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Full-term deliveries might soon be rule for Georgia Medicaid

Sunday, Feb. 3, 2013 4:53 PM
Last updated Sunday, Feb. 10, 2013 6:49 PM
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Sarah Biro took her sweet time coming out, but her mother was willing to wait.

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Ashley Biro holds her 1-week-old daughter Sarah, who was born at Georgia Regents Medical Center. Ashley was in her 42nd week of pregnancy when Sarah was born.  SARA CALDWELL/STAFF
SARA CALDWELL/STAFF
Ashley Biro holds her 1-week-old daughter Sarah, who was born at Georgia Regents Medical Center. Ashley was in her 42nd week of pregnancy when Sarah was born.

“She’s in there for a reason and she’s not ready to come out,” said Ashley Biro, who delivered Sarah in the 42nd week of her pregnancy. “I don’t want to force my body to do something it is not ready to do.”

Soon, expectant mothers in Georgia on Medicaid might have to make the same choice about waiting. Gov. Na­than Deal’s proposed budget for fiscal year 2014 includes a line item under Med­i­caid that would end coverage for elective births before 39 weeks of pregnancy, or what is considered full-term.
The move would save the state $5.12 million, according to the budget, though others are skeptical about that.

South Carolina Medicaid already has the policy, and discouraging such elective births has long been the position of the American College of Ob­ste­trics and Gynecology and advocacy groups including the March of Dimes.

The Centers for Medicare and Me­dicaid Services has a campaign to work with states and providers on curbing elective births before 39 weeks in order to prevent medical complications.

However, some obstetricians argue that making it a mandate hampers their ability to work with pregnant women, particularly in areas such as Augusta, where almost all of the surrounding counties lack birthing services and expectant mothers live hours from their provider.

A 39-week rule at one medical center increased the number of stillbirths and heavier babies, according to a 2011 study, while decreasing the number of babies that went to the Neonatal In­tensive Care Unit with complications. That kind of trade-off might be inevitable, physicians said.

The rate of women who decided to be induced or have a cesarean section without medical cause between 37 and 39 weeks of pregnancy had been around 10 percent to 15 percent nationally about five years ago, according to the Medicare center.

It was around 12 percent to 14 percent for Georgia, but then the March of Dimes and others began pushing hospitals to agree to a “hard stop” to elective deliveries before 39 weeks without a valid medical reason.

Delivering earlier puts the baby at greater risk for complications, such as short-term breathing problems from immature lungs, said Dr. Alan Joffe, an obstetrician and community medical director for Peach State Health Plan, a Georgia Medicaid Care Management Organization.

That can put the baby in intensive care for two to three days, he said. Kee­ping a baby out of intensive care saves about $15,000 and means better outcomes for the family, said Dr. Dean Greeson, the senior vice president and chief medical officer at Peach State.

“The 39-week issue caught our attention because it really is a quality of care issue for us and for moms and babies in general,” Greeson said.

Dr. William Barfield, the chairman of University Hos­pital’s Department of Obste­trics and Gynecology, argues that having a mandate ties physicians’ hands when trying to respond to the individual needs of the mother.

“They would like the opportunity to make decisions between themselves and their patients,” he said.

Many expectant mothers coming to Augusta are travelling a long distance to see their physicians, which puts them in a tricky position if they are close to their due date and in early labor but not quite at 39 weeks, Bar­field said. Inducing would allow the birth in a controlled environment as opposed to sending the mother home and having her rush back to the hospital in labor, he said.

“You come flying in, in the middle of the night, deliver rapidly, it’s not healthy for the baby or the mother,” Barfield said. “There’s some healthy things about us being able to make a better decision.”
There are also dangers in waiting too long. A 2011 study published in Obstetrics & Gynecology found that instituting the 39-week rule did decrease the number of children admitted to intensive care from 9.3 percent to 8.5 percent. But the number of stillbirths increased from seven to 17 for the same number of births. That’s what Bar­field fears will be the case with a mandate.

“Every doctor has some of those, and those are your nightmare (cases),” he said. “A healthy baby that should be born in a couple of days and you go to do it and it is too late.”

Those issues are legitimate, and while he supports decreasing the 39-week elective rate, Joffe said Georgia physicians might also bristle at a hard and fast rule.

“What the Georgia (Ob­ste­trical and Gynecological) Society is concerned about is penalties to the physician and loss of autonomy to be able to deal with that situation,” he said.

Dr. Paul Browne, the director of maternal-fetal medicine at Georgia Regents Me­dical Center, said the 39-week rule has already been a success in Georgia as hospitals have implemented it on their own, often in partnership with the March of Dimes initiative.

From that 12 percent to 14 percent rate of elective births before 39 weeks, Geor­gia is now down to 3 percent, he said, citing data the Georgia Hospital Association released last fall. The rate of stillbirths has been largely unchanged in that time.

For that reason, Medi­caid’s projected savings is probably a “gross overestimate,” Browne said. “The savings we’re going to have we’ve realized already.”

But reducing that elective rate clearly results in fewer NICU admissions and fewer C-sections, which is a better use of resources, said Browne, who serves on an advisory committee for South Carolina Medicaid.

“I think that is reasonable,” he said.

It also seemed reasonable to Biro to wait, and to have the birth the way she – and Sa­rah – decided it should go.
“I think it is important,” she said. “In my opinion, I’d rather be pregnant longer and be uncomfortable and give my baby the best chance. She’s doing good.”

Comments (15) Add comment
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itsanotherday1
43212
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itsanotherday1 02/04/13 - 12:45 am
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It seems to me that delivery

It seems to me that delivery earlier than nature calls is unnecessary unless the baby would otherwise suffer harm. I haven't read the law, but if it allows for discretion in the cases of complications, I'm good with it.

Techfan
6461
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Techfan 02/04/13 - 05:24 am
4
5
Wasn't one party griping and

Wasn't one party griping and saying something about putting government between you and your doctor?

wordwright
134
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wordwright 02/04/13 - 07:59 am
3
4
Government control of healthcare

What does Gov. Deal know about birthin' babies? How can Republicans say the Democrats should leave healthcare alone, and then come up with something like this? Bunch of hypocrites--anything to save the fat cats some money.

Little Lamb
46022
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Little Lamb 02/04/13 - 08:47 am
2
1
Government Medicine

When you put government in control of the medical sector, you will get rule upon rule. New rules will emerge every year. Some rules will contradict other rules. It will be hard to keep up with all the rules.

justthefacts
21869
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justthefacts 02/04/13 - 09:01 am
9
1
So funny

Libs complaining about gov't involvement in Healthcare. You ain't seen nothing yet.

JRC2024
8876
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JRC2024 02/04/13 - 10:08 am
4
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wordwright, the "fat cats"

wordwright, the "fat cats" are the taxpayer and we are already overburdened with the costs of the "not so fat cats" with the costs of medicaide.

itsanotherday1
43212
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itsanotherday1 02/04/13 - 10:12 am
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"Wasn't one party griping and

"Wasn't one party griping and saying something about putting government between you and your doctor?"

Yep, when I'm paying for it.

Humble Angela
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Humble Angela 02/04/13 - 12:37 pm
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Techfan...you are correct.
Unpublished

Techfan...you are correct. Someone WAS saying something about putting government between you and your doctor. But YOUR democrats voted for Obamacare, so we all have to deal with what that OTHER party tried to prevent.

Congratulations......you won.....enjoy your trophy.

PUPPYMOMMA
1344
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PUPPYMOMMA 02/04/13 - 02:19 pm
1
1
Gov. Deal knows about as much

Gov. Deal knows about as much as Prissy (Gone with the Wind) about birthin' babies. At least she said it.

Red Headed Step Child
4061
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Red Headed Step Child 02/04/13 - 02:26 pm
0
0
Hmm..

I'd be interested to see what the difference in charges there are in a " term birth" and an elective induction / delivery... Other than the additional medications involved in an induction, it seems like the rest should pretty much be the same cost. I mean, a C-section for a term baby should cost the same as one that is scheduled early, right? Same goes for an induction.. It's been a while since I had my kids, but it seems like the cost for both (one was a term birth, the other was induced 2 weeks early) was about the same. Maybe I'm just behind the times...

If the physicians are so het up about this, maybe they need to adjust their fee charts if they are charging differently based on elective vs term births. I mean, I can understand high risk births being billed differently but for the same 'ole, same 'ole? Nah.

Red Headed Step Child
4061
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Red Headed Step Child 02/04/13 - 02:44 pm
0
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You can look at it another way...

Being a balanced budget state, they do have to trim off wherever they can - if this TRULY is a cost savings that can put budget dollars somewhere else that needs it, what's the harm? They did state this was for "elective" births - I guess you could technically put that in the same category as "elective surgery" - it's a nice to have, but not necessary.

Zhakiayh.Devoe
23
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Zhakiayh.Devoe 02/04/13 - 03:22 pm
0
1
they do not need do that

they do not need do that because some people can't do their whole term

oneofthesane
2201
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oneofthesane 02/04/13 - 05:21 pm
0
0
that would end coverage for elective births before 39 weeks
Unpublished

I want to know what they are considering "elective". Sooooooo if the baby is at risk for still birth if mother going full term, it is an oh-well situation? Soooooo to save money, instead of drug testing FOOD STAMP reciepients and perhaps changing food stamps all together.....like instead of letting them buy whatever they want....give them vouchers to buy brocolli, wheaties, government cheese and pink slime beef etc.....then take half the money you save from food stamps and transfer to medicaid fund and other 1/2 to deficit. Or does that make to much sense?

wordwright
134
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wordwright 02/04/13 - 11:11 pm
0
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What's your definition of a fat cat?

JRC2024...I'm a tax payer, and I'm not a fat cat. The fat cats are not the middle class, and as you so correctly observed, the middle class folks are overburdened with taxes. We are burdened with taxes because we're picking up the slack on both ends. The rich won't pay their fair share, and the poor can't.

Your statement doesn't change the fact that, regardless of ability to pay, the decision of when a baby should be born should be between the doctor and the patient--not a government mandate. An early delivery can mean the difference between a regular delivery and a C-section, which would cost more. An early delivery can mean the difference in the health of the child and/or the mother. A sick baby (or mother) costs more to care for than a healthy one. Most doctors I know would be hesitant to deliver early without a really good reason.

Darby
25670
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Darby 02/05/13 - 05:03 pm
1
0
"Wasn't one party griping and saying....

something about putting government between you and your doctor?"

So glad you noticed techfan. This is about less government (taxes) between citizens and their doctor.

Like I said, so glad to see you are finally getting the picture.

Darby
25670
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Darby 02/07/13 - 01:45 pm
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One more....

...link to another nut-case environmental wacko blog or website. I don't know which and it's certainly not worth taking the time to check out. There’s never anything there but fabrication, factual distortions and fear mongering. Who needs that?

grif9505
14
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grif9505 02/09/13 - 05:19 pm
1
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nothing new

This is not a new topic...Doctors Hospital has been practicing under 39 week ELECTIVE inductions and repeat c-section rule for over two years now...of course there are exclusions that allow for medically indications the MD's just need to document the conditions. Not strange that Dr Barfield who delivers at University would not be in favor of this as they are behind the times in Evidence Based Maternity Care and doing whats best for the moms and babies.

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