Integrating Payor-Segregated Outpatient OBGYN Care Models: The Clinician Perspective

Significant and unacceptable racial disparities in maternal health and gynecologic outcomes exist in the United States, with ambulatory care being a potential contributor. In many academic medical centers (AMCs), publicly insured and uninsured patients receive care in clinics staffed primarily by residents under attending supervision, whereas those with private insurance see attending physicians at a different site. This segregation by payor can translate to de facto racial segregation. This study explores clinician perspectives on payor-segregated care delivery by resident and attending sites in a major AMC and their opinions on integrating these sites.

We conducted semi-structured interviews with attending physicians and advanced practice providers (APPs) from both sites. The interview guide focused on: 1) perceived value of the current care model, 2) attitudes toward care integration, and 3) barriers and facilitators to integration. Interviews were conducted from October 2022 to January 2023 until thematic saturation was achieved. Data analysis involved an integrated approach with grounded theory, with 20% of transcripts double-coded (k = .90).

We interviewed 15 clinicians (10 attendings, five APPs). Although clinicians recognized some value in the existing segregated system, they supported ending it as a moral imperative to combat inequity. They also highlighted challenges and expressed concerns about feasibility of integration. Concerns encompassed maintaining patient-clinician continuity, acceptance of trainees by privately insured patients, potential erosion of mission-driven care, and the risk of racist interactions if a safe space for a vulnerable community is disrupted. Clinicians stressed the need for resources and small-scale trials before full-scale integration.

Although clinicians expressed unity around the concept of integrating ambulatory care delivery, a path toward implementing an alternative model of care remains unclear. This study provides initial insights into disparities in ambulatory OBGYN care and may guide health systems considering care integration.