You Get What You Pay For: A Tale of Two Pregnancies

The Canadian woman couldn’t get her first appointment for eight months, although it was free. The American got an appointment right away, but it cost a fortune. Kira Peikoff at Slate:

When [Canadian patient, Laura Davis,] discovered that she was 10 weeks pregnant, she went to her regular doctor to get a referral to an OB-GYN. She was a healthy woman with a normal pregnancy, so her specialist visit was not prioritized by the system. It was so low a priority, in fact, that the first available OB-GYN appointment was when she was eight months pregnant. This is the norm, according to Davis. Until you’re a few months away from your due date, you’re seen by only your general practitioner. A study conducted in 2012 by the Fraser Institute, a leading Canadian public policy think tank, found that the median wait time in Newfoundland across all specialties from a patient’s initial visit with a general practitioner to treatment by a specialist is 26.8 weeks. “The problem is wait times,” Davis says. “Even if you have money, you can’t buy a faster appointment. If you have a high-risk pregnancy, you would get in a lot quicker, but for a normal one, you probably wouldn’t get in until your last trimester.”

[U.S. patient, Julie Bryant] decided it was time to pay out of pocket to see a better doctor — and since she lives in the U.S., she could. So she found a blog on which New York women leave comments about their experiences with different OB-GYNs, and then made an appointment with Dr. Janice Marks for the very next day. Dr. Marks’ practice is completely private; the reason she doesn’t take insurance, according to Bryant, is that she doesn’t have to. Marks initially spent an hour and a half talking to Bryant about the plan for her care, asking her preferences, and reassuring her. During the following months, which included a scare involving early contractions around 22 weeks, Bryant was always able to reach Marks personally within minutes through her answering service. Marks even called her unprompted during a vacation in Colorado just to check up on her. The total cost out-of-pocket to Marks for all of Bryant’s visits? $12,500.

Comments (14)

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  1. Tommy says:

    What does this prove? Not much, actually. Both scenarios aren’t complete representations of both systems, which both have their flaws and benefits.

    • Dewaine says:

      “This is the norm, according to Davis.”

      But, you’re still right that we’d need more comprehensive study.

  2. John Fembup says:

    “The American got an appointment right away, but it cost a fortune.”

    People who can afford to pay get better stuff and better services.

    So, is it fair to take from the people who can afford to pay, and give to the people who cannot? Does that work? Is that a solution to the unfairness of life? Is it a solution if the taking is disguised as government, collective, action rather than something more direct like, you know, robbery?

    Just askin.

    • Samuel says:

      The other solutions perhaps is war? At one point will those who feel shafted by the society retaliate with violence? Lots of questions.

  3. Samuel says:

    Well, if you don’t have a fortune, then it’s impossible to get care — you don’t really have the option, either.

    • Dewaine says:

      Exactly, the system is broken. Universal health care (Canada) is bad and so is debilitating government involvement (US). We need less government.

  4. August says:

    Before she decided to pay for a private doctor,

    “Bryant, then 34, initially chose to see a practitioner at a clinic that accepted her insurance. “But she never remembered anything about me from visit to visit,” Bryant recalls. “She spent no more than three minutes during our appointments.””

  5. Linda Gorman says:

    Where’s the cost for the Canadian visits? Or are we supposed to believe that they are all free?

    And did the $12,500 include delivery and postpartum follow-up?

    The problem with the Canadian set-up is that most pregnancies are normal–until, all of a sudden, they aren’t.

  6. Dennis Byron says:

    Oddly, for a reason unrelated to healthcare insurance research, I recently came across the 1968 “global-payment, value-based” $450 bill from our then GP for the care of my wife during her first pregnancy, his delivery of our first child, and his checkup of the baby and my wife for the first three or four days (or however long they were both in the hospital).

    He practiced in a very upscale Boston suburb so we’re not talking inner-city community health center pricing here. (We didn’t live in that suburb but in the city next to it. But not the inner city.)

    As was common then, no insurance involved. (As also was common then I’m told, doctors practiced their own kind of “what can you afford” system but that was not proactively the case with us. On the other hand maybe he just looked at our 1966 Chevy Nova with manual transmission and calculated from there.)

    $450 in 1968/1969 vs. $12,500 in 2012. Just based on inflation I think the $450 would now be about $6000. There could be a lot of reasons for the differences over and above inflation: GP vs. OB/GYN? His implicit pricing system (see above)? Malpractice insurance? Decreasing demand (fewer kids being born today per woman causing something…)? The cost of med school? The effect on free-market pricing related to the fact that almost half of all children born in Massachusetts now are paid for by Medicaid?

    [I don’t want to sound old (I am) but boy things were so much simpler then.]

    • John Fembup says:

      Dennis your comment raises some great issues and suggests a perspective that younger people may be unaware of. That is, the extent to which modern medical care has evolved over just the past 40-50 years – and how significantly that evolution has increased the costs of medical care.

      Specifically, your experience with maternity and childbirth in 1968/69 is consistent with my family’s in 1972. At that time, ultra-sound was primitive; pain medications were less-effective, and the malpractice apparatus was much less intrusive. Many medical services that we pay for today just didn’t exist back then. That explains a lot of the difference between the purely inflation-adjusted cost for 1970 procedures vs their actual cost today.

      There are many more examples of evolving medical technologies not just in maternity care but in other medical fields – cat scans; mri’s; arthroscopic surgery; “scopes” of all types; echocardiograms; other modern imaging devices; whole new families of medications such as statins; etc, etc. All improve physicians’ ability to diagnose and treat – and all come with their own incremental cost.

      Aside from advancements in medical technologies, increased malpractice threats and actual lawsuits not only raise physicians’ costs, but have succeeded in driving many ob/gyn’s completely out of their practices especially in Massachusetts. How can that latter cost even be measured?

      Theoretically we might return medical cost to that former, simpler, and less-expensive level we both experienced if we could return to the simpler medical technology that existed 40-50 years ago. But that’s just not practical. We have what we have. And more is coming.

      So I think the biggest challenge America faces in financing medical care is not how medical costs might be subsidized, but how the underlying cost of medical care might become optimally efficient – without sacrificing quality that our technologies, systems, and physicians are capable of delivering.

      Tall order. Unfortunately – in my opinion – the so-called health care debate over the past 40 years, and especially in the past 4 years, failed to engage these issues.

  7. Bob Hertz says:

    Whenever I read an ugly story about Canadian medicine, the root cause often seems to be that there are just very few specialists available in the country. This applies to stories about back pain and heart pain and cancer as well as childbirth.

    Canada is not a poor country. I believe that medical education is subsidized and malpactice insurance is cheap, so a specialist in Canada would not have to make $400,000 to be happy.

    Is there a prejudice against specialists, or just mismanagement of their Medicare plan?

    This seems like an argument for vouchers versus the national HMO that is Canada.