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SPH researchers find higher rates of obstetric interventions among privately insured women

United States hospital-based births covered by private insurance are associated with higher rates of obstetric intervention than births paid for by Medicaid, according to new research from the University of Minnesota School of Public Health.

The latest study was led by health policy researcher Katy B. Kozhimannil, Ph.D., M.P.A., who partnered with fellow University of Minnesota researchers Tetyana P. Shippee, Ph.D. and Beth A. Virnig, Ph.D., M.P.H., as well as UCare Minnesota health care analyst Olusola Adegoke, M.P.H., M.B.B.S, who worked on the study as a masters student at the School of Public Health.

The study appeared this week in the American Journal of Managed Care.

To arrive at their conclusion, the researchers studied the relationship between the primary payer and trends in hospital-based childbirth obstetric procedures, such as cesarean delivery and labor induction. They examined 6,717,486 births across the United States between the years 2002 – 2009.

Though obstetric intervention rates have increased over time for all births, the presence and type of health insurance affected the type of care women received during childbirth.

“After controlling for age, race, clinical conditions and hospital characteristics,” said Kozhimannil, “births covered by private insurance had higher odds of cesarean delivery, labor induction and episiotomy. Not only that, but cesarean rates – which were rising nationwide during the time period we examined – increased more quickly among moms with private insurance, compared to those with Medicaid. ”

Childbirth is the most frequent reason for hospitalization in the United States, and maternity-related expenses including obstetric interventions are substantial expenses among private health insurance plans and Medicaid programs.

Kozhimannil explained that had the rate of increase in cesarean deliveries covered by private insurers instead been at the rate seen by Medicaid patients, the difference would have resulted in 41,614 fewer cesarean deliveries in 2009; a potential savings of nearly a quarter of a million dollars in hospital costs in one year.

“As the number of obstetric interventions goes up, so does the cost to cover them,” said Kozhimannil. “This may ultimately be felt in the form of higher premiums, more expensive copays, or higher deductibles for the privately insured.”

The researchers believe that changes in insurance coverage associated with the implementation of the Affordable Care Act (ACA) could impact the costs and quality of care for women giving birth in US hospitals.

“Through the ACA, increases in private insurance through employer-sponsored coverage or state exchanges could result in unanticipated changes in obstetric care,” said Kozhimannil. “In other words, if women who would have otherwise had Medicaid coverage become eligible for private coverage, they may have higher odds of obstetric interventions.”

The researchers do not know why Medicaid patients are less likely to have certain obstetric procedures, but discuss potential reasons for these differences, including payment rates, hospital policies, clinical decision-making, or patient preferences.

“The changes in the rate of obstetric procedures we uncovered may signal shifts in care or equity concerns, but they may also indicate the potential role that payers can play in shaping health care practices to align with evidence and patient-centeredness, in maternity care and more broadly,” said Kozhimannil.

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