Tuesday, October 30, 2012

Thinking through the Cost of Childbirth

Dr. Lauren Demosthenes is an assistant professor of clinical ob/gyn at the University of South Carolina – Greenville.

I had lunch with my old college roommate last week She’s a new grandmother and was telling me about her daughter who lives in another state.  Her daughter is self pay because she and her husband own a restaurant and have opted out of insurance due to the cost.  She received her hospital bill in the mail and she was surprised at the cost of some of the items.  As she looked through her bill, she saw some items that she wasn’t even aware that she used.  In my county, 20% of our population is uninsured and these charges are important.
What if this was her scenario?
Doctor:  Hi Mrs Kim, so glad to see you.  I see that you are here to have your labor induced.  Welcome to our hospital.  We are going to use something to help get your cervix ready.  You have 2 choices – we have something that costs $12.00 and we have something that costs $810.  They work pretty similarly.  I kind of like the $810.00 one, but you’re paying for it. Which one would you like?
Patient:  Gee Dr. Greene.  I think I would like the $12.00 one if it’s all the same.  You see, I’m self employed and we can’t  afford health insurance so we’re self pay. I would prefer to pay $12 over $810.00.
Doctor:  That’s great.  I’ll see you in the morning on the labor floor.
Next day :  the Labor and Delivery goes well and a healthy baby boy is born with apgars of 9/9.
Doctor:  Now Ms. Kim, we’re going to draw a little test on your baby’s cord blood to make sure he is as healthy as he seems.  His fetal heart rate looked good during labor and his apgars are great, but sometimes we just like to do things to “make sure”.  It only costs $225.00 for you, but it’s a good test for us doctors to do.  It just makes us feel better and it’s what we have always done here at our hospital.
Patient:  Gee, Dr. Greene, the baby is crying and looks really good.   If it’s all the same to you, I’d like to pass on that.  I can probably use that $225.00 to buy him diapers and food and such.  But thanks for thinking of me.
Doctor:  That’s great Mrs. Kim.  Now we’re going to send you over to postpartum.  You had a few stitches and we’ll have pain medicine and ice packs and some other lotions that you can use.  You can ask for whatever you want.  We have witch hazel pads, a nice spray lotion and some foam.  The foam costs $155.00 and we use over 200 of these a month around here so I think it’s a good product.  We’ll bring all of them to you.  That way you’ll have all of them even if you don’t need them.
Patient: Gee Dr. Greene, I think I’ll try some ice and advil first. I did that with my first baby and I was fine. Like I said, I have to pay for all of this myself and I really don’t want anything that I don’t really need.
Doctor:  Sure, Mrs. Kim.  We’re here to provide the best care ever.
The scenario above is pretty much true – all except for the fact that we physicians do not typically know the costs of these items and we often do not consider cost when we write an order.
In Greenville County, where I live, nearly half of our residents are either uninsured or have insurance but have to postpone medical care because of cost. Most of the uninsured are employed, but many aren’t offered insurance at work, while others have access to coverage but can’t afford it.
I am working on a project  to increase cost awareness among obgyn physicians.  Through this project, I believe that we can identify products, services, and tests that are unnecessary, and if eliminated, will not decrease the quality of care. I know that I can do better.  And maybe, just maybe, Mrs. Kim will leave the hospital with more money to spend on her baby.


  1. Sometimes if you refuse a common test at a hospital, in spite of otherwise healthy signs, the doctors and nurses may consider you negligent and tell CPS you are refusing care, and you may be investigated and it can led to lawyers and court cases. I would not want to scare anyone, but it happened to my brother when he asked for one less X-ray out of four on a non-life threatening condition (she was breathing and well colored and good responses, but had a little fluid left to spit out of her lungs, which came out naturally after they finally let the baby out of ICU and allowed mom hold the baby to her chest), because he was concerned for radiation exposure to his newborn daughter. They were reported to CPS anonymously by someone on staff who believed their questions about the tests indicated neglect.

    ~n.c. from NY

  2. Thanks for the great writeup. We went to a birth center that is used to dealing with cash customers. Trying to do anything with our local hospital or even primary care physician on the other hand is ridiculous, and often goes like this:

    Doctor: We need to test you for X, Y, and Z.

    Patient: Ok, well how much does that cost?

    Doctor: I don't do billing, you'll have to ask accounting.

    Patient: Ok.

    (calls accounting)

    Patient: How much is it to test X, Y, and Z?

    Accountant: You will need the medical codes for those procedures.

    (Patient calls back to the nurse, doctor to get accounting codes)

    Accountant: Ok, that will be (2.5 x $Reasonable Cost).

    Patient: Wow, that seems like a lot.

    Accountant: Well, if you call over to three other departments, there may be a cash prepay discount that gets your price down to about the level we eventually get reimbursed from the insurance providers.

    etc, etc, etc...

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    Hope this helps!

    - Jaclyn


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