Laws requiring health plans to provide direct access to obstetricians and gynecologists, and use of cancer screening by women

Health Services Research, June, 2007 by Laurence C. Baker, Jia Chan

Reacting to patient and provider dissatisfaction with the restrictive practices of managed care plans during the 1990s, many states adopted managed care patient protection regulations designed to restrain these health plan activities (Blendon et al. 1998; Noble and Brennan 1999; Sloan and Hall 2002). Limited access to specialists was a common concern, leading many states to enact "direct access" laws, which limit the ability of health plans to require referrals before the plan will cover specialist care. One common form of direct access law provides for women to obtain direct access to care delivered by obstetricians and gynecologists (hereinafter "ob/gyns").

Maryland was the first state to pass an ob/gyn direct access law in 1994 (Henry J. Kaiser Family Foundation 2000). By 2001, 42 states plus the District of Columbia had passed some form of ob/gyn direct access law, all except Alaska, Arizona, Hawaii, Iowa, North Dakota, Oklahoma, South Dakota, and Wyoming (Stauffer and Morgan 2000; Cauchi 2003). All of these laws have in common a requirement that some health plans provide women with direct access to ob/gyns for at least some services, though the specific provisions can vary from state to state. For example, some states require plans to treat ob/ gyns as specialists to which women may go without a referral from their primary care provider, while others require plans to allow women to designate their ob/gyn to be their primary care provider, and some states require both (Henry J. Kaiser Family Foundation 2000; Stauffer and Morgan 2000).

Although often broadly written, these laws would tend to affect care for some women more strongly than others. The laws do not apply to women covered by public-sector health plans such as FEHBP, Medicaid, and Medicare (direct access to ob/gyns for enrollees in these programs was provided for under a 1998 executive order). The Employee Retirement Income Security Act of 1974 exempts plans offered by firms that self-insure. Although the laws vary in whether or not they explicitly apply only to HMOs or are written to cover a broader range of health plans, HMOs seem more likely than other types of plans to have attempted to restrict access to ob/gyns. Thus, these laws might be expected to have their strongest effects on women with private HMO coverage, particularly those in non-self-insured HMOs.

Little is known about the impacts of these laws on health care. Some literature has debated conceptual issues around patient protection laws (e.g., Miller 1997; Sloan and Hall 2002), and has pointed out the need for more information about managed care regulations in general and ob/gyn direct access laws in particular (e.g., Hellinger 1996; Henderson et al. 2002). One study included ob/gyn direct access laws among many others in analyses of managed care patient protection laws, reporting limited effects of patient protection laws as a group on generalized measures of utilization and patient satisfaction (Sloan et al. 2005), but beyond this, we are aware of no empirical evidence on the impacts of ob/gyn direct access laws on care utilization.

Despite the lack of data, proponents view these laws as a beneficial step for womens' health care (e.g., Henderson et al. 2002), often arguing that they will facilitate the delivery of high quality care for women. Among the potential benefits cited are improvements in screening for breast and cervical cancer. A variety of reports suggest that women who see an ob/gyn are noticeably more likely to get recommended screening exams (e.g., Horton et al. 1994; Weisman et al. 1995; Finison et al. 1999; Weisman and Henderson 2001; Henderson et al. 2002; Haggstrom et al. 2004). While it is not clear that these reports effectively distinguish causal effects of seeing an ob/gyn from variations in screening due to an increased propensity of women interested in screening to see ob/gyns, they have frequently been interpreted as implying a causal effect and thus as suggesting that, if direct access laws were successful in increasing utilization of ob/gyns, there would be increases in screening rates.

This analysis empirically investigates the relationship between the passage of ob/gyn direct access laws and the receipt of screening for breast and cervical cancer. We use the fact that different states adopted direct access laws at different times to identify the effects of the laws, comparing changes in health care utilization before and after passage, using contemporaneous changes in nonadopting states to control for time trends.

In principle, one might like to begin an investigation of these laws with an evaluation of direct evidence on whether they influence visits with ob/gyns or other measures of the most proximate potential impacts of the laws. We lack data on these kinds of measures from sources with enough cross-sectional and time series breadth to permit analyses of the type we undertake here. We thus focus on receipt of screening exams which will provide evidence about one important aspect of health care delivery and may also provide indirect evidence about the overall effects of the laws on ob/gyn utilization.