Hospitals pressured to curb elective surgeries

As the industry aims to curb excessive care and control medical costs, some private insurers are deterring hospitals and providers from performing certain elective surgeries, Kaiser Health News and The Washington Post reported.

They're setting their sights on elective early deliveries to cut costs without compromising care--as new research shows hospitals waste billions of dollars on unnecessary cesarean sections.

Insurers also aim to avoid subsequent medical costs to treat feeding, breathing and developmental problems, KHN noted.

Starting this year, hospitals can get more money from UnitedHealthcare if they take action to reduce early deliveries without medical cause, as well as demonstrate lower C-section rates, according to the article.

Similarly, Aetna has adjusted prices for C-section surgeries and renegotiated maternity payments for 10 hospitals to help defray the rising healthcare costs and risks associated with the procedure, FierceHealthPayer previously reported.

Hospitals also are seeing no reimbursements at all for elective early deliveries from certain insurers, including South Carolina Medicaid program and BlueCross BlueShield of South Carolina, according to KHN.

Joining private payers, some states are offering hospitals incentives to reduce elective births and save costs. Hospitals in Washington, for instance, can now share in a $10 million reward for improving on five patient-health measures, including reducing optional early births, Bloomberg News reported. The state also cut $1,000 from the $7,000 to $10,000 in Medicaid payments hospitals receive for uncomplicated C-sections.

If early elective deliveries were reduced to 1.7 percent, nearly $1 billion dollars could be saved annually in the United States, the Leapfrog Group said last year.

Such efforts reinforce a recent commentary published in the New England Journal of Medicine, calling for the United States to adopt evidence-based criteria for the appropriateness of elective procedures to "combat increasing healthcare costs while enhancing access and quality."

Appropriateness guidelines can work, as evidenced in Washington state: A large health system saw fewer elective surgeries and lower costs for osteoarthritis patients after suggesting patients use decision aids before undergoing treatment.

The use of appropriateness guidelines would not only lead to fewer elective procedures but also would protect hospitals and providers from the risks of bad outcomes associated with procedures that were objectively identified as ineffective or unsafe upfront, FiercePracticeManagement previously reported.

For more:
- read the KHN/Post article
- here's the Bloomberg article
- here's the NEJM commentary