653
Medicine and Society
Obstetric Care, Medicaid, and Family Physicians How Policy Changes Affect Physicians' Attitudes THOMAS S. NESBITT, MD, MPH; JEFFREY L. TANJI, MD; JOSEPH E. SCHERGER, MD, MPH; and NORMAN B. KAHN, MD, Davis, Califomia
Recent expansion of Medicaid eligibility for pregnant women and increased reimbursement to physicians who provide perinatal services were designed to improve access to care. Family physicians provide a relatively high proportion of care to pregnant women on Medicaid, especially in rural areas. We surveyed all family physicians who provide obstetric services in 26 northern California counties regarding these changes and perceived barriers to providing obstetric care to women on Medicaid. Of surveyed physicians who limited the number of their Medicaid obstetric patients, 58% stated that recent Medicaid policy changes had increased their willingness to accept new Medicaid obstetric patients. Despite these policy changes, administrative issues and poor reimbursement were cited as the two most notable barriers to providing obstetric care to women on Medicaid. Fear of being sued by Medicaid patients is still seen as a barrier by physicians who have recently discontinued practicing obstetrics and by those who continue to care for a large number of Medicaid obstetric patients. (Nesbitt TS, Tanji JL, SchergerJE, Kahn NB: Obstetric care, Medicaid, and family physicians-How policy changes affect physicians' attitudes. WestJ Med 1991 Dec; 155:653-657)
Prenatal care is recognized as the most cost-effective intervention in reducing infant mortality.I Women in low socioeconomic groups, for whom this intervention appears most important in assuring optimal birth outcomes, often have the greatest difficulty obtaining access to such care.2`5 This situation is worsening in large part because of the reluctance of many physicians to accept obstetric patients who are uninsured or are insured through Medicaid. Low reimbursement, administrative problems, and malpractice issues are the major reasons reported in the literature for physicians limiting Medicaid obstetric patients in their practices.67' Between 1988 and 1990 in the 26 noncoastal northern California counties, the total number of physicians caring for Medicaid (Medi-Cal) obstetric patients decreased from 207 to 166 (a decline of 20%), despite an increase in the total number of Medicaid obstetric patients.8 Recent federal legislation has led to revised eligibility requirements that allow more patients to be covered for prenatal care under the Medicaid program. Many states have increased reimbursement levels to physicians for their care of pregnant Medicaid patients. In California, eligibility requirements have been relaxed to allow pregnant women with family incomes twice the federal poverty level to qualify for Medicaid. The physician reimbursement for global obstetric care under Medicaid in California has risen to more than $1,000, with higher rates being paid under special programs. These changes are intended to improve access to care for lowincome patients. For this to occur, however, physicians would need to increase their willingness to care for Medicaid obstetric patients. These changes are particularly important for family physicians, who care for a high proportion of Medicaid patients
in many areas, particularly in rural America.29-'0 In the western United States, nearly 40% of family physicians still practice obstetrics, representing two thirds ofall rural obstetric providers nationwide. In the 26 noncoastal northern California counties, 30% of obstetric care providers are family physicians, and two thirds of these accept Medicaid obstetric patients compared with only about half of obstetricians in the same area.8 Our study analyzed the effects of recent Medicaid changes on family physicians providing obstetric care in a 26county region of northern California and on their willingness to care for obstetric patients covered under Medicaid. We also analyzed perceived obstacles to providing obstetric care to women covered by Medicaid, comparing the answers of family physicians who are continuing to practice obstetrics with those of physicians who have discontinued practicing obstetrics in the past four years.
Methods The 26 noncoastal northern California counties in which the study was conducted are predominantly rural and represent about 30% of the land mass of California. More than 57,000 births were reported to residents of the study area in 1988-7,000 (12%) more than in the previous year. There was a 10.8% increase in the number of women covered under Medicaid in 1989 compared with 1986. A postcard survey was sent to 748 family physicians practicing in these 26 counties whose names were obtained through a listing of members and nonmembers of the California Academy of Family Physicians. Physicians were asked if they currently practiced obstetrics, had discontinued practicing obstetrics in the past four years, or had stopped providing
From the University of California, Davis, School of Medicine. This work was supported in part by The Sierra Foundation, a private independent philanthropic foundation. Reprint requests to Thomas S. Nesbitt, MD, MPH, Department of Family Practice, University of California, Davis, School of Medicine, 2221 Stockton Blvd, Sacramento, CA
95817.
OBSTETRICS, MEDICAID, AND PHYSICIANS
654
groups of data with long tails. Student's paired t test was used when comparing data between groups.
758 FPs in 26 counties 748 - Postcard
-472 Nonrespondents to postcard survey 95 Quit OB within past 4 yrs
76 of 95 (78%)
Responded to practice status-specific survey
Quit OB > 4 yrs ago or never practiced OB
95 Still practicing OB
28 In residency or teaching (not included in results) 67 (100%)* FPs practicing OB in private practice responded to survey or contacted by phone
Figure 1.-The response of the study population is broken down according to practice status. FP=family physicians, OB=obstetrics, *=confirmed through contact with area hospitals
obstetric care more than four years before or had never practiced obstetrics. The practice status of 652 of 748 physicians (87%) was obtained through this method. To identify 100% of family physicians performing deliveries, area hospitals were contacted, yielding an additional four physicians who were practicing obstetrics and six who had recently discontinued that practice. These physicians were either not listed with the academy or had not returned postcards. Questionnaires were sent to the physicians who were currently practicing obstetrics or had discontinued practicing obstetrics in the past four years. Two mailings were done. Family physicians who had been identified as practicing obstetrics and who did not respond to either mailing were contacted and surveyed by phone. A breakdown of response rates is given in Figure 1. Information was obtained on the physicians that included age, years in practice, details on obstetric experience and practice, and the percentage of patients covered under Medicaid. Physicians were excluded if they were in training, if their primary activity was teaching in a residency program, or if they were primarily practicing in military service. Physicians currently practicing obstetrics were asked if the expansion of Medicaid eligibility or the increase in Medicaid reimbursement had affected their willingness to accept new Medicaid obstetric patients. Physicians still practicing and those who had recently discontinued practicing obstetrics were asked to rank what they considered barriers to caring for Medicaid obstetric patients. Choices on this question included the fear of being sued, administrative problems with Medicaid (delays in reimbursement, paperwork), insufficient reimbursement, Medicaid patients are noncompliant, Medicaid patients are too high risk, concerns about ending up with entire Medicaid families, and practice too full to accept new patients. Survey responses were evaluated using both a weighted rank order score and a frequency distribution analysis. In profiling physician groups, descriptive statistics were used, including the mean with standard deviation and the median in
Results In all, 44 physicians who had limited their obstetric practice before the changes in guidelines responded to the question regarding the effect of these changes on their willingness to take new Medicaid obstetric patients. Of these, 25 (58%) indicated that the changes in reimbursement increased their willingness to accept new Medicaid obstetric patients. Physicians who were continuing to practice and those who had recently discontinued practicing obstetrics were asked to rank their perceptions of barriers to providing obstetric care to Medicaid patients (Table 1). Of 67 physicians who continued to practice obstetrics, 57 responded to this question. Among these physicians, insufficient reimbursement and administrative issues with Medicaid (which included paperwork and delays in payment) were ranked as the greatest barriers to caring for these patients in the weighted rank order analysis. These items were also most frequently ranked first or second. The items least frequently ranked first or second among physicians continuing to practice obstetrics were fear of lawsuits and concerns about having to accept an entire family if they accepted a pregnant Medicaid patient. Of 75 physicians who had recently stopped delivering babies and who responded to our survey, 63 answered the question regarding barriers to caring for Medicaid patients. Among these physicians, insufficient reimbursement and administrative issues with Medicaid also received the highest scores in the weighted rank order analysis (Table 1). Nearly twice as many physicians who had recently discontinued practicing obstetrics ranked insufficient reimbursement as the greatest or second greatest barrier to caring for Medicaid obstetric patients compared with any other barrier. The fear of malpractice suits from the Medicaid obstetric population was a greater concern in this group than among those who are continuing to practice obstetrics. The mean age of physicians who continued delivering babies was 41 + 10 years and that of those who had stopped doing so was 44 + 11 years (P < .05). Years in practice for these groups was 10 + 7 years and 13 + 10 years (P < .05), respectively. The median number of deliveries performed during training for physicians who continued obstetrics (200) was higher than for those who had stopped (150). The median number of deliveries since training was 300 for the continuing group and 200 for the group having recently quit. The median annual number of deliveries performed by physicians who continued practicing obstetrics was 40. The portion of patients covered by Medicaid in the practice was 27% for those continuing obstetrics and 17% for those physicians who had discontinued obstetrics. This difference may be explained in large part by the fact that, in the practices of those who continued practicing obstetrics, 49% of obstetric patients were on Medicaid. Physicians were grouped by size of obstetric practice and exposure to Medicaid to determine the impact these have on the perceptions of barriers to caring for Medicaid obstetric patients. Family physicians who delivered more than 40 babies in 1989 (high-volume obstetric care providers) considered administrative issues to be the most significant barrier, with insufficient reimbursement and concerns about the high-risk nature of Medicaid obstetric patients following close behind (Figure 2). Among these providers, physicians
*r
THE WESTERN JOURNAL OF MEDICINE
DECEMBER 1991
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o
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6
o
TABLE 1.-Perceived Barriers to Medicaid Obstetric Care Perceived Bamers to Care
Practice Status
Continuing Obstetrics (N=57*) ...... Insufficient reimbursement Administrative issues Noncompliant patients High-risk patients Practice too full to accept new patients End up with entire family Fear of being sued Discontinued Obstetrics in Past 4 Years (N=63) ......... I.nsufficient reimbursement Administrative issues Fear of being sued Noncompliant patients High-risk patients End up with entire family Practice too full to accept new patients
Frequency Answered 1 or2
Perrentage of Total Score
20 20 19 16 18 8 8
18.0 15.8 15.2 14.7 10.2 13.3 12.8
41 23 13 11 13 8 4
26.7
20.3 14.9 11.1 10.9 11.3 4.8
'Four physicians perceived no barriers
Medicaid patients, regardless of the percentage of their obstetric practice covered by Medicaid (Figure 3). Concerns about medical risk and noncompliance were cited as of next importance by this group as a whole (Figure 3). Low-volume providers with more than 50% of their obstetric patients covered by Medicaid considered administrative problems and poor patient compliance to be more important barriers than did physicians with less than 50% of their obstetric patients covered by Medicaid. Fear of being sued did not rank as of high a concern as did other issues among physicians with
with higher Medicaid obstetric volume (more than 20 Medicaid deliveries in 1989) had the greatest concerns about the high medical risk of Medicaid patients, with administrative and reimbursement issues close behind. Of interest is the fact that the latter subgroup of physicians had more concerns about Medicaid patients suing than did other family physicians currently practicing obstetrics. Family physicians who delivered fewer than 40 babies (low-volume obstetrics providers) in 1989 ranked insufficient reimbursement as the greatest barrier to caring for
i nbrsuff
X'. ::....:B::-::::B:..:. :: : : > . . ... . .>:Ba-.
ent
re reimbursement
Noncc)mpliant patients
%
I----------
..........
p
I
High-risk patients
.
p
p
.'S.Nl
_~ ~ ~ ~ ~ ~ ~ ~ .:1,1Il:
...............
.
: :
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E
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. . . .
..:................
L Fear of lawsuits
L
.:
.
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....-
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.
I
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............
I
I
I
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I
I
I
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..
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11
11
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22 20 18 16 10 12 14 % of Total Score Figure 2.-The graph shows perceived barriers to caring for obstetric patients covered by Medicaid among 31 family physicians delivering more than 40 babies in 1989. all providers with a high volume of obstetric care, E providers with a high volume of obstetric care and a high volume of Medicaid patients, 1 = providers with a high volume of obstetric care and a low volume of Medicaid patients
0
=
2
4
8
6
=
656
Noncmp~ ~ ~ ~ lian
OBSTETRICS, MEDICAID, AND PHYSICIANS
|e
Insufficient reimbursement
..
..
---W
::BR:Bv:e::::Re:::.* :::ex ............................. .Xee : ::
Noncompliant------
e1eeeWx...
patients
.
::
ve....
::1
..%..
High-risk patients C : s..::.:> . a.
Administrative issues
l::..,
X.
veee.
I
End up with
family 0---
Practice too full
Fear of lawsuits
I
I I
0
I
I
2
I
I
4
I
I
6
I
I
I
8
I
I
I
10 12 % of Total Score
I
I
14
I
I
16
I
I
18
I
I
20
I
22
Figure 3.-The graph shows perceived barriers to caring for obstetric patients covered by Medicaid among 26 family physicians delivering fewer than 40 babies in 1989. U = all providers with a low volume of obstetric care, E3 = providers with a low volume of obstetric care and a high volume of Medicaid patients, S = providers with a low volume of obstetric care and a low volume of Medicaid patients
low-volume obstetric practices, regardless of the percentage of Medicaid patients in their practices. Discussion
The results of this study demonstrate that, for family physicians who practice obstetrics in northern California, increased reimbursement from Medicaid increased their willingness to accept new Medicaid obstetric patients. This study confirms that administrative problems and reimbursement issues are the factors of most concern to both family physicians who currently practice obstetrics and those who recently discontinued this service. These issues have been cited in previous works that included both obstetricians and family physicians.' Therefore, not only have the recent changes been on target as far as these physicians are concerned, but also further efforts are probably warranted in these areas. An issue that does not seem to be consistently a concern among all groups is the fear of lawsuits from Medicaid patients. Family physicians who do more than 40 deliveries a year with a high volume of Medicaid patients and those who have discontinued practicing obstetrics list this as a greater concern than do other groups studied. Interestingly, this has been reported as a persistent concern of obstetricians in one study.6 A recent study in California, however, has shown that Medicaid obstetric patients do not sue more often than other patients (C. Newhart, S. Teran, B. Aved, et al, "A Comparison of Obstetrical Malpractice Suits Among Medi-Cal Patients Compared to Private Pay Patients in Northern California," unpublished manuscript). That this misperception exists in any group of potential providers of Medicaid
obstetric care indicates that state Medicaid programs could benefit by increasing physicians' awareness of Medicaid patients' true propensity for suing. The critical question remains whether changes in Medicaid eligibility and reimbursement improve pregnancy outcomes. Piper and colleagues showed that, in Tennessee, eligibility expansion alone did not improve early use of prenatal care or outcome.11 Their study, however, did not adequately address the availability of Medicaid obstetric providers, which in many areas is declining and presumably is the limiting factor in the timing of beginning prenatal care. Our study suggests that increased Medicaid reimbursement will improve access to obstetric care by family physicians. Some ofthe physicians we surveyed were not aware of the changes in Medicaid. This situation was also reported in a larger study that included obstetricians conducted in the same geographic area.8 This suggests that Medicaid programs might be more successful in attracting providers willing to accept their patients if the programs were to increase their marketing efforts regarding policy changes that positively affect physicians.6 These efforts are already under way in California. Health care policymakers (state legislators and governors) should continue to strive to bring Medicaid reimbursement closer to that of private insurance companies. It appears that this issue is a major factor in decisions about caring for Medicaid patients. Previous work has demonstrated that dollars spent on providing care for Medicaid patients translate into savings of three to four times by preventing later adverse outcomes.12 This would argue for states continuing to raise Medicaid reimbursement for obstetric services until an ade-
THE WESTERN JOURNAL OF MEDICINE
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DECEMBER 1991
*
155
*
number of providers participate in these programs. In addition, while administrative problems have been addressed in many states, further work clearly is necessary, at least in California. The importance of addressing these issues is increasing as eligibility requirements change and a larger proportion of the population becomes eligible for Medicaid quate
coverage. REFERENCES 1. The Report of the National Commission to Prevent Infant Mortality. Washington, DC, National Commission to Prevent Infant Mortality, August 1988 2. Institute of Medicine: The Effects of Medical Professional Liability on the Delivery of Obstetrical Care. Washington, DC, National Academy Press, 1989 3. Nesbitt TS, Connell FA, Hart LG, Rosenblatt RA: Access to obstetric care in rural areas: Effect on birth outcomes. Am J Public Health 1990; 80:814-818 4. Schwartz RH: Infant mortality and access to care. Obstet Gynecol 1989; 73:123-124
6
657 5. Gold LB, Kenney AM, Singh S: Blessed Events and the Bottom Line: Financing Maternity Care in the US. New York, NY, Alan Guttmacher Institute, 1988 6. Troubling Trends: The Health of America's Next Generation. Washington, DC, National Commission to Prevent Infant Mortality, 1990 7. Rosenblatt RA, Whelan A, Hart LG: Obstetric practice patterns in Washington State after tort reform: Has the access problem been solved? Obstet Gynecol 1990; 76:1105-1110 8. Access to Prenatal Care Services in Northern California. Sacramento, Calif, The Sierra Foundation, June 1990 9. Nesbitt TS, SchergerJE, Tanji JL: The impact of obstetrical liability on access to perinatal care in the rural United States. J Rural Health 1989; 5:321-335 10. Onion DK, Mockapetris AM: Specialty bias in obstetric care for high-risk socioeconomic groups in Maine. J Fam Pract 1988: 27:423-427 11. Piper JM, Ray WA, Griffin MR: Effects of Medicaid eligibility expansion on prenatal care and pregnancy outcome in Tennessee. JAMA 1990; 264:2219-2223
12. Institute of Medicine: Preventing Low Birthweight. Washington, DC, National Academy Press, 1985
Medicine and Society
Obstetric Care, Medicaid, and Family Physicians How Policy Changes Affect Physicians' Attitudes THOMAS S. NESBITT, MD, MPH; JEFFREY L. TANJI, MD; JOSEPH E. SCHERGER, MD, MPH; and NORMAN B. KAHN, MD, Davis, Califomia
Recent expansion of Medicaid eligibility for pregnant women and increased reimbursement to physicians who provide perinatal services were designed to improve access to care. Family physicians provide a relatively high proportion of care to pregnant women on Medicaid, especially in rural areas. We surveyed all family physicians who provide obstetric services in 26 northern California counties regarding these changes and perceived barriers to providing obstetric care to women on Medicaid. Of surveyed physicians who limited the number of their Medicaid obstetric patients, 58% stated that recent Medicaid policy changes had increased their willingness to accept new Medicaid obstetric patients. Despite these policy changes, administrative issues and poor reimbursement were cited as the two most notable barriers to providing obstetric care to women on Medicaid. Fear of being sued by Medicaid patients is still seen as a barrier by physicians who have recently discontinued practicing obstetrics and by those who continue to care for a large number of Medicaid obstetric patients. (Nesbitt TS, Tanji JL, SchergerJE, Kahn NB: Obstetric care, Medicaid, and family physicians-How policy changes affect physicians' attitudes. WestJ Med 1991 Dec; 155:653-657)
Prenatal care is recognized as the most cost-effective intervention in reducing infant mortality.I Women in low socioeconomic groups, for whom this intervention appears most important in assuring optimal birth outcomes, often have the greatest difficulty obtaining access to such care.2`5 This situation is worsening in large part because of the reluctance of many physicians to accept obstetric patients who are uninsured or are insured through Medicaid. Low reimbursement, administrative problems, and malpractice issues are the major reasons reported in the literature for physicians limiting Medicaid obstetric patients in their practices.67' Between 1988 and 1990 in the 26 noncoastal northern California counties, the total number of physicians caring for Medicaid (Medi-Cal) obstetric patients decreased from 207 to 166 (a decline of 20%), despite an increase in the total number of Medicaid obstetric patients.8 Recent federal legislation has led to revised eligibility requirements that allow more patients to be covered for prenatal care under the Medicaid program. Many states have increased reimbursement levels to physicians for their care of pregnant Medicaid patients. In California, eligibility requirements have been relaxed to allow pregnant women with family incomes twice the federal poverty level to qualify for Medicaid. The physician reimbursement for global obstetric care under Medicaid in California has risen to more than $1,000, with higher rates being paid under special programs. These changes are intended to improve access to care for lowincome patients. For this to occur, however, physicians would need to increase their willingness to care for Medicaid obstetric patients. These changes are particularly important for family physicians, who care for a high proportion of Medicaid patients
in many areas, particularly in rural America.29-'0 In the western United States, nearly 40% of family physicians still practice obstetrics, representing two thirds ofall rural obstetric providers nationwide. In the 26 noncoastal northern California counties, 30% of obstetric care providers are family physicians, and two thirds of these accept Medicaid obstetric patients compared with only about half of obstetricians in the same area.8 Our study analyzed the effects of recent Medicaid changes on family physicians providing obstetric care in a 26county region of northern California and on their willingness to care for obstetric patients covered under Medicaid. We also analyzed perceived obstacles to providing obstetric care to women covered by Medicaid, comparing the answers of family physicians who are continuing to practice obstetrics with those of physicians who have discontinued practicing obstetrics in the past four years.
Methods The 26 noncoastal northern California counties in which the study was conducted are predominantly rural and represent about 30% of the land mass of California. More than 57,000 births were reported to residents of the study area in 1988-7,000 (12%) more than in the previous year. There was a 10.8% increase in the number of women covered under Medicaid in 1989 compared with 1986. A postcard survey was sent to 748 family physicians practicing in these 26 counties whose names were obtained through a listing of members and nonmembers of the California Academy of Family Physicians. Physicians were asked if they currently practiced obstetrics, had discontinued practicing obstetrics in the past four years, or had stopped providing
From the University of California, Davis, School of Medicine. This work was supported in part by The Sierra Foundation, a private independent philanthropic foundation. Reprint requests to Thomas S. Nesbitt, MD, MPH, Department of Family Practice, University of California, Davis, School of Medicine, 2221 Stockton Blvd, Sacramento, CA
95817.
OBSTETRICS, MEDICAID, AND PHYSICIANS
654
groups of data with long tails. Student's paired t test was used when comparing data between groups.
758 FPs in 26 counties 748 - Postcard
-472 Nonrespondents to postcard survey 95 Quit OB within past 4 yrs
76 of 95 (78%)
Responded to practice status-specific survey
Quit OB > 4 yrs ago or never practiced OB
95 Still practicing OB
28 In residency or teaching (not included in results) 67 (100%)* FPs practicing OB in private practice responded to survey or contacted by phone
Figure 1.-The response of the study population is broken down according to practice status. FP=family physicians, OB=obstetrics, *=confirmed through contact with area hospitals
obstetric care more than four years before or had never practiced obstetrics. The practice status of 652 of 748 physicians (87%) was obtained through this method. To identify 100% of family physicians performing deliveries, area hospitals were contacted, yielding an additional four physicians who were practicing obstetrics and six who had recently discontinued that practice. These physicians were either not listed with the academy or had not returned postcards. Questionnaires were sent to the physicians who were currently practicing obstetrics or had discontinued practicing obstetrics in the past four years. Two mailings were done. Family physicians who had been identified as practicing obstetrics and who did not respond to either mailing were contacted and surveyed by phone. A breakdown of response rates is given in Figure 1. Information was obtained on the physicians that included age, years in practice, details on obstetric experience and practice, and the percentage of patients covered under Medicaid. Physicians were excluded if they were in training, if their primary activity was teaching in a residency program, or if they were primarily practicing in military service. Physicians currently practicing obstetrics were asked if the expansion of Medicaid eligibility or the increase in Medicaid reimbursement had affected their willingness to accept new Medicaid obstetric patients. Physicians still practicing and those who had recently discontinued practicing obstetrics were asked to rank what they considered barriers to caring for Medicaid obstetric patients. Choices on this question included the fear of being sued, administrative problems with Medicaid (delays in reimbursement, paperwork), insufficient reimbursement, Medicaid patients are noncompliant, Medicaid patients are too high risk, concerns about ending up with entire Medicaid families, and practice too full to accept new patients. Survey responses were evaluated using both a weighted rank order score and a frequency distribution analysis. In profiling physician groups, descriptive statistics were used, including the mean with standard deviation and the median in
Results In all, 44 physicians who had limited their obstetric practice before the changes in guidelines responded to the question regarding the effect of these changes on their willingness to take new Medicaid obstetric patients. Of these, 25 (58%) indicated that the changes in reimbursement increased their willingness to accept new Medicaid obstetric patients. Physicians who were continuing to practice and those who had recently discontinued practicing obstetrics were asked to rank their perceptions of barriers to providing obstetric care to Medicaid patients (Table 1). Of 67 physicians who continued to practice obstetrics, 57 responded to this question. Among these physicians, insufficient reimbursement and administrative issues with Medicaid (which included paperwork and delays in payment) were ranked as the greatest barriers to caring for these patients in the weighted rank order analysis. These items were also most frequently ranked first or second. The items least frequently ranked first or second among physicians continuing to practice obstetrics were fear of lawsuits and concerns about having to accept an entire family if they accepted a pregnant Medicaid patient. Of 75 physicians who had recently stopped delivering babies and who responded to our survey, 63 answered the question regarding barriers to caring for Medicaid patients. Among these physicians, insufficient reimbursement and administrative issues with Medicaid also received the highest scores in the weighted rank order analysis (Table 1). Nearly twice as many physicians who had recently discontinued practicing obstetrics ranked insufficient reimbursement as the greatest or second greatest barrier to caring for Medicaid obstetric patients compared with any other barrier. The fear of malpractice suits from the Medicaid obstetric population was a greater concern in this group than among those who are continuing to practice obstetrics. The mean age of physicians who continued delivering babies was 41 + 10 years and that of those who had stopped doing so was 44 + 11 years (P < .05). Years in practice for these groups was 10 + 7 years and 13 + 10 years (P < .05), respectively. The median number of deliveries performed during training for physicians who continued obstetrics (200) was higher than for those who had stopped (150). The median number of deliveries since training was 300 for the continuing group and 200 for the group having recently quit. The median annual number of deliveries performed by physicians who continued practicing obstetrics was 40. The portion of patients covered by Medicaid in the practice was 27% for those continuing obstetrics and 17% for those physicians who had discontinued obstetrics. This difference may be explained in large part by the fact that, in the practices of those who continued practicing obstetrics, 49% of obstetric patients were on Medicaid. Physicians were grouped by size of obstetric practice and exposure to Medicaid to determine the impact these have on the perceptions of barriers to caring for Medicaid obstetric patients. Family physicians who delivered more than 40 babies in 1989 (high-volume obstetric care providers) considered administrative issues to be the most significant barrier, with insufficient reimbursement and concerns about the high-risk nature of Medicaid obstetric patients following close behind (Figure 2). Among these providers, physicians
*r
THE WESTERN JOURNAL OF MEDICINE
DECEMBER 1991
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TABLE 1.-Perceived Barriers to Medicaid Obstetric Care Perceived Bamers to Care
Practice Status
Continuing Obstetrics (N=57*) ...... Insufficient reimbursement Administrative issues Noncompliant patients High-risk patients Practice too full to accept new patients End up with entire family Fear of being sued Discontinued Obstetrics in Past 4 Years (N=63) ......... I.nsufficient reimbursement Administrative issues Fear of being sued Noncompliant patients High-risk patients End up with entire family Practice too full to accept new patients
Frequency Answered 1 or2
Perrentage of Total Score
20 20 19 16 18 8 8
18.0 15.8 15.2 14.7 10.2 13.3 12.8
41 23 13 11 13 8 4
26.7
20.3 14.9 11.1 10.9 11.3 4.8
'Four physicians perceived no barriers
Medicaid patients, regardless of the percentage of their obstetric practice covered by Medicaid (Figure 3). Concerns about medical risk and noncompliance were cited as of next importance by this group as a whole (Figure 3). Low-volume providers with more than 50% of their obstetric patients covered by Medicaid considered administrative problems and poor patient compliance to be more important barriers than did physicians with less than 50% of their obstetric patients covered by Medicaid. Fear of being sued did not rank as of high a concern as did other issues among physicians with
with higher Medicaid obstetric volume (more than 20 Medicaid deliveries in 1989) had the greatest concerns about the high medical risk of Medicaid patients, with administrative and reimbursement issues close behind. Of interest is the fact that the latter subgroup of physicians had more concerns about Medicaid patients suing than did other family physicians currently practicing obstetrics. Family physicians who delivered fewer than 40 babies (low-volume obstetrics providers) in 1989 ranked insufficient reimbursement as the greatest barrier to caring for
i nbrsuff
X'. ::....:B::-::::B:..:. :: : : > . . ... . .>:Ba-.
ent
re reimbursement
Noncc)mpliant patients
%
I----------
..........
p
I
High-risk patients
.
p
p
.'S.Nl
_~ ~ ~ ~ ~ ~ ~ ~ .:1,1Il:
...............
.
: :
:..%
E
Administrative
issues. End up with family
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. . . .
..:................
L Fear of lawsuits
L
.:
.
...
....-
X...........................
I X.
.
I
......
I
I
%
............
I
I
I
I
I
I
I
.1
..
...... .....
11
11
1L
22 20 18 16 10 12 14 % of Total Score Figure 2.-The graph shows perceived barriers to caring for obstetric patients covered by Medicaid among 31 family physicians delivering more than 40 babies in 1989. all providers with a high volume of obstetric care, E providers with a high volume of obstetric care and a high volume of Medicaid patients, 1 = providers with a high volume of obstetric care and a low volume of Medicaid patients
0
=
2
4
8
6
=
656
Noncmp~ ~ ~ ~ lian
OBSTETRICS, MEDICAID, AND PHYSICIANS
|e
Insufficient reimbursement
..
..
---W
::BR:Bv:e::::Re:::.* :::ex ............................. .Xee : ::
Noncompliant------
e1eeeWx...
patients
.
::
ve....
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l::..,
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veee.
I
End up with
family 0---
Practice too full
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I
I I
0
I
I
2
I
I
4
I
I
6
I
I
I
8
I
I
I
10 12 % of Total Score
I
I
14
I
I
16
I
I
18
I
I
20
I
22
Figure 3.-The graph shows perceived barriers to caring for obstetric patients covered by Medicaid among 26 family physicians delivering fewer than 40 babies in 1989. U = all providers with a low volume of obstetric care, E3 = providers with a low volume of obstetric care and a high volume of Medicaid patients, S = providers with a low volume of obstetric care and a low volume of Medicaid patients
low-volume obstetric practices, regardless of the percentage of Medicaid patients in their practices. Discussion
The results of this study demonstrate that, for family physicians who practice obstetrics in northern California, increased reimbursement from Medicaid increased their willingness to accept new Medicaid obstetric patients. This study confirms that administrative problems and reimbursement issues are the factors of most concern to both family physicians who currently practice obstetrics and those who recently discontinued this service. These issues have been cited in previous works that included both obstetricians and family physicians.' Therefore, not only have the recent changes been on target as far as these physicians are concerned, but also further efforts are probably warranted in these areas. An issue that does not seem to be consistently a concern among all groups is the fear of lawsuits from Medicaid patients. Family physicians who do more than 40 deliveries a year with a high volume of Medicaid patients and those who have discontinued practicing obstetrics list this as a greater concern than do other groups studied. Interestingly, this has been reported as a persistent concern of obstetricians in one study.6 A recent study in California, however, has shown that Medicaid obstetric patients do not sue more often than other patients (C. Newhart, S. Teran, B. Aved, et al, "A Comparison of Obstetrical Malpractice Suits Among Medi-Cal Patients Compared to Private Pay Patients in Northern California," unpublished manuscript). That this misperception exists in any group of potential providers of Medicaid
obstetric care indicates that state Medicaid programs could benefit by increasing physicians' awareness of Medicaid patients' true propensity for suing. The critical question remains whether changes in Medicaid eligibility and reimbursement improve pregnancy outcomes. Piper and colleagues showed that, in Tennessee, eligibility expansion alone did not improve early use of prenatal care or outcome.11 Their study, however, did not adequately address the availability of Medicaid obstetric providers, which in many areas is declining and presumably is the limiting factor in the timing of beginning prenatal care. Our study suggests that increased Medicaid reimbursement will improve access to obstetric care by family physicians. Some ofthe physicians we surveyed were not aware of the changes in Medicaid. This situation was also reported in a larger study that included obstetricians conducted in the same geographic area.8 This suggests that Medicaid programs might be more successful in attracting providers willing to accept their patients if the programs were to increase their marketing efforts regarding policy changes that positively affect physicians.6 These efforts are already under way in California. Health care policymakers (state legislators and governors) should continue to strive to bring Medicaid reimbursement closer to that of private insurance companies. It appears that this issue is a major factor in decisions about caring for Medicaid patients. Previous work has demonstrated that dollars spent on providing care for Medicaid patients translate into savings of three to four times by preventing later adverse outcomes.12 This would argue for states continuing to raise Medicaid reimbursement for obstetric services until an ade-
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number of providers participate in these programs. In addition, while administrative problems have been addressed in many states, further work clearly is necessary, at least in California. The importance of addressing these issues is increasing as eligibility requirements change and a larger proportion of the population becomes eligible for Medicaid quate
coverage. REFERENCES 1. The Report of the National Commission to Prevent Infant Mortality. Washington, DC, National Commission to Prevent Infant Mortality, August 1988 2. Institute of Medicine: The Effects of Medical Professional Liability on the Delivery of Obstetrical Care. Washington, DC, National Academy Press, 1989 3. Nesbitt TS, Connell FA, Hart LG, Rosenblatt RA: Access to obstetric care in rural areas: Effect on birth outcomes. Am J Public Health 1990; 80:814-818 4. Schwartz RH: Infant mortality and access to care. Obstet Gynecol 1989; 73:123-124
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657 5. Gold LB, Kenney AM, Singh S: Blessed Events and the Bottom Line: Financing Maternity Care in the US. New York, NY, Alan Guttmacher Institute, 1988 6. Troubling Trends: The Health of America's Next Generation. Washington, DC, National Commission to Prevent Infant Mortality, 1990 7. Rosenblatt RA, Whelan A, Hart LG: Obstetric practice patterns in Washington State after tort reform: Has the access problem been solved? Obstet Gynecol 1990; 76:1105-1110 8. Access to Prenatal Care Services in Northern California. Sacramento, Calif, The Sierra Foundation, June 1990 9. Nesbitt TS, SchergerJE, Tanji JL: The impact of obstetrical liability on access to perinatal care in the rural United States. J Rural Health 1989; 5:321-335 10. Onion DK, Mockapetris AM: Specialty bias in obstetric care for high-risk socioeconomic groups in Maine. J Fam Pract 1988: 27:423-427 11. Piper JM, Ray WA, Griffin MR: Effects of Medicaid eligibility expansion on prenatal care and pregnancy outcome in Tennessee. JAMA 1990; 264:2219-2223
12. Institute of Medicine: Preventing Low Birthweight. Washington, DC, National Academy Press, 1985
