Hanging over my grandparents’ kitchen table was a framed, hand-written receipt from a Brooklyn hospital. It was made out to my great-grandmother and namesake, Martha Ravich, and dated October 1920. It told me two important things: She was in the hospital for almost two weeks after having my grandfather, and the entire stay cost her $2.
Needless to say, my experiences with maternity care some 85 years later were much shorter and much more expensive. According to recently released research, my experience was not outside the norm; the cost of vaginal delivery in the United States rose 49 percent and the price of a c-section 41 percent between 2004 and 2010 alone. Indeed, maternity care in the United States is far more expensive than anywhere else in the developed world, and it’s not because we’re getting more services than women elsewhere. As New York Times writer Elisabeth Rosenthal details in a feature published this weekend, which discusses the research conducted by conducted by Truven Health Analytics for the Times, it’s all about what we expect and how we pay for it.
In most developed countries, maternity care comes as a package that costs somewhere around $4,000 all in; women pay very little, if any, of that. Here, we are charged (sometimes twice) for each service we get, and much of it comes out of women’s pockets.
Rosenthal’s article follows one uninsured woman’s prenatal journey and points out how she was billed $935 by the hospital for an ultrasound that she had already paid a radiologist $256 to read. Another couple mentioned in the article was quoted $265 for a fetal heart scan but then charged $2,775. (Both were able to negotiate their ultimate payments down.) Experts believe that this fee-per-service pricing system encourages health-care providers to offer more, whether it’s additional ultrasounds or more blood tests, and over the years pregnant women have come to expect the reassurance that can come with the extra poking and prodding.
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Adding it all up, hospitals charge about $30,000 for a vaginal delivery and newborn care and about $50,000 for a c-section. Insurance companies usually negotiate down and pay between $18,000 and $28,000. Medicaid pays a lot less—about $9,000 for a vaginal delivery and $13,500 for a c-section. Women are then charged separately by their obstetricians (OBs), whom they pay either by the visit/service or on a flat-fee basis. According to the American College of Obstetricians and Gynecologists (ACOG), this fee ranges from $4,000 in Denver to $8,000 in Manhattan.
Though much of this is paid by insurance, even women with coverage tend to have to pay a few thousand dollars out of pocket (on average, $3,400) to cover co-pays, out-of-network service, or tests for which the insurer refuses to pay. Many women, however, don’t have insurance, and some who do don’t have maternity coverage. In fact, 62 percent of women who have private (not employer-provided) insurance are not covered for pregnancy and birth. This will change in 2014 under the Affordable Care Act, which requires all policies to cover maternity care, but what is included in that maternity package—or, more importantly, what isn’t—is not yet clear.
Women are left wondering not just if an amniocentesis is necessary but worrying about how much it will cost. Renee Martin, one of the women followed in the Times article, pointed to her three-hour glucose test (the worst part of both of my pregnancies). When she threw up all over the floor of the testing facility, her first thought was not just that she would have to come back another day and attempt to choke down the extra-sugary drink but that she’d have to pay twice. Martin is a graduate student, and her husband works for a small music licensing business that does not offer health insurance. They purchased insurance, but not the $800 per month pregnancy rider, which they could not afford. When she first got pregnant, Martin called the hospital and asked for an estimate for prenatal care and delivery. She was told it would vary between $4,500 and $45,000. Following the delivery of a healthy baby, they are now facing approximately $33,800 in bills. The hospital has promised a 30 percent discount on all fees.
To get a handle on the increasing costs and make their services more appealing than their competitors, some hospitals are trying out a flat-fee system. Dr. Dean Coonrod, the chief of obstetrics and gynecology at Maricopa Hospital in Phoenix, told the New York Times that they went to this system two years ago for a few reasons. First, he pointed out that it seemed cruel or at least wrong to ask a woman in labor if she wanted a $1,000 epidural. Second, though, he wanted to engender good will with patients who have a choice both in where they have babies and where they go for health care in the future. As a public hospital whose doctors are all on salary, Maricopa was able to set a price of $3,850 for a vaginal delivery and $5,600 for a c-section, which was based on the average payout from insurance companies. The hospital breaks even on maternity care. Setting a price would be more difficult for other hospitals, especially when private doctors are involved.
Rosenthal explains that the reliance on OBs is actually one of the reasons that maternity care in the United States is so expensive. In most other developed countries, maternity care is left primarily to midwives who charge must less; OBs are only brought in when there are complications. In the United State, where the average vaginal delivery cost $9,775 in 2012, only 8 percent of births are attended by midwives, compared to 68 percent in Britain (where the average vaginal delivery cost $2,641) and 45 percent in the Netherlands (where the average vaginal delivery cost $2,669).
One of the reasons OBs charge so much, however, is because they pay hundreds of thousands of dollars in malpractice insurance each year. In fact, we seem to be stuck in a “more is more” kind of cycle. OBs provide more tests during pregnancy and more intervention during delivery because of threat of malpractice. Women expect more tests and intervention. And each of these adds a line to the bill.
I never expected to pay only $2 like Nana Martha had, but I do remember finding maternity services to be an odd combination of health care and commerce. I first dipped my toe into it a year or so before I even became pregnant when my OB suggested I have genetic testing. As the descendants of Eastern European Jews, there are a slew of genetic diseases/disorders that I could be carrying (two of my aunts carry the Tay Sach’s gene, for example) so I wanted to test for all of them. I agreed with the genetic counselor that I should even have the ones that were not covered by insurance, and I never asked her how much they might cost.
When I started going to my OB, again years before I was pregnant, she was on my insurance plan and visits cost a mere $10 co-pay. By the time I got pregnant, however, she had stopped taking all insurance because the reimbursement rates were not keeping up with the increasing rates of her practice—especially her insurance. She charged a flat fee of $7,500 for the entire pregnancy and delivery with a $500 surcharge if I had a c-section. Luckily, because I was a loyal patient, her staff billed my insurance company first (it covered 80 percent), and then I paid them the rest (about $1,500). Otherwise I would have had to pay thousands first and wait for reimbursement.
About a month before I was due to give birth, I got a bill from Mt. Sinai in which the hospital anticipated my delivery would cost $11,000 and said my insurance company would pay none of it. I was surprised to be getting billed before I even walked in the door and panicked at the idea that none of it would be covered by insurance. The first person I got on the phone explained quite clearly that since I had chosen a doctor who was out of network, everything associated with my pregnancy would be out of network. I argued with her—the doctor was out of network, but the hospital was not. If I showed up there for anything else it would be covered. She agreed that it didn’t make sense, but she didn’t back down. I asked to speak to her supervisor. She said someone would call me back. No one did. I called a few days later and started from scratch. He took one look at the bill and agreed that it must be an error. A few days later a new bill arrived in the mail, which put my estimated out-of-pocket expenses at $0.
That wasn’t exactly the case once I gave birth, however. Mt. Sinai only had a small number of private rooms; they were given out on a first-come, first-serve basis, were ridiculously expensive, and were not covered by insurance. We ended up paying $475 for a room (it was an extra $45 for a park view).
My second time around, I was in the suburbs and I noticed that there was a real competition here between the two hospitals in the area which were both vying for maternity patients. One was considered swankier and was rumored not just to have all private rooms but to offer a lobster and champagne dinner the night after you gave birth. I admit I wanted to go there, but I ended up at the other, because that’s where the OB I chose delivered.
All of these choices that I made were available to me because I had employer-provided health insurance and because I have resources. I was able to cover the extra genetic tests and the room that looked out over Central Park without having to worry that I wouldn’t then have enough money to feed the babies that I was about to take home. I am well aware that this is not the case for many women and that we have to change the system—event the parts of it that I liked, such as ultrasounds at nearly every appointment.
The Affordable Care Act should help in some ways, because it will mean that people like Renee Martin will have some maternity coverage and won’t have to pay the equivalent of college tuition before the baby is even three-months old. This, however, is not enough.
Rosenthal’s article is a stark portrayal of a system that is in desperate need of a major overhaul. Women need to rethink what they expect, hospitals and doctors need to rethink how they bill, insurance companies and Medicaid need to rethink how and when they reimburse, and the legal system needs to rethink malpractice cases. Until we do that, the United States will continue to have the unique distinction of having the most expensive maternity care and one of the highest maternal and infant death rates in the developed world.