Cesarean Delivery Model Meeting the challenge to reduce rates of Cesarean delivery

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1 Cesarean Delivery Model Meeting the challenge to reduce rates of Cesarean delivery Alan Mills FSA MAAA ND November 13, 2014

2 Agenda 1. Background 2. The U.S. Cesarean delivery challenge 3. Cesarean Delivery Model design 4. Results

3 1. Background

4 Types of childbirth delivery Vaginal delivery natural childbirth Cesarean delivery surgical intervention

5 Cesarean delivery problems Poor psychosocial outcomes Risks of major abdominal surgery Pulmonary disorders Compromised breast feeding Complications for later births Increased perinatal mortality Greater cost

6 World cesarean delivery rates 2008 Netherlands (14%) Source: World Health Organization

7 U.S. cesarean delivery rates 2013 WA MT OR ID WY NV UT CO CA AZ NM Lowest rate: 22.4% ND SD NE KS OK TX MN IA MO WI AR LA IL MS IN TN MI KY AL OH GA WV SC FL PA VA NC NY VT NH NJ ME DE MD MA RI CT AK Highest rate: 38.9% HI Source:

8 U.S. cesarean delivery rates 1965: 4.5% 2013: 32.7% Source:

9 U.S. hospital inpatient expenditures 2011 (ages 0 65, $ billions) Heart conditions Normal birth/live born Trauma-related disorders Cancer Osteoarthritis and other non-traumatic joint disorders COPD, asthma Gallbladder, pancreatic, and liver disease Kidney Disease Other CNS disorders Systemic lupus and connective tissues disorders $- $5 $10 $15 $20 $25 $30 $35 $40 $45 Source:

10 2. The U.S. Cesarean delivery challenge

11 How can we reduce the U.S Cesarean delivery rate to a reasonable level (10% - 15%)?

12 My approach 1. Focus on individual States 2. Bring together the State s major stakeholders: Legislators Health agencies Health insurers Medicaid Clinicians (Obstetricians, Certified Nurse Midwives, Licensed Midwives) Women 3. Use AnyLogic simulations as the focus

13 Reasons for using AnyLogic One cogent framework accessible to all stakeholders: GIS visualization Sophisticated agent-based modeling Scalable for many agents State charts and flow diagrams for agent behavior Interface with Excel Robust experiment types Message passing

14 Why agent based modeling? Many heterogeneous agents interacting over time Independent agent behavior Importance of space Network effects Feedback

15 3. Cesarean Delivery Model design

16 Agents Women Obstetricians Certified nurse midwives (CNMs) Licensed midwives (LMs) Hospitals Health insurers Medicaid

17 Data Data from the State: Synthetic data Women Obstetricians, CNMs, LMs Actual data Hospitals Insurers

18 Key behaviors Women Choose primary birth attendant Request delivery attendance Obstetricians Choose Hospital Decide delivery method CNMs Choose Hospital Choose backup Obstetrician Refer delivery attendance Attend vaginal birth Hospitals Insurers/Medicaid Pay claim LMs Choose backup Obstetrician Refer delivery attendance Attend vaginal birth

19 Key behaviors Women Choose primary birth attendant Request delivery attendance Obstetricians Choose Hospital Decide delivery method CNMs Choose Hospital Choose backup Obstetrician Refer delivery attendance Attend vaginal birth Hospitals Insurers/Medicaid Pay claim LMs Choose backup Obstetrician Refer delivery attendance Attend vaginal birth

20 Key behaviors Women Choose primary birth attendant Request delivery attendance Obstetricians Choose Hospital Decide delivery method CNMs Choose Hospital Choose backup Obstetrician Refer delivery attendance Attend vaginal birth Hospitals Insurers/Medicaid Pay claim LMs Choose backup Obstetrician Refer delivery attendance Attend vaginal birth

21 Key behaviors Women Choose primary birth attendant Request delivery attendance Obstetricians Choose Hospital Decide delivery method CNMs Choose Hospital Choose backup Obstetrician Refer delivery attendance Attend vaginal birth Hospitals Insurers/Medicaid Pay claim Messages LMs Choose backup Obstetrician Refer delivery attendance Attend vaginal birth

22 Key behaviors Women Choose primary birth attendant Request delivery attendance Obstetricians Choose Hospital Decide delivery method CNMs Choose Hospital Choose backup Obstetrician Refer delivery attendance Attend vaginal birth Hospitals Insurers/Medicaid Pay claim Messages LMs Choose backup Obstetrician Refer delivery attendance Attend vaginal birth

23 Key behaviors Women Choose primary birth attendant Request delivery attendance Obstetricians Choose Hospital Decide delivery method CNMs Choose Hospital Choose backup Obstetrician Refer delivery attendance Attend vaginal birth Hospitals Insurers/Medicaid Pay claim Messages LMs Choose backup Obstetrician Refer delivery attendance Attend vaginal birth

24 Key behaviors Obstetricians Choose Hospital Decide delivery method Women Choose primary birth attendant Request delivery attendance CNMs Choose Hospital Choose backup Obstetrician Refer delivery attendance Attend vaginal birth Hospitals Insurers/Medicaid Pay claim Messages LMs Choose backup Obstetrician Refer delivery attendance Attend vaginal birth

25 Key behaviors Obstetricians Choose Hospital Decide delivery method Women Choose primary birth attendant Request delivery attendance CNMs Choose Hospital Choose backup Obstetrician Refer delivery attendance Attend vaginal birth Hospitals Insurers/Medicaid Pay claim Messages LMs Choose backup Obstetrician Refer delivery attendance Attend vaginal birth

26 General behavior model 3. Motivations 4. Attributes 1. Input messages 2. Get input 8. Produce output 9. Send output 10. Output messages 5. Experience 6. Rules Agent 7. Context

27 Example behavior: Choose primary birth attendant Agent: Woman 1. Input messages: Childbirth month (data item) 2. Get input: NA 3. Motivations: Desired birth attendant type (data item) 4. Attributes: Residence latitude and longitude (data item) 5. Experience: NA 6. Rules: NA 7. Context: NA 8. Produce output: Get Identifier of nearest desired birth attendant type 9. Send output: Send output to Woman attributes 10.Output messages: Clinician Identifier

28 Example behavior: Choose primary birth attendant 3. Motivations 4. Attributes 1. Input messages 8. Produce output 9. Send output 10. Output messages Agent

29 Message passing Message Class parameters: Message type Sending agent type Sending agent identifier Woman identifier Delivery method Amount Messages are passed using send(object, Agent) through AnyLogic s standard connections link.

30 Visualization Environment (GIS) Obstetricians Women Certified Nurse Midwives (CNMs) Licensed Midwives (LMs) Hospitals Insurers

31 Visualization: Washington State

32 Model demonstration: Visualization

33 User interface

34 Model demonstration: User interface

35 4. Results

36 Significance of the Cesarean Delivery Model First holistic model of the Cesarean delivery challenge Stakeholder focus for Cesarean delivery reform First step toward a complete health system model First step toward reusable agents and behaviors

37 Model demonstration: Results

38 Key results Payment reform by itself won t work as intended A multi-faceted approach is required Retooling the workforce will take time

39 Questions or comments?

40 Review 1. Background 2. The U.S. Cesarean delivery challenge 3. Cesarean Delivery Model design 4. Results

41

42 Thank you

43

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