Initiative to Reduce C-sections
Health Insurance Review & Assessment

A. Problem Analysis

 1. What was the problem before the implementation of the initiative?
Medically unnecessary C-sections have been recognized as an important health issue for women. In many developed countries around the world, there has been an alarming trend of rising C-section rates that are attributed to provider and patient preferences rather than a true medical cause. While C-sections are largely safe they are a major surgical operation that pose greater risk to mother and child than natural delivery. They also impose a significant cost to mothers and their families in terms of financial expenditures and time spent in recovery. A landmark World Health Organization Report (2010) on the Global Numbers and Costs of Unnecessary C sections found that the Republic of Korea had amongst the highest rates of medically unnecessary C-sections in the world, even amongst OECD countries. In 2000, the Ministry of Health and Welfare (MOHW) mandated a nationwide assessment of C-section rates to understand the scale and scope of the problem. The findings revealed that the rate of C-section delivery in Korea was 40.5% - over 2.5 times higher than the WHO-estimated population need of 10-15%. In contrast, in 1990, the national average of C-sections was 18.1%. The assessment also found very high variability in C-section rates among healthcare facilities (0-70%) indicating differences in clinical practice and quality of care. I n 2008, South Korea was estimated to have spent approximately $30 million in medically unnecessary C-sections. The costs of unnecessary C-sections have been identified as a barrier to universal coverage in many countries as public resources can be more effectively spent in other high priority health areas. There are several important factors behind the surge in C-sections in South Korea. On the provider side, these include 1) clinical judgment by provider that C-section is necessary, 2) convenience and predictability of scheduled C-sections, 3) C-sections can result in faster delivery than prolonged labor, and 4) C-sections are more expensive and thus facilities receive greater reimbursement for this service. Women and their families have also had a growing preference for C-sections, as there is a belief that it is convenient and less painful than natural deliveries. Moreover, since the early 2000s, the government extended insurance coverage to C-sections, which greatly accelerated C-section rates since patients were no longer responsible for payment. Although patient preferences are a real and important cause behind rising C-section rates in Korea, studies around the world and in South Korea have found that the majority of unnecessary C-sections can be attributed to provider behavior and decisions. A 2004 study in Korea showed that only 10% of women surveyed who had C-sections had requested it. Thus, as a first strategy, the government’s efforts to address this public health problem focused largely on influencing the behavior of providers and healthcare facilities.

B. Strategic Approach

 2. What was the solution?
There was nationwide consensus that a concerted and effective approach was necessary to bring down the rates of unnecessary C-sections. In 2000, the National Assembly mandated the establishment of the Central Assessment Committee for oversight of all quality assessments of healthcare facilities conducted by HIRA. It was this body that outlined the main objectives and strategy to reduce the rates of C-sections. HIRA was the lead implementing agency of this initiative. The main objective of this initiative were to 1) provide an evidence-base and incentives to influence provider behavior to reduce unnecessary C-sections, 2) to reduce variability of C-section rates across healthcare facilities nationwide, and 3) raise public awareness and education regarding C-sections. The target audience for this initiative was hospitals and clinics with over 200 deliveries per year, and women and their families. The Central Assessment Committee worked in conjunction with the C-Section Reduction group composed of medical experts, consumer groups, and public officials to set forth a multipronged strategy: 1.Establishment of a target rate of C-sections and C-section performance score for all major healthcare facilities A statistical model was developed to determine a target C-section rate adjusted for 15 risk factors to distinguish between medically necessary and unnecessary C-sections. Thus, the risk profile of patients at each hospital was taken into consideration in setting the target rate. The difference between the observed C-section rate and the target rate was used to calculate a standardized C-section performance score. These figures are shared by HIRA with healthcare facilities on an annual basis, which allows them to assess whether they are higher, lower, or within the predicted range of C-section rates. Moreover, they are able to compare their scores with nationwide averages. HIRA provides a detailed report to help facilities to pursue an evidence-based corrective course of action, if necessary. 2. Linking HIRA’s Quality Assessment Rating of Health Care Facilities to the C-section score and Public Reporting Reduction of C-section rates was one of the first three priority services that HIRA linked to quality assessments of healthcare facilities. Hospitals that have excessive rates of C-section risked having an overall poor quality rating for their facility. Quality ratings of healthcare facilities are shared with the government and the public. HIRA also publishes annually the risk-adjusted C-section scores of healthcare facilities and organizes a public information campaign around this event. This focus on C-section rates puts additional pressure on the healthcare facilities to keep C-section deliveries within the evidence-based range. This provides a very strong incentive to facilities to assess their clinical practice and reduce unnecessary C-sections. Moreover, the public becomes more aware of the maternal and child health considerations of C-sections versus natural delivery. 3. Creating Financial Incentives to reduce C-sections. In 2008, an additional strategic approach was included with the creation of the Value-Incentive Program (VIP), which linked financial incentives to the C-section quality scores of health care facilities. During the pilot period, 44 tertiary hospitals were categorized into performance grades and incentive/disincentive thresholds were determined based on the top- and lowest-ranked hospitals in the baseline year (2008). Hospitals with quality scores above the incentive threshold or below the disincentive threshold received an incentive/penalty of 1% of costs paid by the National Health Insurance Service. Incentives were applied to institutions with good grades, institutions maintaining the highest grades, and institutions that showed improvements. By the pilot end, no hospitals received penalties while 21 hospitals received incentives in 2008 and 26 hospitals in 2009 in the total amount of approximately $857,000 USD. Given the success of the VIP program, the program was expanded in 2010 to general hospitals with over 200 deliveries.

 3. How did the initiative solve the problem and improve people’s lives?
The adoption of a pay-for-performance scheme through the Value-Incentive Program is an innovative approach to further influence healthcare provider behavior to reduce the number of medically unnecessary C-sections. While the use of targets and standardized quality scores led to improvements, an evaluation of results in 2007 convinced the Central Assessment Committee that more could be done. Numerous studies have shown pay-for-performance to be an effective approach to promoting behavior change and improving quality of care in hospitals. The initiative to reduction C-sections was chosen as of one of two public health areas for the pilot VIP project in 2007 and 2008. The results of this VIP pilot showed marked improvement of hospitals of all grades (low to high) in reducing the rates of C-section. In 2007 and 2008, 42 and 43 hospitals were below the disincentive threshold while by 2009 all hospitals were above this threshold and none were penalized. The success of the VIP led the program’s further expansion in 2010 to all general hospitals with over 200 deliveries.

C. Execution and Implementation

 4. In which ways is the initiative creative and innovative?
Strategic Element 1: Consultations, Committee Formation, Strategy development The first phase of the C-section reduction initiative set the foundation for action including the convening of stakeholders, building the evidence base, and outlining a strategy. In 2000, HIRA is granted the authority to conduct quality assessments under the National Insurance Act. The Ministry of Health and Welfare establishes the Central Assessment Committee whose mission is to establish the strategy, objectives, and plan for quality assessment of which C-sections are identified as one of three priority areas. In 2001, a nationwide assessment of C-section is conducted and reveals high rates of C-sections and high variability between healthcare facilities. In 2002, a C-section reduction committee is formed of stakeholders and experts. They develop an action plan to reduce C-section rates, which is approved by Central Assessment Committee and the Ministry of Health and Welfare. The plan is published online and informational sessions are held with hospitals. HIRA is identified as the lead agency to execute implementation. Strategic Element 2: Development and application of Risk-Adjusted C-section rates, scores, and quality assessment. -In 2002, HIRA commissions the development of a statistical model to calculate risk-adjusted C-section target rates for all hospitals with over 30 deliveries. The model is developed by clinical (OB/GYN) academic experts and approved by the Central Assessment committee. -HIRA begins work to collect and review data from all target hospitals and applies the model to calculate target C-section rates. -By 2002, each hospital has a target C-section rate and C-section quality score based the difference between target and actual rates. This quality score, in turn, contributes to the overall annual quality assessment rating of hospitals. -The annual quality assessment is performed according to the annual assessment plan, which is developed at each year-end by the Central Assessment Committee and approved by Ministry of Health. Strategic Element 3: Assessment Results Reporting to Hospitals -Starting in 2002, hospitals receive an annual assessment report from HIRA that includes the C-section quality score and benchmarking data to improve their quality of service. -HIRA conducts briefing sessions with individual hospitals to discuss assessment outcome and specific areas of improvement. -Starting in 2007, HIRA initiated quality assessment support consultations that provide training sessions to healthcare facilities to improve scores. Strategic Element 4: Public Reporting and Awareness Activities -By 2002, the assessment result of individual hospitals is posted on HIRA’s website for citizens to consider when selecting health facilities. -In September 2005, HIRA begins public reporting of 179 health facilities with good C-section quality scores. - HIRA organizes public hearings, campaigns, press releases, and advertisements annually promoting awareness of C-section ratings of hospitals. - HIRA and women’s groups also organize events, advertisements, and material promoting greater awareness and information on natural births and C-sections to help women make better-informed decisions. Strategic Element 5: Value Incentive Program - Central Assessment Committee decides that more needs to be done to improve quality in hospitals. C-section reduction is selected as one of two priority quality improvement areas for a pilot Value-Initiative Program (VIP) to create financial incentives and disincentives to further reduce the rate of C-sections at tertiary hospitals. - The pilot project is initiated in 2007 with 43 tertiary hospitals whose performance was evaluated in 2008 and 2009. - In 2009, incentive payments are given to top grade and quality-improved institutions. - January 2010: Lowest grade facilities are visited by HIRA for counseling -Following success of VIP pilot, the program is expanded in 2010 to include all general hospitals with over 200 deliveries. In 2010, the Quality Assessment service and VIP project are presented at the OECD Conference of Health Ministers.

 5. Who implemented the initiative and what is the size of the population affected by this initiative?
This initiative relied heavily on the cooperation of a diverse range of stakeholders: Medical Groups The expertise of medical groups was critical to ensure that the main objectives, strategy, and overall approach were evidence-based and feasible. The Korean Medical Association, Korean Hospital Association, Korean Dental Association, Association of Korean Medicine, The Korean Pharmaceutical Association, the Korean Nurses Association are represented in the Central Assessment Committee. The Korean Medical Association and the Korean Hospital Association are also represented in the Committee for the Reduction of C-sections. Public Agencies HIRA staff and members of the Board of HIRA (including MOHW) represent approximately half of the members of the Central Assessment Committee and are represented in the Committee for C-Section reduction. As lead implementing agency, HIRA officials played a very active role in all steps of the process from design, implementation, to monitoring and evaluation. The National Health Insurance Service was represented in the Committee for C-section reduction. The Ministry of Health and Welfare was represented in the Central Assessment Committee and Committee for C-section reduction. Civil Society The Korea National Council of Consumer Organizations provided the important viewpoint of public concerns both in the Central Assessment Committee and the Committee to reduce C-sections. The Korean YMCA also was represented in the Committee for C-section reduction. The Korea Women’s Association was an important stakeholder in the C-section reduction Committee and led its own efforts to raise public awareness of C-sections as a maternal and child health issue.
 6. How was the strategy implemented and what resources were mobilized?
The C-section reduction initiative was one of the three main measures for quality ratings of healthcare facilities, thus the financial and staff resources for this initiative came primarily from the Quality Assessment department of HIRA. The Quality Assessment department has 3-4 staff dedicated to C-section assessment and 1 IT support staff. The department has an annual budget of approximately $366,000 USD (not including staff salaries). Funding towards specific activities for this initiative included: -Contract with university professors to develop statistical model for estimation of target rates, -Salary and costs associated with data collection and analysis to develop target C-section rates, and -Salary and costs outreach activities including consultations, informational sessions, assessment results reporting, and audits. In particular, the VIP project was a special initiative that incurred additional costs that was also funded by the Quality Assessment department. This included 19 staff members and a budget of $70,000 USD for workshops, public hearings, and trainings. An external company was contracted to conduct surveys of consumers and professionals at a cost of $55,000 USD. Stakeholders from other public agencies like the MOHW as well as consumer groups also contributed substantial time and resources to this initiative.

 7. Who were the stakeholders involved in the design of the initiative and in its implementation?
1.Nationwide establishment of evidence-based C-section rate targets and standardized C-section quality scores As of 2012, 642 health facilities (all facilities with 30+ deliveries annually) were assessed including 44 tertiary hospitals, 79 general hospitals, 127 mid-sized hospitals and 392 clinics. These facilities were categorized into low (C-section rate lower than predicted), ordinary (rate falls within predicted range), and high grades (rate higher than predicted). The standardization of C-section quality scores allows for fair comparison between health facilities regardless of patient profile. This information allows 1) healthcare facilities to assess whether their C-section rate is within predicted range and how it compares to national average, 2) HIRA to identify worst-performing health facilities as a target for quality improvement, 3) gives policymakers an aggregate view of nationwide trends and performance that can be used for evidence-based decision-making. 2.Quality Assessment ratings based on C-section scores Quality ratings of healthcare institutions are a tremendous incentive to change provider behavior and improve efficiency. Reduced C-section rates were identified as one of the top indicators of quality in health services since the quality assessment function was granted to HIRA. It has been used in quality ratings every year since 2001-2013 – over a decade. 3.Public Reporting of Quality Assessments and C-section rates. Public reporting has been a major incentive to behavior change for healthcare facilities. Reporting on HIRA’s website along with press releases and public campaigns is an effective tool to induce behavior change without imposing direct rules or regulation. A 2005 Health Policy Monitor report assessed that public reporting of C-section rates in South Korea would have a strong impact on the quality of health care services and cost-efficiency. 4.Application of Financial Incentives and Disincentives through the Value-Incentive Program. The VIP program was created as an additional strategy to influence provider behavior to reduce C-section rates in hospitals. Health facilities that meet or are below target rates of C-sections as well as those showing marked quality improvement receive financial incentives; worst-performing institutions receive a penalty and are targeted for quality improvement consultations by HIRA. The pilot VIP program demonstrated success in further reducing C-section rates to the participating facilities. This led to full adoption of the program in 2010 and further expansion to general hospitals in 2011. In 2012, approximately $679,500 USD was paid in incentives to 41 institutions, while 4 institutions were penalized in the amount of $21,0000.

 8. What were the most successful outputs and why was the initiative effective?
The initiative to reduce C-sections has robust monitoring and evaluation mechanisms primarily through the role of the Central Assessment Committee. During the initial stages, the Central Assessment Committee was responsible for reviewing and approving the strategy and the action plan proposed by the C-section reduction committee and HIRA. Through monthly meetings, the Central Assessment Committee monitored the development of the statistical model, the information sessions that were held for providers and the public regarding the initiative, and the reporting of the first results to healthcare facilities. Within HIRA, the leading department would identify major activities, targets for all hospitals, the indicators to be used and then send to committee for review. Final approval was given by the Ministry of Health and Welfare. As the initiative is now an integral part of the quality assessment function of HIRA, the Central Assessment Committee reviews on an annual basis each step of the quality assessment procedure including the final results and subsequent actions (e.g. consultations to health facilities). After 5 years of using standardized C-section quality scores, a first comprehensive evaluation report was published in 2007 detailing the trends of C-section rates nationwide and the impact of the initiative on reducing C-section rates. It was from the results of this report that the Central Assessment Committee and policymakers pursued the Value-Incentive Program to further induce reductions in C-section rates nationwide. An evaluation of the Value Incentive Program, which showed initial successes led to the decision to further expand the program in 2010.

 9. What were the main obstacles encountered and how were they overcome?
The medical establishment recognized that there was a nationwide problem of high rates of medically unnecessary C-sections, but were concerned that there was a significant “gray area” where clinical judgment could differ in deciding whether to perform a C-section. Many physicians felt that in cases of even slight risk to mother or baby, a C-section should be performed. In particular, they were concerned about questions of medical malpractice if harm came to mother or newborn because of a decision to pursue natural delivery instead of a C-section. As these concerns were significant not only in the case of C-sections, but in other medical issues, HIRA made the recommendation for the formation of an organization to deal with matters of medical malpractice. By a mandate from the National Assembly, in 2012, the Medical Dispute Mediation and Arbitration Agency was established for fast mediation, fast arbitration, and credible dispute resolution. Both patients and providers can solicit the intervention of the agency to help resolve medical disputes. Another concern of healthcare providers and facilities was the lower payments for natural births compared to C-sections. C -sections generate higher revenues for health facilities because they are major surgeries requiring prolonged in-patient stays and are quicker to perform (i.e. beds are freed so more operations can be performed). HIRA acknowledged the financial considerations of health providers and further incentivized natural deliveries by increasing the insurance reimbursement for doctor’s service fees for natural deliveries compared to C-sections.

D. Impact and Sustainability

 10. What were the key benefits resulting from this initiative?
1.Promoting health of women through reduction of C-section rates The initiative to reduce C-sections is first and foremost an initiative to protect and promote the health and well-being of the mother. Although there are mothers who express preference for C-section deliveries for convenience and other reasons, a 2004 study in South Korea indicated that most mothers would prefer to have natural delivery. Clinically, medically unnecessary C-sections pose greater risk to mothers and newborns than natural deliveries. This initiative resulted in a significant improvement of C-section quality scores. This means that more healthcare facilities were meeting or were below their risk-adjusted target rates for C-sections and thus minimizing the occurrences of medically unnecessary C-sections. The variability of rates of C-sections across healthcare facilities also declined suggesting that providers were influenced both by the risk-adjusted target and data on how their facility compared to others. With the introduction of the VIP program, there has been even greater improvement in C-section quality scores. During the assessment period of 2007-2010, the standard score of the C-section rate improved in all hospital grades (high, ordinary, and low C-section rates). 2.Influencing provider behavior to assess and change C-section practice In South Korea, as in many countries, the high rates of C-sections are largely driven by healthcare providers. Through a multipronged approach, the C-section initiative has significantly influenced provider behavior and decision-making. Importantly, HIRA provided healthcare facilities a clinically and scientific-based method to assess whether their rates of C-sections were higher than they should be. Further pressure through quality ratings and public reporting also induced changes in provider behavior. As healthcare facilities begin to reverse the trend of rising C-section rates, it will further create an institutional culture where C-section deliveries are considered only when necessary. 3.Influencing societal behavior through increased public awareness and improved decision-making In the early 2000s, the public and media were alarmed at the high rates of C-sections in the country compared to the global and OECD average. This helped to spur national action to create the C-section reduction initiative. Since then, annual reporting of healthcare quality assessments and specifically C-section ratings maintains the visibility of this public health issue. This annual public reporting is further reinforced by HIRA and consumer groups, which organize public campaigns and advertisements around the event. This not only puts pressure on healthcare facilities, but also raises awareness amongst the public of why C-section deliveries should be conducted only when medically necessary. Moreover, educational campaigns by consumer and women groups have been critical to raising public awareness. 4.Government can make better evidence-based policy Through the annual collection, aggregation, and assessment of C-section deliveries in healthcare facilities around the country, major stakeholders (e.g. HIRA, MOHW, consumer groups, women’s groups, health facilities) can identify patterns to detect problems and successes that will inform further strategies to reduce C-sections. Importantly, public policymakers have a comprehensive evidence-base from which they can make major decisions to change policy or undertake new initiatives. In fact, it is the evaluation of the C-section rate data since the beginning of the initiative that led policymakers to introduce the VIP program to further influence provider behavior to reduce C-sections. The implementation and evaluation of the VIP program, in turn, will also generate evidence to further refine the strategy to reduce C-sections. The success of this program may also induce the government to consider other health issues where the VIP approach can be used to change provider behavior through incentives.

 11. Did the initiative improve integrity and/or accountability in public service? (If applicable)
Sustainability: The initiative to reduce C-sections is not a one-time initiative but was designed as an integral part of HIRA’s quality assessment services since its inception. Reduction of C-sections was one of the first indicators measured to assess quality; since then the quality assessment service has expanded to include 35 items. Although there has been marked improvement in C-section scores across the nation, there is still much progress to be made, as the rates of C-section in healthcare facilities in South Korea are still much higher than the global average and the WHO recommendation. As such, it is unlikely that this initiative would lose political or public support. Indeed, reduction of C-sections is an important public health issue that has high visibility. It has garnered significant support from the general public, consumer and women’s groups as well as medical associations. HIRA in conjunction with major stakeholders will continue to undertake active efforts to make further progress in this area. Transferability: The multipronged strategy of incentives to reduce C-sections has been particularly effective and one that can be replicated in many countries with high rates of medically unnecessary C-sections. Other countries, such as the United States, currently include C-section rates into their quality assessments of health facilities. Countries with persistently high rates of medically unnecessary C-sections should also consider the additional strategies of public reporting and pay-for-performance models such as the VIP. Health Policy Monitor reports (2005 and 2010) have deemed both the “public reporting” of C-sections and the Value Incentive Program to be highly effective and highly transferable as a strategy to induce behavior change in healthcare providers. In 2010, the MOHW presented the success of Value Incentive Program in inducing declines in C-section rates and improving quality of health facilities at the OECD conference of Health Ministers. Moreover, in 2014, the United States, which also has a high rate (approximately 31%) of C-sections and high variability among states, is now adopting several of the same strategies. The Joint Commission (JCAHO), which accredits hospitals, has mandated that all hospitals report on a series of C-section outcome measures. Although there are no set targets, the hospitals will receive reports comparing their rates with the national average. The Commission stated that mandatory reporting was necessary, as “the removal of any pressure to not perform a cesarean birth has led to a skyrocketing of hospital, state and national cesarean section rates.”

 12. Were special measures put in place to ensure that the initiative benefits women and girls and improves the situation of the poorest and most vulnerable? (If applicable)
The initiative to reduce C-section was the result of a strategic evidence-based effort by the government and medical community to tackle a major public health problem. One key lesson was that having strong scientific evidence to guide our activities was fundamental for the credibility of our approach and to inform decisions throughout implementation. The combined wisdom of experts and rigorous data analysis were essential to develop a solution that was locally-tailored to South Korea and appropriately took into account each individual healthcare facility’s situation. During the course of implementation, we also realized that the establishment of targets and public reporting was not enough. This led to two important developments: 1) The establishment of financial incentives/disincentives through the Value-Incentive Program in 2007, and 2) The establishment of a Quality Support Program also in 2007. The Quality Support Program utilizes the outcomes of quality assessments to conduct training courses, consultations, share best practices and provide technical assistance to poor-performing healthcare facilities. It provides hospitals guidance, and not just a directive, to improve their rates of C-sections. This also fosters a better and more collaborative relationship between HIRA and healthcare providers to work together towards understanding and solving the problem of high rates of medically unnecessary C-sections. It has also helped HIRA to better understand and address the obstacles hospitals face in trying to bring down the rates of C-sections. Finally, one of the most important lessons learned was that HIRA and the medical community should further engage in dialogue with women and their families regarding their health and reproductive choices. These discussions include promoting education and awareness about maternal and child health issues; providing greater information to a woman about her delivery options and her desired birth experience; understanding the factors that influence a woman’s decision-making (e.g. her family, time, resources, personal image); and assessing the barriers and facilitators that allow her to make the best decision with her healthcare provider. In the future, we would recommend further cooperation with women and consumer groups to have a comprehensive approach to promoting sensitivity, awareness and information to women and their families to reduce medically unnecessary C-sections.

Contact Information

Institution Name:   Health Insurance Review & Assessment
Institution Type:   Public Agency  
Contact Person:   Jongsu Ryu
Title:   Senior Adviser for International Cooperation  
Telephone/ Fax:   82-2-2182-2428/82-2-6710-5849
Institution's / Project's Website:  
E-mail:   johnryu@hiramail.net  
Address:   22 Banpo-Daero Seocho-Gu
Postal Code:   137-927
City:   Seoul
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