Obstetric care is generally available in the Netherlands, but a new study finds that financial barriers remain even in a relatively well-developed health care system.
Publication Health issuesA study of high-deductible health plans (HDHPs) in the Netherlands highlighted the out-of-pocket (OOP) burden faced by pregnant women, despite universal access to the plan.1 Combined with the results of a study on HDHPs in the United States published in 2010, American Journal of Managed Care® (AJMCAccording to the Global Health Report (GHGR), economic inequalities in maternity care span both public and private systems, raising concerns about the economic vulnerability faced by pregnant women.2
The financial burden of maternity care in the Netherlands
The Netherlands has taken a major step towards improving maternity care by implementing a bundled payment model.1 In this model, health care providers were given a predetermined budget to cover antenatal, delivery, and postnatal care, creating financial incentives to coordinate care and reduce unnecessary interventions. This was one of several policy interventions undertaken to improve the coordination and quality of maternity care and reduce perinatal mortality, which was relatively high in the Netherlands compared to other European countries.
A Dutch study tested the model using quasi-experimental difference-in-difference methods between 2016 and 2018, assessing obstetric care practices in six bundled-payment regions, including a total of approximately 140,000 pregnancies.
Compared to obstetric care networks that did not participate in the bundled payment model (control group), participating obstetric care networks experienced a 2.74% increase in outpatient midwife-initiated births and a 3.52% decrease in in-hospital obstetrician-initiated births. The model also saw changes in the use of labor induction, which decreased by 1.41%, a 1.16% decrease in planned births, and a 1.33% increase in emergency cesarean sections.
Pregnant women in the US and other countries face financial strain | Image credit: Phushutter – stock.adobe.com
While the clinical changes were modest, the economic impact was more significant: total expenditures per pregnancy decreased by 5%, resulting in savings of approximately $328 per pregnancy. Despite these changes, no differences were seen in key maternal or neonatal health outcomes, such as preterm birth rates or neonatal health scores.
“Total expenditures on maternity care increased in both the intervention and control groups, but expenditures grew more slowly in the intervention group,” the study authors note. “Because of the intervention-attributable lead-on in the second half of 2016 (when the increase in outpatient births and the decline in expenditures began simultaneously), the estimated effect here is likely to be more modest.”
While the authors called these findings “initial and modest” and called for further evaluation of bundled payment models, the study also offers three major lessons for policymakers, payers, and providers considering alternative payment models.
- Bundled payments may influence provider behavior in obstetric care settings
- Bundled payment incentives vary across settings, so heterogeneity in treatment effects needs to be better understood.
- Clearly defining the goals and success criteria of a payment reform before it is implemented will help assess its effectiveness in policymaking.
The U.S. Perspective: “Double Jeopardy”
These findings add international context to the findings from U.S. studies that have revealed that commercially available HDHPs impose a significant financial burden on pregnant women.2 The authors of a cross-sectional study published in 2010 wrote: AJMC More than 1.3 million deliveries from 2012 to 2021 were analyzed.
Our findings show that a woman’s timing of giving birth can have a significant impact on out-of-pocket costs, especially if her pregnancy straddles a plan’s two-year period. This means that for pregnant Americans with HDHPs, giving birth in January could mean double the out-of-pocket costs compared to giving birth in December, because pregnancies that cross calendar years often reset deductibles and out-of-pocket limits.
Specifically, giving birth in January means out-of-pocket delivery costs are $1,310 higher than giving birth in December. Total out-of-pocket costs for the delivery period from 40 weeks of pregnancy to 12 weeks after delivery average $6,308 for a January delivery and $4,998 for a December delivery — a difference of $1,310 due to the timing of the pregnancy alone. Additionally, women whose pregnancies span multiple plan years will pay an average of $1,491 more out-of-pocket for delivery hospitalization alone, and $1,005 more over three years.
This phenomenon, called “double jeopardy,” creates arbitrary financial burdens based on the timing of childbirth, often forcing families to dip into their savings or accumulate medical debt. For women who are underserved, this can have lasting effects on both their financial well-being and their ability to seek necessary medical care.
“These expenditure differences will persist as long as enrollees’ out-of-pocket limits are not met each year,” the authors wrote. “Changing the cost-sharing limits to shorter intervals, such as a few months, could reduce arbitrary differences in cost-sharing that occur depending on the timing of pregnancy.”
A global concern
Both studies highlight similar financial challenges faced by pregnant women in the Dutch and US healthcare systems, despite significant differences between the two, and raise important questions about whether current healthcare systems are effective in protecting pregnant women from financial harm.
Addressing financial barriers to maternity care requires both systemic changes and targeted interventions: for example, a Dutch study suggests that restructuring HDHPs to include tax exemptions for maternity care could reduce the financial burden on pregnant women.1 Dutch policy experts also suggest offering income-related subsidies to reduce out-of-pocket costs for low-income families, as well as expanding the range of services covered in maternity care, such as home visits and transport.
In the United States, reform of HDHPs to prevent “double jeopardy of deductibles” has become a focus for health care advocates.2 One proposed solution is to implement a monthly out-of-pocket cap instead of an annual deductible. 2022 Survey They suggested that a monthly cap of $500 could significantly ease the financial burden on the roughly 24% of people with private insurance.3 For women seeking maternity care, this means more manageable health care costs over a longer period of care, rather than the current system where costs can escalate if a pregnancy spans multiple years.2
Both the Netherlands and the United States are grappling with financial inequalities in maternity care, making clear that no health system is immune to the complexities of cost-sharing structures. HDHPs impose an excessive financial burden on pregnant women and their families, especially when pregnancies last more than one calendar year. Both studies highlight the need for health systems to adapt to the realities of maternity care by implementing cost-sharing reforms and providing more comprehensive coverage.
References
- Scheefhals ZTM, Struijs JN, Wong A, Numans ME, Song Z, de Vries EF. Integration of obstetric care through bundled payment in the Netherlands: initial results and policy lessons. Health Affiliate (Millwood). 2024;43(9):1263-1273. doi:10.1377/hlthaff.2023.01637
- Duffy EL, Randall S, Green S, Trish E. “Double deductible risk: Patient out-of-pocket costs may increase beyond the second year of pregnancy.” Am J Management Care2024;30(6):285-288. doi:10.37765/ajmc.2024.89562
- Shafer P, Horný M, Dusetzina SB. Monthly cost-sharing limits and out-of-pocket payments for privately insured patients in the United States. JAMA Network Open. 2022;5(9):e2233006. doi:10.1001/jamanetworkopen.2022.33006
