Prenatal care characteristics and African-American women’s satisfaction with care in a managed care organization

Women’s Health Issues 13 (2003) 93–103

PRENATAL CARE CHARACTERISTICS AND AFRICANAMERICAN WOMEN’S SATISFACTION WITH CARE IN A MANAGED CARE ORGANIZATION Arden Handler, DrPHa*, Deborah Rosenberg, PhDa, Kristiana Raube, PhDb, and Sandra Lyons, PhDc a

School of Public Health, University of Illinois Chicago, Illinois Haas School of Business, University of California, Berkeley Berkeley, California c Chapin Hall Center for Children at the University of Chicago Chicago, Illinois

b

Received 28 October 2002; received in revised form 4 February 2003; accepted 7 March 2003

This study examined the characteristics of prenatal care affecting women’s satisfaction for two groups of African-American women, those with Medicaid insurance and those with commercial insurance, who sought care through a large managed care organization in the Midwest. African-American pregnant managed care patients (n ⫽ 400), regardless of payer status, were more satisfied when their providers spent more time with them and when their providers engaged them by explaining procedures, asking them questions, and answering their questions. Satisfaction was also higher for both Medicaid (n ⫽ 125) and commercially insured women (n ⫽ 275) when the waiting room was clean and comfortable. The care characteristics most important to an African-American woman’s satisfaction with prenatal care do not appear to be dependent on her payer status, nor do they seem to be particularly dependent on the financial arrangements of her care provider. While improvements in health care delivery tend to focus on increasing technical proficiency to improve pregnant women’s satisfaction with care, prenatal care providers should focus on improvements in patient–provider communication, as well as features of the prenatal care setting (e.g., cleanliness, waiting times, availability of ancillary services).

D

uring the last decade, the health care delivery system in the United States experienced a major restructuring. By 2000, 18.8 million Medicaid beneficiaries were enrolled in managed care, up from 2.7 million in 1991.1 Likewise, the commercially insured population also moved to managed care as employers sought less expensive care alternatives for their employees.2 Included in these populations were many pregnant women for whom managed care is a relatively new form of health care delivery. Because some types of managed care arrangements (e.g., group practice, staff model) are “organized” settings of care where women seek care from a group of providers usually located together, there

is an increased opportunity to monitor, and if necessary modify, the characteristics of the care delivery system to increase women’s satisfaction. Importantly, in order to alter care characteristics to increase women’s satisfaction, it is necessary to document those that women believe to be most significant. The current study examines the prenatal care characteristics associated with patient satisfaction for two groups of African-American women: those with Medicaid insurance and those with commercial insurance. Both groups of women sought prenatal care through a large health maintenance organization in the Midwest employing its own staff of medical care providers.

* Correspondence to: Arden Handler, DrPH, Professor, University of Illinois School of Public Health, 1603 W. Taylor, Chicago, IL 60612. E-mail: [email protected].

Background

Copyright © 2003 by the Jacobs Institute of Women’s Health. Published by Elsevier Inc.

Patient satisfaction is considered, along with health status, to be an outcome of the delivery of health care 1049-3867/03 $-See front matter. doi:10.1016/S1049-3867(03)00031-8

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services.3 Similar to the general literature on satisfaction with health care services,3–5 a variety of prenatal care characteristics have been associated with women’s prenatal care satisfaction.6 –18 These characteristics include: waiting time for an appointment;15 waiting time at the site of care;8,9,11,12,17,18 continuity of caregiver;7,9,11,12,15,17 practitioner type,13 practitioner gender;18 provider ethnicity,18 time spent with the practitioner;12,17 patient–practitioner communication; 6,9,16 –18 and the physical environment of the prenatal care site.12,17 Many of the studies of care characteristics and satisfaction have focused on or included women of color,6 –9,12–15,17,18 but with few exceptions,18 these studies did not explore7,8,12,13,16 or did not find6,9,17 differences in satisfaction with prenatal care among women of various race/ethnic groups. Likewise, even when studies13,15,16 have included pregnant women with different payers (e.g., Medicaid, private insurance), with one exception,15 insurance status was not examined as a possible explanatory variable predicting satisfaction. While there is clearly a substantial literature exploring the characteristics of prenatal care associated with woman’s satisfaction, in general, these studies have often examined only a small number of care characteristics; sometimes utilized small, select samples; questioned women at delivery or postpartum which is problematic with respect to recall bias (i.e., recall of prenatal satisfaction is confounded with recall of delivery satisfaction); used only global measures of satisfaction (e.g., were you satisfied with your care?) which do not adequately tap the varying dimensions of satisfaction;19,20 used satisfaction measures with inadequate rating scales;19,20 and often failed to adjust for potential confounders. In addition, these studies have not provided sufficient understanding of the relationship between prenatal care characteristics and satisfaction for unique race/ethnic groups such as Latinas or African-Americans or for unique insurance groups such as Medicaid recipients or women with commercial insurance. Beyond care characteristics such as provider type or waiting times, a more overarching characteristic of care delivery that may affect a pregnant woman’s satisfaction is the structure of the financial arrangements within which the health care provider provides care. Studies of women participating in Medicaid managed care have focused on a variety of managed care arrangements, including independent practice associations, prepaid group practices, staff model health maintenance organizations (HMOs), preferred provider organizations (PPO), and mandatory participation in a managed care plan without specifying a particular managed care type. These studies have often included women participating in a variety of managed care models21,22 or in one of multiple plans under an umbrella program,23,24 but have not exam-

ined differences between them. Similar to the variety of managed care arrangements studied, women in Medicaid managed care have been compared with several different groups such as women in fee-forservice Medicaid21,22,24 –27 or commercial plan managed care enrollees.22,25,28 Not surprisingly, the results of studies particularly focused on women’s satisfaction with Medicaid managed care have been mixed. Some studies show that women in Medicaid managed care are overall quite satisfied with their health plans29 or that they are more satisfied than their fee-for-service Medicaid counterparts;21,26 others find that satisfaction is either equivalent between these two groups24 or that women enrolled in Medicaid managed care are less satisfied with their health plans than women in fee-for-service Medicaid or low-income women with private managed care.22 When comparing Medicaid managed care recipients in one state’s HMOs to recipients in the state’s primary care case management program, Smith et al.30 found few significant differences in perceived access, utilization, and satisfaction. On the other hand, when comparing nonpregnant Medicaid managed care enrollees with commercial plan managed care enrollees, Ipsen et al.28 found Medicaid enrollees to be greater utilizers of services and more highly satisfied overall than commercial plan enrollees. Several studies have specifically examined the experiences of pregnant women receiving care in managed care delivery systems25,27,31–33 but only two34,35 have looked at patient satisfaction. The postpartum survey by Lawrence et al.34 of women in a large group model HMO found that nearly 90% of these women were satisfied with their care during pregnancy and the newborn period; however, this study was not focused on low income women, did not include maternal race/ethnicity, and did not explore correlates of satisfaction. The survey by Harris et al.35 of Medicaid managed care patients (including pregnant women) participating in 18 managed care plans in the Oregon Health Plan found patients’ perceptions of providers’ technical quality and interpersonal aspects of care to be the most important predictors of patients’ satisfaction with their care and their plan; however, this study included almost all white participants and did not provide a separate analysis for pregnant women. The current study builds on the prior literature describing the relationship between prenatal care characteristics and satisfaction as well as on the literatures concerning the satisfaction of women in Medicaid managed care and that of pregnant women in managed care in general. It improves on the prior studies of the prenatal care characteristics–satisfaction relationship by measuring satisfaction during the prenatal period using a multidimensional scale, by enrolling a larger sample than most previous studies, and by considering a variety of potential confounders of the

A. Handler et al. / Women’s Health Issues 13 (2003) 93–103

care characteristics–satisfaction relationship. Also, as indicated above, little is actually known about how women of different race/ethnic or payer groups rate satisfaction with prenatal care, and prenatal care delivered through a managed care organization, in particular. As such, this study specifically considers the satisfaction experience of one particular race/ ethnic group, African-American women, and explores differences in the care characteristics–satisfaction relationship for women with different payers (i.e., Medicaid, commercial insurance) seeking care in the same large HMO. This study sought to explore two specific questions. Among African-American women seeking care in a large health maintenance organization: 1) What are the characteristics of prenatal care related to a woman’s satisfaction?, and 2) Is the relationship between prenatal care characteristics and satisfaction the same for Medicaid and commercially insured pregnant women? It was carried out as part of a larger study of the relationship between satisfaction and prenatal care utilization.

Study Design and Methods This study was carried out with a convenience sample of Medicaid and commercially insured African-American adult women seeking care at one of two health clinics (urban site or suburban site) operated by a large HMO in the Midwest employing its own staff of medical care providers. For a short time period in the 1990s, Medicaid recipients in the metropolitan area in which the study was conducted were encouraged to switch to managed care and the state Medicaid program contracted with several HMOs serving the commercially insured to provide care to the Medicaid population. Before this time, most women on Medicaid typically received care at public health clinics, community health centers, hospital clinics, and neighborhood “storefront” providers; commercially insured women were less likely to have used public health clinics and “storefront” providers for their care. While this provides a general picture of possible prior prenatal care experiences, this study did not collect data on the previous prenatal experiences for the multiparous women. The managed care organization in which this study took place opened its doors to the Medicaid population several years before the initiation of data collection, March 31, 1998. Data collection was completed August 20, 1999. Any woman (Medicaid or commercially insured) who met the study criteria of being African-American, age 18 years or over, less than 29 weeks gestation, and who consented to participate, was enrolled in the study. Following her prenatal care visit, each woman

95

completed a 35- to 40-min, face-to-face, confidential interview (115 questions) with a trained interviewer from the research team in a private space at the health center. Women were paid $20.00 at the completion of the interview. Institutional review board approval was obtained before the initiation of the study. A total of 836 women were approached for the interview. Ten declined to be interviewed after having been screened; 301 women were screened and were found to be ineligible either because they were younger than 18 years, or were 29 weeks or over in gestational age. Twelve women were interviewed as part of a study pilot period, and 29 women who were “no-shows” according to the managed care clinics’ administrative records were interviewed when they returned at a future visit (⬎29 weeks) to determine if they were “less satisfied” than the women who attended their appointments as scheduled. Whereas 484 women meeting the study criteria were screened and interviewed, only 400 women were included as part of the main analysis dataset, 275 commercially insured women and 125 Medicaid recipients. To be included in the main analysis dataset, a woman had to have a complete medical record abstraction form, have a final gestational age at delivery between 13 and 51 weeks, have legitimate values on the Kotelchuck ratio measure36 of prenatal care utilization (necessary for the larger study of which this study was a part), have an interval between interview and delivery between 0 and 44 weeks (note: this range excludes extreme out-of-range values while allowing for reporting error), and have no missing values on the satisfaction scale. During the interview, reports on personal characteristics, reports on the characteristics of prenatal care, as well as ratings of satisfaction were obtained, as discussed in subsequent paragraphs. In keeping with the work of Ware et al.,19,20 reports of the prenatal care characteristics are distinguished from the ratings of the care experience that comprise the satisfaction scale; the relationship between these reports (characteristics) and ratings (satisfaction) is the focus of this analysis. The dependent variable in this study, satisfaction, was measured using a scale based on the prior work of the researchers.18,37,38 This 30-question scale measures various dimensions of women’s satisfaction with their prenatal care: art of care (e.g., patient–provider communication), technical quality of care, physical environment, access, availability and efficacy, cost and continuity.19,20 For each question, the woman was asked how she would rate her provider or her site of care with respect to a particular attribute (e.g., how would you rate the place you get prenatal care when thinking about the concern the nurses or receptionists show you?). The response categories were on a 5-point Likert scale, ranging from poor to excellent. The satisfaction scale score is a sum of the values on the 30

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scale items converted to a score range in which 100 represents the highest level of satisfaction. The satisfaction scale was highly reliable, as evidenced by its high alpha value (0.97). The validity of the satisfaction scale was measured by correlating the scale with three questions measuring the same constructs as those embodied in a woman’s satisfaction: 1) whether she would recommend the place where she receives prenatal care to a friend (p ⬍ .0001); 2) whether she would recommend her primary care provider to a friend (p ⬍ .0001); and 3) her rating of satisfaction with care overall (p ⬍ .0001). The main independent variables in this study were women’s reports of prenatal care characteristics. The characteristics examined were: provider gender; provider birthplace; provider race/ethnicity; time waited to get appointment; time spent in the waiting room; time spent with the provider; the number of providers seen at site; the type of provider; whether the provider explains procedures, answers questions, and asks questions; whether there were clean waiting and exam rooms; whether there were comfortable chairs in the waiting room; whether there were reading materials in the waiting and examination rooms; and whether ancillary services were available. Women were asked about their usual experience. Scales for some of the related prenatal care characteristics were created as a way to make multivariable analysis more parsimonious. Four separate scales representing the following constructs were created: 1) provider’s communication with the patient (Provider Score) includes whether the provider explains procedures, answers questions, and asks questions; 2) the ambience of the waiting room (Waiting Room Score) includes cleanliness and the comfort of the chairs (reading materials in the waiting room was excluded due to a large number of missing values); 3) the ambience of the examination room (Exam Room Score) includes cleanliness and reading materials in the examination room; and 4) a women’s perceptions of the availability of ancillary services (Availability of Ancillary Services Score) includes availability of nutrition and social work services, drug and alcohol counseling, childbirth classes, parenting classes, and information about breastfeeding. For each scale, the relevant questions were summed and converted to a score in which 100 points represents the most positive reports of prenatal care characteristics. In this study, because we were interested in whether the prenatal care characteristics affecting satisfaction were the same for women of different payer groups, insurance status was a stratification variable; analyses of the prenatal care–satisfaction relationship were conducted separately for Medicaid and commercially insured women. Other variables considered as covariates in the analysis were: 1) personal characteristics of the

woman including age, parity, education, number of adults in the household, number of times moved in last 12 months, monthly income, welfare status, pregnancy intention, importance of prenatal care, barriers to care, satisfaction with life, smoking and drinking during pregnancy, risk status during pregnancy; and 2) characteristics related to the conduct of the study including the clinic site of the interview, number of visits by the time of the interview, and the woman’s gestational age at the time of the interview. For the statistical analysis, the distributions of the personal characteristics, study characteristics, and prenatal care characteristics were generated for the overall population and the Medicaid and commercially insured groups. This was followed by an examination of the unadjusted relationships between satisfaction and these three groups of characteristics for the overall population and for each insurance group. Values of p ⱖ .05 and ⬍ .10 were considered marginally significant. Multivariable analyses to examine the relationship between prenatal care characteristics and satisfaction were then separately conducted for the overall population and for both insurance groups. Given the large number of prenatal care characteristics and potential covariates, multivariate stepwise linear regression was used to guide the analysis; decisions about variables included in the final models, however, were made conceptually and not mechanistically. Three care characteristics variables with a large number of missing values were excluded from these analyses: number of providers, whether the provider was foreign born, and reading materials in the waiting room. For the multivariable analyses, the criterion for keeping variables in the model was set at p ⬍ .10.

Results As might be expected, the Medicaid and commercially insured subsamples differed on a number of personal characteristics (Table 1). The Medicaid sample was significantly less likely to have women in the 18- to 19-year age group; in fact, 80% of the women in the Medicaid sample were 20 to 29 compared with 46% in the commercially insured group. Probably because they were older, the Medicaid women were also significantly more likely to be multiparous. The socioeconomic differences between these two groups were clear: women on Medicaid were significantly less likely to have 13 or more years of education, were significantly more likely to be welfare recipients, to have a monthly income of less than $1000 per month, and to have more than two adults in their household. Women on Medicaid were also significantly more likely not to have wanted the current pregnancy.

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Table 1. Personal characteristics of the total sample and by insurance type Personal Characteristics Age 18–19 20–29 30–39 Parity Primiparous Multiparous Education ⬍12 High school 13⫹ No. of adults in the household 1–2 ⬎2 No. of times moved in last 12 months 0–1 2⫹ Monthly income ⬍1000 1000–2499 2500⫹ Receiving welfare Yes Pregnancy intention Not at any time Wanted later, not now Wanted, earlier or now Importance of prenatal care Very Somewhat Barriers to prenatal care None One or more Satisfied with life Yes Smoking during pregnancy Yes Drinking during pregnancy Yes At least one high-risk visit during pregnancy Yes

Total Sample (n ⫽ 400)

Medicaid (n ⫽ 125)

Commercial (n ⫽ 275)

17.3% 56.5% 26.3%

6.4% 80.0% 13.6%

22.2% 45.8% 32.0%

⬍.0001

36.5% 63.5%

8.1% 91.9%

49.3% 50.7%

⬍.0001

11.8% 28.8% 59.5%

21.6% 37.6% 40.8%

7.3% 24.7% 68.0%

⬍.0001

32.5% 67.5%

25.6% 74.4%

35.6% 64.4%

.05

91.8% 8.3%

88.8% 11.2%

93.1% 6.9%

ns

21.3% 38.4% 40.3%

51.8% 33.0% 15.2%

7.6% 40.8% 51.6%

⬍.0001

25.4%

72.6%

4.0%

⬍.0001

10.3% 57.8% 32.0%

16.8% 60.8% 22.4%

7.3% 56.4% 36.4%

⬍.001

98.8% 1.3%

98.4% 1.6%

98.9% 1.1%

ns

52.8% 47.2%

49.6% 50.4%

54.2% 45.2%

ns

90.4%

86.4%

92.3%

.07

8.8%

12.8%

6.9%

.07

1.3%

1.6%

1.1%

ns

17.8%

15.3%

19.0%

ns

p Valuea

Note. ns ⫽ nonsignificant. p value for the difference in personal characteristics between Medicaid and commercially insured women.

a

As seen in Table 2, the majority of the women in the study were recruited at the suburban site, had fewer than three prenatal care visits by the time of the interview, and were between 17 and 28 weeks of gestational age at the time of the interview. The site of recruitment was significantly different between the Medicaid and commercially insured groups; 71% of the commercially insured women were recruited at the suburban site compared with 42% of the women on Medicaid. Women on Medicaid were significantly more likely to have had fewer than three visits by the time of the interview than commercially insured women despite nonsignificant differences in their gestational age at interview. Table 3 shows the distribution of the prenatal care characteristics for the overall sample and by insurance status. Commercially insured women were more

likely than Medicaid women to have had male providers, to have spent more than 30 min in the waiting room (p ⫽ .09), to have seen three or more providers (p ⫽ .06), to have seen African-American providers, to report that the chairs in the waiting room were not comfortable (p ⫽ .09) and that the examination room was dirty (p ⫽ .05). Women in the total sample expressed a high degree of satisfaction, with an overall mean satisfaction score of 80.3 (Table 4). The satisfaction scale had a skewed distribution; more than 25% of the women had scores greater than 90. Even though women in both groups expressed a high degree of satisfaction, commercially insured women were significantly less satisfied (Table 4) with their prenatal care than women on Medicaid. For the total sample (data not shown) younger women, women with higher life satisfaction, and

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Table 2. Study characteristics of the total sample and by insurance type Characteristics Related to the Study Site of care Suburban site Urban site No. of visits by the interview 3 or less ⬎3 Gestational age at interview 0–16 weeks 17–28 weeks

Total Sample (n ⫽ 400)

Medicaid (n ⫽ 125)

Commercial (n ⫽ 275)

61.5% 38.5%

41.6% 58.4%

70.6% 29.5%

p ⬍ .0001

66.6% 33.4%

76.6% 23.4%

62.0% 38.0%

p ⬍ .01

47.8% 52.3%

43.2% 56.8%

49.8% 50.2%

ns

Significancea

Note. ns ⫽ nonsignificant. a p value for the difference in study characteristics between Medicaid and commercially insured women.

women with no barriers to care had significantly higher satisfaction scores. For the Medicaid sample, women who believed that prenatal care is very or somewhat important and women with higher life satisfaction had significantly greater satisfaction with prenatal care. Among the commercial sample, younger and primiparous women, and women with no barriers to prenatal care were significantly more likely to be satisfied with prenatal care. Characteristics related to the conduct of the study (data not shown) were also related to satisfaction. For all women, satisfaction was significantly higher among those who received care at the urban site. Women in the Medicaid sample who received care at the urban site and who experienced greater than three visits by the time of the interview had significantly higher satisfaction scores. Women in the commercial sample interviewed earlier in their pregnancies tended to have higher satisfaction (p ⫽ .05). The prenatal care characteristics important to a woman’s satisfaction are shown in Table 4. For the total sample, the following care characteristics were significantly or marginally significantly associated with satisfaction: the time a woman waited to get an appointment, the time spent in the waiting room, the time spent with the prenatal care provider, the number of providers seen during the pregnancy, the type of prenatal care provider (i.e., higher satisfaction with nurse practitioners or midwives), whether the provider explained procedures and answered and asked questions, the ambience and cleanliness of the waiting and examination rooms, and the women’s perceptions of the availability of ancillary services. Women in each of the insurance groups were more satisfied (Table 4) when they had a shorter wait to get an appointment (p ⫽ .05 for non-Medicaid women), when they spent less time in the waiting room, when their providers communicated directly with them and showed concern for them, when they perceived that their care site was clean and comfortable, and when they were aware that a variety of services were available to meet their needs. Women with commer-

cial insurance were also more satisfied when their providers were female (p ⫽ .06) and when they were nonphysicians. These women also had greater satisfaction when they spent more than 15 min with their provider and when they saw fewer primary care providers for their prenatal care. Women with Medicaid insurance showed some of the same preferences, but possibly due to smaller sample size, these trends were not significant. After adjustment for personal characteristics and key study characteristics using multivariable analysis, satisfaction for the overall sample was significantly associated with the provider’s interaction with the women, both communication (Provider Score) and time spent with the patient (Table 5). Also significant were the ambience of the waiting and examination rooms, having spent a shorter amount of time in the waiting room (p ⫽ .05), and the availability of ancillary services. Several personal characteristics also were independent predictors of satisfaction, including whether a woman had at least one high-risk visit during the pregnancy, the age of the woman (younger women were more satisfied), and satisfaction with life. In addition, women receiving care at the urban site were more satisfied with their care. The predictors of satisfaction for the Medicaid insured women were similar to those of the overall group (Table 5). However, for Medicaid women, satisfaction was not predicted by the availability of ancillary services, the ambience of the examination room, or time spent in the waiting room. Women on Medicaid were also more satisfied when their providers were physicians (p ⫽ .08). For women who were commercially insured (Table 5), satisfaction was predicted by nearly the same variables as for the overall sample.

Discussion The results of this study suggest that African-American women, both Medicaid and commercially insured,

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Table 3. Prenatal care characteristics of the total sample and by insurance type Care Characteristic Provider gender Male Female Provider birthplaceb U.S. Foreign born Provider race/ethnicity African-American White Other Time waited to get appointment 2 weeks or less Greater than 2 weeks Time spent—waiting room 30 minutes or less ⬎30 minutes Time spent—provider ⬍15 minutes ⱖ15 minutes No. of providers seen at siteb 1–2 3⫹ Provider type Physician Nurse practitioner/midwife Explains procedures All or most of time Some, rarely, or never Answers questions All or most of time Some, rarely, or never Asks questions All or most of time Some, rarely, or never Clean waiting room Pretty clean/clean Pretty dirty/dirty Chairs in waiting room Comfortable/pretty comfortable Not very comfortable Reading materials in waiting roomb Large selection Small selection Clean exam room Pretty clean/clean Pretty dirty/dirty Reading materials in exam room Plentiful/pretty plentiful None Availability of nutrition services Yes No or Don’t know Availability of social work services Yes No or Don’t know Availability of drug and alcohol counseling Yes No or Don’t know Availability of childbirth classes Yes No or Don’t know Availability of parenting classes Yes No or Don’t know Availability of info about breastfeeding Yes No or Don’t know

Total Sample (n ⫽ 400)

Medicaid (n ⫽ 125)

Commercial (n ⫽ 275)

26.8% 73.3%

18.4% 81.6%

30.6% 69.5%

p ⬍ .05

89.5% 10.5%

90.0% 10.0%

89.2% 10.8%

ns

23.6% 65.0% 11.4%

16.3% 76.4% 7.3%

26.9% 59.8% 13.3%

p ⬍ .01

85.5% 14.5%

87.2% 12.8%

84.8% 15.3%

ns

94.8% 5.3%

97.6% 2.4%

93.5% 6.6%

p ⫽ .09

19.1% 80.9%

16.1% 83.9%

20.4% 79.6%

ns

93.6% 6.5%

97.7% 2.3%

91.9% 8.1%

p ⫽ .06

50.1% 49.9%

47.6% 52.4%

51.3% 48.7%

ns

95.0% 5.0%

95.2% 4.8%

95.0% 5.1%

ns

96.7% 3.3%

96.8% 3.2%

96.7% 3.3%

ns

93.5% 6.5%

92.8% 7.2%

93.8% 6.2%

ns

95.5% 4.5%

96.8% 3.2%

94.9% 5.1%

ns

83.3% 16.8%

88.0% 12.0%

81.1% 18.9%

p ⫽ .09

20.6% 79.4%

17.7% 82.3%

21.9% 78.1%

ns

95.3% 4.8%

98.4% 1.6%

93.8% 6.2%

42.5% 57.5%

45.8% 54.2%

41.0% 59.0%

ns

39.3% 60.8%

36.0% 64.0%

40.7% 59.3%

ns

27.3% 72.8%

32.0% 68.0%

25.1% 74.9%

ns

55.3% 44.8

57.6% 42.4%

54.2% 45.8%

ns

74.5% 25.5%

72% 28%

75.6% 24.4%

ns

55.6% 44.4%

56.8% 43.2%

55.1% 44.9%

ns

72.8% 27.3%

72.8% 27.2%

72.7% 27.3%

ns

Significancea

p ⫽ .05

Note. ns ⫽ nonsignificant. a p value for the difference in prenatal care characteristics between Medicaid and commercially insured women. bLarge number of missing values.

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Table 4. The relationship between prenatal care characteristics and satisfaction for the total sample and by insurance type

Care Characteristic Overall satisfaction score Provider gender Male Female Provider birthplaceb U.S. Foreign born Provider race/ethnicity African-American White Other Time waited to get appointment 2 weeks or less Greater than 2 weeks Time spent—waiting room 30 minutes or less ⬎30 minutes Time spent—provider ⬍15 minutes ⱖ15 minutes No. of providers seen at siteb 1–2 3⫹ Provider type Physician Nurse practitioner/midwife Explain procedures All or most of time Some, rarely, or never Answers questions All or most of time Some, rarely, or never Asks questions All or most of time Some, rarely, or never Clean waiting room Pretty clean/clean Pretty dirty/dirty Chairs in waiting room Comfortable/pretty comfortable Not very comfortable Reading materials in waiting roomb Large selection Small selection Clean exam room Pretty clean/clean Pretty dirty/dirty Reading materials in exam room Plentiful/pretty plentiful None Availability of nutrition services Yes No or Don’t know Availability of social work services Yes No or Don’t know Availability of drug and alcohol counseling Yes No or Don’t know Availability of childbirth classes Yes No or Don’t know Availability of parenting classes Yes No or Don’t know Availability of info about breastfeeding Yes No or Don’t know

Total Sample Medicaid Mean Commercial Mean Satisfaction Satisfaction Score Mean Satisfaction Score (n ⫽ 400) Significance (n ⫽ 125) Significance Score (n ⫽ 275) Significance 80.3

82.8

79.1

p ⬍ .05a

78.3 81.0

ns

84.1 82.5

ns

76.7 80.2

p ⫽ .06

80.6 77.4

ns

82.5 81.8

ns

79.6 75.5

ns

78.0 81.3 78.3

ns

80.8 83.1 81.9

ns

77.2 80.2 77.4

ns

81.2 74.6

p ⬍ .01

84.2 73.1

p ⬍ .01

79.8 75.1

p ⫽ .05

81.0 68.6

p ⬍ .001

83.4 55.8

p ⬍ .001

79.7 70.7

p ⬍ .05

72.9 81.9

p ⬍ .0001

79.3 83.3

ns

70.6 81.2

p ⬍ .0001

80.8 69.4

p ⬍ .001

84.0 77.7

ns

79.4 68.5

p ⬍ .01

78.9 81.8

p ⬍ .05

84.2 81.7

ns

76.6 81.8

p ⬍ .01

81.6 56.2

p ⬍ .0001

84.1 57.3

p ⬍ .0001

80.4 55.7

p ⬍ .0001

81.0 59.7

p ⬍ .0001

83.6 66.0

p ⬍ .05

80.0 57.0

p ⬍ .0001

81.5 62.8

p ⬍ .0001

84.0 67.3

p ⬍ .001

80.4 60.4

p ⬍ .0001

80.9 65.6

p ⬍ .0001

83.5 61.3

p ⬍ .01

79.8 66.9

p ⬍ .05

81.3 75.1

p ⬍ .01

83.9 74.6

p ⬍ .05

80.0 75.3

p ⬍ .05

87.4 78.1

p ⬍ .0001

88.8 81.4

p ⬍ .05

86.8 76.5

p ⬍ .0001

81.0 64.7

p ⬍ .0001

83.2 59.0

p ⬍ .05

80.0 65.3

p ⬍ .0001

84.2 77.3

p ⬍ .0001

85.1 80.6

p ⫽ .09

83.8 76.0

p ⬍ .0001

83.5 78.1

p ⬍ .001

87.2 80.3

p ⬍ .01

82.1 77.1

p ⬍ .01

85.9 78.1

p ⬍ .0001

89.3 79.7

p ⬍ .001

83.9 77.5

p ⬍ .01

82.8 77.1

p ⬍ .0001

86.2 78.1

p ⬍ .01

81.2 76.6

p ⬍ .01

81.6 76.3

p ⬍ .05

84.5 78.3

p ⬍ .05

80.4 75.2

p ⬍ .05

82.9 77.0

p ⬍ .0001

84.9 80.0

p ⫽ .05

82.0 75.6

p ⬍ .001

82.1 75.3

p ⬍ .0001

84.2 78.9

p ⫽ .06

81.1 73.7

p ⬍ .001

Note. ns ⫽ nonsignificant. a p value for the difference in satisfaction between Medicaid and commercially insured women. All other p values are for the association between prenatal care characteristics and satisfaction in the total sample or within each insurance type. bLarge number of missing values.

A. Handler et al. / Women’s Health Issues 13 (2003) 93–103

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Table 5. Prenatal care characteristics by satisfaction-final models for total sample and by insurance statusa Total Sample Characteristic Provider Score Waiting Room Score Exam Room Score Availability of Ancillary Services Score Time spent with the provider Time spent in the waiting room Provider type Age Education Number of adults in home Satisfaction with life High-risk Clinic site Visits by the interview Model R-square a

Medicaid Sample

Commercial Sample

Beta Coefficient

Significance

Beta Coefficient

Significance

Beta Coefficient

Significance

.60 .17 .12 .05 2.70 5.30

⬍.0001 .0009 .003 .02 .005 .05

.59 .34

⬍.0001 .005

.63 .14 .15 .04 2.3 5.7

⬍.0001 .02 .002 .09 .05 .05

⫺1.20 6.30 3.20 4.20

4.9

.005

4.0

.08

.03

.003 .04 .001

.4385

⫺4.1 9.3

.09 .009

6.1 ⫺7.0 .4763

.008 .009

⫺1.5 2.4

.02 .05

5.3 3.4 3.5

.05 .06 .03

.4566

Models adjusted for personal characteristics and key study characteristics.

seeking prenatal care in a managed care setting employing its own staff of medical care providers, were similar to women in prenatal care settings in prior studies with respect to the factors associated with their satisfaction. In the current study, participants were more satisfied when their providers spent more time with them and when their providers engaged them by explaining procedures, asking them questions, and answering their questions. The importance of patient– provider communication in patient satisfaction with prenatal care has been repeatedly shown in prior studies of pregnant women’s satisfaction, most of which were not carried out in managed care settings.6,9,16 –18,35 However, in a time of increased enrollment in managed care, in which the typical focus is on reducing the time spent with the patient to reduce costs, it is essential that the interaction between pregnant patients and providers be of high quality. Enhancing the communication skills of providers and ensuring that they are sensitive to diverse ethnic groups and cultures must be part of providers’ professional training as well as ongoing quality assurance activities. In group practice or staff model managed care settings (as opposed to independent practice associations), patient–provider communication can be more easily monitored through such strategies as exit interviews and focus groups; providers with particular problems can then be targeted for intervention. Although most women in this study had short waiting times (30 min or less) to see their providers, waiting time emerged as an important predictor of satisfaction for the overall and commercially insured samples. This has also been demonstrated in prior studies of women’s satisfaction with prenatal care in non–managed care sites.8,9,11,12,17,18 In a fast-paced world with many competing demands, valuing a woman’s time by decreasing her wait at health care

appointments is essential to ensuring her satisfaction with the care experience. Women also placed great importance on the ambience and cleanliness of the examination (overall and commercially insured samples) and waiting rooms (all groups). This supports prior studies of women’s satisfaction with prenatal care12,17 and the more general satisfaction literature39 that suggests that if care settings are not appealing, women may be less likely to utilize services. Women (overall sample and commercially insured) in this study who reported awareness of the availability of more ancillary services had higher satisfaction levels. This finding is in keeping with the fact that comprehensive care is considered to be high-quality care,40 and is consistent with the work of Klerman et al.41 and Handler et al.18 who also found that women had higher satisfaction with care when more ancillary services were or appeared to be available. There have been only two prior studies of pregnant women’s satisfaction with care delivered through managed care delivery systems, neither of which compared women with different payers. In the current study, the higher satisfaction scores of women on Medicaid compared with their non-Medicaid counterparts may be related to their differential expectations of the care experience. While this conjecture cannot be verified from these data, previous studies have suggested that expectations and satisfaction ratings may differ by socioeconomic status. For instance, among HMO enrollees, Carlson et al.42 found that individuals of higher socioeconomic status were more likely to give low ratings to their health plans. Furthermore, that study suggested that the observed differences associated with socioeconomic status most likely stemmed from differing expectations about health care rather than from objective differences in health

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care quality. This hypothesis fits with expectancy theory which posits that persons with relatively modest expectations of the health care system may have a lower threshold for satisfaction.43 Alternatively, Ipsen et al.28 suggest that Medicaid enrollees may be more satisfied with their managed care plans than their commercially insured counterparts because of the following: “1) ease in finding providers, 2) convenience of referrals, 3) being included in a mainstream medical plan and not so easily labeled a “Medicaid patient”, 4) ability to access services that were less accessible prior to managed care, 5) comprehensive medical benefit plans at no cost, 6) comprehensive dental and pharmacy coverage without copayments, and 7) fewer exclusions than many commercial plans.” At the time of this study, Medicaid managed care in the locale where the study was conducted was a relatively new phenomenon. As such, the women on Medicaid may have been moving from “storefront providers”, overcrowded public clinics, or hospital outpatient sites to a care setting that may have been more pleasing compared with those they had previously utilized, either for prenatal or other primary care services. In contrast, women enrolled in managed care through the commercial market may have resented the relative lack of freedom compared with their experiences in the fee-for-service delivery system. Commercially insured women may also have been less satisfied because they paid for their coverage with payroll deductions, cost sharing, and co-payments or they may have had more procedures that were not covered by the plan.28 The current study has several limitations. Although the satisfaction scale used in this study has high reliability and construct validity, it is only one way to measure satisfaction and it is possible that it does not completely capture a woman’s feelings about her care experience. In addition, the measures of both the care experience and satisfaction are cross-sectional; it may be that more highly satisfied women provide more positive reports about their care experience and that higher satisfaction is not the result of “more communication” or their perception of the provision of “more ancillary services”. It is possible that the women in this study were those at the prenatal care sites who were the most satisfied with their care experience, either because the most satisfied women agreed to be screened and interviewed or because the less satisfied women were at the clinic less often and were missed through our sampling process. In addition, this study only measures satisfaction once care is initiated; women dissatisfied with their previous care experience and who did not seek care for this pregnancy are not included. Countering these suggestions of selection bias is the fact that the 29 “no-show” women had a mean satisfaction score higher (83.6) than that for the total

sample (data not shown), not lower, which might be expected if these women’s no-show status was due to dissatisfaction with care. The fact that the sample was not randomly selected within clinics, was clinic-based rather than population-based, and was conducted in one type of managed care setting, may make the study less generalizable. However, while the ability to generalize to other Medicaid and commercially insured African-American women seeking prenatal care may be questioned, this concern is lessened because the current results closely replicate those of a previous satisfaction study by Handler et al.18 in which women received prenatal care from a wide variety of hospital- and communitybased providers. The replication of these results lends credence to the current findings and suggests that they will have relevance beyond the immediate care arrangement described in this study.

Conclusion The care characteristics most important to an AfricanAmerican woman’s satisfaction with prenatal care do not appear to be dependent on her payer status, nor do they seem to be particularly dependent on the financial arrangements of her care provider. The prenatal care characteristics that were most important to women’s satisfaction in this study are those that have been consistently found in prior studies with women of various race/ethnic groups in various care settings. In a time of continued change in the health care delivery system, enhancing satisfaction with care is increasingly important, as satisfaction is a legitimate outcome in its own right. While improvements in health care delivery tend to focus on increasing technical proficiency, the results of this study suggest that to improve pregnant women’s satisfaction with care, prenatal care providers should focus on improvements in patient–provider communication, as well as features of the prenatal care setting such as cleanliness, waiting times, and the availability of ancillary services.

Acknowledgments This research was supported by Grant R40 MC 00094 of the Maternal and Child Health Research Program of the Maternal and Child Health Bureau, HRSA.

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