On August 30th, NPR reported on a National Bureau of Economic Research (NBER) working paper that suggested physicians perform c-sections in order to maximize their pay. The NBER authors state this assumption and then go on to use it to explain why physician-patients are less likely than non-physician-patients to have a c-section birth in non-HMO hospitals. They argue that the different likelihood of c-section is due to physician-patients’ having information necessary to avoid unnecessary c-sections (that are due to physicians’ maximizing their incomes).
In my book, Cut It Out: The C-Section Epidemic in America, I argue that making assumptions about individual motivations is very problematic if one has not talked to the individuals being analyzed. The question, “Do physicians perform c-sections to make more money?” is not explored. Further, to argue that financial incentives are at the root of the c-section epidemic in America, one would have to delve into how physicians are paid for deliveries. Health insurance companies typically pay a global fee for prenatal care and delivery. This fee is a few hundred dollars higher for c-sections, but how the fee is divided among obstetricians in a practice (and few obstetricians practice in solo practices) is complex. Many obstetricians are not paid simply for the births they attend. Rather the global fees are aggregated and then paid to physicians according to the number of call hours they complete. Thus, it is hard to see how physicians have much of a financial incentive to perform a c-section because the increase in pay is not direct and is likely split among obstetricians in the practice.
My research, based on fifty in-depth interviews with maternity clinicians, suggests that a viable competing explanation for the NBER finding is that physicians often have a low threshold for performing c-sections during the course of labor because of liability concerns. Physician-patients may have the information necessary to negotiate with physicians to allow them to continue to try to deliver vaginally and/or physicians may not be as concerned that physician-patients will sue them in the case of a bad outcome and, thus, give physician-patients more latitude during labor.
Also problematic is that that NPR report focused on the assumption of the NBER paper that physicians perform c-sections due to economic incentives, rather than the main empirical finding of the NBER paper. The main empirical finding of the NBER paper is that physician-patients have a different likelihood of c-section than non-physician-patients. The authors focus their conclusion on the finding that “physician-mothers are approximately ten percent less likely to have a C-section.” They conclude, “This paper demonstrates that 10 percent of C-sections represent overuse of healthcare, and that this overuse is not only costly but may have an adverse impact on patients.”
The title of the NPR story—“Money May be Motivating Doctors to Do More C-sections”—and its focus is something that sounds exciting and leads to blaming physicians for the high c-section rate. This is an easy claim to make because it seems to have some kind of intuitive appeal. However, it is has no basis in empirical data analyzed in the NBER paper.
Theresa Morris is Professor of Sociology at Trinity College in Hartford, Connecticut. She is the author of Cut It Out: The C-Section Epidemic in America (NYU Press, October 2013).