A color scan of an ectopic pregnancy, which develops outside the uterus – often inside a fallopian tube. Such pregnancies are never viable and, if not terminated, can lead to rupture of the tube, severe bleeding and even death.
James Cavallini/Scientific Source
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James Cavallini/Scientific Source
When Sara Laub’s period was late, the New York resident skipped things. 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, Laub, 28, had a home test in early July and received bad news: she was pregnant.
Laub went to a family planning clinic because she knew someone could see her there immediately. An ultrasound found no signs of a developing embryo in her womb. This indicated the possibility that Laub had a ectopic pregnancyin which a fertilized egg implants somewhere outside the uterus, usually in a fallopian tube.
Such pregnancies are rare, occurring about 2% of the time, but they are extremely dangerous because a growing embryo can rupture the narrow tube, causing massive and potentially fatal internal bleeding. Laub felt no pain, bleeding or other obvious symptoms of trouble. However, a Planned Parenthood staff member recommended that she go to a hospital emergency room immediately.
A laborious end to a life-threatening pregnancy
Laub didn’t realize it, but she was embarking on 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 legalization of abortion in 1970three years before Roe vs. Wade made legal nationwide – Laub’s experience shows that the process can be arduous.
An ectopic pregnancy in the fallopian tube is never viable. But following the June reversal of deer by the Supreme Court, reproductive health experts say treatment can be dangerously delayed as some states decide to limit abortion services.
Some of these consequences are already being noted in Texas, where strict limits on abortion were instituted last fall ahead of the Supreme Court ruling. Since abortion is now only allowed in Texas in medical emergencies, doctors can wait to perform abortions until pregnant patients face life-threatening complications in order to comply with the law.
“In Texas, we’ve seen people not treat ectopic pregnancies until they rupture,” says Dr. Kristyn Brandi, an obstetrician-gynecologist in Montclair, NJ, who serves as board chair. from Physicians for Reproductive Health, which supports abortion rights.
The 2021 Texas law banned most abortions at around six weeks of pregnancy. Researchers from the University of Texas-Austin asked doctors about the law’s impact on maternal-fetal care. Even though treatment for ectopic pregnancy is not explicitly prohibited by Texas law, uncertainty about what is allowed can cause doctors to delay urgent care. A specialist at an unnamed hospital said the facility no longer offers treatment for some ectopic pregnancies.
About half of the states have adopted restrictions on abortion or are trying to do so.
Laub, who is identified here by her middle name and last name because of her privacy concerns, says she couldn’t help but think of the recent Supreme Court ruling as she went through diagnosis and treatment.
“As frightening as my ordeal felt at the time, I was acutely aware that I was blessed with easy access to treatment, and elsewhere women with my condition face far worse experiences. “, says Laub.
Which led to his $80,000 bill
In the emergency department of Lenox Hill Hospital on New York’s Upper East Side, doctors performed more tests and gave Laub two options: one or more injections of methotrexate, a cancer drug that destroys cells in rapid division and is often used to safely terminate an ectopic pregnancy, or surgery to remove her fallopian tube, where the fertilized egg was lodged. (In some other cases, surgeons may remove the embryo but be able to preserve the fallopian tube.)
Laub opted for the methotrexate injection. After receiving the vaccine, patients need certain follow-up blood tests for several weeks to confirm that the pregnancy is ending or has ended. Laub returned to the ER for blood work and an ultrasound three days after the shooting. She returned three days later and received a second injection of methotrexate since the pregnancy was not terminated. The following week, she repeated the treatment at two more follow-up visits. On July 20, after 12 days and five ER visits, Laub was scheduled to undergo laparoscopic surgery to remove his fallopian tube.
The total costs to date for the medical treatment: an astronomical amount of $80,000. Since his health plan had negotiated discounted rates with the hospital and other providers, all of whom were part of his provider network, Laub’s outlay will be only a fraction of that total. Now it looks like Laub will owe just over $4,000.
That still seems like a lot, she said.
“On the one hand, I am grateful that I was able to be treated when I was not in an acute state,” says Laub. “But it’s a terrible feeling to know that the decision I made about the best course of care comes at such a high cost.”
The hospital points out that its costs were reduced by the discount from Laub’s insurer. “Fees are based on the specific services provided as part of the patient’s treatment,” says Barbara Osborn, vice president of public relations at Northwell Health, a system that includes Lenox Hill Hospital. “Any amount owed by the patient is based on the benefit design and cost-sharing provisions of the patient’s insurance plan.”
Understanding hospital charges can be confusing, as they often don’t seem to reflect the true cost of providing care. It is true in this case. According to a breakdown by Well Rhythms, a company that analyzes medical bills for self-funded businesses and others, Lenox Hill Hospital bills an average of $12,541 for Laub’s surgery, based on publicly available data hospitals submit to the Centers for Federal Medicare & Medicaid Services. But in this particular case, the hospital billed Laub’s health plan $45,020.
“Hospitals will charge whatever they can,” says Jordan Weintraub, vice president of claims for the Portland, Oregon-based company. “They put the payer to refuse items, rather than charging appropriately.”
What’s even more telling is how much it actually costs the hospital to perform the operation. According to WellRithms analysis of federal data, the Lenox Hill cost to perform the laparoscopic procedure is $3,750. The average cost statewide is $2,747.
Nationally, the average outpatient charge for the surgery Laub received is $13,670, according to data from Fair Health, a nonprofit that maintains a large database of health insurance claims. . The average total amount paid by the health plan and the patient is $6,541.
Fees can vary greatly from city to city
Surgical costs for managing an ectopic pregnancy vary greatly by location. But the cost does not necessarily correlate with the ease of access to medical care to end a pregnancy. In the New York metro area, for example, the average rate is $9,587, while in San Francisco the average rate is $20,963, according to Fair Health. New York and California have generous abortion access laws. Meanwhile, places with more restrictive abortion standards do not necessarily charge more for ectopic pregnancy surgery. For example, in the Dallas area the average fee is $14,223, while in Kansas City, MO it is $16,320, both lower than the average fee in Chicago ($18,989) or of Philadelphia ($17,407).
Many women opt for methotrexate rather than surgery to treat an ectopic pregnancy. The drug is successful 70% to 95% of the time without requiring surgery.
The drug is often given in a hospital emergency room because OB-GYNs are unlikely to keep the cancer drug in their offices, experts say. After the injection, patients go home, but should be closely monitored for the next few days or weeks until the embryo is reabsorbed and the pregnancy ends, because until this occurs, the risk of a life-threatening fallopian tube rupture remains. Additionally, patients should have blood tests at regular intervals after an injection to confirm that their pregnancy hormone levels are falling.
After receiving her first shot in the emergency department, Laub was told she had to come back for follow-up blood work in three days and then again after each shot of methotrexate she might need. The charges for those ER visits were likely much higher than if Laub had received follow-up care from an outpatient OB-GYN. The hospital charged between $4,700 and $5,400 for each of these follow-up visits. Laub’s share of the cost was around $500 each time.
Osborn defended the hospital’s approach – forcing Loeb to return to the emergency room each time for his treatment.
“Ectopic pregnancies, which can be life-threatening, require close monitoring and management to ensure successful resolution,” says Osborn. “The emergency context allows for the immediate availability of essential surgical services, as was ultimately needed in this patient’s case.”
But Dr. Deborah Bartz, an obstetrician-gynecologist at Brigham and Women’s Hospital in Boston, wonders if every step of this “close supervision” really had to take place in the emergency room. “It would be really nice,” Bartz says, “if instead she could have been worked on an outpatient basis with a monitoring management protocol.”
KHN (Kaiser Health News) is a national, editorially independent, KFFthe Kaiser Family Foundation.