Childbirth Anesthesia Refusals Spur Probe

Ozzie Chavez knew something about childbirth when she came to Northridge Hospital Medical Center to deliver her fifth baby last summer.

She staggered into the birthing room, contractions coming hard and fast. Her husband, Fred, at her side, she moved into the bed, bearing the increasing pain until it was too much.

It was time, she told her doctor, to begin the spinal-based form of anesthesia known as an epidural block.

“Then the nurse came in and said, ‘That’s $400,’ ” Chavez said.

“I said sure, no problem,” Chavez said. “And then she said, ‘No, you don’t understand. I need the $400 now.’ ”

Her asthma kicking up, hardly able to breathe, Chavez asked her husband to write a check. But anesthesiologist Lori Berke, Chavez alleged in a lawsuit filed this year, refused to take it.

She also refused their credit cards.

“It was a nightmare,” Chavez said. “I felt like an animal. I was on this table and I couldn’t get off.”

Chavez, who was on Medi-Cal at the time, never got her epidural. The birth was all the more painful, Chavez said, because the child, Amy, got stuck, and the obstetrician had to reach into the birth canal and pull her out.

In court papers obtained by The Times, anesthesiologist Berke admitted to refusing to provide the epidural to six women prior to Chavez who also could not pay. She did not specify when the other incidents occurred. Another mother, Mary Pendleton, told The Times that she was forced to pay cash for an epidural at Northridge Hospital.

The attorney for the anesthesiologist group at Northridge Hospital, Barry Silbermann, confirmed that doctors there had refused to provide epidurals for Medi-Cal patients who could not pay. But the hospital says that the practice has recently changed.

Berke’s attorney, Larry Wong, said his client did nothing improper regarding the Chavez case. He would not comment on whether or not she asked for cash from Chavez or other patients, or on the hospital’s policies.

In response to Times inquiries, state and county officials said they have begun investigating the practice of withholding epidurals from women who cannot pay for them, whether at Northridge Hospital or other institutions. Such a practice, they said, appears to violate state and federal law. Charging a Medi-Cal patient for a benefit the agency covers is a violation of state law, said Stan Rosenstein, assistant deputy director of medical care services for the California Department of Health Services.

“To withhold an epidural from a woman in active labor is barbaric,” said Phil Weintraub, spokesman for the American Society of Anesthesiologists. “How can you deny an effective form of pain management?”

Disputes Over Reimbursement Rates

Although there are no statistics documenting the prevalence of this practice, experts say that stories like the ordeal described by Chavez are beginning to turn up at hospitals throughout the nation, as health maintenance organizations and public assistance programs like Medi-Cal attempt to keep reimbursement rates low for obstetric anesthesia.

“It’s more than illegal--it’s unethical,” said Dr. David Birnbach, president of the Society for Obstetric Anesthesiology and Perinatology and a renowned researcher on the efficacy of epidural blocks. “It is morally reprehensible to have two standards of care--a pristine one for women who can pay and a substandard one for women who cannot pay.”

The Chavez case raises questions regarding medical ethics and the quality of care, as well as the little-scrutinized practices of anesthesiologists, doctors who tend to work as free agents and handle their own billing.

Moreover, it is a frightening example of how relations between doctors and patients can turn ugly as private hospitals--lured by federal and state incentives to accept more Medi-Cal mothers as patients--attempt to negotiate the hodgepodge of regulations and fees that make up Medi-Cal.

Northridge Hospital President Roger Seaver would not comment specifically on Chavez’s allegations, which the hospital has denied in legal papers. But in an interview he, too, confirmed that until recently the hospital’s anesthesiologists demanded separate payment from Medi-Cal patients who wanted epidurals. He did not specify when the practice was discontinued.

Seaver did say that the Medi-Cal payment for the procedure is too low. He blamed “over-regulation” for tempting the anesthesiologists to demand money.

“It is somewhat understandable if it happened,” Seaver said. “When you have a regulated system that uneconomically addresses those types of issues, you can’t expect behavior to be perfect across the system.”

There is no question that Medi-Cal’s payments for epidurals are lower than private insurance. The agency reimburses doctors about $57 for the initial insertion of the catheter, and about $14 for every 15 minutes spent with the patient after that. By comparison, private insurers pay from $175 to $300 for the initial procedure, and from $35 to $60 for every 15 minutes spent after that with a patient.

At the root of the problem is a simmering debate among anesthesiologists about the profitability and time constraints involved in providing pain relief to maternity patients, said Dr. Jerry Bissell, immediate past president of the Society for Obstetric Anesthesiology and Perinatology. More and more, he said, there is a division among general anesthesiologists, who view labor and delivery as low-paying and “a hassle,” and those specialists in the field who devote themselves to the growing areas of pain management and obstetrics.

“It doesn’t pay as well as other forms of anesthesia,” said Bissell, who practices in Wichita, Kan., and has devoted his practice to obstetrical work. “It takes a lot of hours.”

Some anesthesiologists are so opposed to working in delivery rooms that job advertisements often are accompanied by highlighted portions reading “No O.B.,” Bissell said.

Bissell said that the reluctance to perform obstetric anesthesia is most prevalent in small hospitals where there are not enough obstetrical patients to warrant a full-time team of anesthesiologists devoted to pain management during birth.

“We hear similar stories from all over the country,” Bissell said, “that women don’t have access to epidural block because they haven’t got their deposit in on time.”

Debate Among Anesthesiologists

The issue is coming to a head in California, where an increasing percentage of the caseload at private hospitals consists of Medi-Cal recipients, who were lured there after the public health agency agreed to pay new, higher rates to obstetricians--but not to anesthesiologists.

Left off the money train that has prompted hospitals and obstetricians to compete for Medi-Cal patients, some anesthesiologists have become so bitter that at a recent meeting of the California Society of Anesthesiologists, doctors floated a resolution declaring that epidural blocks should be deemed “not medically necessary” and therefore payable upfront by patients who wish them.

The resolution failed, but not before igniting a debate in which some doctors suggested that anesthesiologists should refuse to accept Medi-Cal recipients as patients--even if that means leaving them in pain on the delivery table.

Medi-Cal’s reimbursement for epidurals, said Silbermann, the attorney for the anesthesiologist group at Northridge, “is so nominal, it’s nothing.” As a result, he said, the anesthesiologists there, whose members are on contract to the hospital but are not employees, decided that for the purpose of epidurals, Medi-Cal would not be accepted. Patients, therefore, had to pay for the procedure or forgo it, he said.

“It is not unethical to be selective” about which patients to accept, Silbermann said.

He said the group’s members considered obstetrical epidurals to be elective procedures except in emergency situations. During emergencies, he said, the procedure was provided. The practice was discontinued, he said, not because of legal or ethical considerations, but because “it isn’t worth this kind of hassle.”

The notion that an epidural block is elective, and therefore not medically necessary, goes against the guidelines set up by the American College of Obstetrics and Gynecology and the American Society of Anesthesiologists.

Those guidelines, which are followed by Medi-Cal, according to officials there, recommend that epidurals be provided on demand.

“Twenty years ago, an epidural for labor and delivery was a little unusual, but over the years it’s demonstrated to most people’s satisfaction that it . . . is good for both the mother and the child,” said Dr. Julian Gold, co-chair of anesthesiology at Cedars-Sinai Medical Center in Los Angeles. “In the last years, however, I think there has been some concern over the use of epidurals on the part of lots of people--mostly because it costs more.”

‘You Can’t Have Two Standards of Care’

Epidurals provide tangible medical benefits to mothers and babies, said Bissell. During the procedure, a catheter is inserted into the mother’s back, and her lower body is numbed just enough to alleviate pain, but not enough to prevent her from pushing the baby out. She remains awake, and the baby is not born with narcotics in its system, as it might be with other forms of pain relief.

Epidurals can prevent oxygen deprivation to the baby that might occur if the mother is breathing heavily because of pain, Bissell said. They also can prevent acid accumulation in the baby’s blood, and can keep a mother from becoming so exhausted that she can’t push the baby out.

Refusing to provide one because the patient can’t pay, Bissell said, ought to be punished by sanctions against a doctor’s license, something the Medical Board of California said is too preliminary to assess in this case.

“That’s not about anesthesia,” Bissell said. “It’s about the lack of ethics of a physician. That’s no way you treat a patient.”

At Cedars-Sinai, said Gold, as at several other hospitals polled by The Times--including White Memorial and Tarzana Regional Medical Center--the policy is to provide epidurals to patients and doctors who request them, without regard for the patient’s ability to pay.

“You can’t have two standards of care,” said Dr. Patricia Dailey, a Burlingame anesthesiologist who serves on the board of the Society for Obstetric Anesthesiology and Perinatology. “If a woman is in pain and is requesting pain relief, it should be provided.”

Silbermann, the attorney for the hospital’s anesthesiology group, said the additional fee charged Medi-Cal patients--$400--was steeply discounted when compared to the going rate for such services in the private sector.

He claimed that Chavez was being prepped for an epidural when her baby was suddenly born, rendering the procedure irrelevant.

But according to handwritten notes filed by nurse Susan Hatfield and obtained by The Times, Chavez’s obstetrician ordered the epidural at 10 p.m. on July 21 of last year--five hours before Amy was born.

That notation is followed by this one: “Pt. unable to pay cash.”

The baby was born just before 3 a.m. the next day, according to the records. All during that time, Chavez said, she was screaming for the epidural. Unable to provide it, her obstetrician prescribed a narcotic called Nubain, which she said did not relieve all of her pain.

Her mother wired cash from England, Chavez said, but Berke would not accept the confirmation number from Western Union as proof that the money was on the way.

The money did eventually arrive, but then it was too late, she said. It was time to push.

After it was all over, Chavez said, one of the nurses apologized.

“She said it was a policy they were trying to change,” Chavez said.

Based on The Times’ inquiry, Rosenstein said, Medi-Cal is investigating the practices at Northridge Medical Center, and is also attempting to determine if the same thing is happening elsewhere in the state. So far, he said, Chavez’s complaint is the first of its kind against a California hospital.

He called the allegations “very disturbing.”

“As long as it’s been an existing form of anesthesia, we’ve covered it,” said Rosenstein. “It’s part of the program and it’s available to beneficiaries when they want it. There’s no need to show medical necessity and there’s no prior authorization.”

Possible Violations of State, Federal Law

The Los Angeles County Department of Health Services, which oversees licensing of local hospitals for the state, has also begun an investigation, said health facilities manager Jean Olander.

If Chavez’s allegations are true, Northridge Hospital might have been in violation of federal and state law governing the provision of medical services to patients in emergencies, which include labor, Olander said.

“They ask for it [the epidural] and they should get it,” Olander said. “They shouldn’t have to go through this. . . . This is terrible.”

Dailey said the forum for addressing the disparity between Medi-Cal and private insurance reimbursements for the procedure is the Legislature, not the hospital.

“You have to start working to improve reimbursement at some other venue,” Dailey said. “I don’t think you can do it at the bedside.”