Physician incentives and the timing of cesarean sections: Evidence from California

OBJECTIVES. The timing of cesarean sections is studied to examine how physi cian convenience and financial incentives play a role in the decision to pe rform a cesarean section. METHODS. Using birth certificate and hospital financial data from Californi a, the likelihood of cesarean sections being performed at particular times of day was examined, controlling for maternal characteristics and the mothe r's insurance coverage. Two diagnoses associated with cesarean sections are examined separately: fetal distress and prolonged/dysfunctional labor. The hypotheses are that cesarean sections performed for physician convenience are more likely to occur in the evening hours and that type of insurance wi ll affect the incentive to perform cesarean sections to obtain leisure. RESULTS. The probability of cesarean sections for patients insured by a gro up-model HMO is more stable during the course of a day than that for patien ts insured by all other insurance plans. Group-model HMO patients with prev ious cesarean sections are less likely to have cesarean sections in the eve ning hours and are less likely to be diagnosed with fetal distress or prolo nged/dysfunctional labor. CONCLUSIONS. The differences in cesarean sections and diagnosis rates betwe en group-model HMO patients and other patients could arise from several mec hanisms: group-model HMOs provide consistent financial incentives to their staff, they may be better able to guide physician practice, and they might provide staff support to physicians so there is less leisure-based incentiv e to perform cesarean sections. In contrast, nongroup-model HMOs do not app ear to reduce the incentive of physicians to maximize leisure relative to t raditional insurance.