For years, Mrs. Sutton came to see me in the office every three months. Visiting the doctor quarterly was “the right thing to do,” she told me, given the fact that she had both diabetes and high blood pressure.

She always set the agenda at our visits. She brought lists of questions and requests that followed the recommendations of her fellow churchgoers and the health materials she had read.

It came as no surprise to me when she asked to undergo a colonoscopy at age 68, in order to be screened for colon cancer. She had read that colon cancer was treatable if caught early, and several friends had told her that undergoing “the scope” was the most comprehensive means of screening.

I agreed that it was a good idea and dutifully made the referral to the gastroenterologist. When the report came back a few weeks later, I was pleased to learn there were no polyps found.

When I mentioned the test to Mrs. Sutton at our next visit, I assumed she’d be as happy with the results as I had been. Instead, her reaction shocked me.

“How on earth could this cost so much?” she demanded of me. “This is an outrageous bill!” she said, referring to both the colonoscopy charges and the facility fee, which totaled more than $5,000.

“Yes, the prices of medical tests can be hard to believe, but you have Medicare” I told her. Because Mrs. Sutton had ‘Medigap coverage,’ she owed nothing.

The fact that her out-of-pocket costs were zero failed to sway her. It was the principle of the thing. She felt gouged by the price of a procedure which she valued at a few hundred dollars at most.

Unfortunately, there was no turning back. The damage had been done. Mrs. Sutton made very clear to me that she’d never undergo a test that pricey again, even if insurance paid for it.

Furthermore, she told me that she expected me to provide better information about what something might cost beforehand.

Without realizing it, I had fallen into the abyss of medical prices— a topic that still puzzles and enrages millions of Americans.

Like many doctors, what little I know about medical pricing comes from a combination of what my patients tell me and what my family and I experience personally. There was no formal training in medical school about health care spending or the cost-effectiveness of various tests and treatments.

Instead, we were taught to ignore costs and focus on the best care and treatment we could provide. This was health care, American-style. No stone should go unturned in the pursuit of a diagnosis. Any and all resources should be brought to bear in treatment. Payment was almost never discussed in polite company.

Fortunately, I think, doctors are warming to the idea that we must be better stewards of the resources we command.

Pharmaceuticals were long an exception to the cost-is-no-concern rule. Orthodox medical teaching has always emphasized the principle that a well-established, low-priced generic drug is as good as a more expensive name-brand alternative. Yet evidence shows that in spite of mutual doctor-patient desire to discuss drug costs, we docs usually shirk the duty.

Diagnostic tests are an entirely different kettle of fish. Despite patient demand to know the cost of a test or procedure, it’s been very hard to get reliable price quotes. New entities have formed to try to solve this perennial puzzle: One company provides an app that links with insurers’ databases to accurately list contracted prices. Another provides incentives to patients to get tests in-network by offering discounts and sending patients a check for a small portion of the accrued savings.

Which brings me back to Mrs. Sutton, who died before smartphones changed the way we live. Back when she confronted me about the cost of her colonoscopy, there was no app to help her shop around. Nor was there any resource for me to guide her to the most cost-effective alternative.

All of my experience to that point had taught me that patients with insurance simply didn’t care about prices. Mrs. Sutton begged to differ. Her reaction taught me never to make that assumption again.

John Henning Schumann is a writer and doctor in Tulsa, Okla. He serves as president of the University of Oklahoma, Tulsa. He also hosts Public Radio Tulsa’s Medical Matters. He’s on Twitter: @GlassHospital

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Childbirth historically involved a support system of women who assisted a woman from her pregnancy through the birth and in the immediate postpartum period afterward.

Today, obstetricians and midwives provide prenatal care and help a woman deliver her baby. Doulas continue to fulfill the historical role of emotionally supporting a pregnant woman through labor and childbirth, helping her advocate for herself and communicate with her caregivers.

A study published online Thursday by the journal Birth suggests that offering women the support of a certified doula could save Medicaid and perhaps private insurers real money — nearly $1,000 a birth — by reducing cesarean and preterm births.

Previous research has shown lower rates of cesarean births, more satisfaction from mothers and better newborn Apgar scores — a measure of a baby’s condition at birth — among mothers who use doula care. In fact, the American Congress of Obstetricians and Gynecologists says in guidelines for safe prevention of cesarean births that doula care is “probably underutilized.”

This is the first study, however, to show a reduction in preterm births and a net savings for public insurance. Cesarean births — about a third of all U.S. births — cost about twice as much as vaginal births, and the 1 in 10 U.S. infants born preterm (before 37 weeks) incur medical costs 10 times greater than those of full-term infants.

“What is coming together now is a research consensus and a professional consensus of the benefits of doula care,” said lead author Katy Kozhimannil, an associate professor in the University of Minnesota School of Public Health. “The barriers to access are financial, cultural and geographic. The financial barrier ought to be the first to fall.”

Her analysis compared 1,935 women in Minnesota who accepted state doula services covered by Medicaid with 67,147 Medicaid-covered women throughout the northern and midwestern U.S. who didn’t get help from doulas.The doulas visited with the mothers four times leading up to the birth, provided support during labor and delivery and made two postpartum visits to the women.

In comparing the groups, 4.7 percent of the women using doulas had preterm births compared with 6.3 percent of the women who didn’t get doula help. Similarly, 20.4 percent of doula-supported women had cesarean deliveries compared with 34.2 percent of the women without doulas All told, an estimated $986 per birth would be saved if all the women received doula services, the analysis found.

How doulas decrease the odds of a cesarean birth isn’t entirely clear. One way might be by reducing cesareans recommended out of convenience, such as during a more slowly progressing labor.

“One of the questions doulas are trained to help women remember to ask is, ‘Is this an emergency or do I have time to think about it?’ ” Kozhimannil said. “If it’s an emergency, it’s outside the doula’s scope of work. If it’s not, that’s an opportunity for the doula to help the woman come to a decision with her clinician.”

However, there is a potential risk if inadequately trained doulas practice outside their scope of care, says Aaron Caughey, chair of the Department of Obstetrics & Gynecology at Oregon Health & Science University in Portland.

“I can’t think of a lot of negatives fundamentally in the routine use of doulas,” he said. “But in my clinical experience, the one possible negative is that a lot of the time the individuals who use doulas have a certain mindset about birth, and the doula can sometimes serve to block the clinician from practicing in the way the clinician might wish.”

For example, a doula might discourage a woman from agreeing to a rupture of membranes recommended by a clinician even if breaking her waters is medically indicated, he said. If physicians, midwives and doulas work together from the start, disputes over care are less likely.

Why doula care might affect preterm birth is also uncertain but might partly result from a reduction in stress because of the support of a doula during prenatal care, Caughey said.

Kozhimannil’s team analyzed preterm births and cesarean births separately, but another analysis that combined them revealed no reduction in cesareans among preterm births. She said that’s a good thing because it means the reduction occurs among healthy deliveries and not the complicated ones more likely to need a C-section.

Although the researchers adjusted the analysis for mothers’ age and race/ethnicity and having high blood pressure or diabetes during pregnancy, the groups may still have been too different for adequate comparison, wrote Adam Powell, a health economist and president of Payer+Provider Syndicate, in an email.

He pointed out that the larger control group may have included some doula-assisted births, albeit a small number, but that the better health of the women in the doula group may not have been fully accounted for in the statistical adjustments.

“It is not surprising that the intervention group was in better health than the control group as the intervention group had to be proactive about their health in order to be included in the group,” he wrote since only 15 to 20 percent of the mothers eligible for Medicaid-covered doula services used them.

The study’s findings would be stronger if the women had been randomized through a lottery to receive doula support or not, Powell said.

Even so, insurers can look through their own claims for answers. “Medicaid programs and health care companies generally have the data to conduct these analyses with their own data,” Kozhimannil said. “There is no reason they shouldn’t consider adding doula care or at least exploring that option.”

She pointed out the importance of this study’s findings in terms of the racial disparities in poor birth outcomes in the U.S.

“It’s important in an equity context because preterm birth is so much more frequent among black women compared with white women and preterm birth is the largest contributor to infant death,” Kozhimannil said. “The infant mortality rates and the disparities in infant mortality are something we’ve been reckoning with as a country for 100 years without good progress. Any identification of interventions that can help address issues related to preterm birth and especially disparities in preterm birth is urgently needed.”

Tara Haelle is a freelance health and science writer based in Peoria, Ill. She’s on Twitter: @tarahaelle

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