By Dmitry Dukhovny, MD MPH
A woman delivered a baby boy at 30 weeks’ gestation at a Boston hospital. After birth, the infant required a ventilator for 3 days. The family visited every day, traveling over 45 miles each way, for the first 2 weeks of their baby’s life. After her husband went back to work, the mother visited infrequently because she relied on friends and family members to transport her to the hospital, as her obstetrician did not allow her to drive herself. At three weeks of age, the baby was doing quite well; however, he still required hospital observation for several more weeks until he was mature. The parents asked to transfer their baby to a hospital closer to home. The Boston hospital attempted to do just this, but the family’s insurance provider denied the request.
Within a 20 mile radius in Boston, there are six tertiary Neonatal Intensive Care Units (NICUs) that care for sick newborns. The babies in these NICUs are born to women who live locally or are transferred from a distant hospital that could not provide the initial care of a sick newborn. Despite the large number of NICUs in a small region, these units are often filled to capacity. At times, clinicians become desperate to create bed spaces to accommodate infants about to be born. To generate more space, a well baby can be discharged home. Other babies who are stable, but still require hospital support, can be transferred to a community Special Care Nursery (SCN), known as a retro-transfer. Retro-transferred infants may require continued care in the SCN for days to months before they are ready to be discharged to home.
The concept of transferring women with a high-risk pregnancy and retro-transferring hospitalized infants is embedded in a grander picture of regionalization of perinatal services. This was first established in the 1960s and has been shown, both nationally and internationally, to reduce infant mortality. However, the retro-transfer process sometimes meets a roadblock: the insurance company. A typical, but startling, response to retro-transfer requests is that “non-emergent ambulance rides are not covered by the insurance company.” Thus, either the infant’s family or the hospital has to incur the cost of the ambulance, or the baby remains in a Boston NICU until discharge home.
The retro-transfer offers benefits to all parties involved: (1) baby is transferred to a SCN closer to home, making it easier for parents to visit; (2) tertiary NICUs have more space for high-risk admissions; and (3) the census in the SCN increases. The two hospitals can maintain a mutually beneficial relationship, ensuring that the community hospital recoups profits from the infant’s retro-transfer after losing revenue by transferring the pregnant woman to the tertiary center. While the true cost of hospital care for a baby in a community vs. a tertiary center is difficult to ascertain because of payer variation and privacy, the literature suggests that it is cheaper to provide the same level of care in the community than it is at larger tertiary centers.
Being a rationale consumer, if there is a process that is mutually beneficial to all parties and is economically cheaper for the payer, this “win-win” situation should be a no-brainer. Instead, the payer often puts up barriers by refusing to cover the ambulance ride, causing a bottleneck of patients in the tertiary NICU, and limiting the number of new babies that can be accepted. In addition, the family incurs several inconveniences: the travel distance, traffic, missed work, visiting expenses such as parking and food (some NICUs provide subsidies for families), and the emotional cost of being a significant distance from their child. And, what is the financial barrier? – The ambulance cost! Just like most healthcare rates, this cost is negotiated between payer and hospital, but typically costs at least $1,000 (a cost likely to be covered within several days because of the difference in hospital costs at a NICU vs. SCN). The NICU provides a transport nurse, and babies only require monitoring, a transport incubator (provided by the NICU), and occasionally oxygen.
I am having trouble identifying reasons why some payers reject a “non-emergent ambulance” transfer of infants. It’s illogical for two reasons: (1) the family incurs additional financial and emotional hardships; and (2) the bottom line –the payers are likely paying more money in the long run by refusing to expend the ambulance fee. If they don’t care about the former, they should about the latter.
Dmitry Dukhovny, MD MPH is an Assistant Professor of Pediatrics at Oregon Health & Science University, Neonatologist and Pediatrics Health Services Researcher.