Childbirth is the most common reason for hospitalization in the United States.1 Concern is growing regarding the high and rising financial burden of childbirth for privately insured families.2 Previous studies assessing this burden have focused on out-of-pocket spending for maternal care, including hospitalizations for delivery.2 However, there are no recent national data on out-of-pocket spending across the childbirth episode, including both deliveries and newborn hospitalizations. We estimated this spending using national commercial claims data.
We analyzed 2016–2019 data from Optum’s deidentified Clinformatics Data Mart, which includes 12 million annual privately insured enrollees in all states. The University of Michigan exempted this study from human subjects review.
The unit of analysis was a “childbirth episode,” defined as a delivery linked to ≥1 newborn hospitalization covered by the same family plan. Deliveries were hospitalizations for female patients aged 12 to 55 years that began in 2016–2019 and had ≥1 claim with a birth-related diagnosis, procedure, or revenue code. These codes were based on the Pregnancy Identification Algorithm, which was developed by translating validated International Classification of Diseases, Ninth Revision, Clinical Modification codes for identifying pregnancy episodes to International Classification of Diseases, 10th Revision, Clinical Modification (ICD-10-CM).3 Newborn hospitalizations were hospitalizations for patients born in 2016–2019 that had ≥1 claim with a newborn-related diagnosis, procedure, or revenue code. These hospitalizations began on or after the admission date of deliveries but before discharge. Episodes only involved 1 newborn hospitalization unless multiple births occurred (eg, twins). Families could account for multiple episodes.
The outcome was out-of-pocket spending, defined as the sum of deductibles, co-insurance, and co-payments. This quantity represents the minimum amount families owe for childbirth hospitalizations. An additional potential source of financial liability comes from “surprise bills”, defined as charges from out-of-network providers for care at in-network hospitals. These bills were beyond the scope of this analysis but were assessed in a separate manuscript.4
We adjusted out-of-pocket spending to 2019 dollars using the Consumer Price Index for All Urban Consumers.5 For each family, we calculated out-of-pocket spending for the delivery and newborn hospitalization(s); the sum of these quantities was “total out-of-pocket spending.” We calculated mean total out-of-pocket spending and the proportion of episodes with total out-of-pocket spending exceeding $5000 and $10 000.
We conducted subgroup analyses among episodes involving cesarean birth or neonatal intensive care. All differences between subgroups were significant owing to large sample sizes; consequently, confidence intervals are not reported.
Analyses included 398 410 episodes. Deliveries in these episodes linked to 404 449 newborn hospitalizations. Mean age of mothers was 32.0 years (SD 4.6); 116 958 (29.4%) episodes were covered by high-deductible health plans (those with a health reimbursement arrangement or health savings account).
Among the 398 410 episodes, mean out-of-pocket spending for the delivery and newborn hospitalization(s) was $2281 (SD $1706) and $788 ($1654), respectively. Mean total out-of-pocket spending was $3068 ($2579) and comprised of deductibles ($1292, 42.1%), coinsurance ($1711, 55.8%), and copayments ($66, 2.2%). Spending exceeded $0 for 377 388 (95.0%) episodes and exceeded $5000 and $10 000 for 67 792 (17.1%) and 4052 (1.0%) episodes (Table 1).
Among 136 571 (34.4%) episodes involving cesarean birth and 23 360 (5.9%) involving neonatal intensive care, mean total out-of-pocket spending was $3389 ($2957) and $4969 ($5871) (Fig 1). Among the 23 360 episodes involving neonatal intensive care, 2052 (8.8%) had total out-of-pocket spending exceeding $10 000.
During 2016–2019, privately insured families paid ∼$3000 out-of-pocket for maternal and newborn hospitalizations. For 1 in 6 families, out-of-pocket spending exceeded $5000. Out-of-pocket spending was driven by deductibles and coinsurance and was higher when cesarean birth occurred. When neonatal intensive care was required, out-of-pocket spending averaged $5000 and exceeded $10 000 for ∼1 in 11 families.
Because details on plan benefit design were unavailable, the generalizability of findings to all privately insured Americans is unclear. However, the proportion of childbirth episodes covered by high-deductible health plans in this study is consistent with the prevalence of such plans among Americans with employer-sponsored insurance.6
Economic theory suggests substantial cost-sharing is justified when care is unnecessary.7 Childbirth hospitalizations, however, are not unnecessary. To avoid imposing undue financial burden on families, private insurers should improve childbirth coverage. An incremental step would be providing first-dollar coverage of deliveries and newborn hospitalizations before deductibles are met. Ideally, however, insurers would waive most or all cost-sharing for these hospitalizations, consistent with the approach taken by Medicaid programs and many developed countries.8
Findings have clinical implications. Before delivery, clinicians should counsel privately insured families to understand their childbirth benefits and to save money when possible if large bills are expected. After delivery, clinicians should screen families for financial hardship, particularly families experiencing resource-intensive hospitalizations, such as those involving neonatal intensive care.
Dr Chua conceptualized and designed the study, collected the data, analyzed and interpreted the data, drafted the initial manuscript, and reviewed and revised the manuscript; Drs Fendrick and Conti conceptualized and designed the study, analyzed and interpreted the data, and reviewed and revised the manuscript; Dr Moniz conceptualized and designed the study, analyzed and interpreted the data, reviewed and revised the manuscript, and provided study supervision; and all authors approved the final manuscript as submitted and agree to be accountable for all aspects of the work.
FUNDING: Dr Chua’s effort is supported by a career development award from the National Institute on Drug Abuse (grant 1K08DA048110-01). Dr Moniz is supported by career development award from the Agency for Healthcare Research and Quality (grant K08 HS025465). Funded by the National Institutes of Health (NIH).
POTENTIAL CONFLICT OF INTEREST: Dr Moniz reported receiving grants from the Agency for Healthcare Research and Quality and receiving personal fees from Society of Family Planning outside the submitted work; Dr Fendrick reported receiving consulting income from AbbVie, Amgen, Centivo, Community Oncology Association, Covered California, EmblemHealth, Exact Sciences, Freedman Health, GRAIL, Harvard University, Health & Wellness Innovations, Health at Scale Technologies, MedZed, Penguin Pay, Risalto, Sempre Health, State of Minnesota, Department of Defense, Virginia Center for Health Innovation, Wellth, and Zansors. He has received research support from the Agency for Healthcare Research and Quality, Arnold Ventures, Gary and Mary West Health Policy Center, National Pharmaceutical Council, Patient-Centered Outcomes Research Institute, Robert Wood Johnson Foundation, State of Michigan, and Centers for Medicare and Medicaid Services. He reports having equity in V-BID Health; the other authors have indicated they have no potential conflicts of interest to disclose.
FINANCIAL DISCLOSURE: The authors have indicated they have no financial relationships relevant to this article to disclose.