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Birth center hearings conclude

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Usage, conversion rates questioned

By Marty Finley

Two warring philosophies on the Visitation Birth & Family Wellness Center’s business model clashed one last time Tuesday during the final day of testimony for the certificate of need hearing.

Attorneys for Hardin Memorial Hospital, Flaget Memorial Hospital and Twin Lakes Regional Medical Center said the proposed birth center in Elizabethtown would have to attract a usage rate nearly four times the national average for birth centers, convert the majority of home births in its service area and completely ignore home birthing trends in Jefferson County to reach utilization projections it has offered in its application.

Home birth growth rate questioned

The center has projected it will see roughly 100 births in year one and 200 births in year two with a projection to make money in its second year.

Roger Cochran, an expert witness in health planning and partner with Morgan Healthcare Consulting, drafted the utilization projections and said he relied heavily on information from the Centers for Disease Control and Prevention, the National Vital Statistics System and lengthy conversations with certified nurse midwives Mary Carol Akers, founder of the center, and Susan Stapleton, who once managed a birth center, to develop his model.

In essence, Cochran’s model projects home birth rates in Kentucky to increase from 0.9 percent of all births in 2009 to 1.2488 percent by 2014, which he applied to each county in the service area, which is expected to exceed 20 counties.

When looking at the conversion of home births to freestanding birth centers, Cochran said he found no hard data to accurately make a prediction so he consulted Akers and Stapleton and those conversations helped him conceive the notion that the center could capture 90 percent of the home birth population in its primary service area.

During cross examination, attorney Mathew Klein scrutinized the model, asking Cochran why he did not apply the 0.3 percent national birth center usage rate to the service area for a more “reasonable” projection. Using that approach, roughly 52 of the 17,269 births in the service region would be delivered at the center, Klein said.

But Cochran said the national rate is simply an average and includes states that have no access to birth centers. He said he was uncomfortable using the national rate because there is a wide disparity between states and their uses of birth centers.

Klein also asked why Cochran did not include a deduction adjustment in the model to allow for Medicaid patients who prefer home births, specifically considering roughly 23 percent of freestanding birth center patients use Medicaid nationally and approximately half the mothers in the Lincoln Trail region are Medicaid users. The center does not plan to accept Medicaid patients.

Cochran said he found no data showing the number of Medicaid patients in Kentucky who elect to undergo home birth so he could not adequately offer a deduction.

Akers, who returned to the stand briefly Tuesday, testified Medicaid does not reimburse home births in Kentucky.

Klein asked Cochran if he was confident enough in the center’s viability to invest his own money into it.

“I don’t invest my money in health care, thank you,” Cochran said.

Conversion projections scrutinized

A chart submitted during testimony showed the usage of midwives and home births is higher in rural parts of the state in counties with less than 100,000 residents. The chart in particular showed smaller numbers of home births in Fayette, Jefferson and Kenton counties. Klein said Hardin County was not included in the data but it could be assumed it would have smaller numbers of home births because its population exceeds 100,000.

The chart also showed less than 50 home births in Jefferson County during 2009, only 2 of which were midwife assisted.

Michael Baker, an attorney for Flaget, said the model’s determination that it could attract more than 100 home births from Jefferson County in year two is outrageous in light of the information and accused Cochran of glossing over the detail because it did not fit the narrative he was trying to reach.

“It didn’t support your hypothesis so you threw it out,” he said.

Cochran said he did not discard the information but declined to use it in his projections because the chart only reflected one year – too small of a sample to detect a trend.

Hearing Officer Kris M. Carlton asked Cochran if he had any hard data to support the conversion of 90 percent of home births or if he simply took Akers at her word that the rate was realistic. Cochran said he did not have hard data but he listened intently to Akers and trusted in her experience.

Utilization projections are based solely on home births. Cochran said he expects some hospital births to translate to a freestanding birth center because residents explore new and unique services, but he said home births and freestanding birth centers have more in common and are easier to convert because they are both out-of-hospital experiences.

Chicago-based consultant Richard Baehr returned to the stand to rebut Cochran’s testimony, pointing to information from the National Vital Statistics System that shows the volume and percentage of births in birth centers have declined since 1990 with the occasional uptick.

Comparatively, Baehr said national statistics show home birth rates have not significantly dropped off or been replaced by birth center births but make up the bulk of out-of-hospital births, which he said contradicts the notion the center basically could consume the home birth population in its service area.

Baehr argued the freestanding birth center birth rate rarely exceeds 50 percent of total out-of-hospital births, even in states where there are a number of birth centers with high volumes.

Baehr said the birth center’s proposed usage rate would place Kentucky among the top three or four states in the country for birth centers by year two, which he said is not realistic.

J. Guthrie True, attorney for the birth center, fired back at Baehr, saying the charts he presented do not illustrate true conversion rates because they do not reflect the impact on communities when the first birth center opens up in a state. Baehr agreed but said the information is close enough to suggest a 90 percent home birth conversion rate is unreasonable.

True later stated hospitals opposing the center were not truly concerned about the center’s possible failure but rather fearful of its possible success, which could breed more birth centers around the state and cut into hospital births. Baehr said he was not hired to defend hospitals’ reasons for opposing the center but rather to analyze the feasibility of the business model.

“The model doesn’t work for me,” he said.

Conflict of interest?

In a slight departure, True called on Linda Bragg, chief nursing officer for HMH, to question her about a discussion she had with a nurse employed at the hospital during the third day of testimony at the Kentucky Bar Association in Frankfort on March 13.

The nurse, who declined to release her name to The News-Enterprise for fear of disciplinary action or reprisal by HMH, attended multiple days of the hearing in support of the birth center.

True asked Bragg if she or anyone else at the hospital attempted to dissuade anyone from supporting the center or pressured anyone to offer opposition. Bragg said no.

Bragg said she approached the nurse and cautioned her that any discussions she had with the media about her support for the center could be perceived as a conflict of interest by the hospital. Bragg said she approached the nurse because of her intent to grant an interview to a reporter.

When asked who would make this perception, Bragg said she would discuss the matter with the hospital’s human resources department. If an investigation was undertaken, Bragg said, it could lead to disciplinary action.

True asked Bragg if she approached the nurse to intimidate her or attempt to influence her opinion.

“Absolutely not,” she said.

Marty Finley can be reached at (270) 505-1762, or at mfinley@thenewsenterprise.com.

What's next?

The certificate of need hearing has wrapped up, but there is still work to do before a decision is rendered.

Final transcripts are expected by April 5 and written closing statements from both sides are due by April 25. Hearing Officer Kris M. Carlton said she would attempt to write a portion of her decision before written statements are submitted to expedite the process but did not present a timeline on when her ruling would be final.

Both sides have waived deadlines to give Carlton more time to review the case.

She said certificate of need hearings take priority so she hopes to reach a decision as soon as possible.