Legislators take issue with Minnesota's millions spent on unnecessary early labor

ST. PAUL

For most pregnancies, doctors widely agree, keeping baby inside until 39 weeks is best for everyone. Yet Minnesota taxpayers pay millions of dollars each year for pregnant women to be induced early when it's not medically necessary.

For most pregnancies, many experts say, a full-scale hospital isn't needed for safe births, yet state taxpayers routinely foot the bill for thousands of dollars in payments for a physician-supervised hospital stay when a birthing center or midwife would suffice -- at about half the cost.

Those are the arguments behind several health care changes to state-funded programs proposed by state lawmakers and Gov. Mark Dayton. With taxpayers paying all or much of 38 percent of pregnancies statewide, the proposed changes have the potential to affect the entire birthing industry.

But consensus has been hard to find -- perhaps impossible for one of the proposals -- despite widespread agreement on the goals: appropriate care without needlessly spending money.

In that sense, the proposed pregnancy-care changes are typical of much of the Minnesota and national debate over health care reform: For every proposal, it seems, there are 10 reasons to do it and 10 reasons not to.

"Some have said that it takes $1 billion to achieve reform," said state Rep. Jim Abeler, R-Anoka, who chairs a key House committee and authored the House health and human services bill containing proposals seeking the changes. "I would suggest you need a $1 billion deficit to achieve reform. It takes a crisis to change things."

Following a compromise, one of the proposals -- aimed at eliminating early inductions -- appears likely to become law. But the future of another -- a sweeping change to the way the state reimburses for pregnancies and births -- is much less clear.

Lawmakers from the GOPcontrolled House and Senate are in the process of unifying each chamber's proposals, while Dayton, a Democrat, waits.

Eliminating 'elective' inductions

For the past 30 years, as treatment for preemies has improved, the rates of inducing labor without a medical necessity and scheduling cesarean sections have increased, according to the March of Dimes, which seeks to reduce premature and low-weight births. Between 1989 and 2004, rates of inductions increased from 9 percent to 21.2 percent, according to the nonprofit, citing widely used national figures. As recently as 2007, 71 percent of C-sections and inductions were elective, meaning they weren't needed to protect the health of the mother or her baby.

Increased uses of fertility treatments resulting in multiple babies is one cause -- but the majority of it is something else, said Marianne Keuhn, program services director at the Minnesota chapter of the March of Dimes.

"There's this general belief that even if your baby's born at 34 to 35 weeks, everything will be OK," Keuhn said. "It gives kind of this false sense of security. Some women will say, 'I'm far enough along and I'm tired,' and you can't blame them. But there are still some very concrete things that happen in those last weeks."

In the last six weeks of pregnancy, a baby's brain will almost double in size, growing neural connections that help learning and coordination. The lungs also are still developing, as are several other organs.

So though babies are considered "full term" at 37 weeks, babies born even a few weeks before 39 weeks are at risk of a host of complications and developmental delays or disabilities. The March of Dimes has advised doctors to take early unnecessary inductions and C-sections off the table at the beginning of their relationship with their patients.

According to the March of Dimes, premature birth, on average, almost doubles the cost of caring for the mother and multiplies the cost of caring for the infant more than tenfold.

In short, it's worse for the mother, worse for the baby and worse for taxpayers in a cash-strapped state where taxpayers pay for nearly four in every 10 births.

"We want to stop elective induction of labor before 39 weeks," said Dr. Jeff Schiff, medical director of Minnesota Health Care Programs, which taxpayers fund. Early inductions often lead to C-sections.

Dayton supports Schiff's proposal to require doctors and others to file reports when they induce labor early -- or risk not getting paid. For months, Abeler had been pushing a stronger stance: The state would simply stop reimbursing doctors, hospitals and health care providers when they induce early without a medical reason. Last week, he compromised, giving in to Schiff's way of thinking.

"It's really a nationwide coming of age, so to speak, to do what's best for mother and child," said Carol Busman, a clinical nurse specialist for maternity care at HealthEast Care System, which includes St. John's Hospital in Maplewood, Woodwinds Health Campus in Woodbury and St. Joseph's Hospital in St. Paul. In 2007, HealthEast adopted a policy barring medically unjustified inductions before 39 weeks. Today, 3.8 percent of pregnant patients at HealthEast are induced, and the group says all of those inductions are medically needed.

Though met with skepticism from some in the medical community, HealthEast, as well as Fairview hospitals in 2009, have declared their policies successes.

'Pregnancy care homes'

Healthier babies and happier moms are also among the core goals of another proposal -- this one more controversial -- to change how births are paid for.

Under Abeler's proposal, "pregnancy care homes" would become mandatory for state-funded pregnancies by 2014. The idea is to force doctors, nurses and midwives, as well as hospitals and insurers, to figure out how to keep pregnancy costs down.

Under the plan, the use of midwives -- nurses who specialize in deliveries without complications -- would be mandatory, while the use of full-scale hospitals would be discouraged for the vast majority of pregnancies.

It's a nod to stand-alone birthing centers, a recent and increasingly popular addition to the options available for women. They are small facilities, often houses, staffed by nurses, midwives, birthing coaches and other non-M.D.'s that accept only women not expected to have complications. The aim is to give women the comfort of home -- but with a team of experts on hand to bring about a safe birth.

Another benefit: They cost about half to three-fourths what the same births would cost in a typical hospital.

Last year, a Democratic-led proposal allowed birthing centers to be reimbursed by state-funded health insurance programs. "This kind of makes them mandatory," Abeler said.

The idea was the brainchild of Dr. Steve Calvin, an independent physician specializing in maternal and fetal medicine. Calvin's plan, which Abeler supports, encourages the shift to lower-cost births by setting a basic rate the state will pay for a birth -- and offer no more. Thus, the lower wages of midwives, compared with obstetrician gynecologists, would be inviting -- as would the lower cost of a birthing center, compared with a hospital -- if the care providers don't want to spend more than they'll get back.

High-risk pregnancies would not be affected by the proposal.

The bundled cost for pregnancy care likely would be about $9,000 to $10,000. The figure would be calculated by averaging three years of state reimbursements, which currently pay doctors and facilities for each test or procedure.

"This will realign the incentives," Calvin said. "The incentives right now (are) the more you do, the more you get paid. The people who do what I do get paid a lot, but we're not needed for 80 percent of pregnancies. It will drive quality and reduce costs and remind everyone that pregnancy is not a disease for which the only cure is a C-section."

Currently, midwives figure in about 10 percent of births. Calvin said he believes that figure ought to be 30 percent to 40 percent. Calvin himself could stand to benefit. He's converting a house he bought into Minneapolis' first free-standing birth center across the street from Abbott Northwestern Hospital.

Not all are on board

But that doesn't mean all birth centers are on board with his plan.

Amy Johnson-Grass, owner and director of Health Foundations Family Health and Birth Center, St. Paul's first free-standing birth center, doesn't see the need for such a massive reform.

"There are other ways to realize a lot of these savings than this whole new thing," said Johnson-Grass, whose center has performed more than 60 deliveries since opening last year on Grand Avenue. She tells patients to expect to pay about $6,000. (Go to TwinCities.com to see a video of a water birth there.)

Johnson-Grass said that if the state's insurance programs, which cover poor and lower-income families, simply required pregnant women to see a midwife first, many would stick with it and give birth in a free-standing center like hers. "The rest (of the proposal) is redundant," she said.

Hospitals also aren't on board with the plan and probably wouldn't be fond of Johnson-Grass' idea either.

"It still is about patient choice, and most mothers want to have their babies in a hospital," said Mary Krinkie, vice president of government relations for the Minnesota Hospital Association. Krinkie is quick to say that the MHA isn't opposed to free-standing birthing centers but doesn't want the importance of hospitals lost in the discussion. "With the Medicaid population, regrettably, they may not have gotten as good prenatal care. There might be more of a risk there, and patients at risk need to be in hospitals. This is not the approach we would take."

Distributed by McClatchy-Tribune Information Services.