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Only in America
July 1, 2013 8:17 AM   Subscribe


 
"What do you think the total cost of a woman’s pregnancy should be, from prenatal checkups through delivery and newborn care?"

$0!

"Your answer is higher than % [sic] of other readers' responses."

Okay, fine. $1.

"Your answer is higher than 21% of other readers' responses."

Sheesh. That's why the American way is the priciest. The NYT doesn't even bother to imagine that its price question should be able to take zero for an answer.
posted by barnacles at 8:33 AM on July 1, 2013 [15 favorites]


Terrifying. Not surprising. Inexcusable. American.

Memail me if you've navigated this successfully and have tips. Yep.... You guessed it.
posted by RolandOfEld at 8:34 AM on July 1, 2013 [6 favorites]


Can't the children just pull themselves out by their bootstraps? They've had since conception to prepare.
posted by Renoroc at 8:37 AM on July 1, 2013 [36 favorites]


I know you Americans have a fucked up health care system, that's knowledge that lives in my head. If you get in an accident, you might have to make the choice of losing a finger because you can't afford the surgery-- I get that.

But even with all that, my mind finds it hard to comprehend you would charge women to give birth.

WTF America.
posted by Static Vagabond at 8:39 AM on July 1, 2013 [6 favorites]


Hey, at least we get what we pay for! Paying double the cost means twice as good an outcome, right? Oh, wait, The US Has The Highest First-Day Infant Death Rate In The Industrialized World. The underlying report blames the mothers, particularly teen moms. Because sex education and access to contraception in the US is terrific.
posted by Nelson at 8:41 AM on July 1, 2013 [25 favorites]


This is hardly surprising since in the US there is nothing putting downward pressure on healthcare costs. Medical institutions are on an endless treadmill of "we've got better facilities than the guys down the road because we have the machine that goes PING and they don't", which doesn't address the fact that nobody needs the machine that goes PING. Meanwhile the bulk of costs are paid by insurance programs which have struck a deal with the providers that say they'll pay X % and the provider gets to eat the rest. Since the providers are supporting multiple insurers they really have no idea what the true cost of any procedure is beyond "whatever we can get for it", so the uninsured are going to get soaked.
posted by Runes at 8:41 AM on July 1, 2013 [3 favorites]




There is ONE way to keep labor and delivery costs down in the US; don't do it in a hospital. I had my second child at home, and the total cost for all our prenatal care (except for ultrasounds) plus the delivery was $2800. However, that requires an uncomplicated pregnancy and delivery, which you don't know that you're going to get until after the fact. It was a very special set of circumstances that made me comfortable with the idea of giving birth at home, and the idea that you'd have to weigh that comfort against a literally 10-fold difference in price is nauseating.
posted by KathrynT at 8:50 AM on July 1, 2013 [7 favorites]


The underlying report blames the mothers, particularly teen moms. Because sex education and access to contraception in the US is terrific.

Don't forget access to prenatal care, especially in states that want to shut down Planned Parenthood clinics! Also terrific!
posted by rtha at 8:51 AM on July 1, 2013 [2 favorites]


And remember ladies, if you didn't want to have that baby, you should've been careful! What's that, you couldn't afford birth control? Well I'm not gonna pay money for you to be a strumpet! Oh, you were raped? Life is a beautiful thing to come from such horrors, you should be thankful! No, I'm not going to help you pay for the baby, and besides, I'm not entirely sure you weren't asking for it.

Note: A significant minority of Americans actually believe this, or if we're talking elected officials, a significant majority in many states.
posted by zombieflanders at 8:52 AM on July 1, 2013 [34 favorites]


Shit like this is why foreigners I think I'm exaggerating or kidding when telling healthcare stories
posted by The Whelk at 8:52 AM on July 1, 2013 [1 favorite]


Nelson: Is it possible the expense of pregnancy combined is part of the reason that we have the highest first-day infant death rate in the industrialized world? I'm imagining that many poor mothers aren't getting the pre-natal care they need because they can't afford it.

This certainly is the case for other medical conditions - people ignore problems they have because seeing a doctor is prohibitively expensive (and then end up in the emergency room when the problem becomes un-ignorable).
posted by el io at 8:53 AM on July 1, 2013 [7 favorites]


Yeah if you don't have good insurance having a baby is preposterously costly. Even with insurance, there are co-pays for many/most of the prenatal visits, although I was pleasantly surprised to walk out of the hospital with little or no balance after our last one.

For a country that professes to love babies, this is an odd way to show it.
posted by Mister_A at 8:55 AM on July 1, 2013


Mister A: regardless of how much we love babies, we love capitalism more.
posted by el io at 8:57 AM on July 1, 2013 [6 favorites]


The Whelk, it's not that we think you're exaggerating or kidding, we just hope you are, because the alternative is too horrible to contemplate.
posted by peppermind at 8:59 AM on July 1, 2013 [3 favorites]


el io: definitely, there's been lots of studies on what a good investment pre-natal care is, but I'm too depressed to search them out right now. I fear a good part of why having babies in the US is so expensive is many Americans believe poor people shouldn't reproduce. It's a sort of fiscal eugenics.
posted by Nelson at 9:00 AM on July 1, 2013


I fear a good part of why having babies in the US is so expensive is many Americans believe poor people shouldn't reproduce. It's a sort of fiscal eugenics.

If this was really true, they'd be all about subsidizing sex ed, birth control, the day-after pill, rape and incest exemptions, and reproductive health care in general. And yet, at the legislative and judicial level it's going the completely opposite direction, which means that it's something darker and more hateful than that.
posted by zombieflanders at 9:05 AM on July 1, 2013 [17 favorites]


Some context here: Health care costs in general are growing at slower and slower rates, and will likely continue to do so as the Affordable Care Act kicks in; the article focuses on the explosion of cost growth from 2004 to 2010, but doesn't say much about growth since then.

Also, maternity care will be mandatory for all insurance plans beginning next year, though as the article notes what coverage will be like is an open question.

More importantly, with the ACA, we might begin to truly wage war on fee-for-service medicine, which is a huge driver of cost growth. This paragraph was the kicker for me:

Only in the United States is pregnancy generally billed item by item, a practice that has spiraled in the past decade, doctors say. No item is too small. Charges that 20 years ago were lumped together and covered under the general hospital fee are now broken out, leading to more bills and inflated costs. There are separate fees for the delivery room, the birthing tub and each night in a semiprivate hospital room, typically thousands of dollars. Even removing the placenta can be coded as a separate charge.

Some efforts toward bundling are starting to occur, but I expect them to accelerate as regulations get tighter.

I guess what I'm saying is, as bad as the American way of health care is, it's going to get better.
posted by Cash4Lead at 9:06 AM on July 1, 2013 [7 favorites]


This makes no sense at all. That money could be better spent on the child's upbringing and giving it a decent start in life. I'm glad the ACA is starting to bite, but it should never have gotten to this situation in the first place.
posted by arcticseal at 9:11 AM on July 1, 2013


I guess what I'm saying is, as bad as the American way of health care is, it's going to get better.

Never underestimate the ability of profit-driven entities to subvert the best intentions of legislators.
posted by Thorzdad at 9:13 AM on July 1, 2013 [4 favorites]


When I was a kid, healthcare was not a business. Now it is, and everything about it is worse.
posted by Mister_A at 9:16 AM on July 1, 2013 [1 favorite]


Never underestimate the ability of profit-driven entities to subvert the best intentions of legislators.

What legislation are we talking about that had some best intentions in it? Was it the one where the public option was off the table but the giveaway to insurance companies made it into law?
posted by DU at 9:17 AM on July 1, 2013 [6 favorites]


Well y'all are doing it wrong. What you do is set up a shell LLC corporation out of state that executes a three-way credit-default swap between itself, the hospital, and the infant (using a credit line obtained in advance against the infant's future earnings). Then you take a taxable loss on the maternity care in the name of the LLC, close up shop, and let the tax loss fall through to your personal income taxes while the shell corporation enters chapter 11 bankruptcy and passes the actual loss on to the infant's credit line. Then you sell options on any future medical malpractice settlements for the pregnancy to a hedge fund, and send the infant's bill to a collections agency -- ruining his credit, but of course he has 18 years before he actually needs it and in that time the credit report will get reset. I figure on a $50,000 birth, I should be able to turn a three or four thousand dollar profit.
posted by miyabo at 9:23 AM on July 1, 2013 [51 favorites]


Try switching providers in the middle of your pregnancy. They do this thing called a "global bill" which means they charge you for the whole shebang if you use their services even for only a couple months. So I got 2 global bills, one from the first provider that I fired when I was 36 weeks pregnant, and another from the second provider who I switched to and ended up birthing with. So I paid twice for my son's prenatal care and birth.
posted by rabbitrabbit at 9:24 AM on July 1, 2013 [1 favorite]


I haven't lived long enough under full Republican rule to really comprehend the full effects of the laws that are being passed around and about my (female) body on a regular basis, but I know enough to understand that my absolute #1 fear in life has been winnowed down from a nebulous array of disasters to just one thing: getting pregnant. I have actively not wanted children since I was a little girl, but I can't find a single doctor who is willing to permanently sterilize me because I don't have children (or, as they say, because I don't have children yet). The hard numbers in this article give me a different angle, though! Do you think they might humbly allow me full control of my reproductive status if I brought in proof of my income accompanied by a list of current expenses, in order to showcase the fact that I would be bankrupted several times over if I was legally maneuvered into carrying an unwanted pregnancy to term and giving birth in a hospital?

At the risk of making Republicans everywhere pump their fists with joy at having successfully quashed the spirit of yet another woman, these laws have made me choose celibacy. I have a fundamental incompatibility with hormonal birth control and no other method short of permanent sterilization can maximize the possibility that I will never be forced to pay the physical, psychological, and financial toll of being forced to bear an unwanted child.

Also, as someone who was born into generational poverty who was the first in her family to escape the cycle -- only because I was celibate into adulthood; my family of origin is devoutly religious, and took me out of all of my health classes in school so I couldn't learn about fertility or birth control -- I can attest that no legislative body in the country has taken any large-scale action on this topic that will do anything except continue to encourage poor people to keep having more babies. Perpetuating a permanent underclass is the American way.
posted by divined by radio at 9:24 AM on July 1, 2013 [33 favorites]


So I guess the main thing to take away from this is... happy Canada day?
posted by sarastro at 9:25 AM on July 1, 2013 [20 favorites]


It was a very special set of circumstances that made me comfortable with the idea of giving birth at home, and the idea that you'd have to weigh that comfort against a literally 10-fold difference in price is nauseating.

There is a third way, and the article even mentions it. My son was born in a freestanding, independent birth center - a bit more like giving birth in a (very homelike) doctors office than at home. I gave birth in a room that looked like (and was set up like) a regular bedroom, with an awesome tub nearby, but hidden away were basic medical interventions (oxygen, I know for sure) that could buy time if there was an emergency, and they had selected their location so the ER was less than 1/10th of a mile away. Total number of people in the building when my son was born: me, my husband, the midwife, her assistant, their student, and our baby. My son was born around noon and I was home with him that afternoon.

I believe the total price (my insurance paid 100%) was around $3500, including the midwife care.

Of course, our birthcenter closed, due to a combination of high insurance rates and pressure from the copycat "birth center" that opened inside the hospital (with 100% more medicalization of pregnancy). But were I some kind of venture capitalist I would open a chain of midwife-centered freestanding birth centers nationwide, with a tag line like "all the safety of the hospital, all the comforts of home".
posted by anastasiav at 9:30 AM on July 1, 2013 [3 favorites]


I had monthly, then biweekly, then weekly prenatal visits, then an emergency c-section with Thing1, after several false labours (super heavy contractions) that included a shot for his immature lungs.

Cost to me: $80 for the semi-private hospital room for 2 people — the 4-person room would have been free.

Yes, indeed: Happy Canada Day!
posted by wenat at 9:30 AM on July 1, 2013 [2 favorites]


Scene: Hospital OB/GYN room

Birthing Mother: YOU DID THIS TO ME!!!!!
New Father: Honey, it's ok, we both wanted this baby.
Birthing Mother: NOT YOU! THE NEOLIBERAL CAPITALIST FASCIST SYSTEM!
posted by wcfields at 9:30 AM on July 1, 2013 [11 favorites]


My parents were shocked at how much it cost to have me, in 1967. They were just getting by, had been saving for a down payment for a house, and the cost of my birth really set them back.

They didn't make the same mistake twice. For the birth of my younger brother, my mom went down to stay with her parents in Mexico and have him delivered at the town hospital. The best part of this story, for me, is that I get to tease my brother that they got him on discount.
posted by vacapinta at 9:36 AM on July 1, 2013 [20 favorites]


My son was born in a freestanding, independent birth center

This had actually been my plan! But our FSBC only had 3 suites, and they were all full, so we converted to home birth at the last minute, my husband and my mother and my doula flying around and tidying up and scrubbing our tub and wrapping our mattress while I gritted my teeth through early contractions on a birth ball. (Of course all that activity stopped my labor cold, and after having no contractions for an hour, we had to break my water to get the baby to come after all, but c'est la vie.) My midwives actually carried oxygen and pitocin along with other medications; that was part of the circumstances that made me comfortable with a homebirth. Midwives are not allowed to give those interventions in all states.
posted by KathrynT at 9:38 AM on July 1, 2013


When I was a kid, healthcare was not a business.

Hey, Otzi the Iceman has joined Metafilter!
posted by yoink at 9:39 AM on July 1, 2013 [7 favorites]


My first child I payed one single $15 co-pay for my entire pregnancy and labor and delivery. That was it. $15. I never saw a bill since I didn't owe anything, and I never got an explanation of benefits because our insurance at the time was not so great about sending them. So I have no idea how much that all cost total, but I'm guessing upwards of $60k.

My second child was born at home. I paid $3800 out of pocket over the course of nine months. Then about three months after her birth, I received nearly $1200 of it back from my insurance, making the total cost about $2600.

The difference was that the first one didn't come out of my pocket and the second one did. But even though my first child didn't cost me more from somewhere.

Honestly, I think everyone should start off seeing a midwife and be referred out to OBs when needed, and then referred out to perinatologists when needed. It would certainly help costs without reducing level of care.
posted by zizzle at 9:39 AM on July 1, 2013 [3 favorites]


First baby - born safely at home, $4k cash, the midwife waited an entire year to be paid in full while I made payments. Beautiful experience, my son didn't leave the house for the first two weeks after his birth other than little trips onto the deck to get some sunshine.

Second baby - born at a hospital, since I was too rural to feel comfortable with my backup medical options for a homebirth (and I was in a different state and too far away from my first awesome midwife). $2k cash after insurance, not including prenatals, and he was born an hour after we arrived (we were caught in a thunderstorm on the drive in and I went through transition on the highway). I spent the entire fucking hour begging the nurses not to make me lie down and having paperwork shoved in my face.

Never again.
posted by annathea at 9:42 AM on July 1, 2013 [1 favorite]


, I think everyone should start off seeing a midwife and be referred out to OBs when needed,

But then insurance companies make less money and hospitals make less money, and then people will sneer that a midwife isn't a doctor and thus you don't love your child and that you're basically trusting a fortune teller with your family's health.
posted by MisantropicPainforest at 9:43 AM on July 1, 2013


Our kid was just born at home, planned and what not. $2800 out of pocket after our insurance benefit of $1000. If we'd gone to the hospital it would have been about $35K with about a hundred bucks out of pocket for the ultrasound.
DERP
posted by Stonestock Relentless at 9:45 AM on July 1, 2013


But even with all that, my mind finds it hard to comprehend you would charge women to give birth.

We don't. We charge them for medications, use of hospital rooms, medical services, etc.
posted by escape from the potato planet at 9:47 AM on July 1, 2013


you know what they meant
posted by MisantropicPainforest at 9:49 AM on July 1, 2013 [10 favorites]


While they deplore the use of Abortion as "Birth Control", America's "Highest First-Day Infant Death Rate In The Industrialized World" IS the Republican version of Birth Control. And reading about divined by radio's semi-voluntary celibacy will make them high-five and declare "Mission Accomplished". There is nothing NOT evil about this.
posted by oneswellfoop at 10:14 AM on July 1, 2013 [3 favorites]


> When I was a kid, healthcare was not a business.

Hey, Otzi the Iceman has joined Metafilter!


If Ötzi lived today, health care still wouldn’t have to be a business in his part of the world. Italy has a very nice publicly funded system.
posted by wachhundfisch at 10:18 AM on July 1, 2013


Honestly, I think everyone should start off seeing a midwife and be referred out to OBs when needed, and then referred out to perinatologists when needed. It would certainly help costs without reducing level of care.

Yep, that's how it works in some other countries. I did the same thing when I gave birth here in the USA. There were (count them) exactly three midwives in all of NYC that took my insurance, and happily one of them was close to me.
posted by gaspode at 10:20 AM on July 1, 2013


So has someone figured out the true cost of being "southern by the grace of god" yet?
posted by The 10th Regiment of Foot at 10:25 AM on July 1, 2013 [1 favorite]


Slate's predictably panglossion take on this issue: Yes, Childbirth Is More Expensive in the U.S. But You Get What You Pay For.

Conspicuously omitted from the Slate article is any mention of the fact that America has the worst first-day infant mortality rates in the industrialized world, as another poster pointed out up-thread.

The Slate article dwells more on the first-person experience of medical care than on the outcomes. But I've been through the American system twice now, with two kids, and while I honestly can't complain too much about the care we got, it in no way made the sticker-price seem justified considering that allowing people to be born is one of the most basic pre-conditions for keeping a society going I can imagine. And not everyone is fortunate enough to have a job that offers the kind of insurance coverage mine does. Many people I know would have been completely financially hobbled for life just to have picked up the tab for one birth.

The fact that so many basic necessities of living in society are now priced beyond reach of most people in the US forces us into a mode of personal spending that's largely dependent on credit, which allows the financial industry to siphon off more of the revenue they earn without providing any tangible benefit. The more our system requires credit in order for people just to function and take care of life necessities, the less economic value and spending power people get from their own wages and the more gets siphoned off to the financial sector. It's disgraceful and unsustainable.
posted by saulgoodman at 10:31 AM on July 1, 2013 [7 favorites]


"I fear a good part of why having babies in the US is so expensive is many Americans believe poor people shouldn't reproduce. It's a sort of fiscal eugenics."

If you are poor enough birthing a baby is paid for by the state.

As far as that highest day 1 mortality rate...Can that data be parsed into full term vs. Premature births?
posted by Gungho at 10:38 AM on July 1, 2013


Given the US is 1 and Canada is 2 in first day infant mortality I'm not sure you can argue its because of a lack of affordable health care. Probably more a question of the definition of live birth and intervention in certain circumstances.
posted by JPD at 10:43 AM on July 1, 2013 [5 favorites]


"I fear a good part of why having babies in the US is so expensive is many Americans believe poor people shouldn't reproduce. It's a sort of fiscal eugenics."

If you are poor enough birthing a baby is paid for by the state.


I don't think the state pays enough and it's worse than eugenics, it's a way of ensuring that poor people remain endebted to their creditors from birth, much like how the children of indentured servants fell under the same debt contract as their parent.
posted by The 10th Regiment of Foot at 10:43 AM on July 1, 2013 [1 favorite]


The gap in coverage isn't the indigent - they really do get everything paid for by the state - but it is those just above real poverty that end up getting completely screwed.

BTW - here is an article on first day mortality rates in Canada.
posted by JPD at 10:48 AM on July 1, 2013 [2 favorites]


If Ötzi lived today, health care still wouldn’t have to be a business in his part of the world. Italy has a very nice publicly funded system.

Just because the state pays doesn't make it not "a business." The state pays for all the military hardware the US purchases; that doesn't mean that Raytheon isn't a business.

This isn't a minor quibble, by the way. Debate about healthcare costs and the best way to approach them is badly broken in the US for all kinds of reasons, but among those reasons is a persistent fiction on the left that somehow if the state pays then it's all "free" and everybody gets to have everything they ever wanted out of a medical system for nothing: yippee!

The question of who pays and how is only a part, in fact, of the equation for designing a sensible system for both reining in and equitably redistributing medical care costs. The US system is badly fucked for all kinds of reasons but simply transferring final payment to the federal government (i.e., to all of us as taxpayers) would do little to fix the problems in the system (and for the middle-class families being talked about in the article would be unlikely to do much to restrict overall out of pocket expenses). Single payer systems can be well designed and badly designed, they have their strong points and their weak points. There are plenty of "single-payer" systems out there where the well-off are explicitly or tacitly encouraged to purchase supplemental private insurance and where they get a markedly better class of treatment than poorer people do in that whole, vast, grey area of quasi "elective" medical treatments (an area, by the way, in which lots of birthing options fall).
posted by yoink at 10:51 AM on July 1, 2013


Begin with this:

Name one CEO of A hospital at any decent size city who does not make over a million dollars a year!

Ok. Now mommies and daddies to be: you have to help pay for this salary.
posted by Postroad at 10:54 AM on July 1, 2013 [1 favorite]


But then insurance companies make less money and hospitals make less money, and then people will sneer that a midwife isn't a doctor and thus you don't love your child and that you're basically trusting a fortune teller with your family's health.

Good thing there're others who believe that people should have an informed choice of options and affordable access to whatever options they choose. FWIW my son might have suffocated to death before delivery if we hadn't been in a hospital with an obstetrician. Doctors exist for reasons other than to line the pockets of insurance companies, even if the American plutocracy makes it seem otherwise.
posted by audi alteram partem at 10:55 AM on July 1, 2013 [5 favorites]


Just because the state pays doesn't make it not "a business." The state pays for all the military hardware the US purchases; that doesn't mean that Raytheon isn't a business.


Of course true, but when a business also only has one possible customer that customer gets a lot more say in the prices they pay.
posted by JPD at 10:59 AM on July 1, 2013


Good thing there're others who believe that people should have an informed choice of options and affordable access to whatever options they choose

Informed choice of options and affordable access does not lead to an outcome where the majority of births are done in hospitals with OBs and with a historically high C-section rate.

FWIW my son might have suffocated to death before delivery if we hadn't been in a hospital with an obstetrician. Doctors exist for reasons other than to line the pockets of insurance companies, even if the American plutocracy makes it seem otherwise.

All of which is evidence in support of the argument that doctors should handle complicated deliveries, not all deliveries.
posted by MisantropicPainforest at 11:08 AM on July 1, 2013 [1 favorite]


If you are poor enough birthing a baby is paid for by the state.

That varies enormously from state-to-state, because states administer medicaid benefits. Many states (including my own) have a long history of deliberately making access to medicaid benefits difficult. In fact, to avoid having to expand its medicaid coverage, rather than extend benefits to everyone in the state who already qualifies under Federal guidelines (which it's widely known the state doesn't do currently), the legislature recently turned down funds from the Federal government that would have (at least in the near term) covered all of the state's medicaid costs.

Basically, rather than let all the people who currently qualify for medicaid get it and expanding medicaid coverage as the new health care act requires--even when doing so would have saved the state huge sums right now--our state said, nope. We're going to keep paying it all ourselves and keep excluding large numbers of people the Federal laws should qualify already, forget expanding the existing coverage.

So, no, that's not necessarily true. And besides, my point isn't about the dirt-poor. It's about the large numbers of people who end up having to take on large debt burdens just to exist. US birthrates have actually been dropping precipitously for years now, and some have suggested the cause is high-levels of student loan debt. Isn't it just as likely the high costs of birthing children are a factor?

(Also: It's funny how often people take a cynical position on these issues and just wave them away, saying "Well, hell, we'll be better off with lowering reproductive rates anyway" when in the US at least, that's not an issue. The US population is growing primarily because of immigration. Our birthrates are currently the lowest they've ever been. And yet, somehow, our problems aren't evaporating.)
posted by saulgoodman at 11:12 AM on July 1, 2013 [1 favorite]


this illustrates the problem with the "single payer" will solve all our problems school of US health reform advocacy. birth is *not* a profit center for hospitals and the fact is that the system can't figure out how to make birth something other than an absurdly expensive horrorshow because doing so would involve marginalizing the doctors and equipment and replacing that with a lot of "social care" pre-birth. a safe and cheap birth is all in the pre-natal care because, in the end, the woman is going to be doing the work. but hospitals will continue doing birth the way they do, not because it makes them money, but because they are to tied down by, essentially, ideology to think clearly about the problem... and because brith is never going to be a profit center.

Of course true, but when a business also only has one possible customer that customer gets a lot more say in the prices they pay.

except when that customer is the Department of Defense...
posted by ennui.bz at 11:12 AM on July 1, 2013


Informed choice of options and affordable access does not lead to an outcome where the majority of births are done in hospitals with OBs and with a historically high C-section rate.

Good. I apologize for not being clearer above, but I'm one of those people who believe in choice of options. If people don't want to deliver in a hospital, they shouldn't. I also think there's plenty of room for reform in both financing and practices of medicine.

All of which is evidence in support of the argument that doctors should handle complicated deliveries, not all deliveries.

Again, perhaps I should have elaborated more above, because I did not mean to imply that doctors should handle all delivers. I think people should have the choice of having their deliveries in a hospital attended by a physician, and I think that that choice, as with all medical care, should be accessible and affordable (made possible through some sort of state intervention, not that I'm likely to see it in the US in my lifetime). We made the personal choice to deliver in a hospital because complications can't necessarily be predicted and when they occur, as they did in our case, we wanted immediate intervention on hand.
posted by audi alteram partem at 11:19 AM on July 1, 2013 [2 favorites]


Name one CEO of A hospital at any decent size city who does not make over a million dollars a year!

Pftt! A measly million? Who'd work for that little? The CEO of our local hospital "non-profit" system made $6.1M last year.
posted by octothorpe at 11:19 AM on July 1, 2013 [2 favorites]


How are they not making huge profits on these births, though? Our son's total tab was in the realm of $20,000 and it was mostly a smooth delivery (okay so, my wife was induced, and they actually kind of screwed that procedure up a bit, but there were no life-threatening complications). Basically, two-to-three days rental of a room, a couple of gowns, some saline water, occasional visits from a nurse, and some relatively routine medications come out to $20,000 and nobody's making money on that? I don't see how that's possible. They didn't do much of anything extraordinary, except for the induction.

Markets are supposed to function to bring down the costs of routine services, in classical market theory. Why isn't that working when it comes to child birth?
posted by saulgoodman at 11:20 AM on July 1, 2013 [3 favorites]


Is there where I admit on metafilter that this is relevant to me? (I mean, I'm only 10 weeks along so please no one say anything on the twitters and if there's no baby in February we can just pretend this conversation never happened). We're currently planning to go with two wonderful local midwives for a hopeful home birth (closest birth center is around an hour away, but they carry oxygen and pitocin and are all about transferring up to and during birth if that's what's called for.), but because of the high cost of living in our area, we have to put seven thousand dollars down. We've got guaranteed in-network coverage through Healthy NY, but they don't reimburse until after the birth and we're supposed to pay up front. AND because of the ACA, Healthy NY is being discontinued in January for individuals. We're supposed to be able to buy some sort of new insurance then in the healthcare marketplace, and maternity has to be covered and is no longer a pre-existing condition and all, so yay, but we won't even know what our options are until October.

It's all very stressful. I think I'm going to go take a nap. Or cry. One of those things.
posted by PhoBWanKenobi at 11:33 AM on July 1, 2013 [22 favorites]


saulgoodman: How are they not making huge profits on these births, though? Our son's total tab was in the realm of $20,000 and it was mostly a smooth delivery...
The hospital may have provided you with a statement that included such figures, but they probably settled with your health insurance plan (assuming you had one) for much less, like a fifth or even a tenth of that. The prices on American medical statements are complete fabrications, utter fantasies that have nothing to do with the value, cost, or actual transaction price of anything at all.

When my wife and I had a baby just over a year ago, there was a line item on the statement for "Supplemental anesthesia" or something - a second dose of drugs in her epidural. The hospital was charging something in the neighborhood of $1,000, but ultimately accepted the insurance company's "adjustment" to $12. The total adjusted price for the entire hospital stay was something like a tenth of what the hospital initially billed for.
posted by Western Infidels at 11:46 AM on July 1, 2013



except when that customer is the Department of Defense...


I know you think this is pithy - but it isn't actually very true. The DoD does ridiculous extravegant things on cost+ development programs where there is lots of scope for graft - but that usually does not accrue to the shareholders as margins and returns are pretty strictly limited. In fact most of the time that's the DoD doing something dumb.

On actual procurement contracts the DoD is quite aggressive about limiting margins and returns for the companies. I'm not saying there isn't loss and graft - but in terms of actual remuneration to the capitalists they do keep returns capped. You can't say that for healthcare. I mean if you had a DoD model you'd pay drug companies to develop drugs at some low margin with no risk, and then let them earn their costs back + a little bit on actually selling it to you.

Births are profit centers if you can select for upper middle class people who are healthy, educated, and insured/self insured. You tend to get a pool of healthy birthers and babies, but the pricing is designed to reimburse a facility assuming their population of births looks like the general population. There is a reason why Cornell-Weill has a dominant position in birthing for rich people in NYC. Or why Greenwich hospital has such a nice birthing ward.

Its the same dynamic as outpatient surgical centers.
posted by JPD at 11:51 AM on July 1, 2013 [1 favorite]


The prices on American medical statements are complete fabrications, utter fantasies that have nothing to do with the value, cost, or actual transaction price of anything at all.
Why is this? Are medical providers hoping that occasionally they'll get paid the full amount of whatever they put on the medical statement?
posted by kadonoishi at 11:53 AM on July 1, 2013


Are medical providers hoping that occasionally they'll get paid the full amount of whatever they put on the medical statement?

If you don't have an insurance company negotiating on your behalf, that's how much you'll be on the hook for.
posted by KathrynT at 11:58 AM on July 1, 2013 [2 favorites]


According to this recent analysis, $20,000 is pretty typical once all associated costs (things like those extra anesthetic doses and the cost of letting your newborn sleep in a room) are taken into account.

I guess they might have charged us extra for all the extra pitocin they pumped into my wife not realizing their monitor wasn't accurately reporting the strength and duration of her contractions because it had malfunctioned. It took them a couple of hours before they would take my wife's word for it that she was still having strong contractions when the machine showed otherwise. Our experience having a good doula on hand with the next birth was much better, even without an epidural... But it still wasn't cheap.
posted by saulgoodman at 11:59 AM on July 1, 2013


Even the shittiest hospitals in nyc have relatively fancy labor, delivery, and NICU resources. I don't understand how it's not a profit center.

I just gave birth a week ago, in a hospital, with an OB, and no interventions other than antibiotics for my GBS+ status. I had 4 ultrasounds during my pregnancy: dating, NT scan, 20 week anatomy, and post-date scan. My friend, with the exact same OB, gets one every visit, because she asks for them.

This isn't about doctors vs. midwives; it's about the lack of incentives to keep costs down. If you read the Slate article linked above, you'll see that the American woman and the Canadian one had the same outcomes, but the American one got "reassurance," for which she paid tens of thousands of dollars more. I don't know how you solve that, but pointing the finger at doctors isn't the answer.
posted by snickerdoodle at 12:00 PM on July 1, 2013 [2 favorites]


If you don't have an insurance company negotiating on your behalf, that's how much you'll be on the hook for.

So these very high prices on medical statements are a way of attacking defenseless people?

The period reported on in the NYTimes article seems to be mainly 2004 - 2010. I think the ACA is going to fix most of this, and by the end of this decade, the medical system will have changed enough that this article will seem to report on a bygone era of barbarism. But I'm glad to see articles like this coming out now, when ACA rules that can fix these problems are being finalized.

The main practical reason I was happy to see Obama win in 2012 was that he and his people will implement the ACA. Sebelius just last week extended a giant middle finger to made an accommodation for religious employers so that their employees will get coverage for contraception.
posted by kadonoishi at 12:20 PM on July 1, 2013


Why is this? Are medical providers hoping that occasionally they'll get paid the full amount of whatever they put on the medical statement?

Previously

The short version: an incredibly fucked up relationship between insurers and care providers, where providers don't know how much they can hope to be reimbursed by Insurance Company X for Procedure Y, and have to make a wild guess when they bill an insurer. If they guess low, they get what they bill for. If they miss high, they get the insurer's maximum allowed benefit. Thus: they wildly overbill for everything, and if you are an uninsured patient with no bargaining power, you are fucked.
posted by Mayor West at 12:23 PM on July 1, 2013 [4 favorites]


So these very high prices on medical statements are a way of attacking defenseless people?

Yes. They somewhat-ameliorate the problem by offering discounts after the fact to people without insurance, but you have to know they are there and have the resources available to track and negotiate all your bills. When my infant son had to be rushed to the ER with croup*, we got bills from four separate institutions -- the ED at the hospital, the pulmonologist who worked at the hospital, the Pediatric unit at the hospital, and the admitting physician, who worked for a different hospital entirely. It was a lot to sort through, and we never knew when we were done being billed and done paying. And we have insurance!


*fun fact: what's worse than hearing your baby struggle to breathe in the back seat? Hearing him stop breathing entirely!
posted by KathrynT at 12:34 PM on July 1, 2013 [1 favorite]


Snickerdoodle-- if your Doctor is giving your friend ultrasounds that have no medical benefit, then surely it's okay to point the finger at that particular Doctor?

On a higher level, the insurance company should look at that and say "Hey, why were these ultrasounds performed, there seems to be no medical reason? Stop doing that." Or on an even higher level, a board someone would look at the stats as see that Dr. Oct is doing 10% more ultrasounds then the country average, and look into why.

But ideally, the Doctor themselves wouldn't waste their talents and instead choose not to carry out any medical procedures that solved no purpose.
posted by Static Vagabond at 12:46 PM on July 1, 2013


I think the cultural attitudes around childbirth and pregnancy have an impact, too. Like women in the US are a lot more conservative about eating certain things "just in case" and there seems to be a lot more anxiety over childbearing and screwing the child up than what's reported from women I've known who were pregnant in other countries. If an OBGYN says you should do an ultrasound "to be safe" a woman might wonder what kind of mother she is if she doesn't do it and that anxiety seems pretty bad in the US.
posted by PhoBWanKenobi at 1:00 PM on July 1, 2013 [4 favorites]


The best thing I've ever read on why US medical billing is so fucked up is Bitter Pill: Why Medical Bills Are Killing Us, previously on Metafilter. While the relationship between insurers and care providers is incredibly fucked up, it's not the direct cause of opaque bills. Hospitals way overcharge patients without insurance because it's the starting point in a negotiation, they assume up front the uninsured patient can't pay in full. Insurance companies and Medicare have well established rate sheets of what they will pay for a procedure, which is itself a problem.

A great adjunct to this NYT article would be what various major insurers generally cover for a US childbirth, what the pre-negotiated prices are. Presumably Medicare isn't paying for a lot of births.
posted by Nelson at 1:07 PM on July 1, 2013 [1 favorite]


This is also a problem single-payer would solve, as there would be one negotiating party only and rates for services could be standardized.
posted by saulgoodman at 1:13 PM on July 1, 2013 [1 favorite]


We are on our second pregnancy now, and have done two ultrasounds. We have insurance, with maternity coverage. The first ultrasound ended up costing about 275 out of pocket. The second cost 530. Why the huge increase? At the beginning of the second appointment my wife mentioned that her sister had delivered her third child with a cleft soft palate. Even though there is a very small percentage chance of this having any relevance to our pregnancy, and the fact that it would be impossible to detect during the ultrasound even in that rare circumstance, and further that it would be an entirely safe pregnancy in any case, they assigned the "high risk" consultant to us. This is the person whose normal job would be to break the news to parents about severe abnormalities detected during pregnancy that would pose risks to the health of the mother or child.

Even though we never asked to be consulted, and the consultant and the technician clearly stated there was no risk, we get to pay double for the service, with absolutely no notice.
posted by odinsdream at 1:13 PM on July 1, 2013 [5 favorites]



So these very high prices on medical statements are a way of attacking defenseless people?


That is the net effect, yes. The uninsured, or the poorly insured (like me!) bear the brunt of our medical systems comical inefficiencies.

Because there is no consensus among disparate insurance companies on what they will pay for "procedure X"...hospitals bill MUCH MUCH higher for "procedure X" than it actually costs, as has been noted upthread. With good insurance, the difference is "adjusted" away...but without insurance the patient is on the hook for this entire inflated amount.

In other words, health insurance companies and hospitals have quite effectively offloaded a lot of the costs of our medical system inefficiency onto the poor, the uninsured and the
underinsured.


I happen to be undergoing a case study in this myself! I recently got a bill from a hospital visit I had TWO YEARS ago for nausea and vomiting. During the course of my short stay in the ER the on duty MD decided to order a chest xray. At the time this seemed insane and I balked, but went ahead and did it anyway...you know...because I am not a f*cking doctor. I later learned that because of the US Fee For Service model this test was largely unnecessary...but boy did I end up paying for it.

Now...every procedure at a hospital...EVERYTHING...from bandaids to heart surgery has either a CPT or HCPCS code attached to it. These codes allow Medicare and Medicaid to price services rendered at a hospital, and if you get an itemized bill from a hospital you can look up these codes to find out what Medicare / Medicaid would pay for your procedures...what you will find is that your procedures are often inflated up to 20x the actual national average cost for a given procedure.

You can find the average and local costs of a given procedure from a CPT or HCPCS code at CMS.gov

Going back to my chest xray (CPT CODE 71020). The national average cost for this procedure is about $31.32 - which is what medicare would pay. The hospital bill I got for a 71020? $523.21

This was typical of every procedure on my itemized bill...each line item was usually inflated between 10 and 20 times the national average cost for a given procedure based on what Medicare or Medicaid would pay.

Steven Brill, in his fantastic Time Magazine piece, points out that, ironically, Medicare and Medicaid is the closest thing we have in the US to an ACTUAL MARKET in health care. The problem in the US is that there are MULTIPLE markets in healthcare...and in some markets its a buyers market, in some markets its a sellers market. If you are in individual...without a large health insurer like Medicare or Blue Shield or whatever negotiating on your behalf...you are just plain screwed...and you get to foot the entire inflated bill...hence paying for the fallout from our inefficient system made of a patchwork of public, private and the uninsured.

Even if you are insured, like I am, my shitty Kaiser health care left me on the hook for most of the bill as part of my deductible.

What unhealthy behaviors have I learned from the US Medical System?

1) Do not ever go to a hospital unless you ABSOLUTELY NEED. TO.
2) If not unconcious, refuse as many tests as you can.
3) Be suspicious of everything hospitals do to you

The saddest thing is that I am only half joking. Gross.
posted by jnnla at 1:21 PM on July 1, 2013 [5 favorites]


Snickerdoodle-- if your Doctor is giving your friend ultrasounds that have no medical benefit, then surely it's okay to point the finger at that particular Doctor?

My friend had a miscarriage 3 months before getting pregnant again, so she wants to see the baby every time she comes in for an appointment. She's asking for them, and there's no medical reason not to do it. If my OB had refused, she would have found another OB. From the doctor's perspective, it's harmless, insurance is paying, and it makes the mom happy, so why risk losing a customer? I can't blame someone for making a perfectly rational decision in this context.
posted by snickerdoodle at 1:50 PM on July 1, 2013 [1 favorite]


Now...every procedure at a hospital...EVERYTHING...from bandaids to heart surgery has either a CPT or HCPCS code attached to it. These codes allow Medicare and Medicaid to price services rendered at a hospital, and if you get an itemized bill from a hospital you can look up these codes to find out what Medicare / Medicaid would pay for your procedures...what you will find is that your procedures are often inflated up to 20x the actual national average cost for a given procedure.

A bandaid actually wouldn't; most supplies and drugs don't get a CPT/HCPCS code. Medicare actually doesn't pay on a fee for service basis for things like heart surgery that require an inpatient stay, there's a separate system for inpatient cases where they pay a (mostly) flat rate for the whole stay based on the expected resource consumption for that type of case (as defined by Diagnosis-related group).
posted by strangely stunted trees at 2:38 PM on July 1, 2013


Good thing there're others who believe that people should have an informed choice of options and affordable access to whatever options they choose. FWIW my son might have suffocated to death before delivery if we hadn't been in a hospital with an obstetrician.

Yup, mine too. I was very close to needing an emergency c-section and a midwife at home would have had no way of realizing it or treating the problem effectively without a c-section. Transit and time waiting in the ER would have cost my son brain cells, if we'd even known there was a problem.

And it wasn't a "complicated delivery" until it was.

The answer to this is not to lower the standard of maternity care until we're literally bragging about our caregivers having basic medications. The answer to this is single-payer health care.
posted by the young rope-rider at 2:53 PM on July 1, 2013 [10 favorites]


if you are an uninsured patient with no bargaining power, you are fucked.

That is what the Court system is for. Demand via discovery what the lowest they got paid for the same and call that the actual rate.

I'm guessing there is case law somewhere on telling 'em to bill you are the actual market rate VS what they sent you. But I've never had to brief that out because I use the Suture-self home surgery kit.
posted by rough ashlar at 2:57 PM on July 1, 2013


Snickerdoodle, do you mean the rational choice is for the doctor to do as the patient asks, or they might lose that customer? I guess that's true from a business point of view-- but you understand that the system is made a little worse because of that? Insurance premiums for everyone in your friends insurance pool will go up because of her unrequired scans, to the point where a few people might then have to forgo insurance.

"There's no medical reason not to do it"

See, that's a really odd phrase to me, and pretty much the antithesis of medical care. When you pull that apart, what does it mean? That a Doctor should carry out any medical procedure a patient asks for as long as it doesn't harm them, even it it does nothing for their health? If my Doctor advertised that, I don't think I'd go to him anymore.

There's no medical reason not to give me a full-body MRI each time I walk into my Doctors with the sniffles, but it's obviously a waste of resources, whether my insurance covers it or not-- it's true that I might get lucky and discover a cancer very early on, but the cost to society at large is much greater then my chance of getting lucky.

I don't know anything about your friend-- perhaps because of her history, the Doctor decided the stressed caused not doing the scans would be potentially harmful to the pregnancy, who knows, not me. So I can only speak on a higher level, that healthcare is millions of people, and the goal is to get the best outcomes (on average) per dollar spent. If we are wasting money doing unnecessary procedures, then that's less money in the system to actually help people, or, in the US, that's higher premiums, and excludes people that could have been helped.
posted by Static Vagabond at 3:17 PM on July 1, 2013 [1 favorite]


The answer to this is not to lower the standard of maternity care until we're literally bragging about our caregivers having basic medications.

High quality midwifery (particularly in states supportive of midwife models) is not a lowered standard of care. It seems kind of weird to imply that it is.
posted by PhoBWanKenobi at 3:35 PM on July 1, 2013 [2 favorites]


Wow, this one really resonated with me. I'm an American living in the UK; my wife and I moved here a couple of years ago. We're still figuring things out, still sort of idly discussing whether we'll go back to the US some day or not. We'd make more money if we went back, so that's part of the calculation -- but we're happy here, and we like our jobs and mild winters and the way the hills around us are green year-round, and how much money is all that stuff worth to you?

So you try to add it up. The bike path we can take to the ocean; the 900-year old gatehouse we see from our window; the 400-year old pub we can take our friends to. The NHS. (But on the other hand, a plane flight to see our families and most of our friends. The idea that we might never feel a blazing-hot summer again.) Sometimes it's tough to put a price on things.

We're having a daughter in a few weeks. We're excited and terrified and all the stuff I guess most parents probably are. What we're not doing is asking and worrying about how much the birth will cost, because the answer is zero pounds, zero dollars, a number that sounds great in any currency. We have a midwife we've seen a bunch of times, we've had a few ultrasounds, we can have our daughter on either a midwife-led unit (in a hospital, so literally 2 minutes from help in an emergency), or on the higher-risk labour ward, or at home (if we really wanted to, which we don't). It's all been great. We've been the recipients of a bunch of hand-me-down maternity books from my wife's sisters, still in the US; there's all kinds of stuff in there about how much this or that will cost if you don't have insurance or maybe even if you do, and all of it sounds like just absolutely the last fucking thing in the world I would care to think about right now. So I guess at minimum I could start mentally adding in the crazy maternity/birth costs quoted here to what we make here. But there's more to it than that.

I keep thinking about an article/essay that was linked here a while ago, by someone talking about how the death of someone he or she loved in the UK was made in some small measure easier by not having to worry about money, by knowing that extra bits of care weren't bankrupting anyone. What is it about birth and death that throws these health care systems into such sharp contrast? I guess by taking crippling financial costs out of the equation, you let people concentrate on the emotions that matter -- in some cases anguish, in other cases joy, but in no case fear that you won't be able to pay the bill. I still don't know how to put a price on that, but I'm leaning towards saying it's enough to make us stay.
posted by chalkbored at 4:20 PM on July 1, 2013 [9 favorites]




Midwife-led care for low-risk women was found to be better for a range of maternal outcomes, reduced the number of procedures in labour, and increased satisfaction with care. For some maternal, foetal, and neonatal outcomes reviews found no evidence that care led by midwives is different to that led by physicians. No adverse outcomes associated with midwife-led care were identified.

But really, what MisantropicPainforest said: "People will sneer that a midwife isn't a doctor and thus you don't love your child and that you're basically trusting a fortune teller with your family's health." I think that the women of metafilter are intelligent enough to read the literature for themselves and make their own decisions about their bodies and their families.
posted by PhoBWanKenobi at 4:37 PM on July 1, 2013 [2 favorites]


Thanks Mayor West, I read the whole thing.

Inflated prices on medical statements now make even less sense to me. Belk's first recommendation was to demand that hospitals stop billing at inflated rates.

Interesting new information I got out of Belk's piece:

-- Malpractice suits and malpractice insurance have been declining in frequency and cost for a decade. Malpractice insurance itself is not a particularly significant cost for doctors. But the dread of facing a malpractice suit does hang over them a lot.

-- Neither patients nor providers know what medical services cost. Pharmacists don't know what medications cost until they key half a dozen pieces of information into a database query.

-- Pharmaceutical company "research" costs are largely advertising costs.

-- Learning to deal with insurance companies is, in Belk's opinion, the hardest part of starting a medical practice. Medicine itself is easy in comparison.

-- Doctors don't take the tack of simply refusing insurance and taking cash for service because then they wouldn't be allowed by insurance companies to order outside procedures from specialists, which would greatly diminish the doctors' ability to help their patients.

-- Getting insurance companies to pay up is so arduous that doctors hire billing companies.

-- Hospitals don't know what insurance will pay, and bill high so they don't get underpaid. If an insurance company does occasionally pay high, it motivates the hospital to keep their inflated charges.

-- People without insurance get punished by the high charges, and thus they are pushed into buying more insurance and fancier plans.

-- "Insurance companies have managed to develop an almost perfect system of 'profit through incompetence'." They lose paperwork, nail doctors for mistakes in filing etc and wind up not paying.

Health insurance looks like a beautiful business from a money point of view. You can hire cheap/incompetent employees for everyday tasks, and that results in _more_ profit. Hire expensive MBA types to run schemes like occasionally paying full billed rate for a procedure; an occasional payout motivates the hospitals to keep up their ludicrously inflated charges. Patients can't pay cash because the stated prices are way, way inflated, so they're pushed into buying health insurance. Medical providers can't do cash-only because, once enough people use health insurance, that would take away too many customers. And for a bonus: keeping everyone in the dark about actual costs puts you in position to collect the gains from improved/cheaper technology by continuing to charge the old rates while paying out less to the providers.

Maybe I understand better now how the prices on medical statements came to be so ludicrously inflated (money people in insurance companies maneuvered hospitals into doing it) and who benefits (insurance companies have control over what they pay out; insurance companies gain more customers because people on their own face inflated prices). But it still doesn't make any sense. I don't see why hospitals allowed this to happen. Did Medicare cause them to get used to accepting prices from outside? Are insurance company money types that much better at maneuvering?

I do think the ACA will fix this. A small note in the NYTimes last October said, to my surprise, that the federal government will offer two nationwide health insurance plans, one via a federal agency and one via an independent nonprofit. In other words, there was a public option in the ACA after all. It's just done "under contract" by the US Office of Personnel Management and maybe the Government Employees Health Association, rather than "directly" by the federal government, which seems like a distinction without a difference.

If everyone has insurance, and the insurance is more strictly regulated, and there are competing government/nonprofit plans, and pricing is more public due to various measures, I'd think inflated billing would lose its motivations and go away.
posted by kadonoishi at 4:38 PM on July 1, 2013 [4 favorites]


I've also read (can't find a cite) that what is considered a perinatal death in the U.S. would often be recorded as a stillbirth in other countries.
posted by Ralston McTodd at 4:41 PM on July 1, 2013


That is the net effect, yes. The uninsured, or the poorly insured (like me!) bear the brunt of our medical systems comical inefficiencies.

Just yesterday I was watching TV and a commercial for one of those "cash for America" sketchy personal loans type companies came on. In it, actors portrayed individuals describing their hard-on-their-luck circumstances that caused them to need this company's services, and how it saved them. "My car broke down!" and all that. And then one of them came up and it was "I had an asthma attack and had to go to the hospital and ended up with all these medical bills."

I scared my boyfriend yelling at this fictional TV commercial character because of how fucked up that is. 1. That our system would be ok with someone getting a terrible interest rate personal loan to pay off a medical bill and 2. That this (again, fictional) dude didn't seem to realize he could negotiate a payment plan with the hospital on much better terms that that usurious loan.

Ugh.
posted by misskaz at 4:42 PM on July 1, 2013


chalkbored, not that it's of any import at all but your daughter's birth will take place for a total cost of about £1300 for the delivery (averaged across all NHS births in England). It's been a pretty good rule of thumb for me that whenever I've seen any US healthcare bill that the co-pay is pretty much identical to what it costs the NHS to deliver the whole service. I think there are about another £1000 or so of costs involved in pre and post-natal care.
posted by ambrosen at 4:42 PM on July 1, 2013


We're paying for the very high profits in the health care sector of the economy, for lack of coordination in the health care system, for profits to insurance companies.
posted by theora55 at 4:43 PM on July 1, 2013 [1 favorite]


Health care in America is ludicrously expensive - "Considered on a cost per patient per day basis, Americans spend more than four times as much on hospital care as many other countries."

America's hospital industry prepares for upheaval - "Physician, know thy costs: The reforms, and the other pressures on the hospitals, have prompted them to launch a big efficiency drive."
posted by kliuless at 4:56 PM on July 1, 2013


That is what the Court system is for. Demand via discovery what the lowest they got paid for the same and call that the actual rate. 

Yeah because of course anyone who's struggling with medical costs can afford more time off work and all the other hassles and expenses of litigation. Especially a family with a newborn. Perfectly reasonable solution for most people.
posted by saulgoodman at 6:09 PM on July 1, 2013


I miscarried at 4 months, had good insurance and paid well over $1000 out of pocket. I can't even imagine how much it would have cost if I'd carried to term.
posted by Foam Pants at 6:10 PM on July 1, 2013 [1 favorite]


There is a trend called Unaccompanied Childbirth that enrages me and I believe fear of costs contributes to it.
posted by bq at 7:48 PM on July 1, 2013 [3 favorites]



"Making women choose during labor whether you want to pay $1,000 for an epidural, that didn't seem right." Dr. Dean Coonrod, chief of obstetrics and gynecology at Maricopa Medical Center in Phoenix


Damn skippy.
posted by bq at 7:49 PM on July 1, 2013


These articles make me thank my stars for my really good insurance. I paid $100 for my delivery, and my insurance was billed for about $15k. I'd say the full cost of all baby-related medical stuff was under $300.

But I have to say, beyond all that, the best thing about my insurance is that my company has specific employees whose entire job it is to deal with insurance questions. If I thought something was billed incorrectly, I didn't call my insurance company. I dropped an email to our healthcare concierge and they consulted the insurance documentation and gave me a straight answer, in writing, that I could refer back to if wires got crossed later. This is literally a priceless service as far as I'm concerned.

I know I'm very lucky. Reading articles like this depresses me.
posted by town of cats at 8:49 PM on July 1, 2013 [1 favorite]


This is horrifying. When I had my baby nine months ago, the only thing I paid for during the entire process was for two ultrasounds, and even then they were subsidised. This is despite my waters breaking early so that I was hospitalised for six weeks (in a very nice, new and state of the art teaching facility) and my premature daughter needing to stay in the special care nursery for almost three weeks. The whole situation was stressful but I never had to worry about the cost. It didn't cross my mind even for a second.


Actually, that's a lie. I did have to pay Medicare $300 in my tax last year as always. I never appreciated how lucky we are in Australia until I started reading Metafilter.
posted by Wantok at 10:15 PM on July 1, 2013


Yeah because of course anyone who's struggling with medical costs can afford more time off work and all the other hassles and expenses of litigation

If one does not fight, one gets steamrollered.

Corporations use that to their advantage, most do not want to fight. And if you stand up, the lawyer is in house/on retainer and already being paid.

One can take the lumps or one can choose to fight back.

A one sided contract agreed to under duress with open ended pricing, sure sounds fair eh?
posted by rough ashlar at 10:21 PM on July 1, 2013


Markets are supposed to function to bring down the costs of routine services, in classical market theory. Why isn't that working when it comes to child birth?

Because people generally don't shop for healthcare based on price in the US.

Why not? Because the providers don't publish the prices. You don't find out until you've purchased already. Classic market failure due to information asymmetry.
posted by dave99 at 2:03 AM on July 2, 2013 [1 favorite]


I would also add that in many states nurse midwives are nurse practictioners with years and years of formal education, hundreds of hours of clinical experience, and master's degrees in nursing and women's health.
posted by MisantropicPainforest at 5:57 AM on July 2, 2013


dave99: People don't have the negotiating leverage needed either because medical services are often not optional and a matter of life or death. Even if people had pricing information, they will never be in a sufficiently strong negotiating posture to exert meaningful pricing influence over many medical procedures and products. It's a genuine market-failure situation that no amount of invisible hand-waving is going to make vanish.
posted by saulgoodman at 7:26 AM on July 2, 2013 [2 favorites]


One can take the lumps or one can choose to fight back.

OR, one can choose to "fight back" by working against this punitive, ridiculous system itself, as a society, not by expecting our sickest and most vulnerable members to expend energy they simply don't have to negotiate a system so complicated that even highly educated physicians need to hire consultants to manage it.
posted by KathrynT at 8:38 AM on July 2, 2013 [5 favorites]


Why not? Because the providers don't publish the prices. You don't find out until you've purchased already. Classic market failure due to information asymmetry.

Its more than that - I'll almost guarantee you that even if prices were transparent people would look at higher prices as a signal for higher quality. Its just not something the market can solve.
posted by JPD at 11:37 AM on July 2, 2013 [1 favorite]


Because the providers don't publish the prices. You don't find out until you've purchased already. Classic market failure due to information asymmetry.

It is published, just very obscure: Compare how Maine hospitals charge for common services (Bangor Daily News article with infographic)
posted by anastasiav at 1:15 PM on July 2, 2013


Hospitals and other medical providers have been "fixing" prices for payers for years......and no one has changed that....so why isn't health insurance like auto insurance? Online, competitive and telling us that we will get great service???
posted by OhSusannah at 3:56 AM on July 4, 2013






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