Consumerism and (hospital) Birth Part I – Insurance Incentives
I’ve had a chance to birth my two kids at two of the most progressive hospitals in the nation and have some thoughts running around in my head about the pros and cons of such birthing options for the completely normal birth. Since health care seems to be sucking up ever increasing resources and birth is a feminist issue at its core, I thought I’d use this space to pen some of my (flaky, sleep-deprived) thoughts.
To start, I suppose I should define progressive. These are mother-centered hospitals with enormous (12+ women) CNM midwife groups that encourage doulas and natural birthing if you so desire. Hospital #1 is a teaching hospital which also has a long-standing CNM (certified nurse midwife) degree program inside a university that is known for integrated primary care; the CNM practice is integrated into a larger ‘woman’s health center’ type place that is lovely. Hospital #2 is the primary hospital in the region for a large HMO which has one of the longest-standing hospital midwife programs in the country; it contracts out all of its high-risk births to another hospital in the region so the midwives actually rule the roost so to speak at HMO hospital. It is also a WHO ‘baby friendly’ hospital – so no arguing about whether or not a pacifier will be given, etc.
I myself saw only a midwife for prenatal care in both pregnancies. In some ways, seeing a midwife within these large groups is great – when things came up that were possibly out of the norm, a quick email to high-risk OBs quickly resolved the issue. Everything is all coordinated with my primary care doctors; my prescriptions are seamless; even my (and the newborn’s) followup apt-making is seamless.
But there are some drawbacks of these big groups. First, there is no guarantee (and very low odds) that your midwife will be on-call when you deliver. This is how they keep costs down; but it also kind of wrecks (what is in my view) one of the attractions of midwife care – that you have a personal relationship of enormous trust with your provider.
The second is that you must birth in a hospital. If I’m completely honest with myself, that wasn’t a complete drawback for the first birth. Even though I have a mother who (for the 1980s) was pretty progressive in terms of how she interacted with pregnancy, I had my doubts and the hospital seemed ‘safe.’ My husband was even more skeptical of the process. And even though I wanted a anesthesia-free birth, the knowledge I could change my mind at the last second was somehow comforting. So, I had probably the best in-hospital, low-intervention birth you could want. But it was a very lengthy labor and, despite the best care and great facilities, I found all the poking and prodding annoying during and especially after delivery. After a 32+ hour labor (nearly 20 of it at the hospital) and less than a 30-hour post delivery stay, we walked out knowing (at least with a normal, low-risk pregnancy) why people choose to birth at home.
Fast forward 4 years and we were expecting #2. We also had different insurance….the HMO insurance that keeps costs down by making sure everything ‘normal’ is done within their facilities. Well, birth is normal. Normal enough that people like me should be able to have a baby at home. But my house is not their facility. We toyed with getting a homebirth midwife. But at the end of the day, we could not justify the cost differential of home vs hospital birth.
And that is lesson #1. We pay over $600/month in insurance premiums for our family of 3 (now 4) which is matched by my husband’s employer for great insurance. A hospital stay copay is $100/night. My entire birth and our 2 night hospital stay cost a $200 copay. Sure, it was billed out at $7500 – and that is cheap because it was a midwife attended birth within an HMO that pays providers salaries rather than by procedures with no epidural (so no anesthesiologist charge), no interventions, nothing but a bag of pitocin when I started bleeding a bit more than desired and two nights of a hospital bed. But I only had to pay $200.
A homebirth is obviously cheaper than $7500. In this area, they seem to run $4-$5K. But because we have an HMO (which, for the record, I actually love in so many other respects both in terms of care and in terms of overall efficiency of health care provision), none of that would have been picked up by the insurance.
Look, I had a nice birth experience and have a healthy baby. I am incredibly happy with my prenatal and postnatal care. But this is likely our last child, and I’m mourning my lack of homebirth this time (and I’ll tell you why in my next post). And I’m feeling angry that I have to mourn that. What kind of choice is that? $200 vs $4500? The incentives are such that I chose the less efficient option (and the more emotionally draining option) because the out-of-pocket costs. Something is incredibly perverse in this cost structure, don’t you think?