Private care, public care
Approximately 1,400 babies are born in Daviess County each year. An estimated 900 pregnant women (63 percent) receive prenatal care through eight local obstetricians in private practice. Until recently, the 500 remaining women (37 percent) received prenatal services from two midwives at the Green River District Health Department. In any given month, the health department caseload was 250 to 300 pregnant women and another 40 to 50 new pregnant women turned to the department for care.
Absorbing the cost of care
Most of the women served by obstetricians are insured through private insurance plans. Most who sought care at the health department were insured through Medicaid, a health care program funded by state and federal governments. To qualify for Medicaid, their annual incomes could not exceed 185 percent of the federal poverty level*. The health department also provided prenatal care for women who did not qualify for Medicaid but could not afford health insurance.
Problems in caring for the poor
Some obstetricians in private practice do not accept Medicaid and uninsured patients because their caseloads are already full and reimbursements from the Medicaid program are substantially less than reimbursements from insurance companies. Medicaid and uninsured patients also tend to miss appointments more often and are at high risk for complications. Poor women are more likely to smoke, not follow directions during pregnancy, and have substance abuse problems. And the language barrier, with an increasing number of immigrants here, is a hurdle to care.
Medical supervision required
Birth Data (2003)
|Number of live births||25-bed acute care facility|
|Crude birth rate (per thousand)||25-bed critical access facility|
|Low birth weight||365-bed|
|Births to single unmarried women||116-bed|
|Births to mothers under 18||216-bed|
Source: Kentucky Cabinet for Health and Family Services, 2003-Vital Reports http://chfs.ky.gov/dph/vital/2003vitalreports.htm
Government regulations require that the midwives at the health department be supervised by an obstetrician. Obstetricians claim that they must assume too much liability when providing oversight for health department midwives, and that drives up their already high malpractice insurance premiums.
Forced to cut the program
This year, health department officials were unable to reach an agreement with local obstetricians to provide supervision. So in September 2006, under pressure from state regulators and insurance carriers, the health department eliminated much of its prenatal care program, including prenatal exams. The health department continues to provide various programs and services for pregnant women – nutrition counseling, Women, Infants and Children program, Building Stronger Families program, etc.
Health department reaches out to obstetricians
Concerned that hundreds of pregnant women may not have access to prenatal care, health department officials approached local obstetricians to accept its Medicaid referrals. If patients do not qualify for Medicaid and are unable to pay, the health department offered to reimburse obstetricians the Medicaid rate by using a $70,000 state grant and $47,000 from local health taxes. Seven obstetricians agreed to accept established health department patients during their current pregnancy and four agreed to take new patients. A month into this referral system, 269 pregnant women patients had been accepted by local obstetricians.
Different setting could be good or bad
Assigning pregnant women to obstetricians in private practice ensures continuity of care through delivery. It establishes a relationship between the doctor and patient that can benefit both the pregnant woman and her child. It creates a central location for medical records and ongoing care. However, some are concerned that Medicaid and uninsured pregnant women will feel less welcome in private practice settings.
Given the volume and unique challenges in serving Medicaid and uninsured patients:
Without proper prenatal care, babies are more likely to be born preterm, putting them at high-risk for health problems and learning disabilities. The pregnant women who are most vulnerable are poor, single mothers and immigrants.
* Federal poverty level for single women without children: $10,160
* Federal poverty level for single women with two children: $15,735