How Arkansas Lowered Its Cesarean Rate Quickly
How Arkansas Lowered Its Cesarean Rate Quickly
By Jill Arnold
July 7, 2017
Arkansas Center for Healthcare Improvement (ACHI) published a report in May 2017 which shows that after three years of a multi-payer, statewide payment reform initiative bolstered by Medicaid expansion, the overall state cesarean rate dropped from 35 percent to 30 percent in the population measured.
Known as the Arkansas Health Care Payment Improvement Initiative (AHCPII), the program uses payment reform strategies such as patient-centered medical homes (PCMHs) and shifting from traditional fee-for-service reimbursement to payment and delivery models based on episodes of care. Cesarean rates are one of the measures associated with the perinatal episode of care.
The drop in total cesarean rates among births financed by Medicaid and Arkansas Blue Cross Blue Shield is shown in the table below next to Centers for Disease Control and Prevention (CDC) data for the same years. A total cesarean rate is calculated by dividing the total number of cesareans by total number of live births.
In a 2014 report, CDC listed each state’s NTSV cesarean rate for the first time, which is the rate of cesarean births among first-time moms giving birth to a single, term baby in the head-down position. The Department of Health and Human Services' Healthy People 2020 target for the national rate of NTSV cesarean births is 23.9 percent or lower.
While the ACHI report provides insight into the total C-section rate, CDC data show how first-time moms with low-risk deliveries have fared. Arkansas, which is known for ranking near the bottom of the bottom half of states in public health measures, is now only about one percentage point away from meeting the Healthy People 2020 target for low-risk C-sections.
Compared to Delta region cohorts Mississippi and Louisiana, as well as the United States as a whole, Arkansas’ NTSV rate fell dramatically between 2013 and 2014 and remains lower than the U.S. average in 2016. (CDC data: 1997, 2009, 2013, 2014, 2015 and 2016)
Although Arkansas was one of the last states to implement the 2003 revision to the U.S. Standard Certificate of Live Birth, which could have impacted reporting on certain measures, it is unlikely that it would have resulted in such a significant drop.
Hospital data in the dark
A 1995 Arkansas law called the State Health Data Clearing House Act was amended in 2005 in part to limit the type of data that the Arkansas Department of Health (ADH) could share publicly. While state departments of health throughout the country vary widely in the information they choose to share publicly, Arkansas is an outlier in its legislative suppression of publicly available data at the hospital and payer level. Data shared via the Arkansas All-Payer Claims Database (APCD) as part of the Arkansas Healthcare Transparency Initiative established in 2015 contains no such restriction. A 2017 amendment to the Arkansas Healthcare Transparency Initiative Act, however, now mandates that ADH share hospital discharge data for the uninsured, vital statistics, and disease registry data with the state’s all-payer claims database. The result is that valuable ADH data that rounds out the healthcare utilization landscape will soon be integrated into the APCD and available to request along with claims data.
Voluntary reporting of data on maternity care measures is also limited in Arkansas, with only five out of 40 hospitals with maternity services reporting their data to the Leapfrog Group.
Without transparency, hospital successes like curbing the overuse of cesareans for first-time moms with low-risk deliveries aren't available to the public and statewide trends are easier to miss.
I asked Dr. William Golden, the Medical Director of the Arkansas Medicaid program, why he thinks Arkansas suddenly emerged as a national leader in the reduction of unnecessary cesarean births. Arkansas Medicaid finances approximately two-thirds of births in the state. When practice patterns in obstetrics affect the Medicaid population, they are affecting the majority of pregnant women in the state.
Working in conjunction with Arkansas Hospital Association and the Arkansas Foundation for Medical Care, Arkansas Medicaid has sponsored an inpatient pay-for-performance program called Inpatient Quality Incentive (IQI) for more than ten years.
In 2009, Medicaid implemented a quality improvement program which used payment incentives for hospitals to lower their high rates of early elective deliveries.
The program reduced early elective deliveries over 95 percent and reduced the number of births before 39 weeks by 3,000 per year by 2013.
In a paper published in the Journal of the Arkansas Medical Society in 2013, Golden and colleagues wrote that the total cesarean rate in Arkansas Medicaid claims data for the period between April 1, 2009 and March 30, 2010, was 34 percent. Some of this was due to the high rate of repeat cesareans and the authors state that fewer Arkansas physicians and hospitals offer vaginal birth after previous C-section (also known as VBAC) "because of perceived risks and staffing issues.”
Lowering low-risk repeat cesarean rates is also a Healthy People 2020 goal, but one that Golden recognized would be difficult to work on in Arkansas. He instead decided to work toward preventing primary cesareans, which over time will result in fewer repeat cesareans.
In 2013, Arkansas Medicaid began a quality improvement program that collects NTSV (low-risk) cesarean rates from hospitals and offers payment incentives specifically for the reduction of their NTSV rate. Arkansas Medicaid finances approximately two-thirds of births in the state. When practice patterns in obstetrics affect the Medicaid population, they are affecting the majority of pregnant women in the state. Starting with a baseline rate NTSV rate of 28 percent, the incentive program reduced that rate to under 24 percent over three years.
The result of a combination of statewide collaboration, shifting from fee-for-service to pay-for-performance, Medicaid expansion and hospital-level quality improvement is that Arkansas found itself with a low-risk cesarean rate lower than the national average and bucking the regional trend of cesarean overuse.
See where Arkansas ranks in NTSV rates and repeat C-section rates: preventaccreta.org/data
Jill Arnold is a founder of the National Accreta Foundation, a non-profit organization working to eliminate preventable maternal mortality and morbidity related to placenta accreta.
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