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August 26, 2008

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Isn't it silly for them to turn me down when I hand them just such an alternative?

No. Insurance is based on risk or reducing risk. One way insurance companies have done this is negotiating a cap on reimbursements, especially for obstetrics and pediatrics. The company reimburses hospitals one amount for a birth--regardless of method of delivery. Many people don't know that. The hospital doesn't receive more money for a c-section.

As much as you think that a home birth with a CNM will be safer for you, the truth for the insurance company is that if you do have an unforeseen event causing a transfer, the fees of transportation, ER admittance, and whatever else adds to what they must reimburse the hospital. It's economics as much as statistics, CJ.

Yuck on the threat. I didn't get one penny back from my homebirths, but they covered the NICU stays of both my boys and it would have been ugly financially if they hadn't. (For anyone reading who says, see, look how expensive homebirth can be, even the NICU docs and nurses constantly reassured us that they would have been in the NICU no matter where they were born.

Amy F., thanks for chiming in. I hadn't remembered about your NICU experiences and appreciate your perspective.

Sarabeth, I know you're closer to the whole hospital billing/reimbursement issue than I am, but I am going to need some convincing before I agree with you. My previous insurer, a BC/BS PPO, reimbursed me for (part of) my midwife's services at the out-of-network rate, no questions asked. The insurer before that, a BC/BS HMO, contracted with a group of homebirth providers to cover either homebirths or hospital births at 100%. That's part of why this is vexing to me -- the apparent randomness.

My husband is saying, and sounding oh so wise as he does, that an insurance company's business model involves accepting increased variability in favor of a lower mean. Yes, J&D found a 3% emergency transfer rate among homebirth patients. Average costs are still going to be lower among that population.

Also, if insurers are paying a flat rate regardless of delivery mode, why are we seeing stories like this? I believe that some insurers can negotiate contracts in which they reimburse at a single rate regardless of what's involved in the actual birth. But I have no idea how widespread such contracts are. The existence of different birth-related CPT codes with their various modifiers suggests to me that it's still fairly common for providers to be reimbursed at variable rates.

Somehow, I've gotten myself into defending insurers, which I don't want to do. My statement is still true depending on the company and the hospital. Certainly, the OBs only get paid one rate. The hospital probably gets more reimbursement due to the longer residency in hospitals of c-section patients. (I was one of those who got out after 48 hours, AMA. Boy were my husband's colleagues mad at me!) Are there some insurers who didn't negotiate the flat rate? Probably. Are there insurers who will cover home birth? Sure. There are probably more of them that don't. I'm in the midst of a pretty big project, so I don't have time to give you numbers.

I think the story explains itself and why some insurers refuse women who had c-sections. That's a reason for universal health insurance of some kind. Probably half of women who had c-sections would require one again if pregnant, even if OBs weren't worried about complications of VBAC. It's too much of a risk for the company (again, a reason to get away from our current health insurance system).

Personal story: I had a goal of increasing my life insurance after I had a child. I was refused because I had once been treated for a cold-induced asthma. That ICD9 code was there on my records. It was hell to get a doctor to say that I did not have asthma. Oh, let's add to that a diagnosis of gestational diabetes in my first pregnancy. Oh, that labeled me as a higher risk. Another appeal to my primary care doctor to write a letter explaining that I was not high risk. We fought for increased payout, finally getting what we wanted. I still don't fault the insurance company for being careful.

It's all about risk. I do hope, fervently, that you don't need a transfer, and that if you do, that insurance will not balk at paying for the care. After all, complications in delivery can rarely be predicted. You should clarify what they meant, and maybe put up a fight about why they won't pay for your CNM-assisted birth. Perhaps this insurer has had some catastrophic home births in the past, creating the aversion to cover the cost. Throw your data at them. It's worth a try.

Sarabeth, I think it's unlikely that I will persuade a neonatologist's wife that this is a prudent choice ;-), but I hope we can keep talking as time permits for both of us. (Life is busy here too.)

I was dreaming about this last night, a hazard of googling before bed, and I was thinking that no matter how they structure their reimbursements, there are more people to reimburse with a hospital birth: the OB, the anesthesiologist (for the vast majority of hospital births around here), the pediatrician, plus the facility fee. With an uneventful homebirth, there's just one fee. And the large majority of homebirths, esp. for multips, are uneventful.

We can agree that insurance companies generally suck even while you defend the things you find defensible. I think everybody has exasperating insurance company stories to tell. Oh, and about the stats/econ thing from your first comment: I have to think that statistics drives insurance company economics, or why would they hire flotillas of actuaries? (Hee hee, I am imagining a sea full of guys with pocket protectors and old-fashioned naval hats. (To which the lone actuary who reads this blog is going to say, "Pocket protectors???"))

Man.

You need to learn to keep your head down.

;-)

I would definitely check to see exactly what they meant by their veiled threat. I would also keep on them to get them to pay SOME of it -- use your statistics and papers and other evidence.

At least homebirth is legal there -- we know at least one family here that had an "under-the-radar" homebirth because they are not quite legal.

CJ, you are right. You will not be able to convince me, a woman who had a high-risk, fretful, and traumatic birth experience, that your choice is a good one. The fact that an athiest and someone as devout as you can even have discussions is wonderful.

I do like your image of the flotilla. Wonderful.

As for more people to reimburse, yep. That won't change how insurers view the stats, though. I have enjoyed our exchange, CJ.

CJ, this may be something for a private e-mail discussion, but I focus entirely on insurance company litigation. I do not represent your health insurer (since you don't live in my state), so it's not a conflict for me to speak with you about this.

First, as to your question about whether they will refuse to cover YOUR care if something goes awry during the homebirth, they would most likely have to prove that it is something that went awry because of the homebirth. That would be difficult for them, but the problem is that you would have outstanding medical bills and that they may force you to sue them to force them to cover the bills. That discussion is very, very long and complex and I won't get into it here. Suffice to say that it's very dangerous for an insurer to carte blanche refuse to cover services for an insured.

Now, as to the baby, they could most likely NOT refuse to cover the child's care, no matter what happened. The argument they would most likely make would go something like this: your child has (x problem) because of the homebirth, and we told you beforehand that homebirth is dangerous. It is, however, virtually impossible for a health insurer to refuse care to an infant in certain types of insurance plans (and I don't know what type you have). Anyway, this is all broad spectrum advice -- and I must qualify this by saying that I'm NOT giving you legal advice -- but I would be happy to discuss it with you in more detail privately.

I know you want a homebirth. Is there a middle ground, like a birthing center? I know that my health ins. does not cover homebirth, but they WILL cover birth in a birthing center. Thankfully there is a well-respected one right near my house, so I suppose that's what I'll be doing when I have kids.

You just made me even more grateful that my province covered my homebirth 100%. My husband and I have thought about moving in the future, but I really want to stay here until we're done having kids. The system is so good -- and if I do have to transfer there's an excellent hospital and my midwife would be with me the entire time.

I hope it all works out, CJ. It still boggles my mind that insurance companies in the States don't latch on to homebirth -- it would save them so much money.

I'm not sure how much more I'm going to argue with the insurance company. I'm already wondering if they've flagged my name -- "Review OB claims carefully." I went into this thinking we'd be paying out of pocket for the midwife's services. We paid for our first homebirth ourselves, at a time when we had very little money. (The two insurers mentioned above covered us during different parts of my pregnancy with Pete, not while I was pregnant with Joe.) Frugal soul that I am, I felt it was worth every penny even at a time when I was compelled to make pennies go a lot further.

There's something really distinctive about having a baby at home -- a tranquility that was absent for me in the hospital, a reassuring kind of ordinariness (laughing together in my living room, even in transition) coupled with a profound sense of the miraculous (not that hospital births are less miraculous -- I just felt it so keenly at home). Practically speaking, being at home and being able to use whatever comfort measures work for me has made an immense difference in my experience of pain. I honestly do not remember a minute of real pain from Pete's birth, and Elwood agrees that he had the same perception. He said he knew I was working hard, but that I never said anything stronger than "I'm really uncomfortable." (And I am not, alas, a suffer-in-silence type, so that's a pretty good indicator that it just never got painful. I remember hurting for one contraction during Joe's birth, not at all with Pete.)

Homebirthers are often criticized for valuing the experience of birth, but it's hard to explain how extraordinary the experience was for me -- simply incomparable. I didn't have the PPD issues afterward that I did with the first two; didn't have the marriage adjustment issues either. I'm pretty motivated to stay home for this birth unless I have a medical indication to go to the hospital. I'll have a talk with my midwife about whether this has been an issue previously, and a talk with the hospital, if I wind up there, about what billing info goes to insurers (i.e., just plain-vanilla CPT codes and costs, or narrative reports that would say "Pt transferred following attempted homebirth").

It would be unfortunate to have to transfer for whatever reason, and unfortunate to have to deal with billing hassles afterward, but they're risks I'm willing to assume.

Well, I'm sorry about that. I had a question, but you answered it in the last paragraph of your last comment.

I'll pray that all will go well. AND, right now I'm rooting for you on the dissertation front. You can do it!!

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