SALT LAKE CITY — The price of childbirth keeps going up — for insured moms and their families.

Even folks with great insurance may experience sticker shock at the cost of having a baby these days because they are paying more of that cost. The average out-of-pocket spending for maternity care rose 49% from 2008 to 2015, driven largely by insurance deductibles, according to an analysis of national data by researchers at the University of Michigan published in the journal Health Affairs.

“I was seeing in my clinical practice that women who had good health insurance through their job — even Cadillac insurance — were worried about the cost of care,” said Dr. Michelle H. Moniz, an OB-GYN and assistant professor in the Department of Obstetrics and Gynecology at University of Michigan in Ann Arbor. “I wondered what was going on and if it was playing out nationally.”

To figure that out, Moniz and colleagues looked at 657,061 women who had employer-based health insurance and who gave birth between 2008 and 2015 (the last year complete data was available), adjusting the cost for inflation. Using insurance claim data, they analyzed costs incurred for care starting 12 months before the delivery through three months after. The researchers wanted to capture all related pre-pregnancy expenses; many women seek care and advice prior to becoming pregnant to address related issues and optimize the outcome, Moniz said. Three months after delivery would pick up pregnancy complications and pregnancy-related conditions.

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The study said the average patient share of costs for vaginal deliveries rose from $2,910 to $4,314 over the course of the study period, while their share for C-section deliveries rose from $3,364 to $5,161. The average cost for all, regardless of delivery method, was $3,069 in 2008 and $4,569 in 2015.

Almost all the women had some out-of-pocket costs associated with maternity care. But “the magnitude of that expense was really striking to us,” said Moniz. “I was not expecting that — and I don’t think a lot of my patients have that kind of money saved up and ready to go in case of health care expense.”

The standardized cost of maternity care was actually pretty stable over that time period, so while it was clear the share patients pay for the birth of a child was rising, it took a little digging to figure out why. The findings were simple: The women were shouldering a higher proportion of the cost of having a baby, primarily through deductibles.

The study

About 55% of women having babies with coverage have insurance through the commercial marketplace, while about 45% have Medicaid, which covers costs for very-low-income women.

The Affordable Care Act was supposed to make screenings and treatments related to pregnancy more readily available, telling insurance companies they had to cover those costs. But it also said they could make patients pay copays, coinsurance and deductibles.

Insurers took that to heart. The increase in out-of-pocket costs for insured patients skyrocketed.

Deductibles are an amount one must pay on health care before insurance begins to cover costs. Coinsurance is a percentage of costs paid by the insurance and the insured person, respectively. For instance, the insurer might pay 70% and patients 30% of whatever costs the insurance covers. On deluxe plans the breakdown might be 90% and 10%. Copayments tend to be flat fees the insured person pays for a certain service, like $25 for an office visit and $100 for the emergency room.

Among study highlights:

  • The share of women with deductibles rose from 68.5% in 2008 to 86.6% in 2015.
  • There were also increases, albeit smaller, in the share of women with coinsurance payments. And some women had to pay all three: deductibles, copayments and coinsurance.
  • The share of women with any out-of-pocket maternity spending was 98.2% in 2015, compared to 93.7% in 2008.
  • In 2015, household income made virtually no difference in average out-of-pocket maternity spending. A mere $2 separated the average predicted spending for lower-income and higher-income working women.

“Maternity coverage is important for healthy mothers and babies,” the study authors wrote. “This is especially true in light of growing rates of chronic conditions among women presenting for childbirth. Financial burdens place women at risk for delaying or deferring maternity care. ... Late or insufficient prenatal care increases the risk of maternity complications, including prematurity and stillbirth. Inadequate postpartum care may lead to poor management of postpartum depression and chronic conditions.”

Seeking care

Maternity care providers are seeing more complex maternity cases, from more women giving birth for the first time at older ages to an increased number of women with chronic conditions like asthma, high blood pressure, diabetes and substance use disorder, Moniz told the Deseret News.

They need to be treated for those conditions to ensure good pregnancy outcomes, she said, adding one reason they studied data on births from 12 months before to 3 months after delivery was because services sometimes aren’t billed as pregnancy related, though they are.

While out-of-pocket costs have gone up, some steps help lower overall costs, starting with getting early prenatal care and following doctor’s orders.

Intermountain Healthcare takes systemic action to lower costs, using evidence-based medicine, according to Anne-Marie Savage, executive director for Obstetrics and Neonatal Operations for the Utah-based health care system.

“With evidence-based practice, the goal is to provide the highest quality of care at the lowest cost to patients. We’re very sensitive to costs, because we know more moms have more out-of-pocket costs than ever before,” she said.

Among other steps, Intermountain documents patients’ past pregnancy history as part of a process to create a “risk score” that can help decide some aspects of care.

“Most pregnancies are low-risk and without complications,” said Jean Millar, executive clinical director for women and newborns at Intermountain. “For those, the length of stay is probably the biggest component of cost.”

While standardized costs are pretty stable, that doesn’t mean some individuals don’t have higher costs. When women must be seen more often for complex health issues, costs go up. An abnormality in the baby’s development can increase costs, especially if a specialist is needed. Delivery by caesarian section, more common in some parts of the nation than others, also drives higher costs.

There are also conditions that can develop after delivery, like postpartum depression or pregnancy-related high blood pressure or heart failure, among others, that drive up an individual’s maternity costs.

The cost of medication, of labor, how long someone is in the hospital, whether a mom is older and her case more complex, the fact that health care providers see more moms who are sick and thus need more services and sometimes longer hospitalization all push costs up on an individual basis, Savage said.

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If a mother has high blood pressure, diabetes, obesity or other conditions, that can also impact baby’s health, and thus pregnancy-related costs, Millar said.

The industry has taken steps, too, to protect both patient safety and to lower costs. The Association of Women’s Health, Obstetric and Neonatal Nurses, a national nursing organization, recommends moms go into labor naturally, rather than inducing labor. That can reduce risk, length of stay and the need for intervention, Savage said. Also, The Joint Commission recommends no elective labors before 39 weeks unless there’s a medical condition that makes it necessary.

Such measures inevitably improve costs, Savage said.

Experts believe reducing complications and lowering costs could lead to lower insurance costs and reduced deductibles. They could certainly slow the rate of cost increases.

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