history of c-section, that's a big problem with the c-section rate over 30%.

[wombatclay]

As for making medicine non-profit, then why would drug researchers research new medications, and why would doctors go to med school if they could not expect a return on their investment of time and money into their training? I don't think most people are that altruistic.

Have you watched Sicko? It's true that no country has a perfect system, but many countries have much better health care than the US and deliver it through a socialized system.

My DH is in the bio-med/bio-tech field... they get a lot of money from the government to develop treatments for this or that (he specifically works on joint inflamation). His salary isn't affected by how much the treatments developed in the lab cost the consumer... it's based on the regular university pay rate, rounded out by federal grants. So whether the lab sells the product for 10 dollars or ten thousand dollars, the profits don't really feed back to the people working in the lab. It goes "to the company" as a whole, and from there, more than likely, into a CEO's golden parachute.

[saimeiyu]

It ought to be illegal to deny someone insurance coverage for that. Well, then again, I think the whole health insurance industry ought to be scrapped. It's nothing but a money-grubbing farce made necessary and acceptable by corporate greed.

[AlexisT]

Most hospitals are non-profit, actually. So is Blue Cross/Blue Shield. The pressures on the medical system are much more complex than profit motive.

As for Sicko... don't get me started again. The US system is far from perfect, but it painted a ludicrously rosy picture of how other countries work.