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Abstract BackgroundTraditional prenatal care includes up to 13 in person office visits, and the cost of this care is not well-described. Alternative models are being explored to better meet the needs of patients and providers. OB Nest is a telemedicine-enhanced program with a reduced frequency of in-person prenatal visits. The cost implications of connected care services added to prenatal care packages are unclear.MethodsUsing data from the OB Nest randomized, controlled trial we analyzed the provider and staff time associated with prenatal care in the traditional and OB Nest models. Fewer visits were required for OB Nest, but given the compensatory increase in connected care activity and supplies, the actual cost difference is not known.Nursing and provider staff time was prospectively recorded for all patients enrolled in the OB Nest clinical trial. Published 2015 national wages for healthcare workers were used to calculate the actual labor cost of providing either traditional or OB Nest prenatal care in 2015 US dollars. Overhead expenses and opportunity costs were not considered.ResultsTotal provider cost was decreased caring for the OB Nest participants, but nursing cost was increased. OB Nest care required an average of 160.8 (+/- 45.0) minutes provider time and 87.8 (+/- 25.1) minutes nursing time, compared to 215.0 (+/- 71.6) and 99.6 (+/- 29.7) minutes for traditional prenatal care (P<0.01). This translated into decreased provider cost and increased nursing cost (P<0.01). Supply costs increased, travel costs declined, and overhead costs declined in the OB Nest model. ConclusionsIn this trial, labor cost for OB Nest prenatal care was 34% higher than for traditional prenatal care. The increased cost is largely attributable to additional nursing connected care time, and in some practice settings may be offset by decreased overhead costs and increased provider billing opportunities. Future efforts will be focused on development of digital solutions for some routine nursing tasks to decrease the overall cost of the model. Trial Registrations: ClinicalTrials.gov Identifier: NCT02082275

INTRODUCTION: This study calculates the financial margins for delivery of routine antenatal care as reimbursed by Medicaid. Prenatal care cost varies with overhead, provider type, and number of office visits. Antenatal care is only one component of the global obstetric bundle, which also includes intrapartum and postpartum care. METHODS: Revenue was based on 2015 Medicaid reimbursement for the pregnancy global package (CPT 59400). All fifty states were represented. Provider time cost was estimated using mean wages for obstetricians and midwives, or using national mean wage data when state-specific data was unavailable. Staff time for provision of low risk prenatal care was determined prospectively from a study of 133 low risk patients. Sensitivity analysis was performed by varying overhead as a percentage of total revenue. Routine prenatal labs, ultrasounds, intrapartum care, and postpartum care were not included in our analysis. RESULTS: Patients received an average of 215 minutes of direct provider time per pregnancy. At the 50th percentile for physician payment and assuming overhead is 40% of revenue, practice margins varied by state from -$1,061 to +$785, with a median of -$161. This does not include the cost of intrapartum or postpartum care. The median margin for antenatal care was negative if overhead exceeded 18% of revenue. CONCLUSION: In a majority of states, reimbursement for the global obstetric package reimbursed by Medicaid is less than the actual cost of prenatal care alone. Improving reimbursement or decreasing costs is necessary to make maternity care cost-effective for obstetrics practices.