Fig.3

DEATH-TO-CASE RATES FOR LEGAL ABORTION, UNITED

Fig. 4 STANDARDIZED DEATH-TO-CASE RATES, BY WEEKS

OF GESTATION, COMPARED WITH STANDARDIZED

BIRTH-RELATED MORTALITY RATE, U. S., 1972-1975

By Elizabeth Moore

The abortion fee of the future might be determined by "postoperative measurement of the fetal Toot," if a standard graduated-ree proposed by a prominent public official 18 adopted by the abortion industry.

Abortion clinics have been urged by another leading abortion proponent to minimize the consequences of the Hyde Amendment by billing Medicaid for such abortion-related services as pregnancy tests, pelvic exams, lab work and contraceptives.

These proposals appear in separate articles in the July/August 1980 issue of Family Planning Perspectives, a publication of Planned Parenthood's research affliate, the Alan Guttmacher Institute.

The first article is written by Willard Cates Jr., Chief of the Abortion Surveillance Branch of the federal government's Center for Disease Control in Atlanta. Cates argues in favor of a uniform scale for abortion services one which would utilize a standard "baseline fee" with a graduated cost increase corresponding to increased gestation. The primary purpose of his system, he says, would be to discourage delay and to "promote abortions" early

NATIONAL RIGHT TO LIFE NEWS October 27, 1980

in pregnancy.

A table of sample fees in the article lists a "baseline" charge of $160, applicable to pregnancies between 7-8 weeks; the cost rises to $175 at 9-10 weeks, $200 between 11-12 weeks, and $225 during the 13th and 14th weeks. Abortions done earlier than the 7th gestational week, however, are priced at $175 largely because incomplete procedures are statistically more common then, and because of the possibility that a patient may not be pregnant. At 19 weeks, the highest fetal age figure appearing on the chart, the proposed fee reaches $300.

Because pre-operative diagnosis of gestational age is "an imperfect art," and because such information is "the crucial factor in setting a graduated fee," Cates writes that such a determination should "be based on objective criteria, such as postoperative measurements of fetal foot size." His price chart thus includes fetal foot Tength in millimeters for each gestational category.

Cates presents a number of "advantages" which he attributes to his proposal, and several potential problems as well. He states that the present system, in which abortion price

ags tend to increase markedly at the end of the first trimester, "encourages delay within the first 12 weeks" and then penalizes the patient "if the delay takes the pregnancy beyond 12 weeks gestation." Noting that the 12th week is "not a major turning point," Cates concludes that one of the greatest benefits his plan offers is to "encourage the woman to seek an abortion as soon as possible" and to "promote abortions at earlier and safer gestational ages."

The article also claims that the quality of pathological review might be enhanced because of the absolute necessity of examining the fetus, and that ectopic (tubal) pregnancies, incomplete abortions, and similar problems would be brought to the immediate attention of the clinic's

surgical staff. Cates adds that certain complications could then be reduced, that more accurate medical records would be kept, and that providers' insurance costs might also be lowered. He further states that the scheme would lead to a more educational type of counseling, thereby "minimizing any resentment a woman might feel about the cost of the abortion." And, finally, Cates suggests that "the graduated-fee system might help dispel rumors about clinics' greater interest in profit than in patient care."

On the negative side, Cates concedes that monitoring of abortion Tacilities might become necessary because "greedy clinics could abuse the (system) by claiming that gestational age is greater than it actually is."

Another problem which Cates foresees is "additional risk of psychologic morbidity." This, he notes, is a consequence of using "postabortal fetal measurements to determine gestational age" - a practice which tends to intrude "on the subconscious pattern of denial that surrounds decisions to terminate pregnancies." For this reason, Cates suggests that other objective criteria be considered as alternatives to fetal foot measurements should the latter prove "unduly

traumatic. His solution: crown-torump length and fetal weight.

Controversy

By Willard Cates, Jr.

What yardstick to use to set fair and equitable charges for specific medical procedures is a subject of continuing debate. No consensus has been arrived at by physicians concerning the appropriate fee for tonsillectomies or hysterectomies, two surgical interventions that have been common in our society for the past half century. It is hardly surprising, therefore, that there are questions concerning not only what constitutes fair and equitable charges for abortion, a relative newcomer to the medical care system, but how such costs should be arrived at. A recent national study shows that the charge for a first-trimester outpatient abortion performed in an abortion clinic is about $165, while the same type of abortion performed in a hospital costs about $250, exclusive of the surgeon's fee which may add an additional $160-$250; the cost of a second-trimester procedure may be two or three times that of a first-trimester abortion.1

This leap in abortion fees between the first and second trimesters was initially related to differences in abortion procedures performed before and after 12 weeks following the last menstrual period. In the early 1970s, it was widely held that curettage procedures should be performed only at 12 or fewer weeks' gestation, and instillation procedures thereafter. However, the development of dilatation and evacuation, a safer and less traumatic procedure for the patient who requifes a second-trimester abortion, has largely eliminated the need for instillation. Yet the fee system spawned by the difference ⚫between curettage and instillation lingers on,

The trimester approach to abortion fees does not, in reality, take into account either

Willard, Cates, Jr.is Chief of the Abortion Surveillance Branch at the Center for Disease Control in Atlanta, George. A somewhat different version of these remarks ~ presented at the third annual meeting of the National Alation Federation on July 16, 1979. The author wishes

thank David A. Crimes, Howard W. Ory. Carl W. Tyler, Jr., Cherl Roľuick and Sadja Greenwood for their rmonts and suggestions.

Je 12, Number 4, July August 1980

the difficulty of the procedure or the risk of complication. The length of time required to perform an abortion procedure and the risk of complications should be viewed as a continuum: The more advanced the pregnancy at the time of the abortion, the longer the procedure and the higher the risk of complications. The 12-week threshold is not a major turning point. In fact, the difference between 12 and 13 weeks' gestation is simply one day, namely between the 90th and 91st day after the last menstrual period.

The trimester-fee approach encourages delay within the first 12 weeks. Thus, the patient can delay deciding whether or not to have an abortion without incurring any increased cost, while the facility can delay scheduling without losing any income. Whatever the reason for the delay, the risks of the procedure are increased. Moreover, if the delay takes the pregnancy beyond 12 weeks' gestation, the doubling of the fee is an excessive penalty, borne only by the patient.

Two recent events illustrate the difficulties inherent in the current fee-setting system: • A multiparous woman requested an abortion from a freestanding clinic, explaining that nine weeks had elapsed since her last menstrual period. The clinician judged from the size of her uterus that the woman was 14 weeks pregnant. She was told that the procedure would cost $375 rather than $175-the charge for a first-trimester abortion. She attempted a self-induced abortion, and suffered complications, following which she returned to the clinic. After the pregnancy was terminated, measurement of the fetal tissue showed that she had actually been nine weeks pregnant at the time she initially requested her abortion.

A nulliparous, moderately obese woman requested an abortion from her family physician 10 weeks after her last menstrual period; he confirmed that she was 10 weeks preg nant, and immediately referred her to a nearby abortion facility. However, because the clinic was overscheduled, the next avail

able appointment was two weeks later. When the woman came in at that time, the clinic physician estimated that she was 14 weeks pregnant. Because the state law requires that all abortions after 12 weeks' gestation be performed in hospitals, the clinic referred her to the local community hospital. The cost of the prostaglandin instillation procedure that was performed was more than $600; had the clinic accepted her for treatment when she was referred originally, she could have undergone a suction curettage at a cost of $150.

These experiences highlight several problems involved in the delivery of abortion services. Determining gestational age is an imperfect art, resulting in wide fluctuations in the estimates of the duration of pregnancy, in one instance, the estimate was too high, in the other, too low. Both misestimates resulted in unfortunate outcomes for the women. Although the abortion facility, in one instance, was responsible for the delay, the financial penalty was paid by the woman, the clinic accepted none of the responsibility.

I suggest that in the interest of public health and fair play, the trimester-fee approach be replaced by a graduated-fee approach for all abortions performed in outpatient clinics. Such an approach is based on the degree of difficulty of the procedure, the skill required of the clinician, the equipment necessary, the time required for the operation, and the risks of morbidity and mortality from the procedure.

The graduated-fee approach would be scaled to the length of gestation, and thus would directly reflect the difficulty and risks of the procedure. The determination of the actual gestational age would be based on objective criteria, such as postoperative measurements of fetal foot size. A baseline fee would be established, and the fee for the abortion would increase with the length of gestation, as is shown (for illustrative purposes only) in Table 1. The level of the baseline shown is taken from the average

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