Restricting access to neonatal intensive care: effect on mortality and economic savings.

Objective. Neonatal intensive care for very low birth weight (VLBW) infants is expensive, and cost-containment policies have been proposed that would restrict care according to birth weight. We examined the potential reduction in neonatal intensive care unit (NICU) VLBW charges and the impact on survivors if care were not offered to infants of extremely low birth weights or gestational ages. Design. We reviewed hospital charges for a retrospective cohort of VLBW infants born during the 5-year period from 1988 to 1992. Local charges and survival statistics were applied to national VLBW birth statistics to estimate the national effects of a birth weight-based rationing program. Setting. A high-risk perinatal referral center. Patients. A consecutive sample of 1361 VLBW infants was tracked from birth to discharge home, transfer to a level II nursery, or death. Main Outcome Measures. Hospital charges and survival. Results. Mean charges per survivor ranged from $250 654 for infants weighing <500 g to $74 101 for those weighing 1000 to 1500 g. Policies denying care to infants born at <500, 600, or 700 g would lead to total NICU care savings of 0.8%, 3.2%, and 10.3%, respectively. Applying the local birth weight-specific survival rates, such policies applied nationally would not have offered care to 136, 575, and 2689 potential survivors annually. Birth weight-based rationing schemes also are shown to increase further the racial disparity of NICU deaths. Conclusions. To attain significant reduction in NICU charges, policies offering care to the larger or more mature VLBW infants only will result in denying care to many infants who would otherwise survive.