Other issues that should be addressed:
- the need for rigorous study of open fetal surgery for other fetal anomalies
- prognostic factors for success and for complications
- long-term outcomes in neurologic development of children and fertility of mothers
- a comparison of costs between fetal and postnatal treatment.
WHAT THIS EVIDENCE MEANS FOR PRACTICE
Although we may want to intervene as early in life as possible (that is, the fetal period) to achieve the best outcomes for the child, we need to weigh the short-term benefits of intervention against the known risks that intervention poses for the mother in the current pregnancy as well as the potential implications for future pregnancies (ie, the need for all future deliveries to be by cesarean section), not to mention the unknown long-term effects of intervention on both the child and society.
Bundled payments may help us deliver higher-quality, more efficient, and less costly care
Centers for Medicare and Medicaid Services, US Department of Health and Human Services. Fact Sheet: Bundled Payments for Care Improvement Initiative. Washington, DC: DHS; 2011. http://innovations.cms.gov/Files/fact-sheet/Bundled-Payment-Fact-Sheet.pdf. Accessed December 6, 2012.
There is little question that health care in the United States needs reform. The culture of “more is better” is not sustainable economically—nor does our health as a whole reflect the amount of money that we spend on health care, compared with other countries. Although the future is not yet clear, one proposed mechanism for reform is the institution of bundled payments—the grouping of multiple services into one “episode” for payment purposes. An episode might include inpatient hospitalization for pneumonia, for example, or the grouping of surgery with post-discharge care. In obstetrics, all pregnancy care could be grouped into one episode. The concept behind bundled payments is to provide incentives to institutions and providers to delivery higher-quality, more efficient, and less costly care.
If bundled payments become the reality for obstetric care in the future, how will that affect the way we care for our patients? Instead of blindly ordering all available tests, we need to consider thoroughly whether the patient truly needs a test to improve pregnancy outcomes. We also need to consider whether other measures might be avoided safely to keep costs within the bundle. A few examples:
- Is a screening fetal echocardiogram really necessary in a diabetic woman if the ultrasound anatomy scan is sufficient to rule out any cardiac anomaly that might require intervention in the delivery room?
- How will we integrate the expense of cell-free fetal DNA aneuploidy testing and microarray analysis, not to mention the extended counseling sessions that will be necessary to explain findings of uncertain clinical significance, into the bundle? Will “low-risk” patients need to pay out of pocket?
WHAT THIS EVIDENCE MEANS FOR PRACTICE
Few physicians entered medicine to worry about costs. Most of us want to worry about our patients. Yet, the reality is that scientific curiosity and a desire to do more—and to do it sooner, faster, and safer—are no longer sufficient justifications for many clinical decisions. We soon may need to figure out how to get what we need without spending as much in the process. In doing so, we may find ourselves moving away from the computer screen and back to the bedside—where we belong.
- Will a second ultrasound scan to visualize the fetal spine in a patient with a normal alpha-fetoprotein level be included in the bundle or paid for by the patient?
These issues may seem trivial, but we can no longer afford to order every test available. We will need to spend more time examining and counseling our patients so that they feel they are still getting the best care possible.
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