On October 19 2019, a Facebook page shared the following screenshot of a tweet, including what looked to be a hospital bill with a $39.95 charge for “skin to skin contact” after a mother’s cesarean section:
In the original tweet with a date not visible, the Twitter user described the $39.95 charge for parents to “hold their newborn baby” as a “REALLY tight microcosm of capitalism.” The tweet was originally published in March 2019:
A screenshot of the same tweet racked up tens of thousands of shares when it was posted by Facebook page “The People for Bernie Sanders” on March 8 2019, and thousands more still when the page “Union Thugs” shared the image of a bill the following day.
In the image, an “Itemized Statement of Services” included a description of the service, a CPT code, a quantity, and amount. Part of the statement was not visible, but what was read as follows:
- LEVEL 1, Quantity 19, $52.82;
- LEVEL 2, Quantity 38, $212.04;
- DELIVERY C SECTION, Quantity 79, $3,106.28;
- SKIN TO SKIN AFTER [C-SECTION], Quantity 1, $39.95;
- IP LACTATION CONSULTANT LVL 1, Quantity 2, $61.96
- COMMERCIAL INSURANCE PAYMENT, Quantity 1, -$6.087.15
- CONTRACTUAL ALLOWANCE ADJUSTMENT, Quantity 1, -$5566.82
“Payments & adjustments” amounted to a total credit of $11,653.97, against what appeared to be a total original balance of $13,280.49 on the far left of the image. The amounts in the bill did not add up to the $13,280.49 total charge, so presumably the bill had additional pages. $11,653.97 minus $13,280.49 equaled $1,626.52, the remaining balance after insurance and allowances were calculated.
Also visible in the upper left hand corner of the screenshot was a partial number, “-016.” That indicated perhaps the bill was dated “2016,” which aligned with earlier news reporting on a purported $39.95 “skin to skin after c-section” bill controversy.
On October 6 2016, UPI reported:
A Utah dad shocked to be charged $39.35 on a hospital bill for “skin to skin” contact after his son’s birth recouped the charge with a humorous GoFundMe page.
Ryan Grassley, 37, posted a photo to Reddit showing the bill he received after the recent birth of his son, Samuel, at Utah Valley Hospital in Provo.
The bill included a $39.35 charge for “Skin to Skin after C-Sect.”
“I had to pay $39.35 to hold my baby after he was born,” Grassley wrote in the Reddit post.
Grassley told WPIX-TV a nurse allowed him to hold the newborn to his wife’s chest and neck. He said their experience with the hospital was overwhelmingly positive and he shared the photo of the bill because he found it “funny and a bit ridiculous.”
The New York Post also covered Grassley’s Reddit post. On October 3 2016, Grassley shared the image of a bill to Reddit’s r/pics (as u/halfthrottle). Its original date (September 23 2016) is visible in the top left hand corner:
Incidentally, a repost of the original was shared to r/ABoringDystopia in March 2019. A top comment on the original 2016 post with more than 12,000 upvotes asked about the quantity of “79” next to c-section, and another commenter surmised that it had to do with “minutes,” not surgeries:
What about the 79 C-sections?
It’s minutes. Divide by 79 and it comes out to the same rate as the skin to skin. So no, OP didn’t get charged extra for this, they just broke it out separately for some sort of documentation reason … My bet is that had she not done the skin to skin contact it would have been listed as 80 minutes of C section.
Other Reddit users did the math, extrapolating that the $3,106.28 charge for 79 units or minutes of a c-section worked out to roughly $39.32 per whatever unit that line item was describing. Another reader chimed in to provide a self-identified real-life example of the mechanics of operating room billing:
Sorry, but we bill differently and not $400/hr. Each surgery is given a set number of billable units. Scheduled c-sections are 6 units I believe. Then every 15 minutes is another billable unit. For a 79 min section that’s 6 initial units plus 6 time units. Medicare/Medicaid pay out at about $20/unit. The most I’ve ever seen for private care is $63/unit.
Now someone will do the math and say, “see! That’s way more than $400/hr!” But that is only anesthesia time. It doesn’t account for pre-op/post-op time (which can be significant). None of that matters to me anyway, I’m essentially salaried and the hospital pockets the majority of whatever it gets paid.
Also, if that section happens at 3:39 AM I don’t get special pay for pulling my ass out of bed and driving into work.
A Canadian also weighed in, adding their own comparison:
Canadian here. I’ve never even seen a medical bill! I had no idea it cost $13G to deliver a baby.
A 2006 Canadian Institute of Health Information report estimated that a C-section costs $4,600, compared with $2,800 for a vaginal birth
A poster saying they were from United Kingdom stated:
Brit here. All “free”! And less of our taxes go towards that than the US system too…
Seeing a “lactation” consultant is also free because breastfed children are statistically less reliant on the health service in the future. So it’s actually a benefit to the health service to encourage breastfeeding. Health care should never have a profit motive.
Grassley later commented on the thread, providing further details about the $39.95 baby-holding experience:
The nurse let me hold the baby on my wife’s neck/chest. Even borrowed my camera to take a few pictures for us. Everyone involved in the process was great, and we had a positive experience. We just got a chuckle out of seeing that on the bill.
He also said a nurse asked his wife if she wanted to “do skin to skin contact” after the baby was born, “[to which] of course anyone would say yes.” That exchange in part was why they found the bill’s $39.95 charge amusing:
During the C-section the nurse asked my wife if she would like to do skin to skin after the baby was born. Which of course anyone would say yes too. We just noticed it in the bill today and had a laugh. All these internet points I’ve been showered with make me feel better about the $40. This could be my proudest moment as a father.
On October 4 2016, Grassley created a humorous GoFundMe page, “I had to pay $40 to hold my baby.” It contained images of the moments after the baby was born; it raised $145 before it was deactivated for unknown reasons. While people continued to react with chagrin while seeing and sharing the post three years later, others maintained that the complex and seemingly unreasonable charge was being presented in a confusing and out-of-context way.
A Reddit user claiming to be a labor and delivery nurse commented on the post:
As a labor and delivery nurse, I can kind of explain this. I didn’t know that hospitals charged for it, but doing ‘skin to skin’ in the operating room requires an additional staff member to be present just to watch the baby. We used to take all babies to the nursery once the NICU team made sure everything was okay. “Skin to skin” in the OR is a relatively new thing and requires a second Labor and Delivery RN to come in to the OR and make sure the baby is safe.
As is often the case with viral, conversation-sparking experiences shared on sites like Reddit, responses to the claim also sometimes go viral. A since-deleted Facebook post shared on October 4 2016 (archived here) originally said:
[On October 4 2016] an image went viral. This picture was of a hospital bill. On that bill was a line item for “skin to skin after csec. $39.35”. Doulas, activists, advocates, and regular people are up in arms. How DARE the hospital charge someone to hold their baby! That’s ludicrous, right!?!
No. It isn’t.
During a caesarean, many people become shaky, nauseous, uncomfortable, even faint. These are normal physiological reactions. In order to facilitate skin to skin in the OR, and extra nurse needs to be available to assist. And before people scream that “there’s a nurse for the baby”, there is, but that nurse has other responsibilities in the OR. They aren’t either holding the baby or twiddling their thumbs. So yes, an extra nurse is needed.
I sit on an advisory committee for Sunnybrook. Nurses are the LARGEST budget item. They don’t appear out of nowhere and they don’t grow on hospital bulletin boards. Their time and their presence are valuable and should be valued.
We can either keep screaming about the big, bad, awful hospital system, or we can acknowledge that concessions on their part might just mean concessions on ours too.
Let’s talk instead that this hospital is doing skin to skin in the OR! That’s amazing! We should be celebrating that!
Birth workers especially, stop. Just stop. Stop bashing hospitals when they give us, and our clients, exactly what we asked for.
That poster (a woman named Meaghan Grant) is from Canada, not the United States, where costs to patients for childbirth are significantly lower. Janet Frank, a spokesperson for Utah Valley Hospital, was unable to comment on Grassley’s bill specifically, but said in a statement about the viral furore:
In general, Utah Valley Hospital is an advocate for skin-to-skin contact between a mother and newborn directly after birth. Skin-to-skin is a best practice with proven benefits for both mom and baby. We do everything possible to allow skin-to-skin after both vaginal and C-section births. In the case of a C-section, where the bedside caregiver is occupied caring for the mother during surgery, an additional nurse is brought into the OR to allow the infant to remain in the OR suite with the mother. This is to ensure both patients remain safe. There is an additional charge associated with bringing an extra caregiver into the OR. The charge is not for holding the baby, but for the additional caregiver needed to maintain the highest levels of patient safety.
Frank said that the charge was not for holding the baby, but for the presence of an “additional caregiver” present to ensure that both mother and baby “remain safe.” Nevertheless, the $39.95 billing line item was not only surprising to those unaffiliated or unfamiliar with hospital processes. MarketWatch reported on the viral post when it was first shared, describing maintaining “skin to skin” contact in an operating room as occasionally a “challenge.”
MarketWatch spoke to an obstetrician and professor at Harvard Medical School, Dr. Neel Shah:
It’s “a hard thing to do in an operating room,” since the surgical area needs to stay sterile and requires an extra nurse for supervision, according to Dr. Neel Shah, an obstetrician and professor at Harvard Medical School.
“The hospital probably had the right idea” in doing that, said Shah, especially since most Americans are born in small hospitals with staffing limitations. “It’s a big resource commitment to put a nurse in an operating room… I don’t think it’s standard.”
Still, it’s an bizarre line item to see because hospital bills don’t typically itemize every cost associated with a hospital stay, Shah — who was “dumbstruck” when he first saw the bill — said.
Shah was not the only doctor or administrator who was surprised by the billing line item. Another doctor and professor said such charges are usually bundled with others when they do exist, and another doctor from Harvard told reporters that itemization in medical bills can be unnecessary and confusing, and it typically angers patients:
[The $39.95 skin to skin line item and reaction to it] speaks to a larger “absurdity” too, [Shah] said: that the way billing is done can vary widely between different hospitals, especially when it comes to the final number dictating how much patients will pay out of pocket. Patients typically don’t find out how much they’ll owe for a procedure until they’re faced with the bill.
The fee is also unusual since most hospitals use bundled payments, charging one fee for something as common as a C-section, said Dr. Stephen Patrick, assistant professor of pediatrics and health policy at Vanderbilt Medical School and a pediatrician who specializes in training and care for sick newborns.
“Most insurance plans would say, ‘Here’s the fee, that’s it,’ even if there was a line item charge like that,” Patrick said.
Dr. Ateev Mehrotra, an associate professor of health-care policy and medicine at Harvard Medical School, agreed, saying that there’s no need for an itemized bill. The insurance plan pays a fixed amount, which is all that should be shown on the bill, he said.
Other numbers on the bill are also concerning, Mehrotra said.
The charges totaling more than $13,000 for the birth are “made up numbers and then the ‘adjustments’ are where the reality comes in,” he said. The charges “should be removed from the bills. All they do is anger patients and add to confusion.”
Patrick referenced the “sterile field” in an operating room as a possible reason skin-to-skin contact costs more on paper, but added that such contact was not as difficult as it seems.
Shah observed that the widespread reaction to the bill made sense:
It would make it easier to interpret bills if everyone had a standard way of billing and a standard way of representing charges, but that’s typically not the case … We [in the United States] have a truly insane way of billing patients for services.
That underlying issue appeared in an October 4 2016 Vox article (“A woman had a baby. Then her hospital charged her $39.35 to hold it”) about the viral bill image. Adding that a Vox writer did a project in which he “tried to figure out the cost of his wife’s birth before it happened,” and “made dozens of phones calls to different billing offices, but couldn’t find anyone who could tell him how much an uncomplicated birth would ultimately cost,” the news site quoted a previous related piece:
What struck me the most about my quest to learn about hospital prices was the fact that consumers have no way of knowing where a hospital stands on the vast pricing spectrum. Consumers have few options to interact with pricing until after they have received treatment. It’s significantly easier to find out how much it costs to park at a hospital than how much it will cost to get treatment.
All of this results in a system where consumers are totally divorced from prices. This is dangerous because prices are a key ingredient to a healthy market. We rely on prices in every industry to communicate value and drive competition. A lack of transparency can lead to an artificial inflation of prices, making consumers pay more for treatment that is of no better quality.
To recap, Reddit user Ryan Grassley (u/halfthrottle) shared an image of a September 2016 medical bill for his wife’s c-section to r/pics on October 3 2016. After that post, numerous social media users in the United States and elsewhere engaged in discourse about the bill itself, medical billing in the United States, and the country’s overall state of affairs with respect to how healthcare is dispensed and funded.
Grassley’s photograph of a $39.95 “skin to skin” contact charge prompted at least two threads of discussion — first, whether it was real and unaltered, and a second discussion about whether the charge was fair and justified. That secondary aspect of the discussion (whether the charge itself was acceptable to Americans) was a matter of opinion, not fact. But the first — whether it was authentic and presented accurately — was confirmed both by Grassley to the media and by Frank in a statement from the Utah hospital that issued the bill.
For myriad reasons and in a practice controversial among both among medical experts and the general non-expert population, Grassley’s family was billed $39.95 for skin to skin contact with their newborn following a 2016 C-section.