NEWPORT BEACH, Calif.— Hoag Memorial Hospital Presbyterian, one of the largest and most respected facilities in Orange County, needed to move quickly.

A big insurer had warned that its maternity costs were too high and it might be cut from the plan’s network. The reason? Too many cesarean sections.

“We were under intense scrutiny,” said Dr. Allyson Brooks, executive medical director of Hoag’s women’s health institute.

The C-section rate at the time, in early 2012, was about 38 percent. That was higher than the state average of 33 percent and above most others in the area, according to the California Maternal Quality Care Collaborative, which seeks to use data to improve birth outcomes.

Within three years, Hoag had lowered its cesarean section rates for all women to just over a third of all births. For low-risk births (first-time moms with single, normal pregnancies), the rate dropped to about a quarter of births. Hoag also increased the percentage of women who had vaginal births after delivering previous children by C-section.

In medicine, this qualifies as a quick turnaround. And the story of how Hoag changed sheds light on what it takes to rapidly improve a hospital’s performance of crucial services, to the benefit of patients, insurers and taxpayers.

Decreasing C-sections results in “better health to mothers and better health to babies and lower costs,” said Stephanie Teleki, senior program officer at the California HealthCare Foundation, which helped fund the data collection and analysis by the California Maternal Quality Care Collaborative. “That’s like a nirvana moment in health care.”

Experts have long been troubled by the wide variation of C-sections among hospitals nationally. (In California, the rates range from 18 percent to 56 percent.)  Certainly there are instances in which C-sections are typically recommended – such as a baby in breech position. But the disparities suggest that decisions are being driven by factors other than medical necessity – such as doctors’ time constraints and malpractice concerns.

Over the past few years, there has been a coordinated push to cut C-section rates in other states and in births covered by Medicaid, the health coverage program for low-income Americans.

Across California, data publicly released by the California HealthCare Foundation, the Pacific Business Group on Health and others in the past few years have underscored the differences in how hospitals handle maternity care. http://www.chcf.org/publications/2014/11/tale-two-births  http://www.pbgh.org/storage/documents/PBGH_C-Section_NTSV_Variation_Report.pdf

Despite the increased transparency, however, many hospitals don’t act until dollars are at stake, said Dr. Elliott Main, medical director of the California Maternal Quality Care Collaborative. That’s what happened with Hoag, which Main said is now becoming a model for others.

“In quality improvement, we call it ‘the burning bridge,’” he said. “You can’t just stay still. You’ve got to move.”

Focus on Physicians

At Hoag, where more than 6,000 babies are born each year, Brooks and other administrators knew that they had to focus on changing the mindset and behavior of physicians. “Hospitals don’t do C-sections, doctors do,” she said.

So they took some aggressive steps. First, they shared the data with all the physicians in the department without names — then decided to reveal the names. Suddenly, everyone knew who had exceeded or come in under the average.

“There was a lot of upheaval,” Dr. Jeffrey Illeck, a community OB-GYN and the hospital’s obstetrics department chair. “None of us want to look bad in front of our peers. … And some looked horrible.”

Some physicians reacted with surprise and frustration. Initially, many attributed the high rates to the patients, saying they were older, had more complicated pregnancies or demanded scheduled C-sections.

Dr. Amy VanBlaricom, an OB-GYN who delivers about 25 to 30 babies a month, said she wasn’t opposed to sharing the data. But she said doctors were worried that the rates would be used to penalize them rather than to drive improvement.

“It’s very heated,” she said. “We should use this data as an opportunity rather than a polarizing topic.”

VanBlaricom already tracked her own rates, which she said fell in the middle of the pack, and has only seen a small drop since. But she said being aware that Hoag is monitoring the C-sections has changed how she thinks about her practice and has encouraged her to let women remain in labor longer.

That’s what Hoag administrators were aiming for – a realization among doctors that C-sections should not be undertaken lightly. They carry surgical risks, including serious infection and blood clots, and require longer hospital stays.

“Doctors and patients look at cesareans as an easy way to time the birth,” said Dr. Marlin Mills, chief of perinatology at the hospital. “But a C-section is not benign. It’s a big surgery.”

The costs are also well-documented. Surgical births cost nearly $19,000, compared to about $11,500 for vaginal births, according to the Pacific Business Group on Health, an organization of employers that is also working to bring down C-section rates around the state.

The business group worked with the hospital on the financial side. It enlisted the help of some of the biggest local employers, including Disney, and another insurer, Blue Shield, to adjust payments so the hospital didn’t earn more from elective C-sections than vaginal births.

In addition, the hospital set new scheduling rules. In the past, doctors could simply call in with the woman’s due date and schedule the birth. Now, they would have to fill out a detailed form, with some requests needing special approval.

The hospital also stepped up its patient education, encouraging women to wait for labor to come naturally.  If patients did want an elective C-section, they would have to sign an easy-to-understand consent form in the doctor’s office that detailed the risks.

The nurses received end-of-year bonuses if they helped the hospital reach certain goals on reducing surgical births.

The hospital opened an obstetrics emergency department and gave more responsibility to “laborists,” doctors who were there around the clock to respond to emergencies, monitor women in labor and deliver babies.

Dr. Alex Deyan, who delivered more than 500 babies at the hospital last year, used to turn away patients who wanted vaginal births after cesarean sections. With a busy private practice, Deyan said he couldn’t always be immediately available if labor didn’t go as expected and a woman needed a C-section. That changed with the laborist program.

“Having in-house doctors 24/7 is a huge benefit,” Deyan said. “I can be a little more patient.”

Good for Patients Too

Holly Grim appreciated Hoag’s approach. She knew she didn’t want a C-section with her second baby. Her first labor at another hospital in December 2013 was long and painful and ended with a cesarean section that kept her in the hospital for days. Her son was healthy, but she said, “this wasn’t exactly how I had it planned – not even close.”

This time, she needed to get back on her feet quickly so she could chase after her 16-month-old. She decided to switch doctors and hospitals. And in early April, she got her wish — giving birth naturally to an 8-pound girl, Agnes, at Hoag.

The day after Agnes was born, the family was packing up to go home. She didn’t have any restrictions on lifting or driving, and she wasn’t in severe pain. This, she said, is how childbirth is supposed to be.

“I’m feeling really good,” she said as she nursed Agnes, wrapped in a blanket decorated with pastel footprints. “I’m relieved I’ll be able to run around after my son.”

Kaiser Health News (KHN) is a national health policy news service. It is an editorially independent program of the Henry J. Kaiser Family Foundation.

CLEVELAND — It’s difficult to imagine that a seven-story glass building will soon take the place of what’s now a vast hole near the corner of Carnegie Avenue and 105th Street in Cleveland. But Cliff Kazmierczak, who is with Turner Construction and overseeing the transformation, points to the gray sky, tracing a silhouette with his fingertips. In two years, he says, the Cleveland Clinic’s nearly $300 million cancer center is slated to open here.

“The big thing is to make the patient comfortable with the treatments that they’re going through,” he says of the building’s design. “So lighting, light colors, [and] as much natural light as possible are always very important to cancer patients.”

Kazmierczak came to this project after overseeing construction of the cancer hospital at Ohio State University a few hours south of here. All around the U.S., the health care industry is building up to take care of an expected influx of cancer patients.

Ohio is not alone in this building boom. The Advisory Board Company, a firm that does health care consulting, works with hospitals and doctors. Last year it found that about 25 percent of its members that have oncology departments were either constructing a cancer center, or had built one in the past three years. The Advisory Board’s Deirdre Fuller says people are more likely to get cancer as they get older.

“Now that everyone is looking forward and seeing the aging of the baby boomers,” she says, “it’s certainly adding some fuel to that fire.”

And most boomers will get health insurance through Medicare — which is a steady paycheck for hospitals.

Dr. Brian Bolwell heads the Cleveland Clinic’s cancer institute. He says hospitals have to meet the need.

“In the past five years, volumes go up, depending on location, between 5 and 10 percent a year,” Bolwell says. “And there’s no end in sight to that volume of growth.”

The Cleveland Clinic, along with its local competitor, University Hospitals, treat about 70 percent of the region’s cancer patients. And when the Cleveland Clinic opens its new center, the two will be located within a five minute drive of each other.

Historically, state governments have required hospitals to meet a certificate of need before building a hospital. But beginning in the late 1980s, states across the country began deregulating. Ohio’s certificate of need requirements for hospitals ended in the late 1990s, though it still requires it for long-term care facilities.

Dr. Nathan Levitan, who heads the cancer center at University Hospitals, doesn’t seem worried about the competition. His 4-year-old hospital, he says, is mostly full every day.

“We discharged over 11,000 patients with cancer in 2014,” Levitan says, “which is about a 20 percent increase over just a few years beforehand.”

He says that’s because both hospitals employ and contract with thousands of doctors. And in the world of cancer care, doctors have a lot of influence.

People usually don’t shop for cancer treatment until they are diagnosed, and at that moment their doctor’s advice on where to go matters a lot.

Bill Ryan leads a hospital advocacy group in Cleveland. He says that with so many expected patients, building is good for a hospital’s bottom line and good for patients.

“If you can run enough procedures through a facility, you’re going to get some economies of scale that will generate [a profit] margin,” he says. “The other thing you get when you run enough procedures through a facility, is a level of expertise that improves the quality of care that the individual gets.”

And when talking about the future of cancer care, hospital leaders tend to talk about quality. They insist that focusing on the quality of care will eventually lower the cost to patients, too.

This story is part of a reporting partnership with NPR, WCPN and Kaiser Health News.

Kaiser Health News (KHN) is a national health policy news service. It is an editorially independent program of the Henry J. Kaiser Family Foundation.

Recovering from pneumonia is an unusual experience in the 10-bed intensive care unit at the Carolinas HealthCare System hospital in rural Lincolnton, North Carolina. The small hospital has its regular staff in Lincolnton, but Richard Gilbert, one of the ICU patients, has an extra nurse who is 45 miles away.

That registered nurse, Cassie Gregor, sits in front of six computer screens in an office building. She wears a headset, and her voice is piped into Gilbert’s room via computer speakers.

A doorbell sounds before the camera turns on, alerting Gilbert that the nurse is looking in. They chit-chat as Gregor monitors Gilbert’s vital signs. The nurse asks how he’s feeling and if there’s anything he needs.

Carolinas HealthCare System monitors ICUs in 10 of its hospitals from this command center near Charlotte. The command center is staffed 24-7 with a rotating crew of seven to nine nurses and doctors who specialize in critical care. Everyone on the team also does bedside shifts.

Carolinas HealthCare started this project about two years ago and says it’s good for staff and patients.

For one thing, medical staff at the command center can maintain a constant focus on patients. The command center is quiet — none of the alarms are going off that most ICUs need to alert nurses and doctors down the hall that they’re needed. Dr. Scott Lindblom says it’s a nice change of pace.

The peace, he says, “makes it a much more pleasant environment actually to work in than what we’re used to — the usual chaos of the ICU.”

Nurse Kimberly Purtill agrees.

“We might see a trend up with their white blood cells,” Purtill says, or “a trend up with their temperature, and their blood pressure going down.” All those symptoms might be warning signs of an infection.

“If you were off yesterday as a bedside nurse, and you’re on today, you don’t have the picture from yesterday,” she continues.

But the command center staff has easy access to medical histories and other data on the computer screen, she says, so it’s easy to give the bedside staff a heads up.

Lindblom oversees critical care for Carolinas HealthCare System and says there are clear signs the virtual ICU is working.

“We’re taking care of more patients than we were two years ago,” he says, “and across the system, our mortality rate is dropping … and our length of stay is dropping. It’s almost the perfect storm of good care.”

Among the 10 hospitals in the program, ICU mortality is down 5 percent and length of stay is down 6 percent. Lindblom says virtual care doesn’t get all the credit. He notes the hospitals have also rolled out a program to better manage sepsis, which is a leading cause of death. But Lindblom says that virtual care helps with that program and nearly everything else in the ICU.

Leah Binder is president of The Leapfrog Group, a national advocate for better hospital care. She said the gold standard is to have critical care doctors on-site, not on-camera.

“However, that’s not always possible for every hospital and particularly in rural areas,” Binder says, “so second to that is a virtual environment.”

As technology leads to better care, she says, it could also lead to lower costs.

In the Midwest, Avera Health estimates its virtual ICU has resulted in $70 million worth of savings over the past 10 years. Deanna Larson, who oversees the project for Avera, says that from one hub in South Dakota, Avera monitors patients as far away as Minnesota and Wyoming.

“I think we quit calculating miles a while back,” she says, and laughs. “It’s a very vast area of land.”

Before virtual care, Larson says, complicated cases were often transferred to major medical centers. Now some of those patients can stay closer to home, and that’s good for them, their families, and the town’s economy.

“Keeping 10 or 12 patients more … means another nursing job that stays local,” Larson says, “maybe another lab tech job. What the technology is really doing is keeping those economics closer to home and helping them maintain viability.”

In other words, it may help the hospital in a small community stay open.

In Lincolnton, a town of about 11,000, Dr. Jessica Fox said her ICU has been much busier.

“The unit went from basically having a couple patients, and closing all the time because we were having to transfer so many patients, “to now being almost full all the time because we’re able to keep patients here, ” Fox says.

From his ICU bed, lifelong farmer Richard Gilbert says the more people looking after him, the better.

“That’s sort of like me and farming,” Gilbert says. “If I’ve got a five-man job, and I go out there with two people, [I] might miss something.” But if you have your whole crew working, he says, “you don’t miss anything. You get it done.”

This story is part of NPR’s reporting partnership with WFAE and Kaiser Health News.

Kaiser Health News (KHN) is a national health policy news service. It is an editorially independent program of the Henry J. Kaiser Family Foundation.

Requiring patients to get blood work and other tests before undergoing cataract surgery hasn’t been recommended for more than a dozen years. There’s good reason for that: The eye surgery generally takes less time than watching a rerun of “Marcus Welby, MD” — just 18 minutes, on average. It’s also incredibly safe, with a less than 1 percent risk of major cardiac problems or death.

Yet more than half of Medicare patients received at least one pre-operative test in the month before undergoing surgery to remove cataracts in 2011, a recent study found.

Some doctors were much more likely than others to order a complete blood count, urinalysis, cardiac stress test and the like. Thirty-six percent of ophthalmologists ordered pre-operative tests for more than 75 percent of their patients, according to the study, which was published last month in the New England Journal of Medicine.

“Their patients were no sicker or older,” says Catherine Chen, an anesthesiologist at the University of California, San Francisco, and the lead author of the study. “It suggests that it’s habit or practice patterns.”

The study compared the prevalence and cost of pre-operative testing in the month before 440,857 Medicare beneficiaries had cataract surgery. Testing expenditures for Medicare patients during the 30 days prior to cataract surgery were 42 percent higher than the average monthly Medicare spending for testing on those patients during the previous 11 months, a difference of $4.8 million.

Cataract surgery used to take a few hours and require general anesthesia. In those days, preoperative testing made more sense, says Chen. Now people often receive only a topical anesthetic eye drop to numb the eye or sometimes a local anesthetic that may include a sedative for relaxation.

But research shows that today, pre-operative testing for cataract surgery doesn’t result in fewer adverse events or better surgical outcomes, regardless of a patient’s health, says Chen.

“It’s so low risk it’s almost like saying you’re going to get your nails done,” she says. “There’s always a chance you’ll get hit by a car or have a heart attack on the way,” but it’s unlikely to happen at the nail salon.

Please contact Kaiser Health News to send comments or ideas for future topics for the Insuring Your Health column.

Kaiser Health News (KHN) is a national health policy news service. It is an editorially independent program of the Henry J. Kaiser Family Foundation.