Friday, October 7, 2016

About that $39.35 charge for holding a newborn baby

By now you've probably heard about the hospital that charged $39.35 for a woman who just had a cesarean section to hold her baby.

The baby's father posted a copy of the bill on Reddit, and it drew over 11,800 comments. The story was also widely circulated on Twitter.

At least one labor and delivery nurse on Reddit and a spokesperson for Utah Valley Hospital where the baby was born stated that the charge was not for holding the baby, but rather it was because an extra nurse had to be brought into the room to watch the baby while the first nurse took care of the mother.

I'm not buying it. The only way to justify charging for the presence of a second nurse would be if she had to be called in from home. If the nurse was already in the hospital which I'm sure she was, the five or so minutes that it would take for her to stand by while the mother holds the baby would surely not take her away from the routine duties of a labor and delivery nurse.

This is especially true for Utah Valley Hospital which delivers about 3600 babies per year. Only about 30% of them or about three per day are born by cesarean section.

And who says a second nurse is even required? Most cesarean sections are performed under epidural or spinal anesthesia. The mothers are awake and perfectly capable of holding a newborn child. An anesthesiologist or nurse anesthetist is always in the room and is primarily responsible for caring for the mother anyway.

Like most hospital charges, the $39.35 figure appears to be the product of some bean counter's imagination. Why $39.35? Why not $39.95 or $68.87?

Apparently Intermountain Healthcare (a system which includes Utah Valley Hospital) has some other interesting billing practices. This is what one Reddit commenter had to say:

Hey, I know this world: we had to pay $700 for our son to stay in my wife's room. Here, I'll explain: my wife was billed $700 per night after her c-section, and my son was also billed $700 per night for his room.

Here's the kicker: they shared the same room!! So, I thought it was a mistake, right? So I called the horrible people at Intermountain Healthcare to point out that they had billed two charges for the same room. They're
[sic] response? "We bill each patient for the full room charge." Yep, they billed my wife $700 for her room, and my baby $700 for the same room. They also doubled the nurse charges (even though, again, my baby didn't have his own nurses.)

He refused to pay, and the bill was sent to a collection agency.

Congratulations on the birth of your son.


Anonymous said...

What makes me FURIOUS about this is that the money goes to pay for ADMIN. NOT the doctors, nurses, etc. who provide the care.


Dr Umesh Bilagi said...

Because of few people our medical is getting bad name

Skeptical Scalpel said...

I don't know how the money could be given to the nurse in this scenario. He would be a salaried employee and not entitled to any extra pay. The hospital shouldn't have charged for this anyway.

I agree that this sort of thing gives medicine a bad name.

PGYx said...

Full disclosure: I'm a doctor and totally sick of our bloated medical system.

I'm all for reducing upper management pay, but I also think we need to remember the incredibly high overhead hospitals have. People often think that the services they got were worth less than the [insurance negotiated] rate and that they should get the bulk price on each medication.

We forget hospitals still have to buy/ maintain $$$ equipment and buy expensive disposable supplies in addition to paying huge electric bills, admin salaries, nursing aides, custodial staff etc. The inflated cost for an aspirin, for example, helps cover some of this. Do you expect the janitor to donate his services? I once worked for a community hospital that requested post-tax donations from staff to cover the cost of equipment. HA!

If we want to lower medical costs, we need to reduce overhead costs and upper management salaries.

Skeptical Scalpel said...

I agree with most of your points. However, I have to laugh when hospitals cry poor. If they are so impecunious, why do they spend so much money on advertising which has ben shown to be ineffective []? How can they afford to open gleaming new towers and annexes and purchase numerous properties in their neighborhoods?

William Reichert said...

This discussion aside, I hope you had a nice trip to Ireland.
Did you have any discussions about Irish / American differences in
medical care /cost with the natives?

Chris said...

I think you're right that all they had to do was grab a nurse who was already present in the hospital, i.e. there nurse was not called in from home. But I think from an admin standpoint, whenever the nurse is somewhere doing something (from giving a flu shot in the ER to standing in a room with a newborn), the hospital needs to be billing for something. A nurse is never paid in a direct way related to the procedures that they take part in, but rather are a tool of the hospital to create billable encounters.

All I'm trying to say is this is a way for the hospital to make up for the extra nurse's lost time that would have been spent doing other important procedures somewhere in the hospital (that the hospital would be billing and getting money for).

Skeptical Scalpel said...

Chris, you may be right, but here's what I think. I don't know how long the skin-to-skin session takes, but if it's 10 minutes, I doubt if the nurse was even missed from her usual post. If it's longer, then maybe someone else had to cover something for her, but still no actual money was spent so I don't see why the hospital deserves to be paid for that.

Here's an example of a similar situation. Sometimes a sick patient needs to go off the floor for an x-ray with a nurse accompanying. It might take 30 to 45 minutes, and another nurse has to cover the other patients of the nurse going to x-ray. It happens all the time. I don't think most hospitals charge for that activity.

Skeptical Scalpel said...

William, yes it was a great trip. Ireland is a wonderful country. I had lunch with a surgeon friend who gave me a tour of the Royal College of Surgeons in Dublin. It's a fantastic old building. We did discuss some of the differences in our systems. They seem fairly satisfied with theirs.

Anonymous said...

Looking forward to the Ireland trip blogs.

Skeptical Scalpel said...

Anon, I may have something for you soon.

Cutter said...

Perhaps he should be grateful that he wasn't also billed for staying in the room with his wife and child...

Skeptical Scalpel said...

Yes, they could have charged him for every minute he spent in the room even if he didn't spend the night.

Anonymous said...

MS4 here - Last year on OB/Gyn I was in a largely surgical OB rotation (MFM). We did at least 3 CS's a day. Every time they did skin to skin. The way they managed this - the nurse and or peds team took the baby from me (the med student) and did an initial exam. Then they carried the baby approximately 6 feet to the mom and stood there, spotting the baby. Then when mom was done they walked the baby 6 feet back. No extra personnel was called in. The exact people who were there anyway were capable of walking a little bit. Which makes sense since ORs don't typically accommodate staff with mobility issues. ... Not sure where the $40 cost comes in during this scenario.

Anonymous said...

My sister-in-law delivered and did the whole "room-in" thing that hospitals encourage. Her baby spent the entire 24 hours or so in the room with the mom. They had a $6K!!! nursery charge. She called the hospital to understand this since they didn't use the nursery. The charge was for the availability of the nursery!? ... I am sure the ICU was available if she had had a post-partum hemorrhage. Should they be charged for that? ... I am currently well, breathing on my own, circulating my own blood. I can't imagine what charges I am accruing for the availability of advanced life support services in my community. Wow!

Skeptical Scalpel said...

Thank you both anons for your excellent comments. Anon 1 confirms that it is possible to accomplish skin-to-skin with available personnel. No extra help is needed.

Anon 2, that is a great story. I guess I am racking up charges at my local hospital's coronary unit with stands ready if I have an MI.

Pfannenstiel said...

I'm an Ob/Gyn at a busy hospital (approx 6000 deliveries per year) and funny enough I have recently taken over one of the committees tasked with working on the skin-to-skin dilemma. I call it a dilemma exactly because of personnel issues with spotting the maternal-newborn dyad. Our goal is for skin-to-skin to last the entire time that it takes to close the incision (approximately 30-40 minutes). Yes, skin-to-skin can be a shorter duration but you could make the case that only 10 minutes is hardly beneficial to the newborn. In our hospital we are trying to not separate the new family at all. Much as the MS4 noted above, the baby is delivered and then handed off to the waiting pediatrician/nurse/respiratory tech. After the initial exam with apgars, the newborn is then supposed to be placed on the mother's chest and observed for any evidence of hypoxia and safety. Being in a completely flat and supine position without any guardrails on the OR table means that the mother cannot be left alone with the newborn.

Our anesthesiologists have adamantly declined to watch over the dyad citing their need to observe the patient and stay in touch with the surgery. The pediatrics nurse has patients in the NICU to attend to, so while in the OR has another nurse watching over his/her patients. There are two L&D nurses in the OR, one is for computer documentation and another is the circulator. So right now, the NICU nurse is supposed to watch over the skin-to-skin for the first 15 minutes, then another 3rd L&D nurse must come in to take over the last 25ish minutes. That 3rd nurse is usually the break and 'resource' nurse who acts as a helping hand in the vaginal delivery rooms to assist the primary nurse. For about a month, everyone worked well together and skin-to-skin went according to plan. But then the NICU lost a staff member and everything fell apart. The 3rd 'resource' nurse became busier as an assistant to the charge nurse. Now our patients get barely 10 minutes with their newborn before the newborn and new father are shipped off to the newborn nursery.

So one would think that with all this staffing that skin-to-skin would surely occur with each scheduled C/S (about 3-4 per day) and perhaps with unscheduled C/S as they come up, but things on L&D never seem to be straight forward.

In our OB/Anesthesia/Peds committee, we have yet to find a satisfactory personnel solution to the skin-to-skin problem. We have even talked of somehow trying to find grant money so that we can hire a dedicated person, but for what amounts to a total of perhaps 120-180 minutes of 'spotting' a day it becomes a gross waste of money to pay a highly skilled nurse not to mention a waste of their skills.

So when I heard about this $40 on my Facebook feed going to pay for skin-to-skin I actually thought that this was a paltry sum. But I also don't know how much time the new mother actually got to spend with her newborn. If indeed it lasted only 10 minutes, then $240 cost per hour would like explain the cost of an extra person.

Skeptical Scalpel said...

Pfannenstiel, thank you for your explanation. Nothing is ever as simple as it seems. I'm still not sure how the $39.35 cent charge was calculated. Are nurses making $240 per hour at your hospital? If so, I doubt you have a shortage of nurses even if it's only $120 per hour.

What happens with the skin-to-skin for moms who deliver vaginally? Don't many of them have epidurals? Or is skin-to-skin just for c section moms? How important is skin-to-skin? Does omitting it lead to poorer outcomes for mother or baby or is it just a marketing tool?

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