Is direct access to obstetricians/gynecologists effective at improving maternal health behaviors?

The growth in managed care has affected many aspects of women's health care. Managed care attempts to contain costs by limiting access to specialists and designating a primary care physician (PCP) or gatekeeper. Because women's health care services are typically shared between the PCP and the obstetrician/gynecologist (OB/GYNs), health care for women may have been particularly affected by the changes resulting from managed care. According to the 1996–1997 Community Tracking Survey (Center for Studying Health System Change 2001), PCPs responded that they serve as gatekeepers to specialists for approximately 36 percent of their patients. In response to this concern, states have moved to require health insurance plans to permit direct access to OB/GYNs (hereafter “direct access” laws).1 These mandates can take the form of direct access without a referral or by allowing an OB/GYN to serve as the patient's primary care provider. As many women's health issues are time sensitive, direct access laws permit this doctor–patient relationship directly without the need for referrals from the PCP. Currently, 42 states mandate direct access to OB/GYNs (Baker and Chan 2007; Council on Affordable Health Insurance 2007;). Moreover, direct access to OB/GYNs will be mandated at a national level with the passage of federal health care reform. The Patient Protection and Affordable Care Act (HR 3590) expressly states: (A) DIRECT ACCESS.—A group health plan, or health insurance issuer offering group or individual health insurance coverage, described in paragraph (2) may not require authorization or referral by the plan, issuer, or any person (including a primary care provider described in paragraph, (2)(B)) in the case of a female participant, beneficiary, or enrollee who seeks coverage for obstetrical or gynecological care provided by a participating health care professional who specializes in obstetrics or gynecology.2 Additionally, the American College of Obstetricians and Gynecologists (ACOG), a proponent of women's health reforms, argues that direct access to OB/GYNs can “greatly improve women's health” (ACOG 2010).3 Given the federal and state attention to direct access legislation combined with the suggested motivations for improved health outcomes, an understanding of the potential benefits of these insurance mandates is warranted. Proponents argue that direct access legislation can improve access to care and outcomes, possibly through earlier initiation of prenatal care through an OB/GYN. Policies promoting prenatal care can identify a range of prenatal problems, prevent delayed treatment for complications or delayed prenatal care utilization, or promote healthy behavior. The earlier expectant mothers initiate prenatal care, the earlier that positive health behaviors can be initiated (or reinforced), including vitamin use,4 and reduction or elimination of smoking, alcohol, or drugs. Many of these risk factors can contribute to increased risk of prematurity and other negative health outcomes. Additionally, direct access legislation may encourage preconception appointments, which has the ability to address maternal behavior or identify risk factors before a pregnancy occurs (Kost, Landry, and Darroch 1998; Atrash et al. 2006;). These considerations may improve maternal health as well as birth outcomes, in addition to possibly reducing negative health behaviors during pregnancy (e.g., tobacco or alcohol use). On the other hand, insurance mandates like direct access to OB/GYNs may have a limited effect on pregnancy-related care and outcomes. It is possible that the number of women who are impacted by direct access legislation is quite small. For example, firms that choose to self-insure are protected from state-level mandates by the federal Employee's Retirement Income Security Act (ERISA). Because of the ERISA exemption, state mandates mainly affect individuals with private insurance plans (HMOs and PPOs), but not self-funded plans. Additionally, approximately 40 percent of U.S. births are funded through Medicaid,5 which are also not subject to insurance mandates. Even within the population of women potentially affected (women with private insurance—HMOs or PPOs), direct access to OB/GYNs for pregnancy-related care may not have been restricted. In other words, women in these groups may have always had high access to specialized care during pregnancy. Our investigation, therefore, targets the potential effects on women who were most likely affected by state legislation for direct access. Critics of state health insurance mandates typically cite the costs of providing mandated benefits (Gabel and Jensen 1989; Jensen and Gabel 1992; Udom and Betley 1998;). The Council on Affordable Health Insurance (2007) reported that mandated health benefits are associated with increased health care costs of between 20 and 50 percent. Additionally, prior literature has devoted considerable attention to the labor market effects of mandates on wages and employment (Gruber 1994; Cutler and Madrian 1998; Waldfogel 1999; Baum 2003;). Although direct access laws are motivated by the belief that access improves health outcomes, there is surprisingly little research on the potential health benefits of mandates (and those that relate to women's health, pregnancy, maternity, and family planning) in particular. Generally, the literature has considered an array of mandated health benefits, including mammography mandates, infertility mandates, and mental health mandates. Infertility mandates are associated small negative effects on birthweight, gestation, and Apgar score (Bitler 2008) and an increase in first birth rates for women over 35 (Schmidt 2007). Additionally, nurse midwifery mandates are associated with a decrease in neonatal deaths and an increase in midwife-attended births (Miller 2006). Other studies have considered the effects of parental leave laws on births and health outcomes finding that more generous parental leave policies are associated with reductions in infant deaths (Ruhm 2000), increased births (Averett and Whittington 2001), and fewer postpartum depressive symptoms (Chatterji and Markowitz 2005). In other work, mammography mandates were demonstrated to increase mammography screenings (Bitler and Carpenter 2010). Direct access mandates, however, have been found to be unrelated to breast and cervical cancer screenings (Baker and Chan 2007). In contrast, women who use both generalists and OB/GYN specialists are more likely to receive a higher level of recommended preventative services (Henderson, Weisman, and Grason 2002). Whether this leads to improved health outcomes, however, is an open question. The objectives of this research are to develop a clearer understanding of the relationship between direct access laws and the potential benefits for pregnancy-related care and outcomes.6 In light of both state and federal laws targeting this issue, it is important for policy makers to understand the potential health benefits direct access can provide. To estimate the potential effects of direct access laws, we consider the effects of the legislation on maternal health behaviors during pregnancy, including prenatal care utilization, maternal alcohol use, and tobacco use. Using the introduction of the laws over time, we use a difference-in-difference analysis using two datasets, the Natality Detail File and the Pregnancy Risk Assessment and Monitoring Survey (PRAMS). Our results suggest that there is little evidence that direct access laws are effective at changing prenatal care initiation or maternal health behaviors during pregnancy. Given this null effect in the so-called first stage, we then test the effect of direct access legislation on infant health outcomes, confirming again no identifiable relationship. This finding is consistent across two datasets, a variety of specifications, and subgroups of women who are most likely to be affected by direct access laws. These results coincide with previous findings (Baker and Chan 2007), which suggest that direct access laws have little, if any, effect on health behaviors.