Abstract
Background
There is limited evidence on the effectiveness of financial incentives in improving the shortage of obstetrics/gynecology (OB/GYN) specialists in underserved areas. This study aimed to examine whether the financial incentives for OB/GYN clinics were associated with improved availability of OB/GYN specialists in obstetrically underserved areas (OUA) and potentially obstetrically underserved areas (POUA) in South Korea.
Methods
A cross-sectional study design was employed to observe all cities (n = 240) in South Korea for a period of 10 years (2011–2020). The cities were divided into intervention groups (cities designated as OUA and POUA) and control groups (all other rural districts). A two-way fixed-effects linear regression was used to explore the policy’s association with the number of specialists at the city level. The availability of OB/GYN specialists was evaluated based on the number of total/full-time/part-time OB/GYN specialists and facilities with full-time OB/GYN specialists per 1,000 females of reproductive age. The exposures considered were grant incentives for facility and equipment costs, human resources, and additional reimbursement rates for deliveries.
Results
A total of 240 South Korean cities were identified as analytic samples from 2011 to 2020 (2,400 city-year observations). The number of total OB/GYN specialists decreased (−3.390 per 1,000 females of reproductive age; P < 0.001) in cities designated as OUA and POUA (intervention group) after the introduction of combined financial incentives (grant and additional reimbursement since 2016). Results showed that the number of full-time OB/GYN specialists increased (0.083 per 1,000 females of reproductive age; P = 0.007). However, that of part-time OB/GYN specialists decreased (−3.473 per 1,000 females of reproductive age; P < 0.001). The number of facilities with full-time OB/GYN specialists also increased (5.775 per 100,000 females of reproductive age; P = 0.036).
Conclusion
This cross-sectional study revealed that financial incentives, including grants and reimbursement rates, were insufficient to improve the availability of OB/GYN specialists in underserved areas of South Korea. Therefore, multidimensional financial and nonfinancial approaches are required to ensure a stable supply of specialists at vulnerable sites.
Keywords: Medically Underserved Area, Obstetricians, Gynecologists, Financial Support, Health Workforce, Korea
Graphical Abstract
INTRODUCTION
The shortage of physicians in underserved areas, such as rural areas, can be an issue in middle-, low-, and high-income countries. The chances of proper emergency care, including hospital-based obstetric care, are reduced for those living in underserved areas, such as rural areas. A continuous decrease in hospitals providing obstetric care resulted in more than half of the rural regions having no access to hospital-based obstetric care 2018 in the US.1 The disparity in the geographical distribution of obstetrics/gynecology (OB/GYN) specialists widened between 2006 and 2018 in Japan.2
One demand-side factor for the shortage of OB/GYN specialists is the falling birth rates due to young adult depopulation in rural areas.3 In 2021, South Korea recorded a 0.81 total fertility rate nationwide, the lowest in the world.4,5 Furthermore, young people tend to migrate to urban areas, which are more attractive than rural areas.6 Many medical institutions with emergency maternity care capabilities are closed due to financial difficulties in South Korean rural areas.3 Between 2011 and 2021, OB/GYN institutes with delivery capabilities substantially decreased from 777 units to 481 in Korea.7
The Korean government has implemented various policies to support regions that lack OB specialists or have only one delivery hospital. Since 2011, the Korean government has designated regions that met the following criteria as “obstetrically underserved areas” (OUA) as follow: < 30% of delivery utilization within 60 minutes and > 30% of the fertility population ratio cannot access medical institutions that can only be served within 60 minutes.8
OUA received support for installing OB/GYN units and facilities, equipment, and operating costs since 2011 through government funding called “The supporting program for obstetrically underserved areas” (SPOU). In addition, 57 regions were designated as potentially obstetrically underserved areas (POUA) (areas not currently a vulnerable place for delivery; however, it is likely to be vulnerable in the future when excluding only one delivery room) in 2021. In addition, since 2012, the government has provided 100 million won (≈$77,000) annually with initial facilities and equipment for the installation and operation costs of outpatient OB/GYN units.
While vulnerable areas have received support through project funds, existing studies mainly focus on comparative research examining the policy’s association with geographical accessibility and maternal outcomes.9,10 However, there is limited evidence concerning the policy’s influence on supply-side human healthcare resources, such as physicians. Thus, investigating the impact of government-funded support for facilities and labor costs on supply-side resources is imperative.
Under the mid-term health insurance coverage reinforcement plan (2014–2018), the government raised health insurance reimbursement rates for deliveries provided in OUA and POUA. After the decision of the 14th Health Insurance Policy Review Committee in 2016, a new reimbursement category was created in vulnerable areas for high-risk or late-night deliveries. As a result, the reimbursement fee for deliveries in vulnerable areas has increased by 200% in 2016. In addition, it added 30% of the reimbursement rates for high-risk deliveries (including premature birth, placenta previa, fetal type, and pumped hypertrophy), and added 100% for late-night (22:00–06:00) deliveries. This study examined if the changes in the number of OB/GYN specialists, which are the most basic of obstetrics and gynecology accessibility, were associated with the aforementioned policy interventions.
Many interventions have been employed in the rural areas of middle- and high-income countries regarding the availability (production, recruitment, and retention) and distribution of health workforces.11 The non-financial intervention has been attempted mainly in education and training-related approaches and regulations on service return requirements in underserved areas.11,12 Several financial interventions have been employed to serve the underserved areas, such as paid locums guarantee, school subsidies, loan repayments, various allowances, reducing malpractice insurance costs, and adjusted reimbursement fees.13,14,15,16 However, there is insufficient evidence evaluating the effectiveness of financial incentives, including different mixed sources and funds usage, to improve the shortage of physicians in underserved areas.11,12,13,14,15,16
Therefore, this study examined the association of supply-side hybrid incentives with access to obstetrical care in OUA. Our evaluation addressed the following research questions (RQs):
RQ 1) Were grant-only incentives effective at improving the availability of OB/GYN specialists in OUA and POUA?
RQ 2) Is there any hybrid effectiveness of additional grant and reimbursement rate incentives in improving the availability of OB/GYN specialists in OUA and POUA?
METHODS
This study used annual provider-level data from the Korean Health Workforce Database between 2011 and 2020. The dataset is based on data reported by providers to the Health Insurance Review and Assessment Service, a government agency in charge of claims review and assessment, and contains information on physicians’ employment history, employment type, and hiring/departing date. The Korean Health Workforce Database is the most accurate source for physician employment information in South Korea.
Relying on the city-level variation in exposure to OUA over time, we specified a two-way fixed-effects linear regression to explore policy impacts as follows:
| Yct = β0 + β1Treatmentct + β2Postt + β3 (Treatmentct × Postt) + Xct + μt + θc + εct |
Our treatment group indicator, Treatment is a binary variable indicating whether city c was designated as an OUA in a given year t. For instance, if city AA was designated as OUA in 2015 but not in 2016, this variable would have a value of 1 in 2015 and 0 for the following year. We utilized the Ministry of Health and Welfare’s documents to define the treatment group (OUAs) and control group (non-OUAs). As the central government renews OUA status annually using the criteria mentioned in the Introduction, the number of cities designated as OUA changes over time. Our city-level panel regression approach exploits this within-city variation in treatment status over time to estimate the OUA’s impact on the outcome measure. The indicator Post equals 1 for 2016 (when the government increased delivery reimbursement rates) or later.
Our outcome measure Y included the number of healthcare institutions with OB/GYN specialists and the number of OB/GYN specialists at the city level. We used the total number of facilities (hospitals and clinics) with full-time OB/GYN specialists in each city for the number of institutional measures. For the number of specialist measures, we used the number of full-time and part-time OB/GYN specialists who practiced in each city. When a specialist worked at different hospitals across city borders, our data counted them twice. However, if they worked at different hospitals in the same city, we counted them once. Thus, the total number of OB/GYN specialists may have overestimated the actual specialist workforce. The average total number of OB/GYN specialists during the study period was 8,681 with double counting allowed; in contrast, the average number was 6,416 without double counting. To better reflect the changes in hospitals’ hiring decisions and physicians’ employment types, we use a variable with double counting. Following a previous study, we converted the outcome variables into the number of OB/GYN specialists per 1,000 females of reproductive age (15–44 years) in each city.17
The β3 represents the combined impacts of grant funding supports for areas designated as OUA (Treatment) and increased reimbursement rates (Post). If supporting the costs for facilities, equipment, and operating under the OUA policy led to an increased physician workforce in a city, our estimated β1 coefficient would be positive. If the increased reimbursement rates for deliveries worked in cities designated as OUA, β3 would be positive.
The μt represents year-fixed effects that absorb demographic and socioeconomic shocks common to all cities. Our model also controls for city-fixed effects (θc), which absorb unobservable time-invariant factors at the city level. The unit of analysis was city year. We included a city-level fiscal self-reliance ratio (Xct) to control for a time-varying factor that may correlate with OUA designation and outcome measures. Additionally, we clustered standard errors at the city level.
The outcomes of the intervention group (cities designated OUA and POUA with financial incentives) and the control group (all other rural areas without financial incentives) were compared. Our main study sample consisted of a balanced panel featuring all cities with complete data (n = 240) over a 10-year period (2011–2020). Crude annual changes in the number of OUAs and part-time and full-time gynecologists in the treatment (OUA) and control groups (non-OUA) during the study period are shown in Supplementary Table 1. Sensitivity analyses were also performed. First, we used data from cities in rural areas (n = 89) to determine whether changes in sample restrictions affected the results. Second, we added city-specific linear time trends to the regression model to control for differential trends in outcomes at the city level. The results of the sensitivity analyses (Supplementary Tables 2 and 3), which were similar to the main findings, would indicate the robustness of our findings.
Statistical analysis
All analyses were performed using Stata version 17 (StataCorp LLC, College Station, TX, USA). We used two-sided tests, and P < 0.05 was considered statistically significant.
Ethics statement
This study was approved by the Institutional Review Board (IRB) of the National Medical Center (IRB No. NMC-2021-04-052) and waived the need for participant consent because of the use of anonymized claim data.
RESULTS
Table 1 presents the descriptive statistics of our study sample at baseline (year 2011). We provided the means and standard deviations of measures for cities designated as OUA during the study period (n = 73) and for cities never designated as OUA (n = 167). The number of part-time OB/GYN specialists per 1,000 females of reproductive age was considerably higher in cities designated as OUA than in cities not designated as OUA. However, cities designated as OUA had fewer full-time OB/GYN specialists (0.295 per 1,000 females of reproductive age) than cities unaffected by the policy (0.333 per 1,000 females of reproductive age). In addition, the number of facilities with full-time OB/GYN specialists was lower in the cities affected by the policy than in those unaffected. Cities designated as OUA also had a lower fiscal self-reliance ratio, indicating a vulnerable environment.
Table 1. Descriptive statistics of the study sample at baseline (2011).
| Variables | Cities designated as OUA | Cities never designated as OUA | ||
|---|---|---|---|---|
| Outcome | ||||
| No. of OB/GYN specialists (per 1,000 females of reproductive age) | ||||
| No. of all OB/GYN specialists | 6.060 ± 4.190 | 1.260 ± 1.144 | ||
| No. of full-time OB/GYN specialists | 0.295 ± 0.176 | 0.333 ± 0.267 | ||
| No. of part-time OB/GYN specialists | 5.764 ± 4.109 | 0.927 ± 1.148 | ||
| No. of facilities with OB/GYN specialists (per 100,000 females of reproductive age) | ||||
| No. of facilities with full-time OB/GYN specialists | 25.059 ± 11.098 | 15.944 ± 9.263 | ||
| Covariate | ||||
| Fiscal self-reliance ratio | 14.030 ± 4.608 | 21.650 ± 7.693 | ||
| Observations | 73 | 167 | ||
Values are presented as mean ± standard deviation.
OUA = obstetrically underserved areas, OB/GYN = obstetrics/gynecology.
Table 2 presents result from the regressions of the number of OB/GYN specialist measures (all, full-time, and part-time specialists). Coefficient estimates in the second column indicate that OUA designation was associated with a significant increase in the total number of OB/GYN specialists by 1.4 per 1,000 females of reproductive age (P < 0.001). However, the combined impact of OUA designation and higher reimbursement rates resulted in a significant reduction in OB/GYN specialists by 3.4 per 1,000 females of reproductive age (P < 0.001). Running regressions separately for the number of full-time specialists (third column) and the number of part-time specialists (fourth column), we found that OUA designation was positively associated with the number of part-time OB/GYN specialists without affecting the number of full-time specialists. OUA designation and a higher reimbursement rate for deliveries was significantly associated with an increased the number of full-time OB/GYN specialists by 0.08 per 1,000 females of reproductive age (equivalent to a 20%-increase from the outcome average; P = 0.007). It was also associated with a substantial reduction in the number of part-time specialists by 3.5 per 1,000 females of reproductive age (P < 0.001). These results indicate that higher delivery reimbursement rates were related to substituting part-time specialists for full-time specialists at cities designated as OUA.
Table 2. Association of OUA policies with OB/GYN specialists (per 1,000 females of reproductive age).
| Variables | Coefficients (standard errors) | |||
|---|---|---|---|---|
| Total No. of OB/GYN specialist | No. of full-time OB/GYN specialist | No. of part-time OB/GYN specialist | ||
| OUA designation | 1.392a (0.285) | −0.016 (0.019) | 1.408a (0.288) | |
| P value | < 0.001 | 0.406 | < 0.001 | |
| OUA X higher reimbursement (post-2016) | −3.390a (0.589) | 0.083a (0.030) | −3.473a (0.594) | |
| P value | < 0.001 | 0.007 | < 0.001 | |
| Post-2016 | −0.560a (0.101) | 0.153a (0.013) | −1.013a (0.099) | |
| P value | < 0.001 | < 0.001 | < 0.001 | |
| Intervention group outcome mean | 5.332 | 0.387 | 4.945 | |
| Control group outcome mean | 1.375 | 0.417 | 0.958 | |
| Observations | 2,400 | |||
Standard errors clustered at the city level are in parentheses.
OUA = obstetrically underserved areas, OB/GYN = obstetrics/gynecology.
aSignificant at 0.01.
Each column shows the separate regression results. The regression also includes city fixed effects, year dummies, and fiscal self-reliance ratio. Standard errors are clustered at the city level.
Table 3 presents the regression results of the number of healthcare facilities with full-time OB/GYN specialists. The OUA designation was not significantly associated with the number of facilities with full-time specialists. However, the OUA designation and a higher reimbursement rate was significantly associated with an increased the number of facilities with full-time OB/GYN specialists by 5.8 per 100,000 females of reproductive age (24% of the outcome mean; P = 0.036). Together with the results in Table 2, we found evidence that the policies combining increased reimbursement rates with grant support (for installing/upgrading facilities) led to changes in the healthcare workforce at the facility level.
Table 3. Association between OUA policies and the number of facilities with full-time OB/GYN specialists (per 100,000 females of reproductive age).
| Variables | Coefficients (standard errors) | |
|---|---|---|
| OUA designation | −0.235 (1.334) | |
| P value | 0.861 | |
| OUA X higher reimbursement (post-2016) | 5.775a (2.707) | |
| P value | 0.036 | |
| Post-2016 | 13.496b (2.514) | |
| P value | < 0.001 | |
| Intervention group outcome mean | 33.316 | |
| Control group outcome mean | 22.850 | |
| Observations | 2,400 | |
Standard errors clustered at the city level are in parentheses. The regression also includes city fixed effects, year dummies, and fiscal self-reliance ratio. Standard errors are clustered at the city level.
OUA = obstetrically underserved areas, OB/GYN = obstetrics/gynecology.
aSignificant 0.05; bSignificant at 0.01.
DISCUSSION
This study reviewed the effects of support policies regarding staffing in the OB/GYN departments being implemented to increase access to prenatal care and delivery in vulnerable areas of Korea. To summarize the analysis results, the number of full-time OB/GYN specialists increased significantly by 0.083 per 1,000 females of reproductive age after the introduction of additional reimbursement in OUA. However, the number of GYN specialists working part-time significantly decreased to 3.473 per 1,000 females of reproductive age. These results suggest that policies targeting obstetrically vulnerable areas may lead to a shift from part-time OB/GYN specialists to full-time staff.
Many studies have reported inadequate prenatal examinations and childbirth-related care in OUA.10,18,19 However, there is a lack of research evaluating the impact of supportive policies in OUA. In South Korea, one study assessed obstetric care experience among pregnant women at the onset of the project supporting OUA; however, comprehensive examinations of policy effects on childbirth-related care access in vulnerable areas remain lacking.20 Considering that the presence of specialists in both OUA and medically vulnerable areas is crucial for addressing disparities in maternal care, understanding the influence of the support project for OUA on the distribution of OB/GYN specialists is important.21,22,23
It is encouraging that the number of OB/GYN specialists working full-time in OUA significantly correlated with additional delivery reimbursements. However, this could reflect a change in the existing OB/GYN specialists’ work patterns rather than a new influx of OB/GYN specialists. Our results do not suggest that higher reimbursement rates alone are sufficient for adequate staffing in OUA. Given the overall decline in the number of OB/GYN specialists in Korea, it is expected to become increasingly challenging to retain OB/GYN specialists in OUA.3 This isn’t to say that market-driven strategies, such as increased childbirth reimbursement rates and subsidies are meaningless; however, relying solely on such measures will inevitably have limitations in sustaining an adequate workforce in OUA.
Although we found a significant increase in the number of medical institutions with full-time OB/GYN specialists in OUA, whether they retained enough OB/GYN specialists for childbirth is still being determined. Childbirth requires the maintenance of a 24-hour medical care system to cover urgent conditions, similar to care for acute myocardial infarction or severe trauma.24 Although environments vary by country or region, having at least three OB/GYN specialists per medical institution to operate the 24-hour delivery care system properly is necessary. However, finding such medical institutions in Korea’s OUA is difficult. It is necessary to prepare comprehensive measures for ensuring adequate medical staffing in critical fields that require timely intervention, such as childbirth.
This study had limitations. First, this study did not evaluate the quality of healthcare providers. A previous qualitative study reported that the main reason mothers in OUA visit OB/GYN specialists outside the region is that they are not satisfied with the quality of obstetric care in OUA.25 The quality of OB/GYN specialists, which is the key to improving the quality of childbirth care in OUA, needs to be evaluated. Maintaining it above a certain level is important to improve the relevance index of obstetric care in OUA.26
Second, it did not examine whether additional higher reimbursement policies for OUA differed between hospitals and clinics. This was because most OUAs had only one or two medical institutions capable of delivering babies, making the distinction between hospitals and clinics less practical. However, follow-up studies should investigate potential differences in the responsiveness of OUA support policies between hospitals and clinics.
Third, considering that the unit of analysis in this study was city-year level, changes in the workplace and the type of work of individual OB/GYN specialists could not be explored. A physician-level analysis will provide evidence on how OB/GYN specialists responded to the OUA support project. For example, individual analysis could reveal whether male or female specialists are more responsive to incentives for OUA.27 Since there are various factors in which medical and pre-medical personnel select their workplace,11,28 employing surveys could provide valuable data on the effectiveness and limitations of OUA support projects.29
Lastly, this study did not address the underlying causes of the limited effectiveness of financial incentives. The sharp decline in birth rates and the consequent decrease in the number of OB/GYN specialists performing deliveries are likely key factors that warrant in-depth analysis.
Nevertheless, this study is the first to explore the association of the OUA support project with the number of OB/GYN specialists in South Korea. Our findings suggest that increased reimbursement rates in OUA effectively boosted the number of full-time OB/GYN specialists. However, we also observed evidence pointing to a substitution of part-time specialists for full-time specialists. Future research should investigate whether these policies contribute to a stable, sufficient supply of specialists capable of ensuring access to quality care in vulnerable areas.
Footnotes
Funding: This study was supported by the Ministry of Health and Welfare, research on the behavior of public health worker (public healthcare workforce monitoring project; grant No. NHIS-2021-1-543).
Disclosure: The authors have no potential conflicts of interest to disclose.
Data Availability Statement: Data cannot be publicly shared because we have used third-party data from National Health Insurance Service. Public use by data users is prohibited. Data are only available from the Review Board of National Health Insurance Service (contact via NHIS) for researchers who meet the criteria for access to confidential data. Any international researcher conducting a joint study with a Korean researcher can access NHIS for customized health information data when completing the requirements. Applications for data are available through National Health Insurance Data Sharing website (https://nhiss.nhis.or.kr/bd/ab/bdaba000eng.do), and additional information can be found at a customized health information data webpage (https://nhiss.nhis.or.kr/bd/ab/bdaba032eng.do).
- Conceptualization: Ko H, Ock M, Lee S, Park JW, Kwak MY, Jang WM.
- Data curation: Lee S, Park JW, Kwak MY.
- Formal analysis: Ko H, Lee S.
- Methodology: Ko H, Ock M, Jang WM.
- Supervision: Kwak MY, Jang WM.
- Writing - original draft: Ko H, Ock M.
- Writing - review & editing: Ko H, Ock M, Lee S, Park JW, Kwak MY, Jang WM.
SUPPLEMENTARY MATERIALS
Year-to-year variation in the number of OUA and part-time and full-time OB/GYNs during the study period (per 1,000 females of reproductive age)
Sensitivity check: rural cities
Sensitivity check: adding city-specific linear trends
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Associated Data
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Supplementary Materials
Year-to-year variation in the number of OUA and part-time and full-time OB/GYNs during the study period (per 1,000 females of reproductive age)
Sensitivity check: rural cities
Sensitivity check: adding city-specific linear trends