The Effects of Insurance Coverage on the Quality of Prenatal Care

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 (obstetriciansgynecologists 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\u3c.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\u3c.001) and fewer for gestational diabetes (P\u3c.001) or anemia (P\u3c.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