that spending on health care in the United States in 2015 accounted for 17.8 percent of the gross domestic product
GDP (Voelker, 2010). he total amount of health-care spend ing-$3.2 trillion-equated to an estimated $10,000 per person. Moreover, compared with 12 other high-income coun tries, health-care spending in the United States as a proportion of GDP was approximately 50 percent more than the next highest country. Yet, health-care outcomes, which included infant mortality rates, were worse in the United States. And, approximately two thirds of U.S. infant deaths result from complications stemming from preterm births (Matthews, 2015). Indeed, in its 2010 annual global Premature Birth
Report Card, the United States garnered a grade of "D" from the March of Dimes for its recognition and prevention of pre term labor in the more than 540,000 neonates born annually before 37 weeks' gestation.
Causes for the excessive health care costs in the United States are attributed, in part, to greater use of medical technology and excessive prices (Squires, 2017). Two recent studies demonstrate the detrimental efect of obstetrics on health care costs. The first report by Nelson and coworkers (2017) described the inefectiveness of 17 -alpha hydroxyprogesterone caproate (17OHP-C) to prevent recurrent preterm birth. Methodology for this trial is presented in Chapter 42 (p. 817). Several lessons can be learned from this investigation. First, use of 17 -OHP-C was legitimized in the United States by a national consensus committee using expert opinion. hese opinions were promulgated, despite FDA reservations that the evidence was lacking in several important respects. However, once approved, 17 -OHP-C was sold by one pharmaceutical company for $1500 for a single, 250-mg injectable dose. Remarkably, this same dose could be compounded and purchased for $25 from local pharmacies. In the subsequent price-gouging controversy, members of the United States Congress intervened to permit continued use of the less expensive 17-0 HP -C.
he second study is a multisite prospective trial of the efectiveness of transvaginal sonography to screen for cervical-length shortening to predict preterm birth (Esplin, 2017). A total of 9410 nulliparous women were studied. he Society for Maternal-Fetal Medicine and the American College of Obstetricians and Gynecologists (2016d) both legitimized universal cervicallength screening in their joint Committee Opinion (Bloom, 2017). And, by 2015, one survey of78 Maternal-Fetal Medicine fellowship programs showed that 68 percent were using universal cervical-length screening to predict preterm birth (Khalifeh, 2017). It was estimated that a modest Medicaid rate of $237 per cervical-length ultrasound would result in approximately $350 million in added health care costs. But, Esplin and associates (2017) found that routine screening for a short cervix was not beneficial. hat is, a widely used intervention was actually inefective. his is a clear example of how unproven technology can seep into widespread practice.
These two reports highlight a substantial problem in U.S. health care, namely, inefective yet expensive interventions introduced into broad use without robust evidence. These two reports also speak to a demand for robust scientific evidence. Scrutiny of other ingredients in the health-care paradigm such as prices for hospitalization, prices for surgical procedures, and prices charged by health insurance companies may illuminate similar contributions to the health care fiscal crisis.