SD27 - Access to Obstetrical Care
Executive Summary: Virginia is experiencing a growing crisis in its obstetrical care system. While the statewide infant mortality rate (10.4 infant deaths per 1,000 live births in 1988) is similar to that of the nation, the five-year average ranges from 7.3 in the New River Valley to 18.9 in the City of Richmond. A study by the Institute of Medicine is representative of many reports documenting that poor pregnancy outcomes (such as miscarriages, preterm or low birth weight deliveries, and infant deaths) are more prevalent among mothers who receive no prenatal care.(*6) In Virginia, however, accessing care early in pregnancy is becoming increasingly difficult for poor women, for uninsured women, and for women in rural localities and inner cities. • In Virginia, less than 60 percent of adolescent mothers receive prenatal care during the first trimester of pregnancy compared with over 80 percent of those who are older. • Many areas of the Commonwealth - particularly those outside the urban crescent from Northern Virginia through the Richmond area into Tidewater - do not have enough physicians who provide obstetrical care. Those areas generally exhibit higher infant mortality rates than elsewhere in Virginia. • Less than half of the physicians completing obstetrics/gynecology residencies at Virginia's medical schools establish practices in Virginia; of those who do, 92 percent locate their practices in metropolitan areas rather than the medically underserved areas which contain one-fifth of Virginia's population. • Population growth in many (predominantly rural) areas that are already medically underserved has not been sufficient to attract and retain physicians. • Less than half of Virginia's obstetricians are accepting new Medicaid patients. (*11) In 51 counties the local health department was the sole location for prenatal care for Medicaid recipients during 1988. • Among Virginia's current obstetrician/gynecologists and family practitioners who have ever practiced obstetrics, nearly one third have given it up and over half of the remainder say that, due to liability concerns, they are very likely do so sooner than usual. (*11) The cost of this crisis is substantial. The State Perinatal Services Advisory Board has estimated that each year more than $1.6 billion in neonatal special care unit costs could be saved in Virginia just through statewide implementation of aggressive preterm birth prevention efforts. (*16) In 1989 the General Assembly passed SJR 168 charging the Virginia Health Planning Board with examining the question of access to obstetrical care. This report to the Governor and General Assembly considers the causes of decreasing access to obstetrical care and identifies ways to manage the problem. Inadequate access is generally caused by one or more of the following: • maldistribution of providers of care, • financial barriers, • system/attitudinal barriers, • lack of public awareness of the problem Caregivers may be available, but located too far away for timely service; the woman may have difficulty obtaining transportation, even to a nearby service site. Direct payments required from the woman for services received may be unaffordable and thereby deter the seeking of needed care. The provider may not be willing to serve the uninsured or underinsured, or there may be a real or perceived difference in the way such women are treated. A woman may delay or fail to seek care because of lack of knowledge about her own health needs or where those needs may be met. Each of these general barriers exist to some extent, singly or in combination, within many parts of Virginia; each must be eliminated or significantly reduced if access to obstetrical care is to be improved. Since the barriers are interrelated, some corrective actions may affect more than one barrier and the success of one action may depend on simultaneous implementation of another. MALDISTRIBUTION OF PROVIDERS Physicians who provide obstetrical care, such as obstetricians and family practitioners, often avoid locating their practices in medically underserved areas not only because of financial considerations, but also because of a desire to avoid isolation from sources of continuing professional education. As a result, the local health department is the coordinator of prenatal care in over two-thirds of the Commonwealth's medically underserved areas. A five-point plan has been developed by the Virginia Department of Health to attract primary care physicians to underserved areas through such avenues as enhancing medical school loan and scholarship programs, developing educational and practice opportunities, and creating financial incentives. In Virginia and in other states, mid-level practitioners such as nurse practitioners and nurse midwives are authorized to perform certain medical acts under the supervision of a physician. These practitioners are particularly important in isolated, rural areas that lack sufficient primary care physicians to meet the medical needs of their residents or, as is the case in 15 of Virginia's health districts, where the area's physicians are not accepting indigent patients. While approximately 1,000 certified nurse practitioners are licensed in Virginia and potentially available for primary care (including about 80 who are employed by the Department of Health), current regulations of the Board of Medicine, Board of Nursing, and Board of Pharmacy pose barriers to the full utilization of these practitioners' capabilities such as by prohibiting nurse practitioners from prescribing or dispensing medications. The Department of Health Professions has established a Task Force on the Practice of Nurse Practitioners; it is currently examining such issues such as prescriptive authority and medical supervision, and is expected to submit an interim report to the Secretary of Health and Human Resources in December, 1989 and a final report in March, 1990. Four Preterm Birth Prevention programs were established in Virginia through the cooperation of local health departments and perinatal centers. These programs, formerly funded by the federal government, were intended to identify women at high risk of early births and provide frequent prenatal visits, counselling, nutrition services, and social work support to minimize the risk of poor pregnancy outcomes. The success of the programs has stimulated interest in expanding the concept to other local health departments as well as into the private sector. Such programs reduce the need for intensive medical care in hospitals. They compensate in part for a maldistribution of physicians. RECOMMENDATIONS I. In order to ensure providers are available throughout the state for all women regardless of their ability to pay, the Virginia Health Planning Board recommends that the Governor and the Virginia General Assembly: A. support funding requests to increase access to basic medical care services by supporting and expanding the Commonwealth's primary care system; B. empower the Boards of Medicine, Nursing, and Pharmacy to pursue the changes necessary to allow for broader participation by nurse practitioners, including nurse midwives, as appropriate, in the delivery of obstetrical care services; C. provide funding and manpower to assist localities in the replication and expansion of joint public and private programs, providing greater access to quality prenatal care regardless of the patient's payment source. FINANCIAL BARRIERS Since its inception in 1966, the Medicaid program has seen a decrease in the proportion of Virginia physicians that participate; this is directly related to the declining percentage of physician charges that are paid by Medicaid. The Medical Society of Virginia survey of obstetricians and family practice physicians indicated that 80% of the responding obstetricians had accepted Medicaid patients at some point in their careers, but that currently, only 63% participate in the Medicaid program. In addition, approximately 45% of obstetricians are currently taking new Medicaid patients, and of those taking new Medicaid patients, over one half are restricting the number of Medicaid patients that they will see. The factors identified in the survey as the three most effective changes that could induce obstetricians to accept, or accept more, Medicaid patients, in order of priority were 1) increased reimbursement 2) less paperwork 3) financial assistance with malpractice premiums. (*11) While major increases in Medicaid reimbursement rates have occurred since 1985, the lack of an automatic inflator has resulted in the value of Medicaid's reimbursement for obstetrical procedures falling from the 25th percentile of physician charges in 1986 to the tenth percentile by 1988. Beginning January 1, 1990, the rate will be raised to the 15th percentile, or $930 (includes prenatal, delivery and postpartum care) for an uncomplicated case; the Department of Medical Assistance Services has requested an additional increase to become effective in July of 1990. Regional variations in prices are also not recognized by Medicaid: in 1989 Medicaid paid $625 statewide whereas the average physician charge for total obstetrical care with a normal delivery ranged from $1,212 in far southwestern Virginia to $2,161 in Northern Virginia. These factors make it difficult to attract and retain obstetrician participation in the Medicaid program: only 49 percent of all practicing obstetricians in Virginia performed one or more Medicaid-reimbursed deliveries in 1988; one tenth of that 49 percent were responsible for half of those deliveries. Another financial barrier is the cost of medical liability insurance, which has been rising for physicians generally and which is significantly higher for obstetricians than for other primary care physicians. The latter aspect has resulted in a decline in the number of physicians performing obstetrical care. The two reasons cited most often by physicians for giving up the practice of obstetrics are high medical liability insurance premiums, and the risk of a medical malpractice action. In addition, respondents to the Medical Society of Virginia survey indicated that "over one-half of the family practice physicians and obstetricians who currently provide obstetric services consider it very likely that they will stop practicing obstetrics sooner than they would ordinarily because of the risk of malpractice suits and/or high insurance premiums." (*11) One approach Virginia has implemented to decrease the medical liability problem is the recently enacted Birth-Related Neurological Injury Compensation Act. The Act created a program designed to provide compensation to ensure lifelong care for infants suffering a neurological birth injury while under the care of participating physicians and hospitals. The Act is currently being studied by a legislative subcommittee for possible revision. Physicians would find obstetrics more attractive, and could be attracted to and retained in medically underserved areas, if their expected costs related to medical malpractice were further reduced. For most indigent persons, Medicaid is the sole source of insurance. The federal Budget Reconciliation Act will soon require Medicaid coverage for certain persons at or below 133% of poverty level; in addition, states may choose under current law to raise that threshold to as much as 185% of poverty. One of the most significant financial barriers to obstetrical care is the lack of a source of payment for medical care services among low-income working women who do not qualify for Medicaid. Many of these women work for small businesses that cannot qualify for or cannot afford to provide traditional health insurance as an employee benefit. These women may forego or delay prenatal care and therefore are more likely to require more costly services at the time of delivery. RECOMMENDATIONS II. In order to remove financial barriers to care, the Virginia Health Planning Board recommends that the Governor and the Virginia General Assembly: A. fund the increase in Medicaid reimbursement rates sufficiently to attract and retain physician participation, incorporate regional variations, and include an automatic inflator to allow reimbursement rates to keep pace with increases in costs of care; phase in eligibility increments as authorized by Federal regulations, to 133% of the poverty level as mandated in the federal Budget Reconciliation Act and ultimately to the fullest extent permitted under federal law; B. enact legislative changes as required to enable private insurance and/or health maintenance organizations to offer affordable plans to small business employers such as has been proposed by Blue Cross and Blue Shield of Virginia, and require those plans to include maternity coverage for their employees and their dependents; (Note: the Board recognizes, however, the relationship between affordability and the nature and number of coverage mandates.) C. focus existing resources and efforts to increase the availability of transportation for women to obstetrical care providers; D. implement such approaches to the medical liability insurance issue as: 1. paying part of the medical liability insurance premiums for medical providers of obstetrical care for medically underserved communities and medically indigent populations; 2. endorsing those recommendations of the legislative study group researching the Birth-Related Neurological Injury Compensation Act which would enhance its utilization and effectiveness; 3. the Commonwealth assuming some or all of the financial risk of medical liability judgments against medical providers who provide obstetrical care for Medicaid and medically indigent patients in collaboration with the Department of Health; 4. encouraging statewide proliferation of medical mediation services such as those offered by the University of Virginia's Center for Public Service; 5. incorporating, within Virginia's approach to managing claims, elements of the administrative review system advocated by the Institute of Medicine. SYSTEM /ATTITUDINAL BARRIERS Women's attitudes toward obtaining early and adequate prenatal care are influenced by a number of factors. Unplanned or unwanted pregnancies pose psychological barriers to the seeking of care; these can be reduced by ensuring the accessibility of family planning services within the health care system. Resistance to seeking needed care may also derive from the expectant mother's lack of peer support and an appropriate role model, a barrier which has been reduced since 1985 through the Resource Mothers program that trains women from the community to provide support services to adolescents who are pregnant. Other factors that influence women's attitudes include conflicts between providers' service hours and other high priority activities such as school or work, the convenience of transportation, and the relative affordability to low income women of out-of-pocket costs for care or transportation. These factors may result in significant attitudinal barriers because they force the woman to make difficult choices about the use of available time or money. The impact of these barriers can be reduced by changing various policies and practices of providers and third-party payors, such as extending case management and other services in conjunction with the BabyCare program. RECOMMENDATIONS III. In order to enhance the system's policies and practices that have a positive effect on women's attitudes toward obtaining prenatal care, the Virginia Health Planning Board recommends that the Governor and the Virginia General Assembly: A. support funding needed to provide the manpower necessary to implement initiatives such as case management for high risk women; B. support funding to expand programs providing counseling and support to adolescents; C. support other related health programs such as family planning and family life education; D. encourage volunteerism by such means as providing for the inclusion of volunteer activity under agencies' liability policies. PUBLIC AWARENESS A pregnant woman may fail to seek and obtain early prenatal care because she is unaware of its importance in obtaining a good pregnancy outcome. Not only potential mothers, but also persons who influence them, need broader, more effective exposure to the benefits of early and adequate prenatal care. The Department of Health has a traditional role in prevention and health promotion. Other health prevention and promotion programs involve both the public and private sectors, such as the Beautiful Babies project sponsored by the March of Dimes, WRC-TV4, and Blue Cross/Blue Shield of the National Capitol Area and Richmond City Health Department's Healthy Futures program. A policy statement by the Virginia General Assembly would foster renewed public awareness of efforts needed within both the private and public sectors. RECOMMENDATIONS IV. In order to increase public awareness of the importance of early prenatal care, the Virginia Health Planning Board recommends that the Governor and the Virginia General Assembly: A. support funding to extend existing public education and information programs, such as the Beautiful Babies program, especially to localities with high infant mortality and low birth weight rates; B. adopt a joint resolution to endorse formally those activities, both public and private, that promote the adoption of early prenatal care by and for all pregnant women, regardless of individual circumstances and to call for the removal of all barriers to care. ________________________________ (*6) Institute of Medicine. 1985. "Preventing Low Birthweight: Summary." Washington, DC: National Academy Press. (*11) Medical Society of Virginia. 1989. "Problems and Solutions Relating to Access to Obstetrical Care Virginia Physicians Respond" Survey Report, December 12. (*16) State Perinatal Services Advisory Board 1988. "Statewide Perinatal Services Plan." Richmond, VA: Virginia Department of Health. |
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