Skip to main content
PMC home page
Health Services Research logoLink to Health Services Research
. 1994 Apr;29(1):75–93.

Health maintenance organizations, independent practice associations, and cesarean section rates.

A D Tussing 1, M A Wojtowycz 1
PMCID: PMC1069989  PMID: 8163381

Abstract

OBJECTIVE. This study tests two hypotheses: that a given delivery is less likely to be by cesarean section (c-section) in an HMO (closed-panel health maintenance organization) or IPA (independent practice association), than in other settings; and that where HMO and IPA penetration is high, the probability of a c-section will be reduced for all deliveries, whether in prepaid groups or not. DATA SOURCES AND STUDY SETTING. A data set consisting of 104,595 obstetric deliveries in New York state in 1986 is analyzed. STUDY DESIGN. A series of probit regressions is estimated, in which the dependent variable is either the probability that a given delivery is by c-section, or that a given delivery will result in a c-section for dystocia or fetal distress. DATA COLLECTION/EXTRACTION METHODS. The Live Birth File is linked with SPARCS hospital discharge data and other variables. PRINCIPAL FINDINGS. HMO setting reduces the probability of a cesarean section by 2.5 to 3.0 percentage points. However, this result is likely to be partly an artifact of offsetting diagnostic labeling and of choice of method of delivery, given diagnosis; a better estimate of the effect of HMO setting is -1.3 percentage points. IPA setting appears to affect the probability of a cesarean section even less, perhaps not at all. And HMO and IPA penetration in a region, as measured by HMO and IPA deliveries, respectively, as a percent of all deliveries, has relatively large depressing effects on the probability of a cesarean section. CONCLUSIONS. Ceteris paribus, the probability of a c-section is lower for an HMO delivery than for a fee-for-service delivery; however, HMO effects are smaller than previously reported in the literature for other types of inpatient care. For IPA deliveries, the effects are still smaller, perhaps nil. However, HMO and IPA penetration, possibly measuring the degree of competition in obstetrics markets, have important effects on c-section rates, not only in HMO/IPA settings, but throughout an area. These results appear to have important implications for public policy.

Full text

PDF
93

Selected References

These references are in PubMed. This may not be the complete list of references from this article.

  1. Bradbury R. C., Golec J. H., Stearns F. E. Comparing hospital length of stay in independent practice association HMOs and traditional insurance programs. Inquiry. 1991 Spring;28(1):87–93. [PubMed] [Google Scholar]
  2. Buchanan J. L., Cretin S. Risk selection of families electing HMO membership. Med Care. 1986 Jan;24(1):39–51. doi: 10.1097/00005650-198601000-00005. [DOI] [PubMed] [Google Scholar]
  3. Dranove D. Demand inducement and the physician/patient relationship. Econ Inq. 1988 Apr;26(2):281–298. doi: 10.1111/j.1465-7295.1988.tb01494.x. [DOI] [PubMed] [Google Scholar]
  4. Hellinger F. J. Selection bias in health maintenance organizations: analysis of recent evidence. Health Care Financ Rev. 1987 Winter;9(2):55–63. [PMC free article] [PubMed] [Google Scholar]
  5. Johnson A. N., Dowd B., Morris N. E., Lurie N. Differences in inpatient resource use by type of health plan. Inquiry. 1989 Fall;26(3):388–398. [PubMed] [Google Scholar]
  6. Kizer K. W., Ellis A. C-section rate related to payment source. Am J Public Health. 1988 Jan;78(1):96–97. doi: 10.2105/ajph.78.1.96-a. [DOI] [PMC free article] [PubMed] [Google Scholar]
  7. Langwell K. M., Nelson L. M. Physician payment systems: a review of history, alternatives and evidence. Med Care Rev. 1986 Spring;43(1):5–58. doi: 10.1177/107755878604300102. [DOI] [PubMed] [Google Scholar]
  8. Luft H. S. How do health-maintenance organizations achieve their "savings"? N Engl J Med. 1978 Jun 15;298(24):1336–1343. doi: 10.1056/NEJM197806152982404. [DOI] [PubMed] [Google Scholar]
  9. Manning W. G., Leibowitz A., Goldberg G. A., Rogers W. H., Newhouse J. P. A controlled trial of the effect of a prepaid group practice on use of services. N Engl J Med. 1984 Jun 7;310(23):1505–1510. doi: 10.1056/NEJM198406073102305. [DOI] [PubMed] [Google Scholar]
  10. McCloskey L., Petitti D. B., Hobel C. J. Variations in the use of cesarean delivery for dystocia: lessons about the source of care. Med Care. 1992 Feb;30(2):126–135. doi: 10.1097/00005650-199202000-00004. [DOI] [PubMed] [Google Scholar]
  11. Placek P. J., Taffel S. M., Moien M. 1986 C-sections rise; VBACs inch upward. Am J Public Health. 1988 May;78(5):562–563. doi: 10.2105/ajph.78.5.562. [DOI] [PMC free article] [PubMed] [Google Scholar]
  12. Stafford R. S. Cesarean section use and source of payment: an analysis of California hospital discharge abstracts. Am J Public Health. 1990 Mar;80(3):313–315. doi: 10.2105/ajph.80.3.313. [DOI] [PMC free article] [PubMed] [Google Scholar]
  13. Tussing A. D., Wojtowycz M. A. The cesarean decision in New York State, 1986. Economic and noneconomic aspects. Med Care. 1992 Jun;30(6):529–540. doi: 10.1097/00005650-199206000-00006. [DOI] [PubMed] [Google Scholar]
  14. Welch W. P., Frank R. G., Diehr P. Health care costs in health maintenance organizations: correcting for self-selection. Adv Health Econ Health Serv Res. 1984;5:95–128. [PubMed] [Google Scholar]
  15. Wilner S., Schoenbaum S. C., Monson R. R., Winickoff R. N. A comparison of the quality of maternity care between a health-maintenance organization and fee-for-service practices. N Engl J Med. 1981 Mar 26;304(13):784–787. doi: 10.1056/NEJM198103263041313. [DOI] [PubMed] [Google Scholar]
  16. Wright C. H., Gardin T. H., Wright C. L. Obstetric care in a health maintenance organization and a private fee-for-service practice: a comparative analysis. Am J Obstet Gynecol. 1984 Aug 15;149(8):848–856. doi: 10.1016/0002-9378(84)90603-3. [DOI] [PubMed] [Google Scholar]

Articles from Health Services Research are provided here courtesy of Health Research & Educational Trust

RESOURCES