The effects of insurance coverage on the quality of prenatal care
M. S. Klinkman, D. W. Gorenflo and T. S. Ritsema
Department of Family Practice, University of Michigan, Ann Arbor, USA. mklinkma@umich.edu
OBJECTIVE: To compare the quality of prenatal care provided to patients
with traditional fee-for-service, health maintenance organization, and
Medicaid insurance using an evidence-based, community-derived prenatal care
guideline. DESIGN: Retrospective cohort study. SETTING: Seven private and
hospital-based prenatal care sites in a suburban county in southeast
Michigan. PATIENTS: A stratified random sample of 267 patients (93 with
Medicaid, 92 with health maintenance organization, and 82 with
fee-for-service insurance) receiving prenatal care from community
physicians (obstetricians-gynecologists and family practitioners) between
January 1, 1991, and December 31, 1992. MAIN OUTCOME MEASURE: Adherence to
explicit prenatal care criteria as measured by an evidence-based prenatal
care guideline developed by a community panel. "Quality scores" were
compared across groups in 4 areas: performance of prenatal screening
procedures or tests, visit-based screening, substance use screening, and
clinician management of abnormal clinical findings. RESULTS: Patients with
Medicaid insurance presented for prenatal care significantly later in
pregnancy (14.5 vs 10.5 weeks, P < .01). No significant differences were
seen between groups in quality scores for screening tests, clinician
management of abnormal clinical findings, visit-based screening, or
substance use screening. The overall similarity in quality scores did
obscure some significant differences in adherence to individual criteria,
particularly in the area of screening tests. Significantly more patients
with Medicaid were screened for genital infection (P < .001) and fewer
for gestational diabetes (P < .001) or anemia (P < .001) than
patients in the other 2 groups. CONCLUSIONS: Although patients with
Medicaid presented for prenatal care later in pregnancy and received a
different "package" of screening tests than the other 2 groups, there was
no overall measurable difference in the quality of prenatal care provided
to patients with Medicaid, health maintenance organization, and
fee-for-service insurance. Clinicians may have altered screening protocols
based on preexisting perceptions of patient risk. Although summary quality
measures are a promising tool for comparative research, they provide an
incomplete picture of the quality of the prenatal care process and must be
interpreted with caution.
