title: Physician incentives and the timing of cesarean sections: evidence from California.
abstract: OBJECTIVE
  The timing of cesarean sections is studied to examine how physician convenience and financial incentives play a role in the decision to perform a cesarean section.
  
  
  METHODS
  Using birth certificate and hospital financial data from California, the likelihood of cesarean sections being performed at particular times of day was examined, controlling for maternal characteristics and the mother's insurance coverage. Two diagnoses associated with cesarean sections are examined separately: fetal distress and prolonged/dysfunctional labor. The hypotheses are that cesarean sections performed for physician convenience are more likely to occur in the evening hours and that type of insurance will affect the incentive to perform cesarean sections to obtain leisure.
  
  
  RESULTS
  The probability of cesarean sections for patients insured by a group-model HMO is more stable during the course of a day than that for patients insured by all other insurance plans. Group-model HMO patients with previous cesarean sections are less likely to have cesarean sections in the evening hours and are less likely to be diagnosed with fetal distress or prolonged/dysfunctional labor.
  
  
  CONCLUSIONS
  The differences in cesarean sections and diagnosis rates between group-model HMO patients and other patients could arise from several mechanisms: group-model HMOs provide consistent financial incentives to their staff, they may be better able to guide physician practice, and they might provide staff support to physicians so there is less leisure-based incentive to perform cesarean sections. In contrast, nongroup-model HMOs do not appear to reduce the incentive of physicians to maximize leisure relative to traditional insurance.
authors.affiliation: Public Policy Institute of California and the University of California, San Francisco, USA. jojo2alum.mit.edu
authors.forename: J
authors.initials: J
authors.lastname: Spetz
authors.forename: M W
authors.initials: MW
authors.lastname: Smith
authors.forename: S F
authors.initials: SF
authors.lastname: Ennis
mesh_terms: D002140:California / Q000453:epidemiology; D002585:Cesarean Section / Q000706:statistics & numerical data*; D003657:Decision Making; D004420:Dystocia / Q000175:diagnosis; D019317:Evidence-Based Medicine; D005260:Female; D005316:Fetal Distress / Q000175:diagnosis; D006125:Group Practice, Prepaid / Q000458:organization & administration / Q000706:statistics & numerical data*; D006279:Health Maintenance Organizations / Q000458:organization & administration / Q000706:statistics & numerical data*; D006302:Health Services Research; D006801:Humans; D007899:Leisure Activities; D009042:Motivation; D010818:Practice Patterns, Physicians' / Q000191:economics* / Q000706:statistics & numerical data; D011247:Pregnancy; D011336:Probability; D013997:Time Factors; D013996:Time and Motion Studies