When Sara Laub’s period was late, the New York City resident called it quits. She had used an intrauterine device, or IUD, for three years and knew her chances of getting pregnant were extremely slim. But after 10 days had passed, Laub, 28, took a home exam in early July and received unexpected news: She was pregnant.
Laub went to a Planned Parenthood clinic because she knew someone would see her right away. An ultrasound showed no sign of a developing fetus in her uterus. This points to the possibility that Laub may have an ectopic pregnancy, where a fertilized egg implants somewhere outside the uterus, usually in a fallopian tube.
These types of pregnancies are rare, occurring about 2% of the time, but they are extremely dangerous because a growing fetus can rupture a fallopian tube, causing massive and potentially fatal internal bleeding. Laub wasn’t experiencing any pain, bleeding or other obvious signs of trouble. Still, a Planned Parenthood worker advised her to go to a hospital emergency department right away.
Laub didn’t realize it, but she began a long — and very expensive — treatment to end the pregnancy. Even in a state that strongly supports a person’s right to make their own choices about pregnancy — New York legalized abortion in 1970, three years earlier. Roe v. Wade made it legal nationwide — as Laub’s experience shows the process can be difficult.
An ectopic pregnancy in the fallopian tube is never viable. But June’s reversal followed Ro By the Supreme Court, reproductive health experts say treatment could be dangerously delayed as some states move to limit abortion services.
Some of the consequences are already being felt in Texas, where strict abortion limits were put in place last fall ahead of the Supreme Court’s decision. Because abortions are now only allowed in medical emergencies in Texas, doctors may wait to perform abortions until pregnant patients experience life-threatening complications in order to comply with the law.
“In Texas, we’ve seen people rupture unless they treat ectopic pregnancies,” said Dr. Christine Brandy, an obstetrician-gynecologist in Montclair, New Jersey, who is board chair of Physicians for Reproductive Health, which supports abortion rights.
A 2021 Texas law banned most abortions at about six weeks of pregnancy. Researchers at the University of Texas-Austin interviewed doctors about the law’s impact on maternal and fetal care. A hospital specialist, who spoke on condition of anonymity, said the facility no longer offers treatment for certain ectopic pregnancies.
About half of the states have or are trying to ban abortion.
Laub, who is being identified by his middle and last name because of privacy concerns, said he couldn’t help but think about the recent Supreme Court decision as he went through the diagnosis and treatment.
“As scary as my ordeal felt, I was acutely aware that I was fortunate to have easy access to treatment, and that women with my condition elsewhere have far worse experiences,” Laub said.
In the emergency department of Lennox Hill Hospital on New York’s Upper East Side, doctors ran more tests and gave Laub two options: an injection of methotrexate, a cancer drug that destroys rapidly dividing cells and is often used to terminate an ectopic pregnancy, or surgery to remove it. Her fallopian tubes, where the fertilized egg was placed.
Opted for lube injection. After getting the shot, patients need follow-up hormone blood tests to make sure the pregnancy is ending. Laub returned to the emergency department three days after the shooting for blood work and an ultrasound. Three days later she returned and was given a second shot of methotrexate as the pregnancy did not terminate. The following week, she repeated the treatment at two follow-up visits. On July 20, after 12 days and five emergency department visits, Laub was scheduled for laparoscopic surgery to remove her fallopian tubes.
Total charges to date for treatment: an eye-popping $80,000. Because his health plan negotiated discounted rates with hospitals and other providers, all of whom were in his provider network, Laub’s out-of-pocket costs were only a fraction of that total. Now it looks like Laub will owe a little more than $4,000.
It still seems like a lot, he said.
“On the one hand, I feel grateful that I was able to get treatment when I wasn’t in an acute condition,” Laub said. “But it’s a terrible feeling knowing that the decision I made for the best path to care comes at such a high cost.”
The hospital noted, however, that its charges were reduced by Laub’s insurer discount. “Charges are based on the specific services provided in a patient’s treatment,” said Barbara Osborne, vice president of public relations for Northwell Health, a system that includes Lenox Hill Hospital. “Any amount owed to the patient is based on the benefit design and cost-sharing provisions of the patient’s insurance plan.”
Understanding hospital charges can be a headache because they often don’t seem to align with the actual cost of providing care. This is true in this case. According to a breakdown by WellRithms, a company that analyzes medical bills for self-funded companies and others, on average Lenox Hill Hospital charged Laub $12,541 for the surgery, based on data the hospitals submit to the federal Centers for Medicare and Medicaid Services. But the hospital charged Laub’s health plan $45,020.
“Hospitals will charge what they can,” said Jordan Weintraub, vice president of claims for the Portland, Oregon, company. “They put it on the provider to deny items instead of billing them appropriately.”
Even more revealing is how much the surgery actually costs the hospital. According to WellRhythms’ analysis of federal data, it costs Lennox Hill $3,750 to perform the laparoscopic procedure. The statewide average cost is $2,747
Nationally, the average outpatient charge for the surgery Laub received was $13,670, according to data from FairHealth, a nonprofit that maintains a large database of health insurance claims. The average total amount paid by the health plan and patient is $6,541.
Surgical charges for managing ectopic pregnancy vary widely depending on the location. But the charges are not necessarily related to the availability of medical care for termination of pregnancy. In the New York City metropolitan area, the average charge is $9,587, for example, while in San Francisco, the average charge is $20,963, according to FairHealth. Both New York and California have liberal abortion access laws. Meanwhile, locations with more restrictive abortion standards do not necessarily charge more for ectopic pregnancy surgery. For example, in the Dallas area, the average charge is $14,223, while in Kansas City, Missouri, it is $16,320, both lower than the average charge in Chicago ($18,989) or Philadelphia ($17,407).
Many women choose methotrexate over surgery to treat ectopic pregnancy. The drug is successful 70% to 95% of the time without the need for surgery.
The drug is often administered in a hospital because OB-GYNs are less likely to keep cancer drugs in their offices, experts say. After injection, patients must be followed closely until pregnancy is terminated, as the risk of life-threatening rupture remains. Also, patients must have blood work done at intervals after an injection to make sure their pregnancy hormone levels are decreasing.
After receiving her first injection in the emergency department, Laub was told she would need to return for follow-up blood work after each injection. Charges for this emergency department visit would likely have been significantly higher if Laub had received follow-up care from an OB-GYN in an outpatient setting. The hospital charged between $4,700 and $5,400 for each follow-up visit. Laub’s share of the cost was about $500 each time.
“She had a long treatment, and it would have been unfortunate if it had been done through the emergency room,” said Dr. Deborah Bartz, an OB-GYN at Brigham and Women’s Hospital in Boston. “It would have been really nice if he could have been worked in an outpatient setting with a protocol to manage surveillance instead.”
In a statement, Osborne defended the hospital’s approach.
“Ectopic pregnancy, which can be a life-threatening condition, requires close monitoring and management to ensure a successful resolution,” Osborne said. “The emergency setting allows for the immediate availability of critical surgical services, as was ultimately necessary in this patient’s case.”
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