Obstetrics and Gynecology Practices and Patient Insurance Type

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1 Women's Health Issues 23-3 (2013) e161 e165 Original article Obstetrics and Gynecology Practices and Patient Insurance Type Greta B. Raglan, BS a,b, *, Britta L. Anderson, PhD a, Hal Lawrence III, MD a, Jay Schulkin, PhD a,c a American College of Obstetricians and Gynecologists, Washington, DC b Department of Psychology, American University, Washington, DC c Department of Neuroscience, Georgetown University School of Medicine, Washington, DC Article history: Received 8 August 2012; Received in revised form 14 December 2012; Accepted 24 January 2013 abstract Background: Despite research on health disparities based on insurance status, little is known about the differences in practice patterns among physicians who cater to privately and non-privately insured patients. The aim of this study was to assess how obstetrician gynecologists (ob-gyns) who primarily see patients with private insurance differ from those who see mainly uninsured or publicly insured patients. This could be informative of the needs of these two groups of physicians and patients. Methods: A questionnaire was mailed or ed to 1,000 members of the American College of Obstetricians and Gynecologists, 600 of whom participate in the Collaborative Ambulatory Research Network. Findings: A 56.4% response rate was obtained. Of the valid responders, the 335 reported providing care to a majority of patients with private insurance ( private group ) and the 105 reported providing care to mostly publicly insured or uninsured patients ( non-private group ) were included in our analyses. Differences between groups included that the private group was more likely to see patients before their becoming pregnant and spent more time on well-woman care. The private group was more likely to see patients who are White, Asian, or between the ages of 45 and 64. The nonprivate group was more likely to see Hispanic patients and those under age 18. Conclusion: Results reveal that ob-gyns who see mostly privately insured patients have different clinical experiences than those who see mainly uninsured or publicly insured patients in terms of patient characteristics, preconception care, distribution of time on activities, and the of likelihood performing certain procedures and screening tests. Copyright Ó 2013 by the Jacobs Institute of Women s Health. Published by Elsevier Inc. Introduction The level of access to health care in the United States is highly variable based on location and insurance type. Individuals with private insurance tend to have better health outcomes on a number of measures as well as superior preventative care when compared to those without insurance or who rely on public health insurance (DeVoe, Fryer, Phillips, & Green, 2003). In addition, those with private insurance tend to have more access to specialist referrals (Ferrer, 2007) and to have a better Supported by Grant no. UA6MC from the Maternal and Child Health Bureau (Title V, Social Security Act, Health Resources and Services Administration, and Department of Health and Human Services (HHS)). Greta Raglan had full access to all the data in the study and takes responsibility for the integrity of the data and the accuracy of the data analysis. * Correspondence to: Greta B. Raglan, BS, American College of Obstetricians and Gynecologists, Department of Psychology, th St., SW, Washington, DC Phone: þ ; fax: þ address: graglan@acog.org (G.B. Raglan). generalized care experience (Shi, 2000). Those individuals who are uninsured or covered by public insurance tend to be more likely to delay seeking care (Hoffman & Paradise, 2008; Sox, Swartz, Burstin, & Brennan, 1998). Those individuals who lack health insurance are also more likely to see an overall decline in health as they approach middle age (Baker, Sudano, Albert, Borawski, & Dor, 2001; Hoffman & Paradise, 2008). Some of these disparities, particularly in access to preventative care, are particularly pronounced in women (Sambamoorthi & McAlpine, 2003). Accessing obstetrician gynecologist (ob-gyn) care before pregnancy has been linked to better pregnancy outcomes that can improve health of offspring as well as better overall health for women (Hillemeier, Weisman, Chase, Dyer, & Schaffer, 2008; Korenbrot, Steinberg, Bender, & Newberry, 2002). Previous studies have found that access to prenatal care depends on many external factors, including a woman s insurance status. These studies have found that uninsured women and women covered by public insurance have less access to prenatal care than do /$ - see front matter Copyright Ó 2013 by the Jacobs Institute of Women s Health. Published by Elsevier Inc.

2 e162 G.B. Raglan et al. / Women's Health Issues 23-3 (2013) e161 e165 privately insured women (U.S. General Accounting Office, 1987; Oberg, Lia-Hoagberg, Hodkinson, Skovholt, & Vanman, 1990; Oberg, Lia-Hoagberg, Skovholt, & Hodkinson, 1991). For all of the information that we have about disparities in access to care based on insurance type, we have little insight into this phenomenon based on the experience of the physicians providing care. This paper looks at whether and how physicians practices differ depending on the insurance status of their patients. In particular, we examine how the insurance status of ob-gyns patients is associated with other characteristics of their patients and a physician s likelihood of performing certain general care services. This paper is particularly focused on addressing the question of whether the services carried out by ob-gyns differed based on their patients insurance in an effort to better understand differences in need or access between patients who have private insurance and those who do not. Methods The method for this study closely followed that of Morgan, Lawrence, and Schulkin (2010) and Morgan, Anderson, Lawrence, and Schulkin (2012). Measures A survey regarding practices, opinions, and patient characteristics was developed by the research department at the American College of Obstetricians and Gynecologists (ACOG). Questions were developed in consultation with practicing obgyns and pilot tested on a sample of practicing ob-gyns with adjustments made before distribution. Institutional review board approval was obtained from ACOG. Physicians were asked questions about their age, gender, practice location, practice characteristics (age, race, insurance type), opinions, and division of time in a series of multiple choice, fill-in-the-blank, check all that apply, and Likert scale questions. Physicians also answered fill-in-the-blank questions about the number of operative procedures they performed, percentage of their patients seeing them as a primary care physician, and percentage of their patients who first made contact with them after becoming pregnant. Participants The study was sent to 1,000 ACOG fellows. Of these participants, 600 were members of the Collaborative Ambulatory Research Network (CARN). CARN members are ACOG fellows and junior fellows in practice who have volunteered to participate in survey studies on a regular basis without compensation; they are typically recruited through advertising or random selection from ACOG s membership rolls. CARN was established to improve the response rate on ACOG Research Department survey studies while maintaining a participant pool representative of practicing ACOG members. The remaining 400 participants consisted of a computer-generated random sample of ACOG fellows and junior fellows in practice who had not received a survey from ACOG during the previous 2 years (non-carn). Procedures A total sample of 1,000 physicians was sent an containing information about the study, a link to the survey, and a password unique to each participant that they could use to log on to the electronic survey. Four reminder s were sent to those who had not yet responded. Paper mailings, which included a cover letter, a questionnaire, and a stamped return envelope, were sent to the 875 participants who had not yet responded and to those for whom we did not have a valid address on record. Those who did not respond to the paper mailing were sent one paper reminder. The 1,000 participants who were contacted had a mean age of 50 years (range, 31 83). Participants who responded by mail did not differ from those who responded electronically in terms of age, gender, or insurance group. Those physicians reporting that more than 55% of their patients participated in Medicaid or Medicare or were uninsured were placed in the non-private group (n ¼ 105). Those physicians reporting that more than 55% of their patients had private insurance were placed in the private group (n ¼ 335). Ob-gyns in the private group were more likely to be female than physicians in the non-private group; therefore physician gender was controlled for in all analyses. Because the non-private group reported more young patients, patient age, a continuous variable of percent of patients under the age of 44, was also used as a covariate in all analyses. The data were analyzed using a personal computer-based software package (IBM SPSS Statistics 20.0, IBM Corp.Ó, Armonk, NY). Descriptive statistics were computed for the measures used in the analyses and reported as mean values standard deviation. One-way analysis of variance was used to compare group means of continuous measures. Differences on dichotomous variables were assessed using binary regression. Analyses were tested for significance using alpha of 0.01 to correct for multiple measures. Results The response rate was 56.4%. This response rate is similar to that of recent ACOG studies (e.g., Leddy, Anderson, Gall, & Schulkin, 2009; Power, Cogswell, & Schulkin, 2009). There were responding physicians from all ACOG districts except district X (Armed Forces), including from the District of Columbia and from every state of the United States except Montana. Respondents mean age ( ) closely matched that of the population to whom the survey was sent ( ). Men and women did not differ significantly in response rates (women, 59% [291/497]; men, 56% [273/488]; p ¼.408). CARN participants were older than non-carn (CARN, ; non-carn, ; p ¼.001), but did not differ on gender, or insurance group. Because of the limited differences, the two groups were combined for analyses. Of the total valid responses (n ¼ 564), 335 reported providing care to a majority of patients with private insurance, private group, and 105 reported providing care to a majority of patients with public insurance or who were uninsured, non-private group. These participants were included in analyses (Table 1). The private group was 58.8% female, whereas the non-private Table 1 Insurance Distribution Insurance Type Non-Private Group (%) Private Group (%) Private insurance Medicaid Medicare Uninsured Other

3 G.B. Raglan et al. / Women's Health Issues 23-3 (2013) e161 e165 e163 group was 45.7% female (p ¼.018). There were no differences in age between the two groups. Female, but not male, physicians in the private group were more likely than those in the non-private group to practice in a group practice (p ¼.003). Demographic information for physicians can be found in Table 2. Table 3 illustrates that the non-private group reported caring for more patients aged 44 and younger, whereas the private group reported more patients aged 45 and older. The private group also reported a higher proportion of White (non-hispanic) and Asian/ Pacific Islander patients, and the non-private group reported more Hispanic patients. There were no differences in the number of African-American patients seen by the groups. Belonging to the private group independently predicted a physician reporting that the majority of patients remained under his or her care throughout their reproductive years. Both private group and older patient ages independently predicted a physician saying that well-woman care was a priority in his or her workload. Belonging to the non-private group and reporting younger patient age predicted reporting that a majority of pregnant patients first made contact after becoming pregnant. In all of these cases, insurance group more strongly predicted the outcome measure than did patient age (Table 4). Neither patient age nor insurance group independently predicted the number of patients reported who see the physician as a primary care physician following obstetrics care, how physicians defined wellwoman care, or the number of nulliparous patients. Private group and older patient age predicted a physician s likelihood of performing vitamin D screens during a well-woman examination, although this was a weak association indicating that other factors may be important (Wald c 2 ¼ 7.09, p ¼.008; Wald c 2 ¼ 19.14, p <.001 respectively). The two insurance groups did not differ in terms of other procedures performed during a well-woman examination. Physicians in the private group reported more frequently screening for family health history during a well-woman examination (F(1, 430) ¼ p <.001). The two groups did not differ in terms of other screening practices during well-woman examinations or initial obstetrics visits (e.g., drug use, sexual abuse). Physicians in the private group reported a greater proportion of patient visits for preconception care (Table 5). The non-private group reported that more patient visits were for gynecological complaints only (Table 5). The private group reported that more patient visits were for periodic well-woman care, and that they spent more hours per week on well-woman care (Table 6). The Table 2 Physician Demographics Total (n ¼ 440) Private (n ¼ 335) Non-Private (n ¼ 105) Age, mean (SD), yrs Gender (% female) Clinical practice setting.003 * Solo/private practice 20.7% 21.3% 19.2% Partnership/group practice 74.3% 76.0% 70.2% Other 4.5% 2.7% 10.6% Practice location.055 Urban 46.6% 47.1% 46.7% Suburban 50.0% 51.4% 47.6% Rural/other 2.5% 1.5% 5.7% Specialty.886 Generalists 29.3% 29.6% 28.6% Specialists 30.7% 31.1% 29.5% Generalist and specialist 39.8% 39.2% 41.9% p Table 3 Patient Characteristics two groups did not differ on the proportion of their patients who saw them as a primary care physician. Table 6 highlights differences in how physicians reported spending their time. The non-private group reported spending more overall hours per week on hospital-based activities, although this was not significant. They also reported spending more time on hospital rounds as well as on management of antepartum patients. In terms of office-based care, the private group reported spending more time on well-woman care and telephone calls. Physicians in the two groups did not differ, however, on the total number of hours that they reported. Table 7 details differences in performance of surgical procedures, with the non-private group reporting performing more anterior and posterior repairs, incontinence slings, and bilateral tubal ligations than the private group. There were no differences between the two groups in terms of obstetrics procedures or total procedures performed. Discussion Non-Private Group (%) Private Group (%) p Race White * Hispanic * African American Asian * Other race Age (yrs) * * The purpose of this study was to assess whether the practices of ob-gyns whose patients are primarily privately insured differ from ob-gyns whose patients are not. In addition, this study aimed to gather more information about these two patient groups to see whether differences linked with insurance type were present. The proportion of physicians reporting that the majority of their patients were not privately insured was relatively low, but these data do suggest that there may be differences in the care provided by these two groups. This study found that ob-gyns who see privately insured patients tend to see more White and Asian patients and more patients aged 45 to 64. On the other hand, providers whose Table 4 Predictions of Obstetrics Gynecologist Practice Patterns Based on Patient Insurance Status and Patient Age b Wald c 2 p Odds Ratio Care through reproductive years Insurance group (private vs * Proportion of young patients Well-woman care priority Insurance group (private vs * Proportion of young patients * Pregnant patients already pregnant Insurance group (private vs * 4.59 Proportion of young patients * 1.03

4 e164 G.B. Raglan et al. / Women's Health Issues 23-3 (2013) e161 e165 Table 5 Obstetricians /Gynecologists Reported Reasons for Patients Visits Non-Private Group (%) Private Group (%) Visits for well-woman care * Visits for preconception care * Visits for gynecological complaints only Visits for obstetric care * Visits for menopausal issues patients are generally not privately insured see more Hispanic patients and more patients under the age of 18. These demographic differences between patients indicate that ob-gyns in the private and non-private group may encounter very different needs from their patients, particularly on the basis of age. Additionally, the finding that physicians who see mostly uninsured or publicly insured patients serve more patients aged under 18 indicates that this group of patients is likely less involved in the private healthcare market and therefore may benefit from additional outreach. This study found that physicians who see publicly insured or uninsured patients are more likely to report that their patients make contact with them after becoming pregnant than those who see privately insured patients. Accessing care from an obgyn early in pregnancy allows for preventative care that can positively affect both the overall health of a woman and her child and future pregnancy outcomes (Korenbrot et al., 2002; Moos, 2003; Moos & Cefalo, 1987). As such, it is important for all women to be able to access preconception care. This study additionally indicates that physicians who treat patients without private health insurance see a smaller proportion of patients for preconception care than do ob-gyns who serve privately insured patients. This is indicative of the fact that limited access to care from a specialist provider means that women who are publicly insured or uninsured are less likely to seek out care before becoming pregnant (Atrash, Johnson, Adams, Cordero, & Howse, 2006). These data highlight the need for increased education related to the importance of preconception care (Frey & Files, Table 6 Average Time Spent by Obstetricians/Gynecologists on Hospital- and Office- Based Activities Mean Hours per Week Spent on Non-Private Private p Hospital-based activities Labor and delivery Gynecological surgery Hospital rounds * Management of antepartum patients * Other (hospital-based) Total hospital hours Office-based activities Well-woman care * Gynecological complaints Prenatal Patient phone calls * Administration Hospital committees/staff meetings Teaching Office consults Other (office-based) Total office hours Total hours p Table 7 Average Number of Surgical Procedures Performed per Month by Obstetricians/ Gynecologists Number of Surgical Procedures Performed (per month) Non-Private Private p Gynecologic Hysteroscopy Hysterectomy Anterior and posterior repair * Dilation and curettage Abdominal sacrocolpopexy Surgical assist Laparoscopy Laparotomy Bilateral tubal ligation * Incontinence slings * Ablation Total gynecologic procedures Obstetric Spontaneous vaginal delivery Operative vaginal delivery Cesarean delivery Cervical cerclage Total obstetric procedures ; Johnson, 2006; Kalmuss & Fennelly, 1990), as well as an emphasis on increasing access to that care. This difference could expose certain women to higher levels of risk in pregnancy outcomes (Jones, Cason, & Bond, 2002). Past studies have emphasized the importance of well-woman care as a major source of preventative care for women (Jones et al., 2002; Morgan et al., 2010; Morgan et al., 2012). The results of this study indicate that physicians who see privately insured women report spending more time on preventative care in the form of well-woman examinations than do those who see publicly insured or uninsured patients. Physicians did not differ substantially, however, on the care provided during a wellwoman examination. Physicians who provide care to mostly publicly insured or uninsured patients reported providing more bilateral tubal ligations, anterior and posterior assists, and incontinence slings than the private group even when controlling for patient age. The differences noted in the current study may be the result of differences in additional patient characteristics. In other research, privately insured have been found to be more likely to access preventative care, and particularly prenatal care (Oberg et al., 1990; Oberg et al., 1991). It has been suggested that this might be because women who are privately insured have different motivations for accessing care or expectations of care from an ob-gyn than do women who are publicly insured or uninsured (Kalmuss & Fennelly, 1990; U.S. General Accounting Office, 1987). Our study has limitations. There may have been practice characteristics not included in our study, such as academic versus non-academic settings, which may contribute to some of the differences observed. We could not include all possible characteristics owing the limited space on the survey. Future research will need to examine these variables. It would be preferable to have information from individual patients detailing both their insurance status and the services that they had received from their ob-gyn to confirm the information given by these physicians. This study also does not address the causes of the observed differences. It may be that the general health needs of privately insured patients differ significantly from those without private insurance patients, or it could reflect differences

5 G.B. Raglan et al. / Women's Health Issues 23-3 (2013) e161 e165 e165 in patient characteristics such as socioeconomic status, education, or expectations about medicine. The majority of our participants reported seeing primarily patients with private insurance. It is important to note that, although this aspect of the data could evidence a limitation in the current study, it may also indicate that access to ob-gyn and other specialist care is more limited for those women who are not privately insured (Sambamoorthi & McAlpine, 2003). Implications for Practice and/or Policy Given the findings from this study, increasing the focus on well-woman and preventive care among ob-gyns who primarily treat women without private insurance might help to raise parity in care. New changes in legislation that make access to women s care a priority may improve the outlook for this at-risk group by requiring more access to ob-gyns without a referral, and may result in fewer differences in the care accessed by women seeking medical help. It will be important to track these effects in the future to determine the overall impact of this legislation. A future study that targeted physicians with broader patient populations, and that included input from patients themselves, could also add considerably to our understanding of these data. References Atrash, H. K., Johnson, K., Adams, M., Cordero, J. F., & Howse, J. (2006). Preconception care for improving perinatal outcomes: The time to act. Maternal and Child Health Journal, 10, S3 S11. Baker, S. W., Sudano, J. J., Albert, J. M., Borawski, E. A., & Dor, A. (2001). Lack of health insurance and decline in overall health in late middle age. New England Journal of Medicine, 345, DeVoe, J. E., Fryer, G. E., Phillips, R., & Green, L. (2003). Receipt of preventative care among adults: Insurance status and usual source of care. American Journal of Public Health, 93, Ferrer, R. L. (2007). Pursuing equity: Contact with primary care and specialist clinicians by demographics, insurance, and health status. Annals of Family Medicine, 5, Frey, K. A., & Files, J. A. (2006). Preconception healthcare: What women know and believe. Maternal and Child Health Journal, 10, S73 S77. Hillemeier, M. M., Weisman, C. S., Chase, G. A., Dyer, A., & Schaffer, M. L. (2008). Women s preconceptional health and use of health services: Implications for preconception care. Health Services Research, 43, Hoffman, C., & Paradise, J. (2008). Health insurance and access to health care in the United States. Annals of the New York Academy of Science, 1136, Johnson, K. A. (2006). Public finance policy strategies to increase access to preconception care. Maternal and Child Health Journal, 10, S85 S91. Jones, M. E., Cason, C. L., & Bond, M. L. (2002). Access to preventive health care: Is method of payment a barrier for immigrant Hispanic women? Womens Health Issues, 12, Kalmuss, D., & Fennelly, K. (1990). Barriers to prenatal care among low-income women in New York City. Family Planning Perspective, 22, , 231. Korenbrot, C. C., Steinberg, A., Bender, C., & Newberry, S. (2002). Preconception care: A systematic review. Maternal and Child Health Journal, 6, Leddy, M. A., Anderson, B. L., Gall, S., & Schulkin, J. (2009). Obstetrician-gynecologists and the HPV vaccine: Practice patterns, beliefs, and knowledge. Journal of Pediatric and Adolescent Gynecology, 22, Moos, M. (2003). Preconceptional wellness as a routine objective for women s health care: An integrative strategy. Journal of Obstetric, Gynecologic, and Neonatal Nursing, 32, Moos, M., & Cefalo, R. C. (1987). Preconceptional health promotion: A focus for obstetric care. American Journal of Perinatology, 4, Morgan, M. A., Anderson, B., Lawrence, H., III, & Schulkin, J. (2012). Well-woman care among obstetrician-gynecologists: Opportunity for preconception care. Journal of Maternal-Fetal and Neonatal Medicine, 25, Morgan, M. A., Lawrence, H., III, & Schulkin, J. (2010). Obstetrician-gynecologists approach to well-woman care. Obstetrics and Gynecology, 116, Oberg, C. N., Lia-Hoagberg, B., Hodkinson, E., Skovholt, C., & Vanman, R. (1990). Prenatal care comparisons among privately insured, uninsured, and Medicaid-enrolled women. Public Health Reports, 105, Oberg, C. N., Lia-Hoagberg, B., Skovholt, C., & Hodkinson, E. (1991). Prenatal care use and health insurance status. Journal of Health Care for the Poor and Underserved, 2, Power, M. L., Cogswell, M. E., & Schulkin, J. (2009). US obstetrician-gynaecologist s prevention and management of obesity in pregnancy. Journal of Obstetrics and Gynecology, 29, Sambamoorthi, U., & McAlpine, D. D. (2003). Racial, ethnic, socioeconomic, and access disparities in the use of preventative services among women. Preventative Medicine, 37, Shi, L. (2000). Type of health insurance and the quality of primary care experience. American Journal of Public Health, 90, Sox, C. M., Swartz, K., Burstin, H. R., & Brennan, T. A. (1998). Which is the most powerful predictor of health care? American Journal of Public Health, 88, U.S. General Accounting Office. (1987). Prenatal care: Medicaid recipients and uninsured women obtain insufficient care. HRD Washington, DC: Author. Author Descriptions Greta B. Raglan, BS, is a research assistant at the American College of Obstetricians and Gynecologists, and a doctoral candidate at American University, Department of Psychology, Washington, DC. Her research focuses on decision making and substance abuse. Britta L. Anderson, PhD, is research associate at the American College of Obstetricians and Gynecologists. Her research focuses on statistical literacy and decision making under uncertainty. Hal Lawrence III, MD, is the executive vice president of the American College of Obstetricians and Gynecologists. His research focuses on well-woman care and collaborative care in obstetrical and gynecological practice. Jay Schulkin, PhD, is the director of research at the American College of Obstetricians and Gynecologists and a research professor in the Department of Neuroscience, Georgetown University, School of Medicine, Washington, DC. His research focuses on decision making under uncertainty, statistical literacy, and medical competence.