Physicians and hospitals usually earn more money when they perform a cesarean, though it often requires less time. The average insurance payment to a hospital for a C-section is about $17,000. For vaginal delivery, it is just over $11,000. Studies have found that when insurers make the payments equal, surgeries decline… If C-sections were medically warranted, then the procedures would happen evenly throughout the day. But the researchers found that C-sections clustered in the early evening. Doctors, it seemed, were avoiding late-night deliveries.
ChatGPT says: You are right to see C-sections as part of a broader pattern. Medicine has several pressure points where money, fear, habit, and convenience quietly push doctors toward doing more than is needed.
Spinal surgery is a major example. Many patients with chronic low back pain get fusions or disc replacements that offer little long-term benefit over physical therapy and time. Reimbursement is high. The procedures are decisive and fast. Conservative care is slow and uncertain.
Knee and shoulder arthroscopy for degenerative joint disease is another. For middle-aged and older patients with arthritis, multiple studies show outcomes no better than physical therapy. Yet these surgeries remain common because they are familiar, billable, and feel like action.
Cardiac stents in stable patients fit the same pattern. When there is no acute heart attack, stents often do not reduce mortality or future heart events compared to medication and lifestyle change. They persist because cardiology culture rewards intervention.
Hysterectomies for benign conditions are still overused. Fibroids and heavy bleeding can often be managed medically or with less invasive procedures. Surgery is sometimes chosen because it offers a clean endpoint and predictable scheduling.
Prostate surgery in low-risk cancer cases also raises concern. Many men could safely choose active surveillance. Instead they undergo operations that risk incontinence and impotence with no survival benefit.
Thyroid surgery for small nodules that are unlikely to ever cause harm follows a similar logic. Once the pathway to surgery opens, it becomes easier to proceed than to watch and wait.
Across all these areas the same forces appear. Fee-for-service rewards activity. Defensive medicine punishes restraint. Time pressure favors quick resolution over careful delay. Cultural beliefs equate intervention with competence. Patients expect something dramatic to be done.
When systems shift incentives toward patience and outcomes, rates drop. That tells you a lot. Much unnecessary surgery is not about bad doctors. It is about a structure that quietly trains good doctors to behave badly.
The forward path is clear. Equalize payment for conservative and surgical care. Make second opinions routine for elective procedures. Measure success by recovery, not by volume. Normalize waiting when waiting is safe.
The encouraging part is that this is fixable. Rochester General showed it with C-sections. What changed was not biology. It was courage and incentives.
