Financing Maternity and Early Childhood Healthcare in The Australian Healthcare System: Costs to Funders in Private and Public Hospitals Over the First 1000 Days

Document Type: Original Article

Authors

1 Menzies Health Institute Queensland, Griffith University, Southport, QLD, Australia

2 Children’s Hospital at Westmead Clinical School, Faculty of Medicine and Health, University of Sydney, Sydney, NSW, Australia

3 Department of Maternal Fetal Medicine, Royal Hospital for Women, Randwick, NSW, Australia

4 School of Medicine, Griffith University, Southport, QLD, Australia

5 School of Nursing and Midwifery, Griffith University, Meadowbrook, QLD, Australia

Abstract

Background
Maternity care is a significant contributor to overall healthcare expenditure, and private care is seen as a mechanism to reduce the cost to public funders. However, public funders may still contribute to part of the cost of private care. The paper aims to quantify (1) the cost to different funders of maternal and early childhood healthcare over the first 1000 days for both women giving birth in private and public hospitals; (2) any variation in cost to different funders by birth type; and (3) the cost of excess caesarean sections in public and private hospitals in Australia.

 
Methods
This study utilised a whole of population linked administrative dataset, and classified costs by the funding source. The mean cost to different funders for private hospital births, and public hospital births in the Australian state, Queensland are presented by time period and by birth type. The World Health Organization’s (WHO’s) C-model was used to identify the optimal caesarean section rate based upon demographic and clinical factors, and counterfactual analysis was utilised to identify the cost to different funders if caesarean section had been utilised at this rate across Australia.

 
Results
We found that for women who gave birth in a public hospital as a public patient, the mean cost was $22 474. For women who gave birth in a private hospital the mean cost was $24 731, and the largest contributor was private health insurers ($11 550), followed by Medicare ($7261) and individuals ($3312). Private hospital births cost government funders $10 050 on average; whereas public hospital public patient births cost government funders $21 723 on average and public hospital private patient births cost government funders $20 899 on average. If caesarean section deliveries were reduced, public hospital funders could save $974 million and private health insurers could save $216 million.

 
Conclusion
Private hospital births cost government funders less than public hospital births, but government funders still pay for around 40% of the cost of private hospital births. Caesarean sections, which are more frequently performed in private hospitals, are costly to all funders and reducing them could impart significant cost savings to all funders.

Keywords


  1. Woo VG, Lundeen T, Matula S, Milstein A. Achieving higher-value obstetrical care. Am J Obstet Gynecol. 2017;216(3):250.e251-250.e214. doi:10.1016/j.ajog.2016.12.033
  2. Levy BS, Mukherjee D. Changes in obstetrics and gynecologic care healthcare triple aims: moving women's healthcare from volume to value. Clin Obstet Gynecol. 2015;58(2):355-361. doi:10.1097/grf.0000000000000099
  3. van den Berg N, Radicke F, Stentzel U, Hoffmann W, Flessa S. Economic efficiency versus accessibility: planning of the hospital landscape in rural regions using a linear model on the example of paediatric and obstetric wards in the northeast of Germany. BMC Health Serv Res. 2019;19(1):245. doi:10.1186/s12913-019-4016-2
  4. Australian Institute of Health and Welfare (AIHW). Health Expenditure Australia 2016-2017. Canberra: AIHW; 2018.
  5. Whitman E. Delivering new bundles to control cost of maternal care. Mod Healthc. 2016;46(33):8-10.
  6. Independent Hospital Pricing Authority (IHPA). Bundled Pricing for Maternity Care. Sydney: IHPA; 2017.
  7. Pomeroy AM, Koblinsky M, Alva S. Who gives birth in private facilities in Asia? a look at six countries. Health Policy Plan. 2014;29 Suppl 1:i38-47. doi:10.1093/heapol/czt103
  8. Tapay N, Colombo F. Private Health Insurance in OECD Countries: The Benefits and Costs for Individuals and Health Systems. Paris: OECD; 2004.
  9. Paris V, Devaux M, Wei L. Health Systems Institutional Characteristics. Paris: OECD; 2010.
  10. Morgan R, Ensor T, Waters H. Performance of private sector health care: implications for universal health coverage. Lancet. 2016;388(10044):606-612. doi:10.1016/s0140-6736(16)00343-3
  11. Lutomski JE, Murphy M, Devane D, Meaney S, Greene RA. Private health care coverage and increased risk of obstetric intervention. BMC Pregnancy Childbirth. 2014;14:13. doi:10.1186/1471-2393-14-13
  12. Dahlen HG, Tracy S, Tracy M, Bisits A, Brown C, Thornton C. Rates of obstetric intervention and associated perinatal mortality and morbidity among low-risk women giving birth in private and public hospitals in NSW (2000-2008): a linked data population-based cohort study. BMJ Open. 2014;4(5):e004551. doi:10.1136/bmjopen-2013-004551
  13. Coulm B, Le Ray C, Lelong N, Drewniak N, Zeitlin J, Blondel B. Obstetric interventions for low-risk pregnant women in France: do maternity unit characteristics make a difference? Birth. 2012;39(3):183-191. doi:10.1111/j.1523-536X.2012.00547.x
  14. Mossialos E, Allin S, Karras K, Davaki K. An investigation of caesarean sections in three Greek hospitals: the impact of financial incentives and convenience. Eur J Public Health. 2005;15(3):288-295. doi:10.1093/eurpub/cki002
  15. Di Lallo D, Perucci CA, Bertollini R, Mallone S. Cesarean section rates by type of maternity unit and level of obstetric care: an area-based study in central Italy. Prev Med. 1996;25(2):178-185. doi:10.1006/pmed.1996.0044
  16. Sandall J, Tribe RM, Avery L, et al. Short-term and long-term effects of caesarean section on the health of women and children. Lancet. 2018;392(10155):1349-1357. doi:10.1016/s0140-6736(18)31930-5
  17. Petrou S, Henderson J, Glazener C. Economic aspects of caesarean section and alternative modes of delivery. Best Pract Res Clin Obstet Gynaecol. 2001;15(1):145-163. doi:10.1053/beog.2000.0154
  18. Henderson J, McCandlish R, Kumiega L, Petrou S. Systematic review of economic aspects of alternative modes of delivery. BJOG. 2001;108(2):149-157. doi:10.1111/j.1471-0528.2001.00044.x
  19. Heer IM, Kahlert S, Rummel S, Kümper C, Jonat W, Strauss A. Hospital treatment - Is it affordable? a structured cost analysis of vaginal deliveries and planned caesarean sections. Eur J Med Res. 2009;14(11):502-506. doi:10.1186/2047-783x-14-11-502
  20. Clark L, Mugford M, Paterson C. How does the mode of delivery affect the cost of maternity care? Br J Obstet Gynaecol. 1991;98(6):519-523. doi:10.1111/j.1471-0528.1991.tb10362.x
  21. Xu X, Gariepy A, Lundsberg LS, et al. Wide variation found in hospital facility costs for maternity stays involving low-risk childbirth. Health Aff (Millwood). 2015;34(7):1212-1219. doi:10.1377/hlthaff.2014.1088
  22. Young D, Twaddle S, Lees A. The costs to the NHS of maternity care: midwife-managed vs shared. Br J Midwifery. 1997;5(8):465-472. doi:10.12968/bjom.1997.5.8.465
  23. Howell E, Palmer A, Benatar S, Garrett B. Potential Medicaid cost savings from maternity care based at a freestanding birth center. Medicare Medicaid Res Rev. 2014;4(3). doi:10.5600/mmrr.004.03.a06
  24. Australian Government. Medicare Levy Reduction for Low-Income Earners. Australian Taxation Office. Medicare Levy Web site. https://www.ato.gov.au/individuals/medicare-levy/medicare-levy-reduction-for-low-income-earners/.  Published 2017. Accessed October 16, 2017.
  25. Department of Human Services. Australian Government rebate on Private Health Insurance. Australian Government. https://www.humanservices.gov.au/individuals/services/medicare/australian-government-rebate-private-health-insurance#a2.  Published 2019. Accessed May 1, 2019.
  26. Australian Government. Medicare Levy Surcharge. Australian Taxation Office. Medicare Levy Web site. https://www.ato.gov.au/individuals/medicare-levy/medicare-levy-surcharge/.  Published 2017. Accessed October 16, 2017.
  27. Australian Bureau of Statistics (ABS). 4364.0.55.002 - Health Service Usage and Health Related Actions, Australia, 2014-2015. Canberra: ABS; 2017.
  28. Australian Institute of Health and Welfare (AIHW). Australia's Mothers and Babies 2015—In Brief. Canberra: AIHW; 2017.
  29. Moore TG, Arefadib N, Deery A, Keyes M, West S. The First Thousand Days: An Evidence Paper. Melbourne, Australia: Murdoch Children’s Research Institute; 2017.
  30. Callander EJ, Fox H. What are the costs associated with child and maternal healthcare within Australia? a study protocol for the use of data linkage to identify health service use, and health system and patient costs. BMJ Open. 2018;8(2):e017816. doi:10.1136/bmjopen-2017-017816
  31. Reserve Bank of Australia (RBA). Measures of Consumer Price Inflation. RBA; 2017.
  32. Independent Hospital Pricing Authority (IHPA). National Hospital Cost Data Collection, Public Hospitals Cost Report, Round 22. Sydney: IHPA; 2020.
  33. Australian Government Department of Health. Archived Private Hospital Data Bureau (PHDB) Annual Reports. http://health.gov.au/internet/main/publishing.nsf/Content/health-casemix-data-collections-publications-PHDBAnnualReports.
  34. Souza JP, Betran AP, Dumont A, et al. A global reference for caesarean section rates (C-Model): a multicountry cross-sectional study. BJOG. 2016;123(3):427-436. doi:10.1111/1471-0528.13509
  35. Zucchelli E, Jones AM, Rice N. The evaluation of health policies through microsimulation methods. In: Health, Econometrics and Data Group (HEDG) Working Papers. York: University of York; 2010. Vol 10.
  36. Bell P. GREGWT and TABLE Macros-Users Guide. Canberra: Australian Bureau of Statistics (ABS); 2000.
  37. Organisation for Economic Co-operation and Development (OECD). Caesarean Section Rates, 2013. Paris: OECD; 2015.
  38. Australian Commission on Safety and Quality in Health Care. Australian Atlas of Healthcare Variation. Canberra: Australian Government; 2017.
  39. Lee YY, Roberts CL, Patterson JA, et al. Unexplained variation in hospital caesarean section rates. Med J Aust. 2013;199(5):348-353. doi:10.5694/mja13.10279
  40. Department of Health. Changes to MBS Items for Obstetrics Services. Canberra: Australian Government; 2017.
  41. Boerma T, Ronsmans C, Melesse DY, et al. Global epidemiology of use of and disparities in caesarean sections. Lancet. 2018;392(10155):1341-1348. doi:10.1016/s0140-6736(18)31928-7
  42. Slavin V, Fenwick J. Use of a classification tool to determine groups of women that contribute to the cesarean section rate: establishing a baseline for clinical decision making and quality improvement. Int J Childbirth. 2012;2(2):85-95. doi:10.1891/2156-5287.2.2.85
  43. McLachlan HL, Forster DA, Davey MA, et al. Effects of continuity of care by a primary midwife (caseload midwifery) on caesarean section rates in women of low obstetric risk: the COSMOS randomised controlled trial. BJOG. 2012;119(12):1483-1492. doi:10.1111/j.1471-0528.2012.03446.x
  44. Johri M, Ng ESW, Bermudez-Tamayo C, Hoch JS, Ducruet T, Chaillet N. A cluster-randomized trial to reduce caesarean delivery rates in Quebec: cost-effectiveness analysis. BMC Med. 2017;15(1):96. doi:10.1186/s12916-017-0859-8
  45. Grobman WA, Rice MM, Reddy UM, et al. Labor induction versus expectant management in low-risk nulliparous women. N Engl J Med. 2018;379(6):513-523. doi:10.1056/NEJMoa1800566
  46. Callander EJ, Creedy DK, Gamble J, et al. Reducing caesarean delivery: an economic evaluation of routine induction of labour at 39 weeks in low-risk nulliparous women. Paediatr Perinat Epidemiol. 2020;34(1):3-11. doi:10.1111/ppe.12621
  47. Bowden SJ, Dooley W, Hanrahan J, et al. Fast-track pathway for elective caesarean section: a quality improvement initiative to promote day 1 discharge. BMJ Open Qual. 2019;8(2):e000465. doi:10.1136/bmjoq-2018-000465
  48. Murphy J, Murray S, Chalmers J, Martin S, Marston G. Half a citizen: life on welfare in Australia. Melbourne: Allen & Unwin; 2011.