Financial incentives linked to cesarean section rate

Women who receive care at hospitals with higher financial incentives for cesarean section may be more likely to undergo cesarean deliveries, according to research published in JAMA Network Open.

“These findings suggest that financial incentives could be associated with variations in the rate of cesarean deliveries across the U.S.,” Rie Sakai-Bizmark, MD, MPH, PhD, investigator at the Lundquist Institute and assistant professor of pediatrics at the David Geffen School of Medicine at UCLA, and colleagues wrote. “A greater understanding of the dynamics that contribute to the relationship between hospital profit and cesarean delivery rates may assist in future steps taken to reduce the rate of unnecessary cesarean procedures.”

Sakai-Bizmark and colleagues conducted an observational, cross-sectional study using data from a nationally representative sample from the Healthcare Cost and Utilization Project’s Nationwide Readmissions Database from 2010 to 2014.

The researchers identified women who underwent cesarean and vaginal deliveries during the study periods. Those who were at low risk for cesarean delivery were included in the analyses.

After identifying cesarean deliveries, the researchers used the difference between charges and costs — such as wages and supplies — to estimate the profit per procedure at each hospital for cesarean deliveries. They categorized institutions in quartiles based on its estimated profits.

The researchers included 13,215,853 deliveries in the analyses, 16.7% of which were cesarean deliveries.

Sakai-Bizmark and colleagues found that profits for cesarean deliveries ranged from $4,969 in the lowest quartile to $26,129 in the highest quartile.

After adjusted for potential cofounders — such as age, insurance type, income, maternal comorbidities and hospital characteristics — they found that women were more likely to undergo cesarean deliveries if they delivered at hospitals that had higher profits per procedure.

They determined that the probability of cesarean delivery was greater in the highest quartile (aOR = 1.08; 95% CI, 1.02-1.14) and second highest quartile (aOR = 1.07; 95% CI, 1.02-1.13; P=.007) compared with those in the lowest quartile.

Sakai-Bizmark and colleagues estimated that if all women received care at hospitals in the lowest quartile, there would have been a 6.7% reduction in cesarean deliveries during the study period.

“Our finding illuminates the important association financial incentives have on hospitals, as a potential ‘upstream’ factor for the high number of cesarean deliveries performed in the U.S.,” Sakai-Bizmark and colleagues wrote. “Our findings should be informative for policymakers and payers to design interventions that can effectively reduce unnecessary cesarean deliveries.”