One of the issues that Amnesty International addressed was postpartum care.  More than half of all pregnancy-related maternal deaths occur in the six weeks following birth, and yet most women aren’t seen for a postpartum checkup until the end of that time period.  The midwife we worked with for our son’s birth provided prenatal checkups at her office during the pregnancy, but once our son was born, she came to us for postpartum checkups.  We had six postpartum checkups in the first eight weeks following the birth, and for four of those visits, she came to our house.  The first postpartum visit was two days after our son was born.  We didn’t have to leave the house to take our son for checkups until he was over a month old.

The $3,000 that our midwife charged was quite a bargain, given all the service she provided.  If there had been a complication that required surgery or emergency intervention, she would have had to refer us to a hospital, but at least the problem would have stood a better chance of being caught than if I hadn’t had any postpartum care at all for six weeks after our son was born.  But in order to get that level of care, we had to pay for it ourselves (most individual health insurance policies in Colorado don’t cover maternity care, and the ones that do offer maternity don’t cover homebirths) and seek out a midwife outside of the traditional American maternity care model.

The Amnesty International report should be an eye-opener for a lot of people.  We spend a vast amount of money in this country on maternity care, and yet our results are quite poor compared with other developed countries.  Hopefully it won’t take two more decades to get back to the level of maternal death rates that we had in the 80s.

All three of these changes sound good at first glance, but the first two are not as cut and dried as they sound.  Ending gender-based pricing in the individual market would likely result in lower premiums for women, but higher premiums for men.  In Colorado, men are more likely than women to be uninsured, and raising their prices would almost certainly mean that more of them would drop their coverage.

Adding reproductive services also sounds like a good idea, but it depends on how much it would increase premiums, as many people already struggle to afford their health insurance.  For people like me, who choose to have homebirths with midwives, would we be paying for maternity coverage and still paying out of pocket for our midwives?  Would people who choose to adopt or not have children be forced to pay for maternity coverage?  Would people who would rather have a high-deductible, HSA qualified policy still have to pay for maternity coverage?  There are a lot of questions around this topic, and I still haven’t seen any solid data indicating how much health insurance premiums would increase if reproductive services were included on all policies.  Group policies in Colorado are required to cover maternity care, and the premiums are far higher than individual policy prices.  But group policies are also guaranteed issue, and it’s hard to tell how much of the premium difference has to do with underwriting and how much has to do with things like maternity care being covered on group plans and not on individual policies.  Currently there are only a handful of individual carriers in Colorado that offer maternity coverage (Rocky Mountain Health Plans, Assurant, and United Health One), and with all of these carriers, the addition of maternity coverage makes the policy significantly more expensive.  Obviously the premium difference wouldn’t be as dramatic if the coverage price were spread across the whole population via a mandate, but I am concerned that it might not be a small rate increase.

The bill that would require standardized EOBs does have my support, as does any legislation that would make health insurance benefits and claims information easier to understand and compare.  Anything that can reduce the amount of time that medical offices and consumers spend trying to figure out benefits and claim information will ultimately make our health care system more transparent and efficient.

If you have an opinion one way or another on these or any of the other bills that were introduced this week, now is the time to contact your representative.

In Carroll’s article, she described a meeting of the Health Care Task Force where the practice of gender-based pricing in health insurance was debated.  I am amazed by the comment from Rep. Jim Kerr, who explained that “women like to shop” and we should thus do a better job of shopping for our health insurance.  And by the health insurance underwriter (a male) who said we should “blame God” for the fact that women’s parts are on the inside and men’s parts are on the outside.  Seriously?  Those comments alone make me hope for gender equality in health insurance just so that we can stop having this discussion.

Senator Carroll also noted in her article that in the individual health insurance market “the rates are already significantly higher than in the small or large group market.”  This isn’t correct – in fact, the opposite is true.  In most states, including Colorado, group health insurance premiums are more expensive than individual premiums.  This is because individual plans can exclude pre-existing conditions or decline applicants with serious health issues.  In addition, group plans have more state mandated coverage (like maternity) than individual policies.  For my own family, a group health insurance plan would be twice as expensive as our individual plan (even for a policy with much higher out of pocket exposure).

It’s a common misperception that group policies are less expensive than individual policies, likely because employers pay a chunk of the group policy premium, masking the true cost of the employee’s health insurance.  The amount that is taken out of an employee’s check is not the actual cost of the health insurance.

Ideally I’d like to see homebirth midwifery legalized and regulated in every state (there are currently 12 states where it is illegal to practice as a home birth midwife).  I’d also like to see it become a recognized covered expense on any health insurance policy that covers maternity (which includes all group policies, but very few individual policies).  In Colorado, home birth midwifery is legal and regulated, but midwives still have to jump through a lot of hoops to get paid on the rare occasions when their clients’ health insurance policies cover home birth expenses.

I know that physicians tend to balk at the idea of home births.  And since the only home births they come in contact with are the ones that go wrong and require a transport to the hospital, I guess it’s reasonable that they would feel this way.  Hopefully this study will help them to recognize home births as a safe alternative for low risk pregnancies.  Of course there is a bit of a turf war involved in the stance on home birth taken by groups like ACOG and the AMA.  And as far as that goes, studies that show the safety of home births aren’t likely to have much impact.

For the last two months of her pregnancy, my friend had weekly ultrasounds, and did more than her fair share of worrying.  When the baby was born, he was immediately taken from his parents and transferred to the NICU, where he was subjected to a range of tests.  He was not allowed to nurse for the first 24 hours after he was born.

Turns out that he’s perfectly healthy.  There are no issues with his intestines, and he was discharged from the hospital without surgery or the two week NICU stay that my friend had been expecting.

I was reminded of my friend’s story when I read this article by Marya at Healthcare etc.  Was my friend’s doctor practicing defensive medicine?  Probably.  Was she just trained to see problems, and thus spotted one that turned out to be nothing?  Whatever happened, it absolutely had an impact on the healthcare costs associated with my friend’s pregnancy and birth.  Eight extra ultrasounds and 24 hours of testing and monitoring in the NICU are not cheap.  She hasn’t seen the EOBs from her health insurance company yet, but I’m sure that the cost ended up being significantly more than it would be been without the looming fear of problems that hung over the last two months of the pregnancy. Luckily my friend has health insurance, so she won’t end up paying directly for the extra care.  But all of us pay for stuff like this in the form of higher premiums.

I found Marya’s article in last week’s technology-themed Grand Rounds, hosted at Medicine and Technology.

Now we just have to get ACOG on board too.  C-section rates in the US are far higher than the World Health Organization recommends, and women here who have a breech baby are routinely herded into the OR, with little choice in the matter.  Jay was born breech, and so was his sister.  Neither was a c-section, and both turned out great (you can pay me later, Jay).  Obviously those are just two incidents (and we all know that anecdotes are not data) but had Jay and his sister been born 30 years later than they were, Jay’s mother would have been subjected to two major abdominal surgeries – which also involve risk - that she didn’t really need.

In the current quest to reform health care, everyone is talking about controlling costs.  Lowering the rate of c-sections would have a significant impact on the cost of maternity care, since vaginal births are much less expensive than surgical births.  Maternity care is something that most women eventually use, and lowered costs would translate to lowered health insurance premiums for all of us.  I have friends here in Colorado who have been subjected to routine c-sections because their babies were breech, and in one case the parents ended up paying several thousand dollars out of pocket for the birth, since the surgery was done at an out-of-network hospital.  A change in protocol for breech births seems like it would benefit mothers, babies, and health insurance companies (and all of us who pay premiums for insurance).  Let’s hope that ACOG follows in SOGC’s footsteps.

I found Amy’s article in Grand Rounds last week, hosted at Florence dot com.

The point is, there really is no one-size-fits-all when it comes to health insurance.  In terms of health care reform, unless someone just starts handing out free health care (without tax increases or premiums…), it will be tough to get people to agree on a single plan, or even a handful of coverage options.

Each state has its own regulations in terms of what all policies in that state have to cover.  The rules are different for group and individual health insurance.  In Colorado, for example, all policies have to cover well-child care, PSA testing and mammograms (based on age).  All group plans have to cover maternity, but individual plans do not.  There are a handful of individual carriers in Colorado that do offer maternity as an optional benefit (Assurant, United HealthOne, and Rocky Mountain Health Plans) but the majority of individual plans do not.  This is because the state doesn’t require it, and the market won’t support it (the premiums are expensive, and very few people choose to pay the extra premiums for maternity care on individual health insurance policies).

For people who get their health insurance coverage from their employer, there aren’t likely to be a lot of choices in coverage, but the employer is probably subsidizing a good chunk of the premiums, which makes it easier to accept whatever is offered.  For people buying health insurance in the individual market, there are lots of options, but pricing and medical underwriting can often limit the choices.

Bill Kramer has written an article about the issues involved in designing a national benefit plan.  Overall, the process and compromises involved sound a lot like what goes into designing private health insurance policies: a delicate balance between cost and coverage, targeting the widest consumer group possible.  The major advantage that the private health insurance market has in this regard is that it can implement a wide range of options, with policies ranging from bare-bones catastrophic coverage to very comprehensive “gold-plated” coverage.

If health care reform ends up involving a public, national health insurance option, it would be wise for them to offer multiple plan designs in order to give people choices in terms of premiums and coverage.  Otherwise, it’s unlikely to appeal to a large number of people.

I found Bill’s article in the Health Wonk Review, hosted this week at Health Care Policy and Marketplace Review, written by Robert Laszewski.

A friend of mine who lives in a smallish Colorado town had a c-section with her first baby after 45 hours of labor.  She wanted to try for a VBAC with baby number two, but was told that she would have to go to Denver a month before her due date and stay near one of the big metro hospitals until she gave birth.  Between her job and taking care of her toddler, that wasn’t a particularly viable option, and so she had a repeat c-section.  In fact, several of my friends had c-sections with their first babies, and all have gone on to have repeat c-sections.  They were all warned ominously that they could suffer uterine rupture if they opted for a VBAC, but none of them mentioned anything about the issues that Kathy raised in her article.

United HealthOne has changed the way they underwrite applicants in Colorado who have had a c-section.  They now charge an additional 30% on top of the standard premiums in these cases.  All health insurance carriers in Colorado cover “complications of pregnancy”, but most of them do not consider c-sections to be complications.  United does consider c-sections to be complications, but only if they are emergency c-sections (ie, not scheduled).  Since most OBs schedule repeat c-sections, it’s rare that a woman would end up with an unplanned, emergency repeat c-section.  So I was a bit perplexed by the new underwriting actions.  But after reading Kathy’s article and learning about the problems that can occur in a subsequent pregnancy following a c-section, it makes more sense.

I found Kathy’s article in the Cavalcade of Risk, hosted last week at Healthcare Manumission.

If you’re up for a little controversy, PalMD at White Coat Underground has written about conscience clauses that allow medical providers to refuse to to provide care if it conflicts with their personal beliefs.  Read the article and then scroll through the comments to see lots of different view points on this issue.  A very good point raised is that the conscience clauses tend to be invoked in matters of reproductive health.  And overwhelmingly it ends up being women’s reproductive health issues that are impacted.  Here in Colorado, a similar issue was raised last year concerning the sale of two Exempla hospitals to a Catholic organization.  It’s a touchy subject with both sides 100% convinced that their own arguments are the only valid ones.  And that makes for an interesting article and interesting comments.  Since this is my article, I’ll weigh in with my own opinion:  If you have a job that entails serving the general public (who have a wide range of beliefs that may be far different from your own) and your conscience prevents you from doing your job, you might be in the wrong profession.

I’ve written about this topic too, and overall, I will say that I agree with Bob.  Enough people are already crying uncle when it comes to health insurance premium increases.  Every time we add a new treatment to the list of things that health insurance companies are required to cover, premiums go up.  As premiums increase, more people find themselves unable to afford coverage.

But that said, I don’t think that the comparison between hair transplants and infertility treatment is completely fair.  I do see the general connection.  But hair loss happens to most men (and some women) eventually.  It’s part of the aging process, and doesn’t really indicate that anything is physically wrong with the person.  In a similar fashion, infertility happens to all women eventually, in the form of menopause.   A person with unexplained hair loss at 25 might have a physical condition that goes beyond normal hair loss related to aging.  In that case, it would be reasonable to expect the person to seek answers.  And the same can be said for people who are experiencing infertility years before the onset of menopause.

Infertility is a medical condition.  If you’ve been through it yourself or are close to someone who’s been through it, you know the heartache that it causes.  For a little more reading on the subject, there are lots of blogs that document the long and winding road of infertility.  In an ideal world, people wouldn’t have to shell out tens of thousands of dollars for infertility treatments.  But without some form of subsidization for health insurance premiums, it’s not realistic to add infertility treatment to the list of conditions that health insurance covers.  Although I would add that it probably feels like a slap in the face to infertile couples who are paying their own way through IUIs and IVFs to know that erectile dysfunction is covered by health insurance.

One of the often-overlooked benefits of health insurance is the negotiated fee schedules that are worked out between providers and health insurance carriers.   When claims are considered “covered expenses” the billed amount is almost always reduced because of network negotiated pricing discounts.  Unfortunately, infertility treatments aren’t covered expenses and don’t get repriced by health insurance networks.  Couples seeking help with infertility use credit cards, home refinancing, private loans, and life savings in order to pay the bill.  They may be able to work out deals with the clinic, or secure a great financing program – but at the end of the day, they’re on their own to pay the bill.

I agree completely with Bob’s position on low-cost treatments and health insurance: “if the cost of a “semen analysis” is reasonably low, why do we need insurance to cover the cost?“  Covering low-cost treatment doesn’t fit the definition of insurance anyway.  But for a lot of couples dealing with infertility, the semen analysis is just the beginning.

I found Bob’s article in last week’s Grand Rounds, which was hosted at In Sickness And In Health.  Barbara did a great job of putting everything together and throwing in a little sci-fi nostalgia along the way.  The Colorado Health Insurance Insider article about the nationwide nursing shortage was included in GR – thanks for hosting, Barbara!