Wednesday, July 3, 2013

What pregnancy care costs, and related writings

Elisabeth Rosenthal's New York Times story on the staggering costs of maternity care in the U.S. featured a short interview with my wife, a family physician who last year gave birth to our third child with a nurse-midwife 12 minutes after arriving at the hospital. She had no postpartum complications and stayed only one night, but nonetheless received a bill of more than $6000 (we received a separate bill for newborn care). Here's what she had to say about the disconnect between this price and her delivery experience:

“Most insurance companies wouldn’t blink at my bill, but it was absurd — it was the least medical delivery in history,” said Dr. Duane, who is taking a break from practice to stay home with her children. “There were no meds. I had no anesthesia. He was never in the nursery. I even brought my own heating pad. I tried to get an explanation, but there were items like ‘maternity supplies.’ What was that? A diaper?”

Pregnancy care costs illustrate 4 reasons that Americans spend far more on health care than residents of any other country in the world: prices for services are too high; you can't find out the prices before you buy the services; the payment model incentivizes providing services that are unnecessary, nonbeneficial, or potentially harmful (e.g., extra fetal ultrasound scans, electronic fetal monitoring during labor); patients with "good insurance" (like the type that paid for the births of our two older children) are insulated from the true cost of their care. (The hospital bill for our second child's birth was more than $8500, but since we only paid $100 out-of-pocket, it was hard to get too worked up about that.)

The solutions to these problems are not simple. Unfortunately, health reform only requires that insurers provide some maternity coverage but doesn't contain skyrocketing prices or discourage doctors from doing things to pregnant women that aren't medically necessary. But how do you know what's medically necessary? Is attempting a vaginal birth after a C-section safe? How about a planned home birth? Here are answers to these and other women's health issues I've blogged about in the past:

1) The decline of VBAC: hearing hoofbeats, thinking zebras

A trial of vaginal birth after Cesarean (VBAC) is successful more than 75 percent of the time. It's a real shame that women in the U.S. are discouraged from attempting them more often.

2) VBAC and home birth: evaluating the evidence

The available evidence indicates that planned home birth is no riskier for babies, compared to planned hospital birth, than is attempting VBAC compared to choosing a repeat Cesarean delivery.

Classifying contraceptives as preventive services and treating pregnant women as if they have fatal diseases is not a rational way to go about improving women's and maternal health outcomes.

4) The next all-natural blockbuster drug

Breastfeeding 90% of U.S. children for the first 6 months of life could potentially save the lives of more than 900 infants and $13 billion per year.

Most women overestimate both their personal risk of developing breast cancer and the potential benefits of screening, driven in part by well-intentioned advocacy campaigns to raise "cancer awareness."

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