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The American Journal of Managed Care August 2014
Personalized Preventive Care Reduces Healthcare Expenditures Among Medicare Advantage Beneficiaries
Shirley Musich, PhD; Andrea Klemes, DO, FACE; Michael A. Kubica, MBA, MS; Sara Wang, PhD; and Kevin Hawkins, PhD
Impact of Hypertension on Healthcare Costs Among Children
Todd P. Gilmer, PhD; Patrick J. O'Connor, MD, MPH; Alan R. Sinaiko, MD; Elyse O. Kharbanda, MD, MPH; David J. Magid, MD, MPH; Nancy E. Sherwood, PhD; Kenneth F. Adams, PhD; Emily D. Parker, MD, PhD; and Karen L. Margolis, MD, MPH
Tracking Spending Among Commercially Insured Beneficiaries Using a Distributed Data Model
Carrie H. Colla, PhD; William L. Schpero, MPH; Daniel J. Gottlieb, MS; Asha B. McClurg, BA; Peter G. Albert, MS; Nancy Baum, PhD; Karl Finison, MA; Luisa Franzini, PhD; Gary Kitching, BS; Sue Knudson, MA; Rohan Parikh, MS; Rebecca Symes, BS; and Elliott S. Fisher, MD
Potential Role of Network Meta-Analysis in Value-Based Insurance Design
James D. Chambers, PhD, MPharm, MSc; Aaron Winn, MPP; Yue Zhong, MD, PhD; Natalia Olchanski, MS; and Michael J. Cangelosi, MA, MPH
Massachusetts Health Reform and Veterans Affairs Health System Enrollment
Edwin S. Wong, PhD; Matthew L. Maciejewski, PhD; Paul L. Hebert, PhD; Christopher L. Bryson, MD, MS; and Chuan-Fen Liu, PhD, MPH
Contemporary Use of Dual Antiplatelet Therapy for Preventing Cardiovascular Events
Andrew M. Goldsweig, MD; Kimberly J. Reid, MS; Kensey Gosch, MS; Fengming Tang, MS; Margaret C. Fang, MD, MPH; Thomas M. Maddox, MD, MSc; Paul S. Chan, MD, MSc; David J. Cohen, MD, MSc; and Jersey Chen, MD, MPH
Currently Reading
Potential Benefits of Increased Access to Doula Support During Childbirth
Katy B. Kozhimannil, PhD, MPA; Laura B. Attanasio, BA; Judy Jou, MPH; Lauren K. Joarnt; Pamela J. Johnson, PhD; and Dwenda K. Gjerdingen, MD
The Effect of Depression Treatment on Work Productivity
Arne Beck, PhD; A. Lauren Crain, PhD; Leif I. Solberg, MD; Jürgen Unützer, MD, MPH; Michael V. Maciosek, PhD; Robin R. Whitebird, PhD, MSW; and Rebecca C. Rossom, MD, MSCR
Economic Implications of Weight Change in Patients With Type 2 Diabetes Mellitus
Kelly Bell, MSPhr; Shreekant Parasuraman, PhD; Manan Shah, PhD; Aditya Raju, MS; John Graham, PharmD; Lois Lamerato, PhD; and Anna D'Souza, PhD
Optimizing Enrollment in Employer Health Programs: A Comparison of Enrollment Strategies in the Diabetes Health Plan
Lindsay B. Kimbro, MPP; Jinnan Li, MPH; Norman Turk, MS; Susan L. Ettner, PhD; Tannaz Moin, MD, MBA, MSHS; Carol M. Mangione, MD; and O. Kenrik Duru, MD, MSHS
Does CAC Testing Alter Downstream Treatment Patterns for Cardiovascular Disease?
Winnie Chia-hsuan Chi, MS; Gosia Sylwestrzak, MA; John Barron, PharmD; Barsam Kasravi, MD, MPH; Thomas Power, MD; and Rita Redberg MD, MSc
Effects of Multidisciplinary Team Care on Utilization of Emergency Care for Patients With Lung Cancer
Shun-Mu Wang, MHA; Pei-Tseng Kung, ScD; Yueh-Hsin Wang, MHA; Kuang-Hua Huang, PhD; and Wen-Chen Tsai, DrPH
Health Economic Analysis of Breast Cancer Index in Patients With ER+, LN- Breast Cancer
Gary Gustavsen, MS; Brock Schroeder, PhD; Patrick Kennedy, BE; Kristin Ciriello Pothier, MS; Mark G. Erlander, PhD; Catherine A. Schnabel, PhD; and Haythem Ali, MD

Potential Benefits of Increased Access to Doula Support During Childbirth

Katy B. Kozhimannil, PhD, MPA; Laura B. Attanasio, BA; Judy Jou, MPH; Lauren K. Joarnt; Pamela J. Johnson, PhD; and Dwenda K. Gjerdingen, MD
Increasing access to continuous labor support from a birth doula may facilitate decreases in non-indicated cesarean rates among women who desire doula care.
This analysis shows that 10% of women with no definitive medical indication for cesarean delivered by cesarean, representing potentially modifiable risks and costs. Cesarean delivery is more costly than vaginal birth (approximately $28,000 vs $18,000 for commercial payers), and 31.3% of US births in 2009 to 2011 were via cesarean delivery.31 From the perspective of a payer, including doula care as a covered benefit would require an investment in professional doula services, and the financial impact would depend on cesarean rates and risk factors in the covered population as well as reimbursement rates related to these services. However, the potential value for this investment is substantial. For example, while fees for doula care vary widely, they average around $1000, and with an approximate $10,000 mean difference between the cost of a vaginal and cesarean delivery, the decision to cover 10 doula-supported births would be cost-neutral if 1 nonindicated cesarean were avoided among these. Of course, continuous labor support is important for women who have cesarean deliveries and offers quantifiable benefits to these women as well.4 Further, the positive outcomes associated with doula support may accrue over time, so the financial rationale for insurance coverage of doula care is strong, especially since cost is a known barrier to access.5,15

Women who report that they would like to have doula care are the same women who stand to benefit most from the known effects of continuous labor support.4,5 Black women (vs white women), women with public health insurance (Medicaid and other government-funded programs which primarily serve low-income women, vs private insurance), and women without health insurance (vs those with private insurance) have higher risks of adverse birth outcomes, but are often least able to afford doula care or access culturally competent care.20 Our findings show that these same groups of women are more likely to report desiring but not having access to doula care, with limited resources being a likely explanation (although this is not directly assessed). While the associations identified in this analysis cannot be interpreted causally, our findings indicated that women who reported wanting a doula but not having one experienced higher cesarean rates than women who did not report wanting doula care, and lower rates than women who had a doula. This suggests that the association between doula support and lower cesarean rates is unlikely due to selection bias (ie, the idea that women who choose to have doulas are those who would have had lower rates of cesarean anyway), which is consistent with findings from randomized controlled trials.4 Our study extends these findings to a broader, nationally representative population. However, more and better data are needed to replicate these findings in a community and policy context. Facilitating access to doula care through health insurance benefits or coverage policies may be an opportunity for research on this topic, by utilizing randomization or staggered starts in implementation. 

Not surprisingly, a majority of certified doulas (89.4%) believed that doula care should be reimbursed through health insurance,15 but there are real barriers to a wide implementation of reimbursement to a new category of services, especially services that are provided in a medical context but not by a healthcare professional. The state of Oregon has addressed this challenge by adapting language about reimbursement for nontraditional health workers to include trained, certified doulas.22

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