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Women's Primary Care in Managed Care:
Clinical and Provider Issues

January 1997 - Number One

By Julianna S. Gonen, PhD


Women's health and managed care are both areas of much recent attention. As the health of women has been undermined in the past due to inadequate attention to gender-specific needs, variations in provider education, and the exclusion of women from research, there is a need to question whether changes in the health care delivery system will perpetuate, exacerbate, or ameliorate these past inequities. With the increased attention to women's health occurring at the same time that the health care delivery system is being radically restructured, it is imperative to assess the impact of managed care on women's health care.

Drawing on findings from their landmark 1993 survey of women's health, Commonwealth Fund researchers opined in early 1996 that "as managed care quickly becomes the dominant source of health care delivery for women . . . understanding its impact on the health of women is crucial."1 Glamour magazine was less sanguine in its assessment. "The bedrock practices of managed care--the gatekeeper system that coordinates care through primary doctors, restrictions on visits to specialists and subspecialists and limits on hospital stays--are hitting women hardest."2 Concerns about women's health and managed care have thus expanded beyond the advocacy and health services research sectors and achieved popular salience.

Women's health "broadly refers to a spectrum of research, prevention and treatments related to maintaining and restoring the health of women. Women's health is a relatively new, generic term that is used in reference to diseases, disorders and conditions that are unique to, more prevalent among, or more serious in women, or for which there are different risk factors or interventions for women than for men."3 If the range of issues that women's health comprises is broad and varied, so too are the types of health care delivery arrangements that fall under the term managed care, which in general refers to the combination of the financing and delivery of health care services. While the classic group or staff model HMO stands as the most recognizable form to many, managed care today is an umbrella term that describes many different types of financing and delivery arrangements. Managed care is "a system of health care delivery that tries to manage the cost of health care, the quality of that health care, and access to that care. Common denominators include a panel of contracted providers that is less than the entire universe of available providers, some type of limitations on benefits to subscribers who use non-contracted providers and some type of authorization system. Managed health care is actually a spectrum of systems, ranging from so-called managed indemnity, through PPOs, POS, open panel HMOs, and closed panel HMOs."4

Managed care has proliferated rapidly, as the market has responded to the need to curtail rising health care costs. According to the American Association of Health Plans, the national trade association representing the managed care industry,5 HMO enrollment grew an estimated 14 percent in 1995, with a total of 58 million members enrolled by October 1995, and the total expected to reach 70 million in 1996. Similarly, PPO enrollment increased an estimated 13 percent from 1994 to 1995 to reach slightly over 91 million members.6 Foster Higgins reported that in 1995, 71 percent of those obtaining health services through their employers were doing so through some form of managed care, up from 63 percent in 1994 and 52 percent in 1993.7 Managed care is also gaining an ever-increasing share of both the Medicare and the Medicaid populations. Approximately 9 percent of Medicare beneficiaries were enrolled in some form of managed care plan in 1995. As of 1994, 43 states and the District of Columbia had a Medicaid managed care program, and 32 percent of Medicaid beneficiaries are now in some form of managed care program.8 The growing dominance of this form of health care delivery demands focused attention to its impact on access to and quality of care for women, including women's primary care.

General Primary Care

Current efforts to restrain health care costs, as well as a desire to improve the health status of populations, both of which are stated imperatives of managed care, have engendered a renewed emphasis on primary care.9 The latest definition adopted by the Institute of Medicine states that "primary care is the provision of integrated, accessible health care services by clinicians who are accountable for addressing a large majority of personal health care needs, developing a sustained partnership with patients, and practicing in the context of family and community."10

In addition to functioning as the initial point of contact with the health care delivery system, a critical feature of primary care is the delivery of preventive and screening services. The latest iteration of the Health Plan Employer Data and Information Set (HEDIS) of the National Committee for Quality Assurance, the most widely used set of health plan performance measures, requires plans to track several indicators in primary care and preventive services, including immunization status (includes flu shots for older and high-risk adults), breast and cervical cancer screening, smoking cessation counseling, and prenatal care. HEDIS also contains measures of the availability of primary care providers and access to preventive ambulatory health services. Because HEDIS measures are used widely by purchasers and increasingly by consumers to assess health plan performance, the elements included strongly influence health plans' priorities in service delivery and quality improvement. They therefore provide important leverage points for influencing both plan and provider behavior.

While managed care holds prevention and primary care among its hallmarks, we must look to the data to determine whether the promised emphasis on health maintenance is being realized. Some of the most recent data published by AAHP on coverage for primary care state that "almost all HMO members are covered for an unlimited number of primary care visits. Thirteen percent of HMO members pay nothing out of pocket for primary care visits; 49 percent make a copayment of $5 per visit. Ninety-nine percent of HMOs' best-selling benefit packages require no deductibles for primary care visits, and 98 percent require no coinsurance."11

Availability and coverage tell only part of the story; additional information is needed to assess the extent to which available services are being utilized. Managed care industry data state that the majority (55 percent) of ambulatory encounters occurring in HMOs are with primary care physicians.12 For all types of primary care providers with the exception of ob-gyns, the mean number of encounters per enrollee per year in HMOs exceeded the national average (taken from the 1992 National Ambulatory Care Survey): 2.62 versus 1.92 for all primary care physicians, 1.14 versus 0.87 for general practice/family medicine, 0.75 versus 0.40 for internists, and 0.25 versus 0.27 for ob-gyns. This provides at least some indication that primary care utilization is emphasized and encouraged in HMOs. As the most highly integrated of managed care arrangements, HMOs supply the majority of available data on managed care plan activity. It is more difficult to discern patterns among looser (and more prevalent) forms of managed care such as PPOs, where the health plan has less control over provider behavior and less ability to collect data.

One way that health plans encourage the use of primary care is by assigning enrollees to a primary care physician. In more integrated plans, this provider acts as a gatekeeper to virtually all health care services, including referrals to specialists, in an effort to coordinate care and to curtail costly specialist utilization. In less integrated plans, however, it is often the independent practice association (IPA) or other provider group with which a managed care plan contracts that determines primary care and gatekeeping arrangements.13 This is critical to bear in mind, as network and IPA-model HMOs have come to far outnumber the more integrated group- and staff-model plans. The use of restrictive networks has been one of the major targets of criticism by consumers dissatisfied with losing their ability to choose their providers. Restrictive networks also may disrupt women's access to women's health providers and networks that have developed outside the managed care framework.

Some plans are responding to these criticisms by relaxing their gatekeeping requirements, allowing self-referral within the plan's network for a copayment. At the same time, many specialists are attempting to adjust to the new demand for primary care created by managed care by redefining their roles in primary care. For example, an independent practice association of specialist physicians in California is attempting to forge a niche providing primary inpatient care. "These critical-care specialists--also called 'intensivists'--want to establish themselves as inpatient-care gatekeepers, allowing the primary-care physician to remain as gatekeeper for outpatient care."14

Women's Primary Care

As the distinct health care needs of women have been increasingly identified, so too have the unique primary care needs of women, needs that extend beyond but include reproductive health care. Issues include concern over barriers to access, both organizational and financial, that prevent many women from obtaining optimal primary care, variation in practice patterns of providers who deliver primary care, and the impact of behavioral risk factors and psychosocial issues on women's health and well-being.15 The components of women's primary care include medical disease areas (such as cardiology and rheumatology), reproductive care (including general gynecology, obstetrics, and oncology), psychology and behavioral medicine (including depression, alcohol and drug abuse, eating disorders, and domestic violence), and preventive medicine (including cancer screening).16 A critical element of primary care that has been neglected is the detection and appropriate treatment of psychiatric disorders. Because the comorbidity of mental and physical disorders has a direct impact on the outcome of those disorders, truly comprehensive primary care must encompass the ability to diagnose and either treat or refer patients for appropriate mental health services. "Just as non-surgical reproductive health care must be combined with non-surgical medical care, so must common mental health issues be integrated into the general medical setting to provide comprehensive cost effective care for women."17

As with primary care in general, preventive services constitute a key element of comprehensive primary care for women. National Health Interview Survey data from 1991 indicated two major problems in women's health-seeking behaviors: not taking preventive health measures to protect against serious illness, and not receiving screening for detecting treatable disease.18 The study found that 40 percent of women aged 40 and above had not received a clinical breast exam in the past 2 years; 46 percent of women aged 40 and above had not received a mammogram in the past 2 years; 43 percent of women aged 18 and above had not received a pap test in the past year; and 21 percent of women aged 18 and above had not received a blood pressure test in the past year. Noting that a regular source of care and periodic health checkups are important safeguards to help women maintain their health, the report highlighted the importance of health insurance coverage to obtaining basic preventive care. While three in five women 18 and over in the study reported risky behavior in at least one of the identified risk factor categories, the majority had not been asked about smoking, diet, exercise, alcohol or drug use during their last checkup. Low-income and minority women were found to have the lowest screening rates for most preventive services, demonstrating the need for outreach and education programs, areas in which providers and health plans can potentially make significant contributions.

A similar analysis of The Commonwealth Fund's 1993 Survey of Women's Health documented the extent to which women do not exploit the potential benefits of clinical preventive services, which greatly compromises their prospects for early detection and timely treatment of disease.19 They determined that the main factors positively influencing the receipt of preventive services by women include insurance coverage and having a regular source of care, while hindrances include financial barriers, minority status, and age. A more recent Commonwealth Fund report stated that "despite being one of the most widely researched, reported, and talked about health topics, prevention is still not widely practiced by, nor made available to, significant number of American women." Reasons for this include lack of information that prevents women from seeking services or taking steps to reduce risk, failure of health professionals to counsel about prevention or refer for screening, or barriers to access, including lack of insurance, lack of transportation, and work and child care difficulties.20 The recent Commonwealth Fund report on preventive care for women contained several broad goals for prevention, including ensuring that "managed care and fee-for-service health plans, whether public or private, should cover the preventive services shown to be effective in protecting women's health."21

Again, we must look to the data to determine how well managed care is meeting the preventive care needs of women. Most available information on women's primary health care under managed care tends to focus on coverage for and receipt of selected preventive screenings (mammography and pap tests), access to ob-gyn providers, and reproductive care. A 1994 Alan Guttmacher Institute study found that annual gynecologic exams were covered by 99 percent of HMOs, compared with 64 percent of PPOs and 49 percent of conventional indemnity plans (over 100 employees); the same study reported that 100 percent of HMOs, 76 percent of PPO's, and 67 percent of indemnity plans covered pap tests. Similarly, 99 percent of HMOs covered mammograms, compared with 82 percent for PPOs and 77 percent for indemnity plans.22 Another study found that all HMOs cover mammography for women aged 50 and over, and that all HMOs cover pap tests, approximately 78 percent covering them annually and 19 percent at the discretion of the provider.23

Coverage of services does not, of course, ensure delivery or utilization. Overall, HMOs have been found to have the same or more physician office visits per enrollee, less use of costly procedures and tests, and greater use of preventive services than in traditional fee-for-service medicine.24 One study found that the proportion of women enrolled in HMOs whose blood pressure was measured at every visit was 93 percent, compared with 67 percent of women nationally.25 Women in HMOs have been found more likely to have received a mammogram, pap test, or clinical breast exam than women covered by traditional insurance.26 There has also been evidence that breast cancer is diagnosed at an earlier stage in women in Medicare HMOs than those in Medicare fee-for-service programs.27

As organized care delivery systems, managed care plans possess at least the potential to influence provider behavior and implement intervention programs with enrollees to improve the delivery of primary and preventive care. Examples of managed care plan activities aimed at improving women's health include distribution of educational materials such as shower cards and brochures to enrollees, newsletters to providers to disseminate health plan guidelines, surveys of enrollees who lack certain screenings, community outreach programs, partnerships with local television stations to increase awareness of women's health issues, and sending caregivers into homes following childbirth.28

Providers of Primary Care for Women

But just as a firm consensus is lacking as to the components of comprehensive primary care for women, so too is there debate over what types of providers are best suited to provide this care. A critical element of women's health has been to emphasize that women's health is more than reproductive health, while not diminishing the importance of comprehensive reproductive health care. This imperative takes on special salience in the context of primary care competency, sparking renewed debate over who is qualified to serve as a primary care provider for women. Family physicians and internists may lack the requisite knowledge of the reproductive system, while obstetrician-gynecologists may not be prepared to deliver comprehensive non-reproductive care. "When systems discourage referral... doctors designated as primary care providers may take on functions for which they are inadequately trained."29

The Fifth Report of the Council on Graduate Medical Education (COGME), which focused on women in medicine (as both patients and practitioners), concluded that physicians should have a broad understanding of, competency in, and ongoing education about [conditions specific to women or more prevalent in women], and gender issues should be incorporated and evaluated at all academic levels.... Women have difficulty receiving comprehensive and coordinated care as a result of deficiencies in physician training and fragmented care.... Medical education at all levels should adopt an interdisciplinary approach to care that relates to the biological, social, and psychological needs of women. Traditional approaches to medical education should be supplemented by programs and fellowships in women's health that integrate relevant issues from all specialties.30

As the scope of services expected from managed care primary care physicians continues to grow, concern has arisen that these physicians are becoming overburdened and may be forced to perform services for which they are not qualified. As this pressure mounts, physicians are trying to position themselves to respond to health plan demands; the American Academy of Family Physicians (AAFP) has expanded its training courses to include new procedures in response to the expressed need from its membership, and internal medicine residencies are expanding their training as well. But adding to their clinical skills does not relieve physicians' worries about increasing both their financial and malpractice risks under capitation agreements.

The flip side of this trend is that many specialists are increasing their primary care roles to preserve their livelihoods in an environment that assiduously avoids costly specialty care. Some internal medicine subspecialists are expanding the primary care parts of their practices, or even becoming full-time generalists, by building on their experience providing primary care to chronic disease patients. Specialists are returning to generalist care in areas where intense competition and managed care have reduced referrals, or where there are not enough patients to sustain subspecialty practice full time.31 The Pew Health Professions Commission noted that four years ago most subspecialists would not have considered becoming generalists; but "as the demand for primary care has grown, they've reinvented themselves as primary-care physicians."32

If there is general concern about the ability of primary care physicians to deliver comprehensive care, this concern is heightened considerably in the context of women's primary care, which has traditionally been fragmented among several medical specialties. During the reproductive years, many women utilize more than one physician for primary care (known as concurrent care). National Ambulatory Medical Care Survey data revealed that excluding obstetric services, three physician specialties provide overlapping services to adult women: family physicians, internists, and gynecologists. The data revealed that 55 percent of women used family practitioners for care, with the balance divided between internists and ob-gyns. These data also showed that gynecologists were almost two times as likely as the other two categories to perform basic women's preventive services such as a pelvic exam, pap test, and breast exam.33

Analyzing data from The Commonwealth Fund's 1993 Survey of Women's Health, Weisman found that one third of women regularly seek care from both a primary care physician and an ob-gyn; these women made 25 percent more visits than women seeing only one practitioner. Thirty-nine percent of women use primary care physicians only, while 16 percent use only ob-gyns as their regular source of primary care. One in 10 women does not have a regular physician at all.34 Women with higher incomes, more education, and private insurance are more likely to use two physicians for primary care. The survey also found that choice of provider influences the amount of preventive care received. Women with no regular physician received an average of 3.8 preventive services during the previous two years, compared with 4.9 for women with a family practitioner or internist, 5.5 for women with an ob-gyn as a regular physician, and 5.6 for women with multiple primary care providers. A 1993 Gallup poll of women aged 18 to 65 found that while women were more likely to have had an exam by an ob-gyn in the past two years, when asked what type of physician they would choose if forced to select only one, only one in five indicated an ob-gyn, while three in five would choose a general practitioner or family physician.

Gallup's 1993 survey of women also asked about use of various types of providers, and found that women were more likely to have had a physical exam by an ob-gyn than by any other type of doctor; 72 percent had a physical exam by an ob-gyn within the past two years, while 57 percent had an exam by other types of primary care physicians, primarily family physicians and general practitioners or internists, during the same period. Of those 72 percent who had a physical exam by an ob-gyn, 54 percent considered their ob-gyn their primary physician (this proportion was 61 percent for women aged 18 to 29). Thirty-six percent of these women said they visited their ob-gyn for preventive or other non-gynecologic health problems.

Although the requirement by many managed care organizations of selecting a primary care physician who is not an ob-gyn may compound the concurrent care tendency, many health plans are responding to consumer preferences and state legislative mandates and either allowing the designation of an ob-gyn as a primary care provider, or allowing open access (self-referral) to such physicians. At least 16 states have laws in place or pending either requiring health plans to allow ob-gyns to be primary care physicians, or mandating direct access to ob-gyns by enrollees, or both. Several of these laws contain provisions allowing individual ob-gyns to opt not to be designated as primary care physicians; several also use the term "women's health care provider" without specifying ob-gyns.35

The first direct assessment of ob-gyns' own views on the primary care role, augmented by managed care plans' views, was undertaken recently by the American College of Obstetricians and Gynecologists.36 Nearly all (99 percent) responding ob-gyns believed that women should be allowed direct access to ob-gyns but were far less in agreement on their level of desire to serve as primary care physicians. Thirty-seven percent reported little or no interest, 37 percent indicated some or high interest, while 26 percent expressed no preference. Most did not want to provide general medical care, while some stated that they do so currently and wished to continue doing so. Fifty-five percent said that ob-gyns should not serve as gatekeepers, and the same percentage expressed no interest in doing so. Seventy percent of the ob-gyns believe little or no additional training is needed for them to serve as primary care providers. Responding managed care plan medical directors disagreed, with 70 percent stating that extensive additional training would be needed. Just over half of the responding health plans allow women to self-refer to ob-gyns, and a third allow ob-gyns to serve as gatekeepers.

In their attempt to provide care that is cost effective and meets the needs and preferences of enrollees, managed care organizations have addressed the provision of women's primary care in various ways. Eighty-one percent of HMOs offer enrollees the choice of an ob-gyn as their primary care provider or allow them to self-refer to one.37 Indeed, 71 percent of HMOs allow self-referrals to an ob-gyn; over 41 percent allow unlimited self-referral visits. The remainder generally allow unlimited self-referrals for obstetric and annual well-woman/pap test/pelvic exams.38 Again, examples help clarify the picture.

Kaiser Permanente of Northern California began working from the premise that a woman can determine who her primary care provider is, and that the focus should shift from services provided to outcomes. Bearing these imperatives in mind, the plan's strategy became one of ensuring that many different types of physicians possess primary care skills, resulting in a major core curriculum project to redesign the provision of adult primary care. Recognizing the resistance of specialist providers to completely retrain as primary care providers, Kaiser opted for a cross-training program to enhance the abilities of specialists to meet the primary care needs of the patients they see.39 Blue Cross of Western Pennsylvania, upon recognizing significant enrollee dissatisfaction with the ob-gyn referral process in their managed care plans, instituted a program to expand access within the existing network. The plan determined that its ob-gyns did not want to be overall primary care providers but wanted to act in that capacity for ob-gyn-related services. The plan expanded the list of services that could be performed in the ob-gyn office and implemented self-referral for an annual ob-gyn visit and for maternity care.40

Non-Physician Providers

Nurse practitioners (NPs), certified nurse midwives (CNMs), and physician assistants (PAs) have also served in primary care roles for women. PAs and NPs have been viewed as physician substitutes in the primary care arena, and during the debates over health care reform their roles (and potential roles) gained increased attention. The Association of Academic Health Centers in 1993 convened a workshop "to examine the educational, professional practice, and public policy issues that impact the ability of [PAs and NPs] to deliver primary care services and, if possible, to recommend actions to ensure that these practitioners are available to help meet the nation's primary care needs, particularly in underserved areas."41 A 1986 OTA study concluded that primary care provided by NPs and CNMs was in fact equal in quality to care provided by physicians, and that they outperformed physicians in the areas of communication and preventive care.42 A subsequent report that synthesized extant literature, as well as a 1993 American Nurses Association study, reached similar conclusions.43

Non-physician primary care providers have been commonplace in HMOs for many years, and "emerging research shows that their use plays a part in HMOs' strategies to controls costs.... In most HMOs, APNs and PAs provide direct patient care to all categories of patients except psychiatric patients."44 A recent study of how HMOs structure primary care delivery noted that while few plans routinely allow enrollees to select an NP or PA as their primary care provider, "NPs and PAs provide primary care as part of a patient care team in most of the HMOs we visited. NPs, in particular, make up a large part of group/staff model plans' primary care staff."45

Conclusions

With managed care becoming the standard in health care financing and delivery, now is the time to begin assessing what import managed care mechanisms have for women's health. Certainly an increased emphasis on primary care and preventive services bodes well. But not all current efforts to define primary care take gender into account. Nor has the managed care industry sought to define gender-specific primary care competencies.

What are the unique primary care needs of women, and how well are managed care organizations meeting those needs? New looks at women's health needs have in turn provoked renewed inquiry into the abilities of various types of providers to meet those needs. Traditional primary care specialties are enjoying newfound appreciation and demand for their skills, while others--such as ob-gyns--who have straddled the primary/specialty division struggle to define their roles in a changing system. In addition, non-physician providers of primary care such as PAs and NPs stand poised to assume greater responsibility as cost containment imperatives enhance their marketability as primary care providers requiring less training and compensation than physicians.

But do these cost containment pressures compromise the quality of care delivered to women? In theory, health plans have an incentive to provide thorough care to enrollees up front, to forestall the development of serious, costly problems later. But in practice it is not clear that such a long-term vision drives health plan decision making, as the payoff for providing primary and preventive care may not be realized readily enough to maintain a plan's short-term viability, particularly in a competitive market with high enrollee turnover.

S
everal questions emerge from this review:

  • What constitutes comprehensive women's primary care?

  • Is it reasonable to expect one provider, of any medical specialty, to adequately manage the full range of health needs of women? 

  • If the answer is no, then how should comprehensive women's primary care be delivered?

  • How can consumers be assured that their primary care needs will be met within managed care settings?

  • How can women be assured of quality services?


Endnotes

1. Collins KS and Simon LJ. Women's health and managed care: promises and challenges. Women's Health Issues 1996;6:39-44.

2. Laurence L. Is managed care good for women's health? Glamour 1996 (August);202+

3. Freudenheim E. 1996. Healthspeak--A Complete Dictionary of America's Health Care System. New York: Facts on File.

4. Peter Kongstvedt. 1996. The Managed Care Handbook, 3rd ed. Gaithersburg, MD: Aspen Publishers.

5. Formerly Group Health Association of America (GHAA).

6. American Association of Health Plans. 1995. 1995 HMO & PPO Trends Report. Washington, DC: AAHP.

7. Michael Pretzer. 1996. The managed-care juggernaut: explosive growth nationwide. Medical Economics (April 15).

8. Gold M, Sparer M, and Chu K. 1996. Medicaid managed care: lessons from five states. Health Affairs (fall).

9. The American Association of Health Plans' Philosophy of Care, the managed care industry's 1996 public statement of its principles, includes the following: "We believe working with people to keep them healthy is as important as making them well. We value prevention as a key component of comprehensive care--reducing the risks of illness and helping to treat small problems before they can become more severe."

10. Donaldson MS et al. 1996. Primary Care: America's Health in a New Era. Washington: National Academy Press.

11. American Association of Health Plans. 1996. HMO & PPO Industry Profile, 1995-1996 edition, p. v.

12. Group Health Association of America. 1995. 1995 Sourcebook of Utilization Data. Washington, DC: GHAA.

13. Felt-Lisk S. How HMOs structure primary care delivery. Managed Care Quarterly 1996;4:96-105.

14. Kertesz L. Specialists taking "gatekeeper" role. Modern Healthcare 1996:47 (May 13).

15. The George Washington University. Women's Health and Primary Care: A Workshop to Build a Research and Policy Agenda. 1994. Washington: The George Washington University.

16. Carlson KJ, Eisenstat SA, Frigoletto FD, Schiff I. 1995. Primary Care of Women. St. Louis: Mosby.

17. Hoffman E. Presentation at American Psychological Association conference, Washington, DC, September 1996.

18. Brown ER, et al. 1995. Women's Health-related Behaviors and Use of Clinical Preventive Services. Los Angeles, CA: UCLA Center for Health Policy Research.

19. Wynn R, Brown ER, Yu H. Women's use of preventive health services. In Falik MM, Collins KS. 1996. Women's Health -- The Commonwealth Fund Survey. Baltimore: Johns Hopkins University Press.

20. Commonwealth Fund Commission on Women's Health. 1996. Prevention and Women's Health: A Shared Responsibility. New York: The Commonwealth Fund.

21. Commonwealth Fund Commission on Women's Health. 1996. Prevention and Women's Health: A Shared Responsibility. New York: The Commonwealth Fund.

22. Alan Guttmacher Institute, Uneven and Unequal--Insurance Coverage and Reproductive Health Services, 1994.

23. GHAA/Kaiser Family Foundation 1994 Market Survey.

24. Miller RH, Luft HS. Managed care plan performance since 1980. JAMA 1994; 271:1512-9.

25. Murata, et al. Quality measures for prenatal care. Archives of Family Medicine January 1994.

26. Makuc DV, Freid M, Parsons PE. Health Insurance and Cancer Screening Among Women. Hyattsville, MD: National Center for Health Statistics; 1994 Aug. 3 Advance data no. 254.

27. Riley GF, Potosky AL, Lubitz J, Brown ML. Stage of cancer at diagnosis for Medicare HMO and fee-for-service enrollees. Am J Public Health 1994;84:1598-1604.

28. See also Heiser N and St. Peter R. Improving the delivery of clinical preventive services to women in managed care organizations: a case study analysis. Unpublished paper prepared for the Commonwealth Fund's Symposium on Promoting the Use of Clinical Preventive Services by Women in Managed Care Organizations, October 30, 1996, Washington, DC.

29. Hoffman E and Johnson K. Women's Health and Managed Care: Implications for the Training of Primary Care Physicians. J Am Med Wom Assoc 1995; 50:17-19.

30. Council on Graduate Medical Education. 1995. Fifth Report: Women and Medicine.

31. Terry K. Here comes more competition--not-so-busy specialists are becoming generalists, too. Medical Economics 1996;200+

32. Quoted in Terry K. Here comes more competition--not-so-busy specialists are becoming generalists, too. Medical Economics 1996;200+

33. Bartman BA, Weiss KB. Women's health care in the ambulatory care setting. Clin Res 1991;39:595A.

34. Weisman CS. "Women's use of health care." In Falik MM, Collins KS. 1996. Women's Health -- The Commonwealth Fund Survey. Baltimore: Johns Hopkins University Press.

35. AAHP data, summer 1996.

36. The survey was sent to two groups of ACOG Fellows with response rates of 78 percent and 52 percent, and to 48 health plans, of which 21 (44 percent) responded.

37. Bernstein A, et al. Women's reproductive health services in health maintenance organizations. Western J Medicine 1995;163:17.

38. GHAA/Kaiser Family Foundation 1994 Market Survey, p. 32.

39. Havens C. Presentation at IBC Women's Health and Managed Care Conference, Philadelphia, July 1996.

40. Neurohr P. Presentation at IBC Women's Health and Managed Care Conference, Philadelphia, July 1996.

41. Clawson DK, Osterweis M. 1993. The Roles of Physician Assistants and Nurse Practitioners in Primary Care. Washington, DC: AAHC.

42. U.S. Congress, Office of Technology Assessment. 1986. Nurse Practitioners, Physician Assistants, and Certifed Nurse-midwives: A Policy Analysis. Washington, DC: U.S. Government Printing Office.

43. Crosby F, Ventura MR, Feldman MJ. Future research recommendations for establishing NP effectiveness. Nurse Practitioner 1987;12:75-79; Brown SA, Grimes DE. 1993. Nurse Practitioners and Certifed Nurse-midwives: A Meta-analysis of Studies on Nurses in Primary Care Roles. Washington, DC: ANA.

44. Dial T et al. Clinical staffing in staff- and group-model HMOs. Health Affairs 1995;168-180.

45. Felt-Lisk S. How HMOs structure primary care delivery. Managed Care Quarterly 1996;4:96-105.