On June 30th, Elisabeth Rosenthal published an article in the New York Times called, “American Way of Birth, Costliest in the World.” In this article Ms. Rosenthal makes some astute observations that I believe are pertinent to the Morning Center’s vision to reform charitable maternity care.
But before we get into how we can reform charitable maternity care, it is important to understand what is happening in the world of fee-for-service maternity care, since that care often dictates the general protocols for providing and even more importantly charging for charitable maternity care.
The overarching problem that is identified in this article is that the actual value of maternity care in the U.S. has been lost in the endless number of ways that medical providers charge mothers/families for things as basic as standard deliveries.
Referring to a particular encounter with one mother who recently had to navigate the maternity care maze in the U.S., Ms. Rosenthal writes:
When she became pregnant, Ms. Martin called her local hospital inquiring about the price of maternity care; the finance office at first said it did not know, and then gave her a range of $4,000 to $45,000. “It was unreal,” Ms. Martin said. “I was like, How could you not know this? You’re a hospital.”
Not knowing whether the pregnancy would fall at the $4,000 or $45,000 end of the range the hospital cited, the couple had a hard time budgeting their finances or imagining their future. The hospital promised a 30 percent discount on its final bill. “I’m trying not to be stressed, but it’s really stressful,” Ms. Martin said as her due date approached.
How and why does the fee-for-service maternity care marketplace tolerate this? Why does the charitable maternity care marketplace tolerate this? Referencing another mother’s experience later on in the article we gain some insight into how this can be possible.
Though she delivered Ellis with a midwife 12 minutes after arriving at the hospital and was home the next day, the hospital bill alone was more than $6,000, and her insurance co-payment was about $1,500. Her first two pregnancies, both more than five years ago, were fully covered by federal government insurance because her husband worked for the Agency for Health Care Research and Quality.
“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?”
Notice that unlike the first example with Ms. Martin, someone else is paying for the maternity care bill – which isn’t necessarily bad in and of itself, but is it a good system? Well, considering the circumstances laid out before us in this example, it seems like there is plenty of room to question not only the efficiency of such an arrangement but how that arrangement could become commonplace. And if you think that these kinds of incidents only occur with paying “customers” and that “there must be a better system when state charity programs administer these kinds of services in bulk for “charitable” hospital prices,” guess again!
Ms. Rosenthal includes a graph in her article comparing how much is spent on an average childbirth in several of the top developed countries in the world.
Notice how much an average childbirth costs in the U.S. Now compare that with this paragraph on how much government aid programs like Medicaid pay on average for deliveries for poor women:
If the high costs of maternity care are not reined in, it could break the bank for many states, which bear the brunt of Medicaid payouts. Medicaid, the federal-state government health insurance program for the poor, pays for more than 40 percent of all births nationally, including more than half of those in Louisiana and Texas. But even Medicaid, whose payments are regarded as so low that many doctors refuse to take patients covered under the program, paid an average of $9,131 for vaginal births and $13,590 for Caesarean deliveries in 2011.
The difference between what an average individual who can either afford to purchase insurance that pays for maternity care or simply pays for maternity care out of pocket, versus what it costs government to pay for charity care is marginal to nonexistent.
Now, it would be very easy at this point for a truly charitable ministry that is funded only by private donations to point fingers at nonprofit laws that protect supposedly charitable hospitals and say something like “hey, the hospitals are basically getting the same amount of money from paying and charity patients alike, and they shouldn’t get preferential tax treatment,” etc. But I think we would be missing the bigger picture.
Charity or not, services and associated products to provide said services DO cost something. And it takes, or at least it should take, the same amount of time, resources, and talents to consistently deliver that ministry or service to the extent that the need is fulfilled. It is a misnomer to think that charity care ought to somehow magically cost less or nothing at all simply because it is done in the name of charity. It costs somebody something!
What we have all forgotten here is the meaning behind one little word that has been battered like a piñata all over the health policy arena by people on all sides. That word is “care”. When we use this word it is often times used in the context of “we have to care for this poor person, who has a medical need” or “we have to care for our physicians and nurses or else there won’t be enough of them and then what will we do?”
Unfortunately, participants of these kinds of discussions often turn their optical zoom dial in to maximum focus one or two minute details rather than taking a step back to look at the big picture and asking the question of “how do we come to an arrangement that gets patients, regardless of income, the care they need, that gets the baby into the hands of his parents safely with intervention only being taken when necessary, and also provide doctors and needed staff an adequate roof over their heads, food on their tables, and time to enjoy their families and not get driven into the ground by working 80-100 hour weeks?” We have to care for how health and maternity care impacts the whole community.
We used to find ways to do this in our communities. Back when there were fewer people in between the relationship of doctors/midwives to their patients, all parties involved were still cared for. And people in the community knew what items and reasonable labor costs were – so, if someone could not pay their doctor for services rendered in money or in kind, the community would come together and share that burden with the doctor by making donations that helped both the doctor and the patient. It’s time to restore that spirit of true charity. Private charity fosters local accountability for both the people providing care and the people receiving care and brings needed transparency. Returning to this model would eliminate the mystery and smog that often times hovers over the economics of our health care and maternity care system in the U.S.
As the Morning Center’s Philosophy of Birth states when it comes to maternity care, “The parents should have the expert advice of the presiding medical care professional and make their own decisions on how labor and birth should proceed.” Nothing more, nothing less. Simply a patient to doctor/midwife relationship.
Speaking of “midwife”, I’ll leave you with one last item from the NYT’s article that suggests a solution Morning Center has been advocating for a while and is acting on:
One factor that has helped keep costs down in other developed countries is the extensive use of midwives, who perform the bulk of prenatal examinations and even simple deliveries; obstetricians are regarded as specialists who step in only when there is risk or need. Sixty-eight percent of births are attended by a midwife in Britain and 45 percent in the Netherlands, compared with 8 percent in the United States. In Germany, midwives were paid less than $325 for an 11-hour delivery and about $30 for an office visit in 2011.
Dr. Palmer of the American College of Obstetricians and Gynecologists acknowledged the preference for what he called “medicalized” deliveries in the United States, with IVs, anesthesia and a proliferation of costly ultrasounds. He said the organization was working to define standards for the scans.
To control costs in the United States, patients may also have to alter their expectations, including the presence of an obstetrician at every prenatal visit and delivery. “It’s amazing how much patients buy into our tendency to do a lot of tests,” said Eugene Declercq, a professor at Boston University who studies international variations in pregnancy. “We’ve met the problem, and it’s us.”