Abstract
Background: This prospective study of all pregnancies explored the impact of infrastructure changes reducing health care disparities over 18 years. Office redesign, hospital privileges, and expanded point of care services allowed family physicians to sustain comprehensive family care including obstetrics.
Research Design: Family physicians leased office space in a chronically underserved urban area, with clinical revenue as the primary funding source. The office was redesigned to focus on providing bilingual services in a low resource community. Practicing physicians met weekly to improve policies for the care of uninsured and poorly insured patients. Independence from hospital and university control was essential for the changes that led to a self-sustaining medical group. The office was open access 7 days a week. A call group of family physicians with hospital privileges for higher risk obstetric care was formed to cover deliveries 24/7 365. This was prospectively designed as a longitudinal study 2005 to 2022. Data on family care and obstetrics were collected.
All physicians followed the American College of Obstetrics and Gynecology (ACOG) guidelines and were subject to hospital peer review. A subset of consecutive patients from the index group, 2019 to 2022, provided detailed data describing office visits, high-risk patients, office ultrasound, nursery services, and subsequent well-child family care. Coding and collections analysis tabulated revenue associated with these deliveries. External audits measured quality and cost.
Results: Data from 13,926 consecutive family medicine deliveries over eighteen years underscore sustainability. A subset of 2,335 deliveries from Medicos 2019 to 2022 validated quality outcomes of high-risk obstetrics and repeat cesarean sections by family physicians. Expanded point of care services data included the first prenatal visit through postpartum, nursery, and early childcare.
Conclusion: This model provides a framework for retaining obstetric services in low-resource, marginalized communities. Independence from hospital control allowed expansion of service which increased access and quality at lower cost.
- Cesarean Section
- Family Medicine
- Fellowships
- Health Care Economics
- Longitudinal Studies
- Obstetrics
- Point of Care Ultrasound
- Reimbursement Data
- Training
Introduction
Despite spending more per capita than other countries, maternal morbidity in the United States has not improved.1–3 These factors include the maldistribution of obstetrically trained physicians, fragmented care, cost, access, and inadequate obstetric training in family medicine.4–7 Corporate medicine and academic policies have not effectively increased the number of family physicians providing maternity care, exacerbating these issues.8–15 Concerns of unmanageable risk and legal consequences have discouraged many physicians from pursuing obstetric practice.16–19 Consequently, as predicted, only a minority of family physicians provide comprehensive mother-baby, child, and family care.20–23
There are conflicting data regarding costs of health care of the uninsured and underinsured. Most urban models heavily subsidize academic medical centers and safety net hospitals for these maternity care services. Clinical revenue is largely dependent on hospital billing policies and procedures with minimal direct involvement by clinicians at the bedside.24–26 Studies about funding and feasibility of obstetric care, have not included family medicine obstetrics (FM OB).
Misaligned institutional incentives and interspecialty conflicts of interest have created barriers which discouraged family physicians seeking obstetric training.27–30 Family medicine has lacked the authority to change hospital bylaws where family medicine was a permanent minority.31,32 Postresidency fellowships in FM OB have been an opportunity to open doors for family medicine as part of the obstetric care team.33,34 Initially, interspecialty support was limited due to skepticism about family physicians’ ability to manage high-risk obstetrics. Over the course of the study, as family physicians demonstrated successful outcomes, collaboration with obstetricians improved. More effective team care was established.
Obstetric outcome studies are usually based on data from academic medical centers. These data emphasize the few days that the mother is in the hospital. Properly structured, family medicine with obstetrics follows pregnancies from initial prenatal care through delivery, posthospital discharge, newborn care, and childcare. There are no longitudinal studies describing the outcomes for family medicine physicians practicing higher-risk obstetrics with coordinated care for the family.
The family medicine obstetrics (FM OB) model has the potential to provide comprehensive family care for marginalized communities.35–37 If expansion of training allows family physicians to acquire hospital privileges for higher risk cases and cesarean section, community-based FM OB could reduce health care disparities through improved access to coordinated family care. As proposed by Green et al, family medicine should consider transitions from urban hospital control to other models.38,39
The primary objectives of this study are to: (1) longitudinally assess the quantity and quality of obstetric care provided by family physicians who had been trained to provide expanded services in FM OB 2005 to 2022; (2) analyze the impact of office and curriculum redesign on clinical revenue and its ability to sustain the program without subsidy; (3) document the program's effectiveness in increasing access for a low resource community and (4) explore the broader implications of the program's success on policy, practice, and future research in maternal health care. By addressing these objectives, the study describes innovative training and practice redesign for a more equitable health care system among marginalized populations lacking adequate care.
Method
Study Design and Participants
This prospective study received approval from the Baptist Institutional Review Board (IRB) and was conducted at a family medicine center, Medicos Medical Center, staffed by physicians who had completed the fellowship in surgical family medicine obstetrics. FM-OB physician faculty completed postresidency fellowships in surgical family medicine obstetrics, which included training in high-risk obstetrics, cesarean section, and point of care ultrasound. The faculty were board certified by the American Board of Family Medicine (ABFM) and the American Board of Physician Specialties (ABPS) related to their obstetric care. These physicians performed an average of 120 to 140 deliveries annually, with an emphasis on continuity of family care including prenatal, postpartum. Baby care and childcare. Mothers remained connected to their babies, other children, and community in one Family Medicine center.
The study included all deliveries and associated obstetric care provided by these fellowship-trained family physicians from 2005 to 2022. On completion of its 20th year in 2019, Medicos undertook a more detailed self-study to measure the attainment of the original goal which was to test the theory that expansion of services and office redesign would sustain a private practice of traditional family medicine with women, deliveries, babies, children, hospital care, and family care.
Hospital Context
Following academic approval, hospital bylaws were revised to expand the scope of practice for cesarean-trained family physicians to include high-risk obstetrics care. Family physicians performed all deliveries after mandatory consultations for specific high-risk conditions, as delineated by updated bylaws, ensuring compliance with the standard of care. All children delivered were Medicaid patients. The study tabulated all downstream collected revenue for children delivered. This included well child visits and sickness visits in addition to that paid for nursery services, circumcisions, and related ancillaries. The call schedule consisted of 6 to 8 family physicians, with backup surgical coverage available through OB-GYN surgeons, family physician faculty, and others, as needed. Physician turnover within the call group was low, with 6 current faculty physicians serving in the program for 10 to 25 years. Call coverage was compensated through a blend of voluntary participation, hospital contract, and consulting fees per case. A second surgeon was available for high-risk deliveries and unexpected emergencies. The qualifications of the second surgeon varied depending on the circumstance. The second surgeon was usually a senior family physician faculty, but also included OB-Gyn, urology, Gyn oncology as needed.
Point-of-Care Services in the Office
Point-of-care services were categorized using CPT4 and ICD-10 codes for routine prenatal and high-risk prenatal care visits. Point-of-care services included electrocardiogram (ECG), X-rays, laboratory testing, office surgery, contraception, Papanicolaou smears, colposcopy, nonstress testing (NST), and complete point-of-care ultrasound (POCUS). All services were audited by Medicaid and third-party protocols to ensure compliance and accuracy in billing and reporting.40,41
Data Collection and Analysis
Prenatal, delivery, postpartum, nursery, and well child data were collected daily on all services. To minimize selection bias and underreporting, records were cross verified weekly with hospital and office databases. A comprehensive review of the maternal database for quality assurance and improvement was conducted weekly. The data were stratified by prenatal risk, hospital events, and patient outcomes, including vaginal deliveries, cesarean sections, and complications. For accuracy, and to prevent reporting bias, independent research assistants, trained in the study protocols, performed all hospital record reviews.
Program Description
Open 7 days a week, family physicians provided immediate bilingual care for all pregnancies, including unscheduled visits. Family physicians managed a broad spectrum of care including prenatal, delivery, postpartum, nursery, and childcare. Acute, chronic and preventive care was provided for all patients. The center was equipped with technology-assisted diagnostic services such as Clinical Laboratory Improvement Amendments (CLIA) waived office lab, ultrasound and nonstress testing. The program structure encouraged immediate availability of diagnostic and procedural services minimizing the need for time-consuming transfers, fragmented care, and unnecessary cost. These were integrated into the office, without appointment, for improved access, earlier diagnosis, and treatment.
A health services coding curriculum described the unbundling of prenatal care services based on the extra work of managing high risk. These services required more time spent managing complexity and providing immediate care ultrasounds, nonstress test (NSTs), and others. Physicians met weekly to review ICD 10 justifications of CPT4 services for obstetric cases, and the ancillary services associated with pregnancy care.40 Frequencies, charges, and collections were tabulated. A sliding scale was developed for uninsured and under insured patients.
The curriculum, office, equipment, and staff were developed to support a comprehensive physician who could provide general medical, obstetric, and pediatric care. This system covered hospital deliveries 24 hours a day while having the office open 7 days a week. Office services were expanded as technology-assisted diagnostic and therapeutic equipment became available at a lower cost. Examples included, but were not limited to, office lab, office surgery, basic radiography, NST and POCUS. These services were in the office and were immediately available. Patients were prioritized, ensuring efficient use of office resources and minimizing delays in diagnosis. For example, on completion of a valid NST tracing, physicians immediately interpreted the results and made management decisions. Patients did not require rescheduling to another facility remote from the initial office. The Patient Centered Medical Home and Choosing Wisely programs were integrated into the curriculum.
Bilingual services were an integral part of redesigned patient care. The clinic hired and trained individuals across all roles—front desk personnel, scribes, medical assistants, fellows, and faculty-level physicians. Several staff members had completed medical training in Spanish-speaking countries. This approach eliminated the need for external contracted services or nonmedical interpreters. Special attention was also given to linguistic diversity, such as Mayan dialects, within the Spanish-speaking community.
The program utilizes a rotating call system where family physicians alternate between full family medicine obstetrics care in the office and being on-call for deliveries in the hospital. While patients may not see the same physician for every prenatal visit, each is assigned to a specific cohort of providers to maximize continuity of care. During delivery, the on-call physician, who has access to the patient’s full medical history, performs the delivery including cesarean sections if necessary. Delivering physicians provide mother-baby care in the hospital and childcare in the office.
Data Stratification and Quality Measures
Data on office visits, hospital admissions, and consultations were compiled to establish comprehensive care profiles for each patient. High-risk obstetrics was defined according to the American College of Obstetrics and Gynecology (ACOG) and by the American Academy of Family Physicians’ ALSO course. This included, but was not limited to, conditions such as gestational diabetes, pregestational diabetes, hypertension, twins, preeclampsia, and previous cesarean deliveries. Inclusion criteria included patients with these complications, while exclusion criteria involved noncompliant, no-show behavior, and abusive behavior in the office.
Results
During the first 5 years, 1999 to 2004, family physicians established a viable group (Medicos) providing obstetric care in an urban bilingual low-resource community.42,43 During the next 18 years, 2005 to 2022, this family medicine center delivered 8,559 more babies with a primary cesarean rate of 21.9%. Family physicians with advanced hospital privileges managed all admissions and allowed family physicians with routine vaginal delivery privileges to assist in all surgical cases.
Other fellowship trained family physicians established independent practices nearby. These physicians became a part of a high risk and cesarean call group coordinated by Medicos. These private offices separate, but similar, in case mix and mission, asked Medicos to provide coverage for 5,367 additional births from 2005 to 2022. Combined with the 8,559 Medicos births, total consecutive deliveries totaled 13,926. Family physicians performed a total of 6,451 cesareans these eighteen years. Repeat cesareans were considered to be higher risk cases than routine.
During the most recent 48 consecutive months, 2019 to 2022, the core group, Medicos, prospectively gathered data on deliveries and 198,664 office visits (see Table 1). Of these, 65% reported Spanish as their native language, 33% were African American. Uninsured patients made 29% of all office visits, and Medicaid was 66% of office visits. Office visits by children ages 0 to 17 were 64,622 (32.5% of total visits 2019 to 2022).
Total Office Visits, Weekend Visits, Pediatric Visits, and Vaccines
From 2020 to 2022, significant external challenges included the COVID-19 pandemic and a large influx of Spanish-speaking immigrants. Office visit volume grew by 10,000 visits per year and has been sustained. Despite the pandemic, clinician stakeholders voted to remain open 7 days a week and offered uninterrupted care when other clinics were closing and turning away patients.
Many newly arrived women were late in pregnancy without prenatal care, and substantial numbers of uninsured pregnant patients faced delays in receiving Medicaid. Tennessee did not expand Medicaid under the Affordable Care Act, but did extend coverage for all pregnancies. Nevertheless, language barriers and social determinants of health (SDOH), often resulted in no coverage. While waiting, these patients were “uninsured” for 2 to 5 months.
On average, patients attended 8 to 10 prenatal visits, and approximately 15% of patients made their first prenatal visit at greater than 20 weeks Postpartum follow-up rates were 75%, which improved from initial community rates of 25%. A few patients spoke variations of Spanish, including indigenous Mayan dialects like Quechua and Mum. In these rare cases family members assisted and translation was not a barrier to quality.
Table 1 describes total deliveries, total office visits, weekend visits, pediatric visits, and vaccinations. Weekend access constituted (22.8%) of all visits, and these were value-added for families with transportation constraints. Maintaining weekend office hours posed challenges, particularly in staffing and resource allocation. Weekend availability added value by defragmenting family care. Medicaid audit data indicated emergency department (ED) usage was lower than our peers.
Table 2 describes how many mothers returned to the index family medicine office with their newborns for subsequent well-childcare. For each cohort year, dollars collected as of Jan 1, 2024, reflect value added for providing care to the children delivered by the family physicians.
Children Delivered by Family Medicine Obstetrics 2019–2022. How Many Newborns Return to Family Medicine for Well Child Care Visits
Table 3 describes 2,335 Medicaid deliveries who received prenatal and delivery care by the index family medicine group, Medicos Family Medicine. In this cohort, 32,524 prenatal visits represented 16.9% of all office visits. High-risk prenatal care, 12,124 offices, was provided in 37.3% of all prenatal visits. Outpatient point-of-care ultrasound services occurred in 25% (8,253) of total prenatal visits. Office-based point of care nonstress testing (NST) occurred in 25.7% (3,124) of high-risk prenatal visits. Nonstress testing (NST) was performed in the office without delay for patients with high-risk conditions such as hypertension, preeclampsia, diabetes, and decreased fetal movement. Trained staff prioritized patient needs with on-site physicians, providing immediate interpretation and management. Office redesign led to improved access and timely management without disrupting office flow.
Frequencies of Prenatal Services, High-Risk Visits, Normal Risk Visits, Point Of Care Ultrasound, and Non-Stress Testing. 2019–2022
More accurate billing of individual services resulted in revenue which was reinvested into salaries, staff, medical equipment, and educational programs. In the years 2019 to 2022, unbundled billing for high-risk visits collected $344,408. Associated ultrasound examinations collected $607,260 and nonstress testing collected $95,798. These services and revenues had previously been collected by the hospital or a subspecialist office.
Previous analyses of family medicine maternity care have excluded the values of providing newborn nursery care, which during 2019 to 2022 collected $344,312. Additional services included birth control for the new mother, newborn nursery care, same-day minor surgery, and subsequent childcare. Detailed financial information is beyond the scope of this article, but, even with billing for additional services, costs were below the 20th percentile when compared with other obstetric providers in Tennessee.41 This led to additional revenue based on pay-for-performance protocols from Medicaid.
High-risk prenatal and delivery care (see Table 4) was a daily event requiring family physicians to balance an open access office with affordability, transportation, and other barriers to hospital care. The data demonstrated the training paradox of high-volume, high-risk events such as cesarean section, and versus low-volume high-risk events such as fourth degree lacerations. A second surgeon was called for intraoperative consultation in 14 cases 2005 to 2022. Complications managed by FM-OB physicians included all types of cases as described in the American Academy of Family Physicians’ (AAFP) Advanced Life Support in Obstetrics (ALSO) textbook. These include, but are not limited to, high-risk cesarean sections, intrauterine fetal demise, preterm labor ranging from estimated gestational age (EGA) 24 to 37 weeks, placenta previa, twins, and 4 cases of accreta.
High-Risk Hospital Case Frequencies Managed By Family Medicine (2018–2022)
Among 8 lawsuits, 5 were dropped, 2 were settled, 1 jury trial found in favor of the family physician. To further contextualize the data presented in Table 4, we compared our outcomes with those of peer institutions within our community that serve similar populations. Based on available data from local community hospitals, our rates of adverse outcomes such as cesarean section rates and NICU admissions are comparable or better. For example, the NICU admission rate for local hospitals was 10%, similarly, our rate stood at 7.7%. Our primary cesarean section rate was 21.9% compared with 29.3% of a peer community hospital. In addition, a Medicaid audit of all OB providers in the state documented quality while our model was in the lowest 20th percentile for cost.
Discussion
The sustained growth and sustainability of this family medicine center suggest a viable approach for the common goals of increasing access, improving quality, and reducing costs. Despite a high density of traditional providers in Memphis, 198,664 visits (2019 to 2022) were made by patients choosing this family medicine group for their obstetric and family care. The performance over time affirms the potential of family medicine obstetrics as a foundational element in low-resource settings.
Our model has been successfully replicated Chattanooga, with similar outcomes in terms of access, quality, and sustainability. Family medicine physicians were trained to provide comprehensive obstetric care, including cesarean sections, while simultaneously providing family care for new mother, baby, children, and the entire family. There are others in Memphis and rural. The success of these suggests that this approach is scalable and adaptable to other low-resource settings, provided there is sufficient investment in training and infrastructure change.
The successful management of high-risk cases and higher risk cesarean section emphasizes the importance of expanded training and specialty neutral credentialing as essential infrastructure elements for providing these services in low resource communities. Construction of a call group is essential. Transportation, language, and psychosocial barriers are best overcome by a call group of trained physicians who are available for the delivery of the family. All physicians must agree to work their share of weekends and holidays.
Stakeholder clinicians with administrative authority are an important part of infrastructure change. Urban corporate executives are out of touch with the needs of low resource communities. Independent small groups of family physicians are well suited for this model of independent practice. In this model physicians created and led team care to expand services, train staff, and fund coverage for weekends in the office and hospital.
Physicians reported that immediately available POCUS performed by the physician at the bedside strengthened the physician-patient relationship. Women reported that this personal relationship was not available in other offices, and they mentioned choosing this office over others based on word-of-mouth referrals. Others have described improved patient satisfaction when ultrasound is performed at the bedside by their physician.45 Over 70% of birthing patients returned to the family medicine office with their newborns and other children. This indicates high satisfaction with the care received.
The National Ambulatory Medical Survey reported the average percentage of pediatrics office visits seen by family physicians was 14.3%.46 At the Medicos Family Medicine Center 2019 to 2022, 32.4% of total visits were childcare. This study, which is the largest and most recent of its kind, reaffirms the association of deliveries with increasing numbers of children seen in the family medicine office. The longitudinal data validates increased access, quality, and practice diversity among patients cared for by family physicians providing obstetric care.
This program has always included information describing frequencies of high-risk OB cases, including gestational diabetes, hypertensive disorders of pregnancy, preterm delivery, and others. Frequently, family physicians have been required to transfer care for these cases. Care is fragmented and costs increase. These data support that family physicians with expanded training can successfully manage these high-risk cases. The presence of these family physicians will be necessary for the resuscitation of obstetric care in rural communities.
Family medicine obstetrics was an unmet need in an urban market despite nearby federally qualified health centers and medical school clinics. This model provided continuity of care for mother-baby pairs and the family. Revenue from nursery care, office ultrasounds, nonstress testing, and other delivery-related services supported the educational and service needs of the program. A curriculum in ethical coding for expanded services and higher-risk obstetrics more than doubled the revenue per delivery for the family medicine group. All expenses were covered without outside funding. Family Medicine Obstetrics, with expanded services, is the logical foundation for rural communities and low-resource hospitals.47
The health services coding curriculum described the unbundling of prenatal care services based on the extra work of managing high-risk. This required more time spent managing complexity and in providing immediate care ultrasounds, nonstress testing (NSTs), and other office services. These, and nursery charges, significantly increased overall revenue. Accurate billing of individual services resulted in revenue which was reinvested into salaries, staff, medical equipment, and educational programs.
The financial sustainability of this model depends on fair reimbursement for added work of night call and time away from family. These physicians received salaries and delivery bonuses exceeding national averages. While the model does require a core group of highly committed physicians, these data suggest that, with proper structure it is possible to avoid burnout and ensure equitable workload distribution. The long-term sustainability of the model is supported by the retention of physicians within the community and the continued growth of the program over 25 years.
The average tenure of physicians in the program has been 10 to 12 years with 6 core faculty remaining for 12 to 25 years. This retention rate compares favorably to national turnover rates in family medicine. While formal physician satisfaction data were not collected, informal feedback indicated high satisfaction with the model’s shared responsibility structure, manageable workloads, and pride in the mission. This balance between work and personal life has contributed to longevity.
To further define the financial sustainability of the model, we analyzed revenue generated from point-of-care services and deliveries against operational expenses. Over the study period, clinical revenue exceeded expenses allowing for investment in staff retention, expansion of services, upgrading of medical equipment, and educational programs.
Accessible comprehensive family care, with special consideration regarding social determinants of health, was an unfilled niche. External validation was provided by comparison to published standards of care and federally mandated standards for quality audits among Medicaid recipients. This system has been validated externally by replication by graduates of the program in Chattanooga 2015 to 2023, as well as in other rural communities.48,49 These programs met the standard of care when delivery outcomes for high-risk patients were compared with outcomes of traditionally trained OB-GYN specialists.41,50
This longitudinal study, conducted in a bilingual, urban, low-resource community fills a gap in research on full-service family medicine obstetrics. While the study provides compelling evidence of the program's success, it has limitations. The observational nature of the study and its focus on a single state may limit the generalizability of the findings. Replication of this model will depend on the avoidance of unfavorable local regulations, subspecialist-dominated health care systems, and insurance restrictions which vary from state to state. Future studies should aim to include more sites to ascertain the model's applicability across different settings.
Several lessons have emerged. Expanding the scope of practice for family physicians requires nonconflicted institutional support and specialty neutral credentialing for privileges. A rotating call schedule and shared responsibility helps manage physician workload while ensuring quality. The expansion of point-of-care services is crucial for addressing the challenges of access and cost in a low-resource, community. Lastly, there is the issue of independent management as a vehicle for overcoming institutional barriers to family medicine obstetrics.
Centralized corporate medicine has created an expensive system of fragmented care,51,52 resulting in maldistribution of obstetric services and the near extinction of family medicine obstetrics.53–55 Current medical education is not consistently providing accessible, high-quality, and coordinated family care.56–58 By demonstrating this self-sustaining model of comprehensive family and obstetric care in marginalized communities, this research encourages a new direction for reducing health care disparities. In the global effort to improve maternal and child health outcomes, family medicine obstetrics is an endangered species worth saving.59
You never change things by fighting the existing reality. Instead, build a new model that makes the old model obsolete. - Buckminster Fuller (1895–1983)
Notes
This article was externally peer reviewed.
Funding: Privately funded by the Medicos team and the Camellia Foundation.
Conflict of interest: The authors have no financial interest and no conflicts of interest regarding the content of this manuscript.
To see this article online, please go to: http://jabfm.org/content/38/2/199.full.
- Received for publication April 18, 2024.
- Revision received May 31, 2024.
- Revision received October 21, 2024.
- Accepted for publication November 25, 2024.
