2026年6月3日 / 美国东部时间凌晨5:00 / KFF健康新闻
在美国生孩子即将变得更加复杂。
从明年1月起，新的计费代码将正式生效，负责产科护理的医生将开始按服务项目收费，针对怀孕、分娩和产后护理相关的就诊和服务单独计费。这与近年来的做法完全相反——过去医生通常会为其所提供的产科护理收取一笔统一的“打包”费用。尽管妇产科医生强烈支持这项改革并已推动多年，但一些患者维权人士和雇主表示，新制度能否带来更好的护理或降低患者成本仍未可知。
美国妇产科医师学会（ACOG）表示，此次改革对于准确反映妇产科医生当前提供的护理服务至关重要。如今的待产患者中，有些人的年龄比过去几十年更大、健康状况更复杂，更有可能存在复杂的医疗和社会需求，且需要在多个诊疗场景下由多名医护人员提供护理。
例如，在当前的产科打包计费体系下，产前就诊次数被硬性规定为13次，“但这实际上并不符合大多数人的实际需求”，新墨西哥大学妇产科系主任、参与与美国医学会联合制定新代码的ACOG委员会成员丽莎·霍夫勒说道。新的按服务项目计费代码将根据患者的个体需求，更好地适配更多或更少的就诊次数，包括线下或远程就诊。
霍夫勒补充道，同样，在当前体系下，“如果有人前来分娩，无论产程长短、分娩复杂与否，计费代码都是统一的，因为我们只有一个代码”。
新的更精准的代码，将帮助越来越多可能参与产科护理的医疗专业人员——比如专注于分娩的住院医师、助产士和母胎医学专家——准确核算其所提供的服务范围，并获得相应的报酬。
但对于患者而言，尤其是越来越多持有高免赔额健康保险计划的人群，一些产科专家表示，新制度可能会导致更高的自付费用。
“费用问题确实至关重要，”劳里·泽菲林说道，她是一名妇产科医生，同时也是健康研究非营利组织联邦基金“实现公平结果”倡议的高级副总裁。“计费条目会增加。这些成本会不会转嫁给患者，尤其是那些商业保险计划、高免赔额计划的参保者？”
泽菲林表示，家庭是否需要支付更多自付费用“实际上取决于支付方如何选择实施这些代码”。
保险行业代表表示，他们对实施时间表感到担忧，因为这需要进行重大的运营调整。
“仓促推行影响深远的美国医学会代码重组，将从根本上改变产科服务的管理和报销方式，”代表保险公司的美国健康保险计划（AHIP）发言人克里斯·邦德说道。
根据联邦法律，医疗机构和健康保险计划需使用标准化代码来记录诊断、手术、服务和耗材。医生和其他医疗专业人员通过由美国医学会（美国医生主要行业协会）开发和维护的当前程序术语（CPT）代码来计费。联邦医疗保险和医疗补助服务中心（CMS）会对新的和修订后的代码进行审核，并根据每年更新的费用表向临床医生报销费用。目前CMS的审核工作正在进行中，明年的拟议费用表将于7月公布。
“我们不知道CMS是否会批准拟议的代码变更，”美国医学会CPT编辑委员会副主席芭芭拉·利维说道。“他们作为观察员参与了全过程，并有机会在整个流程中发表意见。”与此同时，美国医学会正在向医疗机构和支付方宣传新的编码结构。
联邦法律在特定情况下限制了准父母的付费上限。根据《平价医疗法案》，大多数健康保险计划必须为参保者提供免费的预防性产科护理。由联邦卫生资源和服务管理局制定的预防性产科服务清单，包括产前和产后就诊、糖尿病、焦虑症和HIV筛查等多项内容。
不过，打包服务并不涵盖所有项目，孕妇通常已经需要为某些服务支付部分费用，比如超声检查、专科就诊和实验室检测。除了单独计费的医院费用外，她们还需要根据保险计划承担分娩专业服务费的自付部分。
长期以来，按服务项目付费——即医疗机构根据提供的服务数量而非健康结果按项收费——一直令健康政策专家感到担忧，因为这可能会激励医疗机构提供更多、更昂贵的服务。事实上，近年来政策制定者放弃这种收费方式转而采用打包付费的原因之一，就是他们认为打包付费有可能降低成本并提高护理质量，包括将美国约30%的剖腹产分娩比例降至更低——剖腹产的成本显著高于阴道分娩。（但这一目标并未实现。采用打包付费后，剖腹产分娩比例并未出现变化。）
“我一直担心任何会进一步‘拆分’我们医疗体系的做法，”患者维权基金会高级主任凯特琳·多诺万在谈及恢复按服务项目计费时说道。该基金会是一家为美国病患提供病例管理服务的非营利组织。
即便在当前的打包付费体系下，患者也可能会被收取不必要的额外服务费用。多诺万回忆道，她在35岁怀第三个孩子时，她的产科医生告诉她，作为一名“高龄”准妈妈，她需要在怀孕20周后每周进行一次超声检查。
ACOG发言人贾米拉·弗农表示，该学会建议35岁及以上或已知存在风险因素的孕妇进行详细的孕早期超声检查。“后续的超声检查也需根据检查结果和风险因素来确定。换句话说，并没有适用于所有患者的固定超声检查次数，”弗农说道。
“没有任何迹象表明我需要做这些检查，”多诺万说道。“这纯粹是为了敛财。”
美国每年约有360万婴儿出生，分娩是人们经历的最常见医疗事件之一。
不过，生孩子并不便宜。根据彼得森-KFF健康系统追踪机构研究人员对2021年至2023年数据的分析，拥有雇主赞助保险的家庭平均需要支付2743美元。
美国约41%的分娩由针对低收入人群的联邦-州联合医疗补助计划覆盖。这些家庭通常无需承担产科护理的自付费用，新的计费系统不会对他们的财务状况产生影响。
不过，ACOG希望新系统能够帮助医生和其他医疗专业人员改善产科护理，尤其是在产后阶段。
在打包付费体系下，人们往往无法明确产科护理过程中提供了哪些服务，这妨碍了研究人员评估特定服务是否对孕产妇死亡率产生了积极影响——美国的孕产妇死亡率在所有高收入国家中垫底。
产科护理专家尤其关注产后护理。目前已有48个州和华盛顿特区将产后医疗补助覆盖时长从60天延长至一整年。根据新的代码，医生将因提供延长的产后护理获得报酬，而非打包计费体系下推荐的两次就诊。
约翰逊政策咨询公司总裁、医疗补助和母婴健康专家凯·约翰逊表示，产后需要跟踪一系列医疗问题，包括抑郁症筛查、药物使用情况、孕妇的妊娠期糖尿病是否发展为糖尿病，以及心脏功能变化是否在产后恢复正常。
借助新的代码，“我们有机会提供持续的护理，也有了为其提供资金的途径，”她说道。
代表雇主的专家表示，他们理解ACOG为何推动这些改革，但他们担心改革会导致成本上升。
“ACOG称产科医生的薪酬过低，这其中可能有一定道理，”WTW健康管理业务部门的公共卫生负责人、哈佛大学T.H.陈公共卫生学院助理教授杰夫·莱文-谢尔茨说道。
莱文-谢尔茨指出，有报告称就诊强度不断增加，这反映了医生为患者花费的时间和资源更多，也带来了更高的薪酬。“这套新的就诊代码不太可能不受此影响，”他说道。即便患者可能无需直接承担产前和产后就诊的费用，但如果就诊次数增加且代码级别更高，“如果他们的保险计划明年支付更多费用，他们的保险保费也会上涨更多，”他说道。
代表为员工健康福利自担费用的中型和大型雇主的商业健康集团副总裁玛格达·鲁西诺夫斯基表示，她担心新系统会鼓励使用更多、更频繁的检查和更昂贵的医护人员，而非导乐分娩等服务。
“每个学科的按服务项目计费都会激励更多检查和更高等级的医护人员，因为这能带来更高的账单金额，”她说道。
不过，“现在还为时尚早，”鲁西诺夫斯基说道。“行业内许多人都在试图琢磨这一改革将如何发展。”
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Upcoming billing change could make pregnancy pricier
June 3, 2026 / 5:00 AM EDT / KFF Health News
Having a baby in the United States is about to get more complicated.
Under new billing codes that take effect in January, doctors who manage maternity care will start charging à la carte for visits and services related to pregnancy, childbirth, and postpartum care. It’s an about-face from recent years, when doctors have often received a single “bundled” payment for maternity care they provided. Although OB-GYNs strongly back the change and have pushed for it for years, some patient advocates and employers say it’s an open question whether the new system will result in better care or increased patient costs.
The American College of Obstetricians & Gynecologists says the change is crucial to accurately reflect the care OB-GYNs currently provide, with expectant patients — some older and sicker than in decades past — more likely to have complex medical and social needs and receive care in multiple settings from multiple practitioners.
For example, under current bundled obstetrics coding, the number of prenatal visits is set at a fairly arbitrary 13, “which is not really what most people need,” said Lisa Hofler, chair of the Department of Obstetrics and Gynecology at the University of New Mexico and a member of the ACOG committee that developed the new codes in conjunction with the American Medical Association. The new fee-for-service codes will better accommodate more or fewer visits, either in person or remotely, based on individual needs.
Likewise, under the current system, “if someone comes in for a birth, no matter how long or how short their labor or how complicated or uncomplicated their delivery, the global reporting is the same because we only have one code,” Hofler said.
The new, more precise codes will help the growing number of medical professionals who may play a role in maternity care — such as hospitalists focused on labor and delivery, midwives, and maternal-fetal medicine specialists — to account for, and get paid for, the range of services they provide.
For patients, however, especially the growing number with high-deductible health plans, some maternity experts say the new system may result in higher out-of-pocket bills.
“The cost piece is really critical,” said Laurie Zephyrin, an OB-GYN and the senior vice president for the Achieving Equitable Outcomes initiative at The Commonwealth Fund, a health research nonprofit. “There will be more line items. Will that be passed along to patients, particularly those that are in commercial plans, in high-deductible plans?”
Whether families will pay more out-of-pocket “really comes down to how payers choose to implement these codes,” Zephyrin said.
Insurance industry representatives said they are concerned with the implementation timeline, which will require significant operational changes.
“Rushed implementation of far-reaching AMA code restructuring will fundamentally change how maternity services are managed and reimbursed,” said Chris Bond, a spokesperson for AHIP, which represents insurers.
Under federal law, providers and health plans use standardized codes for diagnoses, procedures, services, and supplies. Doctors and other health professionals bill for their services using Current Procedural Terminology codes, which are developed and maintained by the American Medical Association, the main trade group for doctors. The federal Centers for Medicare & Medicaid Services reviews new and revised codes and reimburses clinicians based on a fee schedule, which is updated every year. The CMS review is going on now, and the proposed fee schedule for next year will be published in July.
“We don’t know” whether CMS will go along with the proposed coding changes, said Barbara Levy, vice chair of the AMA’s CPT Editorial Panel. “They were at the table as observers and had opportunities to give inputs throughout the entire process,” she said. In the meantime, the AMA is educating providers and payers about the new coding structure.
Federal law limits how much expectant parents can be charged in certain instances. Under the ACA, most health plans have to provide maternity care that is considered preventive at no cost to members. The list of preventive maternity services, set by the federal Health Resources and Services Administration, includes prenatal and postpartum visits and screening for diabetes, anxiety, and HIV, among other things.
The global bundle doesn’t cover everything, though, and pregnant people typically already pay some of the cost for certain services, such as ultrasounds, specialist visits, and lab work. They’re also responsible for their portion of labor and delivery professional fees based on their insurance plan (in addition to hospital charges, which are billed separately).
Still, fee-for-service payment, in which providers are paid à la carte based on the volume of services they provide rather than on health outcomes, has long troubled health policy experts because of its potential to incentivize providers to do more and pricier services. In fact, one of the reasons policymakers moved away from that arrangement for maternity care in recent years was because they believed bundled payments had the potential to lower costs and improve quality, including reducing the roughly 30% of births in the United States done by cesarean section, which costs significantly more than vaginal birth. (It hasn’t worked. The proportion of births by C-section hasn’t budged under bundled payment.)
“I always worry about anything that is ‘piecemealing’ our healthcare system even more,” said Caitlin Donovan, a senior director at the Patient Advocate Foundation, a nonprofit that provides case management services for sick people in the U.S., of the return to fee-for-service billing.
Even under the current system, patients can get dinged for extra services they may not need. Donovan recalled that when she was pregnant with her third child at age 35, her obstetrician told her that as a “geriatric” expectant mother she needed weekly ultrasounds after her 20th week.
ACOG recommends a detailed first-trimester ultrasound for pregnant patients 35 years or older or with known risk factors, according to spokesperson Jamila Vernon. “Subsequent ultrasounds are also based on findings and risk factors. In other words, there is no set number of ultrasounds for all patients,” Vernon said.
“There was nothing that indicated I needed those scans,” Donovan said. “It was just a money grab.”
With roughly 3.6 million babies born every year in the United States, childbirth is one of the most common medical events that people experience.
Still, having a baby isn’t cheap. It costs families with employer coverage $2,743 on average, according to an analysis of data from 2021 to 2023 by researchers with the Peterson-KFF Health System Tracker.
About 41% of births in the U.S. are covered by the federal-state Medicaid program for low-income people. These families don’t generally face out-of-pocket costs for maternity care, and the new billing system won’t affect them financially.
However, ACOG hopes that the new system will help doctors and other medical professionals improve maternity care, particularly after a baby is born.
With a bundled system, it’s often unclear what services were provided during the maternity process, hampering researchers’ ability to evaluate whether specific services move the needle on maternal mortality rates, in which the U.S. lags every other high-income country.
Maternity care experts are particularly interested in postpartum care. Forty-eight states and Washington, D.C., now provide a full year of Medicaid coverage after childbirth, up from 60 days. Under the new codes, physicians will be paid to provide extended postpartum care, rather than the two visits that were recommended under bundled coding.
It’s important to track a number of medical issues after birth, including screening for depression, substance use, whether a pregnant mother’s gestational diabetes turned into diabetes, or whether cardiac changes returned to normal after birth, said Kay Johnson, a Medicaid and maternal-child health expert who is president of Johnson Policy Consulting.
With the new codes, “You have that opportunity for ongoing care, and you have a way to finance it,” she said.
Experts who represent employers say they understand why ACOG has been pushing for these changes, but they are concerned that they will result in higher costs.
“ACOG is saying that obstetricians are being underpaid, and there’s probably some truth to that,” said Jeff Levin-Scherz, population health leader at WTW’s health management practice and an assistant professor at Harvard’s T.H. Chan School of Public Health.
Levin-Scherz noted reports of increasing visit intensity, reflecting the time and resources a doctor spends on a patient and resulting in higher payment. “It’s not likely that this new set of visit codes will be exempt from that,” he said. Even though patients may not be on the hook directly for the cost of prenatal and postpartum visits, to the extent that there are more visits and they’re coded at a higher level, “if their plan is paying more next year, their insurance premiums will go up more,” he said.
Magda Rusinowski, a vice president of the Business Group on Health, which represents midsize and large employers that self-fund employee health benefits, said she is concerned that the new system will encourage the use of additional and more frequent tests and more expensive providers rather than doulas, for example.
“Fee-for-service in every discipline incentivizes more tests and higher-level providers because that’s what generates higher billing,” she said.
Still, “it’s early days,” Rusinowski said. “Many in the industry are trying to think about how this will unfold.”
KFF Health News is a national newsroom that produces in-depth journalism about health issues and is one of the core operating programs at KFF — the independent source for health policy research, polling, and journalism.
