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?

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7 responses to “Consumerism and (hospital) Birth Part I – Insurance Incentives

  1. Jessica March 27, 2012 at 5:26 pm

    I think you need to give yourself a break on thinking that a home birth would necessarily be more efficient and less emotionally draining. Unless you have some pretty good data on why it would be (and perhaps that is what will be in your next post), I see no reason to over-idealize the home-birth option. Not that I think people shouldn’t do them, I am glad it is an option for more people now than it was a generation ago. But we aren’t doing ourselves any favors if we trade one form of guilt/cultural baggage for another. Just an initial reaction. I look forward to the next post.

  2. Nicole I March 27, 2012 at 5:34 pm

    Mourn probably comes across as too strong of a word. But, I think for myself, a homebirth would be more emotionally fulfilling and less stressful. And I have a hard time understanding how going to a hospital with thousands of $$ of idle capital sitting around is more efficient than having a birth (particularly the types of births I like to have) at home. But we can talk about that in the next post.

    The point of this post, however, is to point out that homebirth isn’t a viable option for everyone due to bizarre cost setups. Who are these more people than a generation ago and why have I (self?) excluded myself from that group?

  3. doctorfreeze March 27, 2012 at 6:59 pm

    The cost disparities of maternity care drive me crazy! I’ve had 3 home births–the first was a planned unassisted birth, the next two with a CNM. My first one was free, obviously; well, it cost a tiny bit because a CNM I knew and worked with came over to check me for tears, give me a few stitches, and prescribe a Rhogam shot. Birth #2 cost me $1200 out of pocket (2 deductibles and a 20% copay on the rest). Birth #3 was $1800 (turns out she’d accidentally under-billed for birth #2). This midwife has recently raised her rates from $3600 to $5K and stopped billing insurance. I could try to bill myself after the fact and would probably get a small reimbursement. But in any case, the cost itself is enough to make me want to do it unassisted again–except I want to have that safety net of someone to prescribe medications, order labs, etc.

    Going to a hospital would still be more expensive with my insurance plan…probably would cost me at least $4-5K out of pocket for an uncomplicated, unmedicated birth. More with medications and definitely more if I had a c-section. Now I’d birth in a hospital if there were a medical (or spiritual) reason to do so, but I’d much prefer to stay home. And the financial part of it is a small but real factor in the overall decision.

    It would really stink if you felt strongly about a birth center or home birth, but couldn’t afford it. I’m lucky to have choices–even though they cost quite a bit either way–and to be able to afford them.

  4. anna April 7, 2012 at 10:06 pm

    so my birth choices weren’t limited due to finances. they were limited due to dumb bureaucratic rules (i could only give birth at the birth center up to 7 days past due, i went into labor 8 days past-i know the midwives have to have that rule, blah blah blah, it still was deeply disappointing). but just adding another voice to the OP, it really sucks to have such an intimate choice made for you by something completely monolithic and impersonal. it’s really diminishing, i think, for women to have these immensely important choices made for them by groups that don’t care about them or their babies, or at least not as much as they do their profits.

  5. mfranti April 7, 2012 at 10:13 pm

    we need a like button on blog.

  6. Nicole I April 8, 2012 at 11:06 am

    doctorfreeze – while I support unassisted births, exploring it *because* of cost incentives is really taking my case to the extreme and unacceptable.

    anna – Thanks for adding this; you are correct to say that such an intimate choice is taken by the medical establishments’ rules for many women. What is so frusterating about your situation is 7 days past due does not really carry that big of an increased risk; it really isn’t about evidence based medicine, is it?

  7. anna April 9, 2012 at 3:50 pm

    you said it, nicole. that it isn’t.

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