Hmo Study Baffles Researcher Patients Get Better Prenatal Care, Have More Complications In Delivery

With millions of Americans migrating to health maintenance organizations, Dr. Mary Aitken set out several years ago to find whether the cost-cutting insurance plans also cut the quality of care for pregnant women and newborns.

What the pediatrician found was a bit of a puzzle. HMOs provided women, on the whole, with the same or better care during pregnancy than women covered by more expensive private insurance received. But once they hit the delivery room, some women covered by HMOs had twice as many complications, including prolonged labor, excessive bleeding and seizures.

Aitken doesn’t know why.

“I think our results raise as many questions as answers,” said Aitken, a pediatric professor at Arkansas Children’s Hospital.

The study looked at the birth records and medical records of 8,000 babies born in 1992 and 1993 in King County, Wash., a large area that includes Seattle. Half the babies were born to women in an HMO and half to women on private insurance. Medicaid and self-paid patients were excluded.

During the pregnancies, Aitken found, women in HMOs - health plans that emphasize preventive medicine and cost containment - were 40 percent more likely to have had ultrasound than women with private insurance. They also were 30 percent more likely to have a baby weighing at least 5.5 pounds - a general marker of good health.

The number of Caesarean sections and amniocentesis tests was comparable between the two insurance groups. And while only a small number of women in the study received what the researchers determined was “inadequate” prenatal care, more of them were likely to be covered by private insurance, not HMOs.

“I think women in both groups should be reassured their prenatal care is comparable,” Aitken said.

But the researchers also found once the HMO mothers hit the delivery room, the story and statistics changed.

Of the women with no known risk factors, such as hypertension or diabetes, those covered by HMOs had twice the risk of experiencing problems during labor. Although the number of women who experienced complications was small, HMO-insured patients had higher rates of maternal bleeding, prolonged labor, fever and seizures.

The number of infants born in distress was also small, but 80 percent of them fell into the HMO group.

Infants may go into distress if contractions during labor compress their heads or umbilical chords, Aitken said. Infection may also cause distress, which can be measured either by a racing or a slow heart rate. Sometimes, infants will pass a stool in the amniotic fluid, she said.

Unlike the “drive-through” deliveries that HMOs were derided for until Congress passed legislation last year requiring them to pay for more than 24 hours in the hospital, Aitken found mothers in both groups stayed in the hospital, on average, two days.

But no one really knows just why HMO patients had more problems during delivery. Is it the HMO patients received less medical care in the delivery room? Or could it be HMOs just keep better records? Will there be any long-term detrimental effect on the HMO babies who were born in distress?

Aitken and her colleagues combed the data to see whether the women themselves could provide any clue to the difference. They could find none. In both insurance groups, the women were largely under age 35, highly educated and non-smoking.

“These questions are not going to be answerable in any one study,” Aitken said, calling for a much larger study of pregnant women, rather than a look solely at birth records.

The need is pressing, she said, as more and more people join HMOs. From 1994 to 1995 alone, the number of Americans joining HMOs rose from 51.1 million to 58.2 million, according to the American Association of Health Plans, an HMO trade association.

“It just doesn’t make sense to say the patients are getting better prenatal care, but the (birth) outcomes are not as good,” Susan Pisano, AAHP spokesperson, said of the study. “And I think it would be irresponsible to conclude, without further study, anything definitive.”

Few studies have compared HMOs and private insurance and the quality of medical care patients receive. Two small studies, one from Massachusetts and one from Oregon about 20 years ago, showed prenatal care under both types of insurance was largely comparable.

More recent studies of Medicaid patients showed similar or better prenatal care in HMOs to private insurance.

But studies of HMOs themselves, both by independent researchers and by the HMO-funded National Committee for Quality Assurance, show plans vary widely in quality, and good prenatal care is often a function of which plan you use, said Dr. Robert Brook, a doctor who has studied the issue for the RAND Corp.

Brook was not surprised by the seeming contradiction in Aitken’s study.

“There’s no question that’s not unusual,” Brook said. “We know from the field an institution can do very well in screening and not do very well in following up on the results that are screened. Just like some hospitals do well in treating diabetes but not in high blood pressure. Unfortunately, there is no such thing as an overall good quality hospital or an overall good quality doctor.”

Brook based his comments, in part, on a study he and other doctors at RAND released Monday that found serious lapses in the quality of health care across the country - patients not getting treated, patients getting the wrong treatment - regardless what kind of insurance coverage they have.

“The bottom line of our study is, it doesn’t matter how you’re paid, or anything else,” Brook said, “There are major problems in quality and we ought to direct some attention to fixing them.”

For Aitken, getting a handle on the problem of quality is what’s important.

“I have no political agenda. I’m receiving my own prenatal care in an HMO right now,” she said. “I just want to make sure patients are getting good and comparable care.”