Call the midwife: Doctors, hospitals, patients all guilty of driving up childbirth costs

July 2, 2013
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Reading the New York Timesfantastic article on the sky-high cost of childbirth in the United States, I realized I was both perpetrator and victim of this situation.

You see, my wife is pregnant right now with our second son, due in September. And it’s not going to be cheap.

I can see the business model of the physicians and hospitals at work as they recommend scans and tests that are of questionable necessity. And yet, when it’s my own wife and son, it’s always easy to think of some terrible outcome that might be averted by just one more test.

“It’s amazing how much patients buy into our tendency to do a lot of tests,” Eugene Declercq, a Boston University professor who studies international variations in pregnancy, told the Times. “We’ve met the problem, and it’s us.”

I can’t deny that he’s right.

The Times article noted that in most other developed countries, midwives handle most of the work with pregnant moms, including prenatal visits and uncomplicated births. In the United Kingdom, 68 percent of births are attended by midwives, compared with just 8 percent in the United States.

OBGYNs, who command much higher fees than midwives, step in only when the risks or needed skill level spikes up.

But my wife, Christina, sees an OBGYN once a month during the fist eight months of pregnancy and then once a week in the final month.

When Christina and I went in for an ultrasound at 18 weeks, we told the radiologist that our niece, born three years ago, had serious heart defects that required multiple surgeries at Riley Hospital for Children.

So even though he found the baby’s heart to be perfectly normal, he recommended and scheduled another ultrasound six weeks later with a pediatric specialist.

When Christina and I got home, we asked ourselves, "Why don’t they just wait to see if any warning signs develop, before doing another ultrasound?" We discussed canceling it, but in the end, we went. We figured it would be better to be prepared for big problems at the delivery, rather than not.

The outcome: No problems at all.

When Christina started having heart palpitations, her doctors referred her to a cardiologist, who ordered a heart monitor she wore for two weeks, and then a follow-up scan. All of it showed nothing, and the cardiologist simply told her to not over-exert herself.

Why couldn’t he have given that advice during the first consultation, then waited to see if it made any difference? Why didn’t we just do that and reject all the extra tests? I guess because we worried there might be something more serious at work.

This past Sunday, Christina woke up at 4 a.m. with painful contractions. The same thing had happened twice when she was pregnant with our first son, and we were determined not to take another needless trip to the maternity triage unit at the hospital.

We phoned the OBGYN on-call, telling him this had happened before and that Christina had been prescribed a drug to calm the contractions. He said he couldn’t prescribe the drug without examining her. He said we could either come into the hospital for a few tests or wait it out by resting and drinking lots of water. We decided to wait it out.

But when the contractions hadn’t stopped after 12 hours, we finally decided to go in.

The hospital performed yet another ultrasound (the third one this pregnancy), and various other tests. All showed nothing of concern. In the end, the doctor sent us home with the advice to rest and take a double dose of Tylenol PM to help Christina sleep.

I walked away thinking, 'Why couldn’t the doctor have simply spent a few more minutes talking on the phone, and just recommended more Tylenol PM to help sleep through the pain?" That would have saved his time and our money.

But the problem is that no one in our scenario had any financial incentive to do otherwise: not the doctor, not the hospital, and not us.

The doctor, who in our case is employed by an independent physician practice, gets paid based on relative value units—the more he generates, the higher his pay—or, at the very least, the greater his leverage for pay the next time his contract is renegotiated.

On top of that, OBGYN physicians have the highest medical malpractice claims, so it’s always in their interest to order as many tests as possible to avert a terrible outcome—and a potential lawsuit.

The hospital has all the same incentives.

And for Christina and me, the cost of just the standard OBGYN visits and delivering the baby at the hospital—even a vaginal delivery with no complications at the cheapest hospital in town—will cost more than the maximum out-of-pocket exposure we have on our health plan with Anthem Blue Cross and Blue Shield.

So no one has any incentive in that situation to take the cautious route, to choose to go with less care based on the most likely outcome—that everything is fine. As a result, we go along with more and more care, and higher and higher costs.

Problem is, the bills do add up—for Anthem and for IBJ. Our premiums are 25 percent higher now than they were in 2009, when Christina was pregnant with our first son. And we’ll pay a deductible of $5,950—nearly 20 percent more than last time.

All of us—doctors, hospitals and patients—have met the problem. It’s us.

  • Call the Midwife response - basically are we the problem
    I have recognised the all taht you have written about above, and it has been the problem since I arrived in the US in 1965. I did my nurses training in England prior to that, 1956-1962. I quickly realized soon after I started work in the US that, as you describe was already the practice here. I decided it wasn't the patient needs, that generated all the un-necessary tests etc, but the green back. I also realized, if they were to take the time to talk to the patient, and get a good history of the situation, most, if not all the tests would not be necessary. When Medicare came in the increase in the abuse of the system doubled. I have nursed in 9 different states, spread out across the country, & it was much the same everywhere, so it is not isolated to OBGYN, all are at fault. In a recent episode with myself, if I had been a regular patient, or part of the profession as you describe without my background, I would have been subject to a series of expensive tests. I insisted they wait & see, that changing the dose in my meds would resolve the problem. Of course it did, the conversation afterwards was, they had just wanted to be certain. My take on it was that it could have been an expensive due to a lack of confidence in themselves etc!
  • You forgot one key issue
    I think many of the points stated in your argument are valid. Our healthcare system is ripe with opportunity to reduce costs. However, I believe you might also consider this. The cost of medical liability and the litigious nature of our society have played a huge role in this. Did you stop to look at it from the provider’s point of view? What if he had prescribed the drug and something went horribly wrong? Although I’m not insinuating this would be your response, but he could be very likely looking at some sort of malpractice claim. In today’s environment, many of the so called “duplicative or unnecessary” tests are prescribed solely so practitioners can protect themselves from malpractice suits.
    • Think Before You Write
      Interesting article. However, despite the blame that doctors, medical professionals and hospitals get for taking care of patients, think first before quoting the New York Times or Time Magazine blaming the cost of healthcare on clinicians. Healthcare costs so much in this country because we do not treat our bodies with respect. We eat too much, exercise very little and yet still demand to be kept alive and in pristine shape into our 90s. WE THE PEOPLE are the reason healthcare is so expensive. Don't blame a doctor or hospital for running scans to ensure your baby is healthy. Afterall, you would likely sue these parties if your baby was not born in perfect health. Moreover, don't ask physicians to keep your 102-year-old grandmother alive when it is finally her time to pass. Too many people demand high cost procedures when sometimes it is time to concentrate on quality of life and a peaceful transition. We cannot demand the best healthcare for all situations without taking responsibility. If you want to go to a midwife to have your child, more power to you, but don't cry foul if something goes wrong and the midwife is not equipped with the training and support to help you out. It's unrealistic to expect the best healthcare in the world to be convenient and free for every citizen under every circumstance all the time and without any personal responsibility! It's not the system's fault healthcare is expensive -- it's yours!
    • Exactly!
      Perfectly stated and accurate.
    • Not easy decision
      Yes there is some personal responsibility (obesity/high rate of diabetes etc); however, to blame this for every illness is shortsighted. I lost a spouse to cancer at a young age. Cancer is notorious expensive to treat; also, spend time in oncology units and you will realize it is not all overweight aging smokers but many in the prime of their life. The newer drugs cost several thousand per month (much higher than elsewhere in the world); it is not so easy to say 'no thanks, I'll take my chances' when given an opportunity to extend your time.
      • Another Good Point
        Johnred, you also bring up a good point. We shouldn't all point fingers to evildoing and lack of personal responsibility. As you point out, tragedy does strike and it's very expensive to care for patients in tragic situations. There is the balance we must undertake. No one in this country wants to limit care for a loved one. And no one should want that as you noted.
      • For Profit Medicine
        We are acheiving the healthcare goals that are set by those in charge of our care: good profits. If we want good outcomes, or reasonable costs, we need to change the game. The current formula is charge the insured people more, provide less service to them, pay less money to the care givers for the services, and keep more money for profit. Who wins? Not the patients! Not the care givers! Not the hospitals! The robber barons running the show are getting $13 million a year, and the share holders are making record profits. That is health care in the USA. CEO and share holders get paid in dollars by the millions. Mothers and babies pay with their lives.
      • call the midwife
        The main cause of skyrocketing cost is the involvement of the government. Perhaps you can explain to me why I paid $4000 for lasik surgery in 2004 and $3200 this year. No government or insurance "paying" for it and open competition.

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