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The Cost of Preventive Care During Pregnancy: A Call to Action

  • Michelle H. Moniz
    Correspondence
    Correspondence to: Michelle H. Moniz, MD, MSc, 2800 Plymouth Rd., Building #10, Rm G016, Ann Arbor, MI 48109-5276. Phone: 734-764-8123.
    Affiliations
    Department of Obstetrics and Gynecology, University of Michigan, Ann Arbor, Michigan

    Program on Women's Healthcare Effectiveness Research (PWHER), Department of Obstetrics and Gynecology, University of Michigan, Ann Arbor, Michigan

    Institute for Healthcare Policy and Innovation, University of Michigan, Ann Arbor, Michigan
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  • Vanessa K. Dalton
    Affiliations
    Department of Obstetrics and Gynecology, University of Michigan, Ann Arbor, Michigan

    Program on Women's Healthcare Effectiveness Research (PWHER), Department of Obstetrics and Gynecology, University of Michigan, Ann Arbor, Michigan

    Institute for Healthcare Policy and Innovation, University of Michigan, Ann Arbor, Michigan
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  • Elizabeth E. Krans
    Affiliations
    Department of Obstetrics, Gynecology & Reproductive Sciences, University of Pittsburgh, Pittsburgh, Pennsylvania

    Department of Obstetrics, Gynecology, & Reproductive Sciences, Magee-Womens Research Institute, University of Pittsburgh, Pittsburgh, Pennsylvania
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      Perinatal care is necessary to prevent and manage adverse outcomes during pregnancy, birth, and the 12 months after delivery, as recommended by the American College of Obstetricians and Gynecologists (ACOG) and American Academy of Pediatrics (
      • Kilpatrick S.J.
      • Papile L.
      • Macones G.A.
      Guidelines for perinatal care.
      ). However, a recent study found that pregnant families incur significant expenses for perinatal care, paying $4,500 on average for maternal pregnancy and childbirth services (
      • Moniz M.H.
      • Fendrick A.M.
      • Kolenic G.E.
      • Tilea A.
      • Admon L.K.
      • Dalton V.K.
      Out-of-pocket spending for maternity care among women with employer-based insurance, 2008-15.
      ). In this study, cost-sharing—that is, deductibles, co-insurance, and co-payments for health care services—disproportionately affected those with lower incomes and chronic conditions, populations at an increased risk of adverse outcomes who may particularly benefit from health care during pregnancy. As such, cost-sharing during pregnancy may be undermining providers’ clinical responsibility to optimize the health of all pregnant individuals and infants during this critical time.
      Based on findings from the landmark RAND Health Insurance experiment (
      RAND Corporation
      RAND's Health Insurance Experiment (HIE).
      ), cost-sharing is a commonly used and effective strategy to reduce overall health care costs. Yet, although cost-sharing may reduce the use of clinically inappropriate health care, it may also inadvertently reduce the use of recommended preventive care—especially for populations living on low incomes. In a 2020 national survey (
      • Long M.
      • Frederiksen B.
      • Ranji U.
      • Salganicoff A.
      Women’s health care utilization and costs: Findings from the 2020 KFF Women’s Health Survey.
      ), one in four women overall reported having had problems paying medical bills in the past year, with higher rates of outstanding medical bills among women with lower incomes and those in poorer health. Because out-of-pocket costs are not prorated relative to income, cost-sharing may be exacerbating inequities in perinatal outcomes.
      The Affordable Care Act (ACA) sought to increase the use of preventive health care by removing cost-related barriers. Under section 2713 of the ACA, most private insurance plans are required to provide benefits and prohibit cost-sharing for preventive services for adults and children as directed by three expert medical and scientific bodies: the U.S. Preventive Services Task Force, Bright Futures for Children, and the Advisory Committee on Immunization Practices (
      Health Resources & Services Administration
      Women’s preventive services guidelines.
      ). In addition, section 2713 also directs the HRSA to specify recommended preventive services for women that insurers must cover without cost-sharing. Initially, HRSA's coverage recommendations were based on those identified in the 2011 Institute of Medicine's report “Clinical Preventive Services for Women: Closing the Gaps” (
      Institute of Medicine Committee on Preventive Services for Women
      Clinical preventive services for women: Closing the gaps.
      ). In 2016, these recommendations were reviewed and updated by the Women's Preventive Services Initiative (WPSI), an expert body of women's health experts convened by ACOG and other medical and health professional organizations to continue the work of the Institute of Medicine committee. Among a range of services, the current guidelines recommend no-cost coverage for at least one annual well-woman preventive care visit for adult women to obtain recommended, age-appropriate services, including services during pregnancy and postpartum (Figure 1) (
      Women's Preventive Services Initiative
      Recommendations for well-woman care: Clinical summary tables.
      ). The guidelines (Figure 2) also allow for additional visits, provided without cost-sharing, to obtain all recommended preventive services (
      Health Resources & Services Administration
      Women’s preventive services guidelines.
      ).
      Figure thumbnail gr1
      Figure 1Recommended preventive services during pregnancy and postpartum.
      Figure thumbnail gr2
      Figure 2National guidance for health insurance coverage of well-woman visits. HHS, Health and Human Services.
      The implementation of section 2713 gave an estimated 20.4 million women expanded coverage for preventive services in 2011 (
      • Sommers B.D.
      • Wilson L.
      ASPE Issue Brief: Fifty-four million additional Americans are receiving preventive services coverage without cost-sharing under the Affordable Care Act.
      ), leading to improved use of mammography, influenza immunization, and blood pressure and cholesterol screening—particularly among women living on lower incomes (
      • Lee L.K.
      • Monuteaux M.C.
      • Galbraith A.A.
      Women's affordability, access, and preventive care after the Affordable Care Act.
      ). Section 2713 has also led to a dramatic reduction in commercially-insured women's out-of-pocket spending for well-woman examinations and contraception, as well as improved use of these services (
      • Becker N.V.
      • Polsky D.
      Women saw large decrease in out-of-pocket spending for contraceptives after ACA mandate removed cost sharing.
      ;
      • Dalton V.K.
      • Carlos R.C.
      • Kolenic G.E.
      • Moniz M.H.
      • Tilea A.
      • Kobernik E.K.
      • Fendrick A.M.
      The impact of cost sharing on women's use of annual examinations and effective contraception.
      ). Despite these advances for the non-pregnant population, individuals are still paying out-of-pocket for preventive care during pregnancy (
      • Moniz M.H.
      • Fendrick A.M.
      • Kolenic G.E.
      • Tilea A.
      • Admon L.K.
      • Dalton V.K.
      Out-of-pocket spending for maternity care among women with employer-based insurance, 2008-15.
      ), suggesting that Section 2713 has not been implemented as intended to protect against the costs of recommended perinatal care.

      Challenges for Implementing Section 2713 for Pregnancy and Postpartum Care

      Three key challenges make it difficult to fully implement Section 2713 and eliminate financial barriers to preventive care during pregnancy: 1) lack of clarity in HRSA and WPSI guidance, 2) current payment models for perinatal care, and 3) inadequate research about optimal prenatal care delivery.
      • 1.
        Lack of clear HRSA and WPSI guidance regarding coverage for prenatal visits. HRSA identifies no-cost coverage of well-women visits as a mechanism to assure that women obtain preventive services during pregnancy without cost-sharing. Current guidance requires first-dollar coverage of specific perinatal services (Figure 1) identified by U.S. Preventive Services Task Force, WPSI, and Advisory Committee on Immunization Practices, but does not include all recommended routine care for pregnant and postpartum individuals. For example, under current guidance, families may face cost-sharing for ultrasound examinations, genetic testing, and prescription medications. Additionally, the guidelines do not specify whether all visits during pregnancy are considered preventive services. Thus, it is unclear whether prenatal visits that do not provide a specified preventive service should be covered first-dollar as HRSA-defined well-woman preventive care. Similarly, it is unclear whether visits or other services to manage chronic conditions (i.e., hypertension, diabetes) in pregnancy should be covered at first-dollar because they prevent adverse birth outcomes for mother and infant. This is a particularly important area of uncertainty, because approximately one in five pregnant individuals has a chronic condition, as we demonstrated in analysis of a large national sample of commercially insured pregnant women in 2018 (Table 1), and these individuals are at greatest risk for adverse outcomes and death. Investment in preventive care and cost-sharing protections for women with these conditions is likely to yield important improvements in outcomes.
        Table 1Select Chronic Conditions Among Delivering Population in Clinformatics and MarketScan, 2018
        Authors' own analysis of Clinformatics and MarketScan datasets—large, national samples of employer-based insurance enrollees with claims for all outpatient prescription fills and all medical use, including in primary care offices, specialist offices, hospital outpatient departments, urgent care centers, retail clinics, ambulatory surgery centers, emergency departments, home visits, community hospitals, and academic hospitals.
        Maternal Chronic ConditionsClinformatics (n = 82,508)MarketScan (n = 271,852)
        Any condition16,829 (20.6)43,457 (19.5)
        Perinatal mood and anxiety disorders
        Includes depression and anxiety.
        7,263 (8.9)15,916 (7.1)
        Chronic hypertension4,063 (5.0)12,605 (5.65)
        Pre-existing diabetes2,230 (2.73)6,336 (2.84)
        Respiratory disease3,086 (3.78)7,458 (3.34)
        Substance use disorder968 (1.19)2,221 (1.0)
        Other
        Includes chronic heart, chronic liver, chronic renal, HIV, pulmonary hypertension, and sickle cell disease.
        3524 (4.3)9,275 (4.2)
        Data presented as number (%).
        Authors' own analysis of Clinformatics and MarketScan datasets—large, national samples of employer-based insurance enrollees with claims for all outpatient prescription fills and all medical use, including in primary care offices, specialist offices, hospital outpatient departments, urgent care centers, retail clinics, ambulatory surgery centers, emergency departments, home visits, community hospitals, and academic hospitals.
        Includes depression and anxiety.
        Includes chronic heart, chronic liver, chronic renal, HIV, pulmonary hypertension, and sickle cell disease.
      • 2.
        Current payment models for perinatal care. Prenatal care is often billed through bundled or global payment codes, based on fewer than four, four to seven, or more than seven prenatal visits. Because multiple services are bundled and billed together with these codes, health plans may not be able to “see” individual preventive services for which pregnant people should have no cost-sharing. This practice may result in individuals being charged out-of-pocket costs for prenatal services that should be provided without cost-sharing under Section 2713 protections. For example, a plan could impose deductible payments for prenatal visits needed for the provision of screening laboratory studies designated as preventive services for which there should be no cost-sharing. In addition to these challenges posed by payment models for prenatal care, the increase in high deductible plans over the last decade has also translated into increasing out-of-pocket costs for health care more broadly among commercially insured individuals (
        • Cohen R.A.
        • Zammitti E.P.
        High-deductible health plan enrollment among adults aged 18-64 with employment-based insurance coverage.
        ;
        Employee Benefit Research Institute
        Trends in cost sharing for medical services, 2013–2018.
        ;
        Kaiser Family Foundation
        2019 employer health benefits survey.
        ;
        • Rae M.
        • Copeland R.
        • Cox C.
        Tracking the rise in premium contributions and cost-sharing for families with large employer coverage.
        ). As a result, commercial insurers can and do shift a substantial proportion of perinatal costs to families. We conducted an analysis of commercially insured women undergoing childbirth in 2018 to evaluate out-of-pocket spending for health care during pregnancy. We found high mean out-of-pocket spending, including mean co-payments of $221, mean co-insurance payments of $1,250, and mean deductible payments of $1,286 (Table 2). Women in low-income households and those with chronic conditions notably experienced higher than average co-payment, co-insurance, and deductible spending for perinatal care. Such high medical bills may limit families' ability to pay for other necessary expenses such as food and rent and to obtain preventive health care during the first year postpartum (
        • Collins S.R.
        • Gunja M.Z.
        • Aboulafia G.N.
        U.S. health insurance coverage in 2020: A looming crisis in affordability.
        ;
        • Collins S.R.
        • Rasmussen P.W.
        • Beutel S.
        • Doty M.M.
        The problem of underinsurance and how rising deductibles will make it worse.
        ;
        Consumer Financial Protection Bureau
        Consumer credit reports: A study of medical and non-medical collections.
        ;
        Consumer Financial Protection Bureau
        Market snapshot: Third party debt collections tradeline reporting.
        ;
        • Hamel L.
        • Norton M.
        • Pollitz K.
        • Levitt L.
        • Claxton G.
        • Brodie M.
        The burden of medical debt: Results from the Kaiser Family Foundation/New York Times Medical Bills Survey.
        ;
        • Himmelstein D.U.
        • Lawless R.M.
        • Thorne D.
        • Foohey P.
        • Woolhandler S.
        Medical bankruptcy: Still common despite the Affordable Care Act.
        ).
        Table 2Mean Out-of-Pocket Spending for Women's Pregnancy Services, 2018
        Authors' own analysis of Clinformatics dataset—a large, national sample of employer-based insurance enrollees with claims for all outpatient prescription fills and all medical use, including in primary care offices, specialist offices, hospital outpatient departments, urgent care centers, retail clinics, ambulatory surgery centers, emergency departments, home visits, community hospitals, and academic hospitals.
        Spending TypeOverall (N = 82,508)Women in Low-Income Households
        Household income <250% Federal Poverty Level.
        (n = 12,122 [15%])
        Women with Chronic Conditions (n = 16,829 [21%])
        Co-payment$221 (293)$249 (343)$307 (372)
        Co-insurance$711 (1250)$780 (1416)$963 (1450)
        Deductible$1286 (1316)$1316 (1338)$1530 (1474)
        Data presented as mean (standard deviation).
        Authors' own analysis of Clinformatics dataset—a large, national sample of employer-based insurance enrollees with claims for all outpatient prescription fills and all medical use, including in primary care offices, specialist offices, hospital outpatient departments, urgent care centers, retail clinics, ambulatory surgery centers, emergency departments, home visits, community hospitals, and academic hospitals.
        Household income <250% Federal Poverty Level.
      • 3.
        Existing gaps in evidence-based recommendations regarding perinatal care delivery. National guidelines (
        • Kilpatrick S.J.
        • Papile L.
        • Macones G.A.
        Guidelines for perinatal care.
        ) from ACOG and American Academy of Pediatrics currently recommend 12 to 14 in-person prenatal visits for low-risk pregnancies—a visit schedule that has not changed since the 1930s. Although we have strong evidence for what preventive services should be delivered during pregnancy (e.g., diabetes screening, maternal vaccination), we have far less evidence for how to deliver them (i.e., visit frequency and modality [in person vs. telemedicine]). The preponderance of bundled and global billing makes it challenging to reliably ascertain prenatal visit count and modality in most administrative data sources, which precludes rigorous evaluation of the effectiveness of prenatal care delivery models. The WPSI requires that preventive services recommendations be informed by high-quality evidence, so these data gaps directly affect capacity to implement the ACA's preventive services provision as intended for pregnant and postpartum individuals.

      Our Call to Action

      Fully realizing the ACA's goal of making health care affordable during pregnancy and postpartum requires intentional action by HRSA, researchers, and policymakers.
      • 1.
        The WPSI can clarify HRSA guidance about coverage of preventive services during pregnancy, so that less is left up to interpretation by plans or providers. Because HRSA updates its guidelines for no-cost coverage of women's preventive services every 5 years, it is time for WPSI to reconsider what types of services for pregnant women should be considered “preventive.” We believe that all pregnancy-related care should be considered preventive, to ensure universal access, promote equity, and optimize outcomes for all parents and their children. Requiring first-dollar coverage of all health care during pregnancy and the year postpartum would simplify guidance and could thereby facilitate more effective and equitable implementation across the country. At a minimum, WPSI guidance should also consider classifying services and medications used to manage chronic disease as preventive services in pregnancy. This change could have a significant impact on families' use of recommended care and would align with recent guidance from the Department of Treasury that allows high-deductible health plans to classify certain chronic disease management services as preventive and thereby cover them before meeting the plan deductible (
        Internal Revenue Service
        Additional preventive care benefits permitted to be provided by a high deductible health plan under § 223.
        ). Such changes could have profound benefits for the 1 in 3 women in low-income households who have private insurance coverage (
        Kaiser Family Foundation
        Women's health insurance coverage.
        ).
      • 2.
        Researchers must fill knowledge gaps related to the effect of cost-sharing on maternal and infant health outcomes, including morbidity and mortality. We need additional research to clarify women's price sensitivity for recommended services during pregnancy and the effects of cost-sharing on birth outcomes and disparities in these outcomes. It is currently unknown, for example, whether a woman who incurs cost-sharing expenses for hypertension is less likely to use recommended services to manage hypertension during pregnancy and whether this affects maternal morbidity and birth outcomes. Cost-sharing may compound other health care access barriers facing women in rural settings, low-income households, and minoritized racial/ethnic groups—potentially leading to underuse of recommended care and worsening of health outcomes and outcome disparities.
      • 3.
        Researchers must also generate a more robust evidence base to inform new prenatal care delivery models. Reduced visit schedules and hybrid models including both in-person and telemedicine visits have emerged during the COVID-19 pandemic and hold promise to improve the value and effectiveness of prenatal care delivery, but the evidence base remains sparse. Because global and bundled billing makes it challenging to reliably “see” prenatal visit count and modality in administrative claims data, it will be crucial to conduct robust, electronic medical record-based studies to better elucidate which components of prenatal care are effective. Partnerships with payers to evaluate the impact of innovative coverage models for prenatal care are another opportunity to advance this literature.
      • 4.
        Policymakers must consider innovative solutions to address the affordability of health care during pregnancy and postpartum. The ACA's preventive services provision was part of a broader goal to improve health care affordability. Preventive services during pregnancy, while often costly for families, are not the most important socioeconomic vulnerability for many peripartum families—rather, it is the vastly more expensive maternal and infant hospitalization for childbirth, particularly for births with adverse outcomes (
        • Acharya Y.
        • Hillemeier M.M.
        • Sznajder K.K.
        • Kjerulff K.H.
        Out-of-pocket medical bills from first childbirth and subsequent childbearing.
        ;
        • Moniz M.H.
        • Fendrick A.M.
        • Kolenic G.E.
        • Tilea A.
        • Admon L.K.
        • Dalton V.K.
        Out-of-pocket spending for maternity care among women with employer-based insurance, 2008-15.
        ). Providing services that can reduce the need for costly care, such as a cesarean delivery for one in three mothers (
        Centers for Disease Control and Prevention
        Births – Method of delivery.
        ) and intensive care for 1 in 10 infants (
        March of Dimes Perinatal Data Center
        Special care nursery admissions.
        ), is not only crucial to prevent and manage adverse perinatal outcomes, but may save costs in the long term. It is incumbent upon policymakers to consider innovative solutions to address families' costs for childbirth, such as policies that reduce costs overall by incentivizing positive outcomes, high levels of safety, and provision of recommended services, as well as policies that shift the burden of childbirth-related costs away from families.

      Conclusions

      Nine in 10 women use perinatal care during their lifetime (
      • Livingston G.
      They’re waiting longer, but U.S. women today more likely to have children than a decade ago.
      ;
      Truven Health Analytics
      The cost of having a baby in the United States.
      ). There are devastating health and personal costs associated with poor maternal and infant health outcomes. Maternity care includes many services that prevent adverse maternal and infant health outcomes and promote the health and well-being of families. Some of these services are formally defined as preventive by the ACA, while others are effectively preventive (e.g., services to prevent complications related to chronic diseases during pregnancy). National leaders in maternity care delivery, research, and policy must act now to better protect families from the costs of pregnancy and postpartum services. Doing so can increase use of recommended care and improve outcomes for pregnant people and their families.

      Acknowledgments

      Michelle Moniz receives support from the Agency for Healthcare Research and Quality (AHRQ), grant #K08 HS025465. Vanessa Dalton receives support from the AHRQ, grant #R01 HS023784. AHRQ played no role in study design; in the collection, analysis and interpretation of data; in the writing of the report; and in the decision to submit the article for publication. Elizabeth Krans is an investigator on grants to Magee-Womens Research Institute from the National Institutes of Health, Gilead, and Merck outside of the submitted work.
      Vanessa Dalton is a paid contributing editor for the Medical Letter and an author for Up-to-Date. She has also served as a consultant for Bind, an expert witness for Merck, and has participated on study sections for the National Institutes of Health and Agency for Healthcare Research and Quality. Michelle Moniz is a paid consultant for RAND and the Society of Family Planning. Elizabeth Krans reports no conflicts of interest.
      Michelle Moniz had full access to all the data in the study and takes responsibility for the integrity of the data and the accuracy of the data analysis.

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      Biography

      Michelle H. Moniz, MD, MSc, is Assistant Professor, Department of Obstetrics and Gynecology and Institute for Healthcare Policy and Innovation at the University of Michigan. Her research evaluates health care reform's impact on women's access, use, and costs for care.

      Biography

      Vanessa K. Dalton, MD, MPH, is Professor, Department of Obstetrics and Gynecology, Institute for Healthcare Policy and Innovation, and Program on Women's Healthcare Effectiveness Research at the University of Michigan. Her research addresses family planning service utilization and costs.

      Biography

      Elizabeth E. Krans, MD, MSc, is Assistant Professor, Department of Obstetrics, Gynecology and Reproductive Sciences at the University of Pittsburgh. Her research seeks to improve health care delivery processes for women with psychosocial risk factors such as substance use.