eAppendix 1. Details on identifying study sample
eAppendix 2. Codes used to identify Cesarean delivery and neonatal intensive care claims
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Chua K, Fendrick AM, Conti RM, Moniz MH. Prevalence and Magnitude of Potential Surprise Bills for Childbirth. JAMA Health Forum. 2021;2(7):e211460. doi:10.1001/jamahealthforum.2021.1460
In 2022, federal legislation will protect families from most surprise bills,1 which are defined as charges for out-of-network-care at in-network facilities.2-4 To illustrate the potential benefits of this legislation, we estimated the frequency and magnitude of surprise bills for deliveries and newborn hospitalizations, which are the leading reasons for hospitalization in the US.
We analyzed 2019 data from Optum’s deidentified Clinformatics Data Mart, which includes 12 million privately insured enrollees in all states.5 Analyses included families with an in-network delivery in 2019 that could be linked to 1 or more in-network newborn hospitalization that was covered by the same family plan (eAppendix 1 in the Supplement). We only included 1 delivery per family. Deliveries were linked with 1 newborn hospitalization unless multiple births occurred (eg, twins). As data were deidentified, this study was exempted from human participants review by the institutional review board of the University of Michigan Medical School; informed consent was not required. This study follows the Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) reporting guidelines for cross-sectional studies.
Potential surprise bills were defined as professional claims from out-of-network clinicians and ancillary service providers (eg, ambulance providers). We estimated the liability for these bills by subtracting typical in-network reimbursement from charges.2-4 Among families with 1 or more potential surprise bill for the delivery, newborn hospitalization(s), or both, we calculated the median total liability for potential surprise bills (sum of the liability across the delivery and newborn hospitalization[s]).
To evaluate whether surprise billing protections would be more beneficial for resource-intensive hospitalizations, we assessed the frequency and magnitude of potential surprise bills among deliveries with and without 1 or more claim for cesarean delivery and among newborn hospitalizations with and without 1 or more claim for neonatal intensive care. For deliveries and newborn hospitalizations, we identified which services accounted for the greatest numbers of potential surprise bills. Analyses were conducted using SAS, version 9.4 (SAS Institute).
Analyses included 95 384 families. Deliveries for these families were linked to 96 881 newborn hospitalizations. Of all families, 17 949 (18.8%) had 1 or more potential surprise bill for the delivery, newborn hospitalization(s), or both. Among these families, the median total liability for potential surprise bills was $744 (25th-75th percentile, $138-$3823); for 6417 families (35.8%), total liability exceeded $2000.
Among 32 203 and 63 181 deliveries with and without 1 or more cesarean delivery claims, 6594 (20.5%) and 5597 (8.9%) had 1 or more potential surprise bill, with a median (25th-75th percentile) liability of $1825 ($272-$5624) and $900 ($124-$3642), respectively (Table 1). For deliveries, the service accounting for the highest share of the 32 837 potential surprise bills was anesthesia for vaginal birth (5369 [16.3%]; Table 2).
Among 5970 and 90 991 newborn hospitalizations with and without 1 or more neonatal intensive care claim, 926 (15.5%) and 8101 (8.9%) had 1 or more potential surprise bill, with a median (25th-75th percentile) liability of $1282 ($217-$10 472) and $262 ($123-$766), respectively (Table 1). For newborn hospitalizations, the service accounting for the highest share of the 35 715 potential surprise bills was neonatal intensive care (6930 [19.4%]; Table 2).
Among privately insured families with in-network deliveries in 2019, almost 1 in 5 potentially received surprise bills for maternal and/or newborn care. For these families, estimated liability for potential surprise bills averaged $744, an amount larger than the estimated liability for colonoscopy but smaller than that for surgical care.2,3 For one-third of families that received potential surprise bills, the estimated liability exceeded $2000. Surprise bills were more frequent and larger when cesarean delivery or neonatal intensive care occurred.
Our study was limited by lack of information on whether families received surprise bills or actual amounts paid. Despite this limitation, our findings suggest that federal protections against surprise bills could benefit many families, particularly when resource-intensive hospitalizations occur. Importantly, these protections will not alleviate the substantial costs of childbirth that occur even without surprise bills. In a study of privately insured women, out-of-pocket spending for maternal care between the 12 months before to 3 months after delivery averaged $4500.6 While surprise billing protections are important first steps, improvements in childbirth benefit design are needed to protect families from undue financial burden.
Notably, the high frequency of out-of-network care in our study, coupled with the fact that childbirth is the most common reason for hospitalization, suggests that childbirth hospitalizations are currently one of the most frequent sources of surprise bills in the US. Consequently, inadequate enforcement of federal protections could result in many erroneous surprise bills. Policy makers may wish to devote additional resources to enforcement for childbirth hospitalizations.
Accepted for Publication: May 11, 2021.
Published: July 2, 2021. doi:10.1001/jamahealthforum.2021.1460
Open Access: This is an open access article distributed under the terms of the CC-BY License. © 2021 Chua KP et al. JAMA Health Forum.
Corresponding Author: Kao-Ping Chua, MD, PhD, 300 North Ingalls St, SPC 5456, Room 6E18, Ann Arbor, MI 48109-5456 (firstname.lastname@example.org).
Author Contributions: Dr Chua had full access to all of the data in the study and takes responsibility for the integrity of the data and the accuracy of the data analysis.
Concept and design: All authors.
Acquisition, analysis, or interpretation of data: Chua, Conti, Moniz.
Drafting of the manuscript: Chua, Conti.
Critical revision of the manuscript for important intellectual content: All authors.
Statistical analysis: Chua, Conti.
Obtained funding: Chua.
Administrative, technical, or material support: Conti.
Supervision: Fendrick, Conti.
Conflict of Interest Disclosures: Dr Fendrick reported consulting fees from AbbVie, Amgen, Bayer, Centivo, Community Oncology Association, Covered California, Emblem Health, Exact Sciences, Freedman Health, GRAIL, Harvard University, Health & Wellness Innovations, Health at Scale Technologies, HealthCorum, Hygieia, MedZed, Merck, Mercer, Montana Health Cooperative, Pair Team, Penguin Pay, Phathom Pharmaceuticals, Risalto, Risk International, Sempre Health, State of Minnesota, US Department of Defense, Virginia Center for Health Innovation, Wellth, Wildflower Health, Yale New Haven Health System, and Zansors; research support from AHRQ, Boehringer-Ingelheim, Gary and Mary West Health Policy Center, Arnold Ventures, National Pharmaceutical Council, PCORI, PhRMA, RWJ Foundation, State of Michigan/CMS; and serving as a coeditor for the American Journal of Managed Care, member of MEDCAC, and partner of V-BID Health, LLC (Partner). Dr Moniz reported grants from Agency for Healthcare Research and Quality during the conduct of the study and personal fees from the Society of Family Planning, RAND, and the University of Pittsburgh Medical Center outside the submitted work. No other disclosures were reported.
Funding/Support: Dr Chua’s effort is supported by a career development award from the National Institute on Drug Abuse (grant number 1K08DA048110-01). Dr Moniz is supported by career development award from the Agency for Healthcare Research and Quality (grant K08 HS025465).
Role of the Funder/Sponsor: The funding organizations had no role in the design and conduct of the study; collection, management, analysis, and interpretation of the data; preparation, review, or approval of the manuscript; and decision to submit the manuscript for publication.