Download PDF
Am J Perinatol
DOI: 10.1055/a-2505-5508
Original Article

Integrating Payor-Segregated Outpatient Obstetrics and Gynecology Care Models: The Patient Perspective

Arina E. Chesnokova
1   Department of Obstetrics and Gynecology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
,
Annie Apple
1   Department of Obstetrics and Gynecology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
,
Karampreet Kaur
1   Department of Obstetrics and Gynecology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
,
Allison Schachter
1   Department of Obstetrics and Gynecology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
,
Elizabeth A. Clement
1   Department of Obstetrics and Gynecology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
,
Marilyn M. Schapira
2   Division of General Internal Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
,
Sarita Sonalkar
1   Department of Obstetrics and Gynecology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
,
Florencia G. Polite
1   Department of Obstetrics and Gynecology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
,
Kavita Vinekar
3   Department of Obstetrics and Gynecology, Sidney Kimmel Medical College, Thomas Jefferson University, Philadelphia, Pennsylvania
,
Abike T. James
1   Department of Obstetrics and Gynecology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
,
Rebecca F. Hamm
1   Department of Obstetrics and Gynecology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
› Author Affiliations Funding None.
› Further Information
Also available at
    Permissions and Reprints

Abstract

Objective Significant racial and ethnic disparities in maternal morbidity and mortality as well as gynecologic outcomes persist in the United States. The role of ambulatory care in obstetrics and gynecology (OBGYN), particularly in facilities that separate resident and attending care along payor (and de facto racial) lines, remains unclear. This study examines patient perspectives on payor-segregated health care delivery in an academic medical center (AMC) and opinions on possible integration.

Study Design This is a qualitative study conducted at a single AMC with payor-segregated resident and attending outpatient sites. Interviews focused on patient perception of experience and value in outpatient OBGYN care, perspectives on the segregated care model, and attitudes about integration. Patients participated in a 30-minute semistructured interview with recruitment continuing until thematic saturation was reached (October 2022–August 2023). Interviews were coded using an integrated approach with grounded theory; 12% of transcripts were double-coded (k = 0.86).

Results We interviewed 26 patients (16 from resident, 10 from attending site). Patients prioritized practical aspects such as clinic proximity and quality of clinician interaction. Most were unaware of the payor-segregated clinic system and disapproved upon learning about it. Opinions varied on topics of telehealth and continuity, indicating diverse patient needs. Notably, minoritized patients valued race and class concordance in clinical spaces. Patients generally supported care integration, conditional upon the preservation of aspects of care they valued.

Conclusion Successful OBGYN care integration requires meeting individual needs while ensuring diversity, safety, and community-oriented care, alongside access and convenience. Incorporating patient voices is crucial for aligning services with expectations and improving patient experiences.

Key Points

  • Patients disapprove of payor-segregated care but prioritize practical aspects over care structure.

  • Minoritized patients valued race/class concordance. Preferences varied on continuity, residents, and telehealth.

  • Clear communication around prior payor segregation and motivations for integration will foster trust.

Keywords

obstetrics and gynecology - ambulatory care delivery - health equity - payment and financing - graduate medical education - patient voice

Supplementary Material



Publication History

Received: 21 October 2024

Accepted: 18 December 2024

Accepted Manuscript online:
19 December 2024

Article published online:
13 January 2025

© 2025. Thieme. All rights reserved.

Thieme Medical Publishers, Inc.
333 Seventh Avenue, 18th Floor, New York, NY 10001, USA

 

  • References

  • 1 ACOG committee opinion no. 649: racial and ethnic disparities in obstetrics and gynecology. Obstet Gynecol 2015; 126: e130-e134
    CrossrefPubMedSearch in Google Scholar
  • 2 Sutton MY, Anachebe NF, Lee R, Skanes H. Racial and ethnic disparities in reproductive health services and outcomes, 2020. Obstet Gynecol 2021; 137 (02) 225-233
    CrossrefPubMedSearch in Google Scholar
  • 3 Vinekar K, Qasba N, Reiser H. et al. Segregation by payer in obstetrics and gynecology residency ambulatory care sites. JAMA Netw Open 2024; 7 (09) e2434347
    CrossrefPubMedSearch in Google Scholar
  • 4 Apple A, Kaur K, Hamm R. et al. Integrating Segregated Outpatient OBGYN Care: A National Survey of Program Directors. 2024
    PubMedSearch in Google Scholar
  • 5 Vinekar K. Pathology of racism—a call to desegregate teaching hospitals. N Engl J Med 2021; 385 (13) e40
    CrossrefPubMedSearch in Google Scholar
  • 6 McClurg AB, Arora KS, Schiff LD, Carey ET, Neal-Perry GS. Dismantling structural barriers: resident clinics refocused on equity. Obstet Gynecol 2022; 140 (05) 739-742
    PubMedSearch in Google Scholar
  • 7 Hassan SF, Viscoli CM, O'Connor PG. et al. Separate but not equal? A cross-sectional study of segregation by payor mix in academic primary care clinics. J Gen Intern Med 2023; 38 (10) 2318-2325
    CrossrefPubMedSearch in Google Scholar
  • 8 Bellerose M, Rodriguez M, Vivier PM. A systematic review of the qualitative literature on barriers to high-quality prenatal and postpartum care among low-income women. Health Serv Res 2022; 57 (04) 775-785
    CrossrefPubMedSearch in Google Scholar
  • 9 Downe S, Finlayson K, Tunçalp Ö, Gülmezoglu AM. Provision and uptake of routine antenatal services: a qualitative evidence synthesis. Cochrane Database Syst Rev 2019; 6 (06) CD012392
    PubMedSearch in Google Scholar
  • 10 Tong A, Sainsbury P, Craig J. Consolidated criteria for reporting qualitative research (COREQ): a 32-item checklist for interviews and focus groups. Int J Qual Health Care 2007; 19 (06) 349-357
    CrossrefPubMedSearch in Google Scholar
  • 11 Woodward EN, Matthieu MM, Uchendu US, Rogal S, Kirchner JE. The health equity implementation framework: proposal and preliminary study of hepatitis C virus treatment. Implement Sci 2019; 14 (01) 26
    CrossrefPubMedSearch in Google Scholar
  • 12 Damschroder LJ, Reardon CM, Widerquist MAO, Lowery J. The updated consolidated framework for implementation research based on user feedback. Implement Sci 2022; 17 (01) 75
    CrossrefPubMedSearch in Google Scholar
  • 13 Saldana JM. The Coding Manual for Qualitative Researchers. London, England: SAGE Publications; 2024
    Search in Google Scholar
  • 14 Corbin J, Strauss A. Basics of Qualitative Research: Techniques and Procedures for Developing Grounded Theory. Sage Publications; 2014
    Search in Google Scholar
  • 15 Peahl AF, Moniz MH, Heisler M. et al. Experiences with prenatal care delivery reported by Black patients with low income and by health care workers in the US: a qualitative study. JAMA Netw Open 2022; 5 (10) e2238161
    CrossrefPubMedSearch in Google Scholar
  • 16 Carrel M, Keino BC, Novak NL, Ryckman KK, Radke S. Bypassing of nearest labor & delivery unit is contingent on rurality, wealth, and race. Birth 2023; 50 (01) 5-10
    CrossrefPubMedSearch in Google Scholar
  • 17 Lorch SA, Baiocchi M, Ahlberg CE, Small DS. The differential impact of delivery hospital on the outcomes of premature infants. Pediatrics 2012; 130 (02) 270-278
    CrossrefPubMedSearch in Google Scholar
  • 18 Thorsen ML, Harris S, Palacios JF, McGarvey RG, Thorsen A. American Indians travel great distances for obstetrical care: examining rural and racial disparities. Soc Sci Med 2023; 325: 115897
    CrossrefPubMedSearch in Google Scholar
  • 19 Kozhimannil KB, Casey MM, Hung P, Prasad S, Moscovice IS. Location of childbirth for rural women: implications for maternal levels of care. Am J Obstet Gynecol 2016; 214 (05) 661.e1-661.e10
    CrossrefPubMedSearch in Google Scholar
  • 20 Wojcik BM, McKinley SK, Amari N. et al. A comparison of patient satisfaction when office-based procedures are performed by general surgery residents versus an attending surgeon. Surgery 2019; 166 (01) 116-122
    CrossrefPubMedSearch in Google Scholar
  • 21 O'Malley PG, Omori DM, Landry FJ, Jackson J, Kroenke K. A prospective study to assess the effect of ambulatory teaching on patient satisfaction. Acad Med 1997; 72 (11) 1015-1017
    CrossrefPubMedSearch in Google Scholar
  • 22 Chesnokova A, Schachter A, Clement E. et al. Integrating segregated outpatient OBGYN care models: clinician perspective. 2024
    PubMedSearch in Google Scholar
  • 23 Chesnokova A, Hamm R. Desegregation of care in obstetrics and gynecology: clinician perspective. Academy Health. 2023 (in 2023 Annual Research Meeting)
    PubMedSearch in Google Scholar