DO INCREASES IN PAYMENTS FOR OBSTETRICAL DELIVERIES AFFECT PRENATAL-CARE

Raising fees is one of the primary means that State Medicaid Programs employ to maintain provider participation. While a number of studies h ave sought to quantify the extent to which this policy retains or attr acts providers, few have looked at the impact of these incentives on p atients. In this study, the authors used Medicaid claims data to exami ne changes in volume and site of prenatal care among women who deliver ed babies after the Maryland Medicaid Program raised physician fees fo r deliveries 200 percent at the end of its 1986 fiscal year. Although the State's intent was to stabilize the pool of nonhospital providers who were willing to deliver Medicaid babies, it was also hoped that wo men would benefit through greater access to prenatal care, especially care rendered in a nonhospital setting. The authors' hypotheses were t hat (a) the fee increase for obstetrical deliveries would result in an increase in prenatal visits by women on Medicaid, and (b) the fee inc rease would lead to a shift in prenatal visits from hospital to commun ity based providers. The data for Maryland's Medicaid claims for the f iscal years 1985 through 1987 were used. Comparisons were made in the average number of prenatal visits and the ratio of hospital to nonhosp ital prenatal visits before and after the fee increase. Data for conti nuously enrolled women who delivered in the last 4 months of each fisc al year were analyzed for between and within year differences using St udent's t-test and ANOVA techniques. The findings indicate very little overall change in either the amount or location of prenatal care duri ng the year after the large fee increase for deliveries. Though signif icant increases in the number of prenatal visits occurred for women wh o lived outside of Baltimore City, it is difficult to attribute these changes solely to the fee increase. Where an effect was observed, it a ppeared to be greatest in nonurban areas of the State, probably becaus e coordination of care by fewer Medicaid providers is more common in s uch areas. The findings do not support the hypotheses that raising fee s for obstetrical deliveries uniformly increase community-based prenat al care. Instead, the findings suggest that tying fee increases for ob stetrical deliveries to the amount of prenatal care provided for each patient may be the best way of increasing the commitment of Medicaid o bstetrical providers to give their patients more comprehensive perinat al care.