A Publication of the
Jacobs Institute of Women's Health
Volume 7, Number 4, December 1999
Looking Back, Looking Forward: 1999 Annual Report
As we look back at our accomplishments in 1999, were especially proud to say we are charting a course for womens health in the future by working with leaders from managed care plans and large employers. Facilitating constructive dialogue with the parties who have the leverage to shape the future is what sets the Jacobs Institute apart from other organizations.
Our two national conferences this year, the first National Summit on Womens Health and Managed Care in March and Value Purchasing: Investing in Womens Health in June, were the culmination of our research, seminars, and panel discussions focusing on womens health and managed care. The conferences were designed to showcase some of the most progressive and women-centered practices in managed care today as models for health plans and employers to adapt.
While national debate continues over consumers rights in managed care systems, the Jacobs Institute directs its efforts toward presenting models for womens health care that have been shown to be effective.
The reports from the meetings, Womens Health and Managed Care: Opportunities for Action, and Value Purchasing: Investing in Womens Health, will soon be sent to all Jacobs Institute members. We also plan to send them to the members of the American Association of Health Plans and the Washington Business Group on Health, our cosponsors for the conferences.
Addressing Health Care Concerns for Older Women
The Jacobs Institute is responding to the needs of older women through initiatives such as our recent Medicare conference, "Women and Medicare: Agenda for Change" in September. Working with The Commonwealth Fund, one of the countrys leading supporters of independent research on health and social issues, we looked further at older womens health status, need for services, costs of care, and satisfaction with care. By bringing together health policy experts from across the country, we highlighted the effects of Medicare on women and identified important issues to be addressed as federal legislators attempt to revamp the Medicare program.
Conference participants addressed the importance of ensuring Medicare remains accessible and affordable to older women. Among the conclusions reached, participants agreed that Medicare should provide more coverage for preventive services and more attention to managing chronic conditions and disabilities, which would benefit both men and women. As Panelist Deborah Briceland-Betts, executive director of the Older Womens League, put it, "If you make it work for women, it will work for men."
In addition, at the request of the National Committee for Quality Assurance (NCQA) and with support from The Commonwealth Fund, weve begun working on guidelines for health plans on counseling women about menopause. NCQA oversees the development of the Health Plan Employer Data and Information Set (HEDIS) and asked the Jacobs Institute to synthesize current menopause counseling guidelines. A new set of HEDIS measures will evaluate how well health plans have counseled female members about their options for managing menopausal hormonal changes; the Jacobs Institutes guidelines will be available to health plans before the plans begin to implement the new measure in January.
At this years Excellence in Womens Health Awards Luncheon, W. Allen Schaffer, MD, of CIGNA (the event underwriter), praised each of the recipients for being "a pioneer and advocate for better health for all women." The honorees were Jane E. Henney, MD, the first woman Commissioner of the US Food and Drug Administration, who helped establish the Office on Womens Health; Elmer Huerta, MD, MPH, Director of the Cancer Risk Assessment and Screening Center of the Washington (DC) Cancer Institute and host of "Cuidando su Salud" ("Taking Care of Your Health"), a nationally syndicated daily radio program on preventive health issues directed to Spanish-speaking communities; and Kenneth J. Ryan, MD, Professor Emeritus at Harvard Medical School, biochemist, obstetrician-gynecologist, and bioethicist, whose leadership of national commissions has helped establish ethical guidelines for human research subjects.
Elizabeth Goodman, MD, of Childrens Hospital, Cincinnati, Ohio, received the 1999 Jacobs Institute of Womens HealthOrtho-McNeil Pharmaceutical Scholar Award. Dr. Goodman is using the $30,000 grant to examine the association between depression, socioeconomic status, and use of mental health and medical services among adolescent girls.
Usha Sambamoorthi, PhD, and colleagues of Rutgers University were awarded the Jacobs Institutes 1999 Leadership Award for their manuscript, "Estrogen Replacement Therapy Among Elderly Women: Results from the 1995 Medicare Current Beneficiary Survey." Their article, along with others submitted for the Leadership Award, is being published in the November/December 1999 issue of Womens Health Issues. We are currently accepting manuscripts for the 2000 Leadership Award on the topic "Putting prevention into practice: closing the gap between what we know and what we do in womens health care." The deadline for the award is March 31, 2000.
Changing Times, Changing Faces
We welcomed to our Board of Governors this year Ezra Davidson Jr., MD, FACOG, and Vicki Romero. We reluctantly say goodbye to Constance J. Bohon, MD, FACOG, president of the Jacobs Institute Board of Governors, and Charles E. Gibbs, MD, FACOG, past president. Both were founding members of the Jacobs Institute, and their vision and leadership have guided the organization to this day.
To our administrative staff, we welcomed Emily Schifrin, MS, as our new project director. Emily is directing our work on womens health and managed care, overseeing the development of guidelines for menopause counseling, and planning next years collaborative conference between the Jacobs Institute and The Commonwealth Fund.
In February we said goodbye to Julianna S. Gonen, PhD, research associate and managed care project director at the Institute. She joined the Washington Business Group on Health as their director of family health. We continue to remember Elizabeth Markle, MPH, CHES, our program assistant for over 3 years, who died March 14, 1999, of complications from cystic fibrosis. Beths primary responsibilities were organizing the Jacobs Institute of Womens HealthOrtho-McNeil Research Award and the Institutes breakfast seminar series. She was a delight to work with, and we miss her tremendously.
The year 2000 marks our 10-year anniversary, and well be celebrating by developing some new projects and revisiting some past favorites. At our annual Excellence in Womens Health Awards Luncheon, well honor popular New York Times health columnist Jane Brody, among others, and announce the results of our survey on the 10 most important advancements in womens health since 1990.
Also in 2000, well begin a new breakfast seminar series, "New Dimensions in Womens Health," and well publish the third edition of our popular Womens Health Data Book.
Making It Possible: Our Members and Donors
Without the generous support of our many members and donors, we would not be able to achieve our goals of improving womens health by funding and presenting research, publishing information, and recognizing leaders in our field. This years contributors (from October 1, 1998, to September 30, 1999) are listed below. We thank you, and we look to you for continued support as we begin our tenth year. To renew your membership, go to the order form.
Martha Romans, Executive Director
American College of Obstetricians and Gynecologists
American Association of Health Plans
American Society for Reproductive Medicine
American College of Radiology
American Board of Obstetrics and Gynecology
American Federation of Teachers
Many contributions were given to honor the life, work, and memory of colleagues, friends and relatives. We would especially like to thank those who honored others through a donation to the Jacobs Institute:
In honor of
In memory of
One in seven women today is 65 or older, and that number will approximately double in one generation, or 30 years, according to Wanda Jones, DrPH, director of the Office of Womens Health at the Department of Health and Human Services. As a result, the Medicare program is challenged to provide more and better health care to more and more people living longer. To evaluate how Medicare affects women and how proposals for revamping the program would do so, the Jacobs Institute and The Commonwealth Fund convened "Women and Medicare: Agenda for Change" in Washington, DC, in September. The meeting of health policy advocates and researchers represented "a new partnership between the Jacobs Institute and The Commonwealth Fund," said Jacobs Institute Executive Director Martha Romans at the day-long conference. "This conference is the first in a series of annual meetings, thanks to The Commonwealth Funds investment in womens health issues and their commitment to extend that investment into the future," Ms. Romans noted.
In providing an overview of federal initiatives to improve womens health, Dr. Jones, the conferences keynote speaker, reminded the group that "100 years ago, ...women and men were both lucky to live to their 50th birthday." Advances in medicine and attention to public health issues have added nearly 30 years to life expectancy, but, she said, "We still have a lot of work to do in affecting health and health practices in this country, let alone disease rates and other problems we face."
Dr. Jones pointed out, "Vitality in old age may actually have less to do with genes and more to do with how we live and the behaviors we practice: physical activity, healthy eating, cessation of smoking, and lets not forget our oral or our mental health as critical components of health and vitality for people of any age."
She stressed the importance of using medical knowledge, research on changing demographics and changing needs, and access to information together to improve overall health. "Its going to be really important that we pull together all the sectors...and address the whole body, the mind and the physical body, [to] ensure that we remain healthy and productive."
Karen Davis, PhD, president of The Commonwealth Fund, framed the days presentations by pointing out that "the face of the Medicare beneficiary is that of a woman." Fifty-five percent of beneficiaries overall are women; of those age 85 and over, 71% are women. Women live on average 7 years longer than men, "but theyre also more likely to have lower incomes and be in poor health," she noted. "Given the likelihood that [women] will live into their 80s and suffer from chronic conditions, the issue of long-term care is particularly important to women," said Dr. Davis. But a lifetime of lower earning power, which results in lower pension benefits, and a lower likelihood of having their own pension at all makes women more likely to rely on Medicaid and Medicare.
Dr. Davis introduced Dorothy Rice, ScD, of the Institute for Health and Aging at the University of California, San Francisco, by pointing out that Dr. Rice "helped lay the groundwork for the enactment of Medicare in 1965," while working at the Social Security Administration. Describing Dr. Rices many accomplishments, Dr. Davis explained how Dr. Rices efforts to establish methods for collecting national health data influenced federal health policy and provided the basis for much of the data analysis and policy discussions that continue today.
"The good thing is that we do live longer, and the bad thing is that we do live longer," joked Dr. Rice, reinforcing the premise that Medicare must take into account womens health issues. By 2040, she noted, "This will be a society dominated by older persons, and many of them older women. We really have to prepare for that society and protect Medicare to prevent the erosion of the benefits for that population group."
Women are more likely than men to have chronic health conditions, Dr. Rice noted, while Medicare was originally structured to cover acute illness, hospital care, and physician services. Even more importantly, "Low-income women on Medicare are in poorer health than women with higher incomes."
Dr. Rice noted that poor women cannot afford so-called Medigap supplemental insurance policies and pay very high out-of-pocket expenses for uncovered services such as prescription drugs. Fifteen percent of women on Medicare spend $100 or more per month on medications.
Dr. Rice summarized the key issues for women regarding Medicare reform, among them the importance of understanding the implications of proposed changes, especially for women with chronic conditions and low incomes. Also, its important to ensure the Medicare benefit package remains adequate and affordable, improve financial protections for low-income people, and address fiscal challenges to preserve Medicare.
"There has to be some attention paid to restraining Medicare costs in the future," said Dr. Rice, "but I really feel that many proposals on the table will place a greater financial burden on older people, especially elderly poor women. We have to find solutions that take into account the financial and the health and the long-term care needs of elderly women," she concluded.
Karen Scott Collins, MD, MPH, assistant vice president of The Commonwealth Fund, presented highlights from her organizations 1998 Survey on Womens Health, focusing on results for older women. Dr. Collins noted that low-income women continue to report problems paying for prescriptions, getting needed care, and seeing specialists. "A large portion of women in both income groups, but particularly low-income older women, had not received cervical or breast cancer screening in the past year," she noted, despite the fact that mammography benefits have improved over the past 5 years.
"Indeed, the rates of preventive care drop off quite dramatically between women in the 45- to 64-year-old group and women 65 and older," Dr. Collins continued. She stated that women who saw both an obstetrician-gynecologist (ob-gyn) and an internist or family practitioner were more likely to get needed preventive services than those who did not see an ob-gyn. Unfortunately, women over 65 are only half as likely as younger women to see an ob-gyn.
In summation, Dr. Collins noted that the longer life expectancy and the increasing risk of heart disease and cancer as women age combine to make access to and use of preventive services a priority for women as they grow older.
Jan Blustein, MD, PhD, assistant professor of health policy and management at New York University, presented preliminary findings from an analysis of the Medicare Current Beneficiary Survey. She focused on prescription drug coverage, trying to determine the extent to which having a policy that covers prescription drugs affects a persons likelihood of filling a prescription and whether gender plays a role. Looking specifically at prescriptions for antihypertension drugs, Dr. Blustein found 19% of elderly people failed to fill their prescriptions. Of those with drug coverage, 17.5% failed to purchase the prescribed drugs, compared with 21.8% of those without coverage. Those without coverage also purchased fewer tablets than those with coverage.
"Income matters," Dr. Blustein stressed. "Particularly, being low income and without drug coverage is the double whammy that puts you in the worst shape in terms of purchasing patterns."
The gender effect is harder to analyze, Dr. Blustein said. Both mens and womens likelihood of filling prescriptions are increased by having drug coverage. However, women are more likely to fill their prescriptions than men, regardless of drug coverage. Dr. Blustein concluded, "Modernizing the Medicare benefit to include prescription drugs will be necessary if drugs are going to fully realize their promise...[of] improving and lengthening life."
Panelist Deborah Briceland-Betts, executive director of the Older Womens League (OWL), lauded the presenters for their research on the effects of Medicare on women. "Repeatedly, OWL has been saying, if you make it work for women, it will work for men."
She praised Dr. Collins for presenting more research showing that income levels affect whether a woman gets needed preventive screening for diseases such as breast and cervical cancer. "Weve made a lot of important steps in the right direction over the last several years in enhancing Medicares preventive screening, but theres a disconnect," said Ms. Briceland-Betts, between the institution of policies and the number of women actually getting screened.
Judith Feder, PhD, dean of policy studies at Georgetown University, commented on the current debate over restructuring Medicare, criticizing the assumption that increasing the roles of managed care and competition in Medicare will improve efficiency and save vast sums of money. "In general, we have some evidence that managed care has been deleterious to the health status of older, poorer people. So the assumptions that its going to improve efficiency and improve quality of care have not been borne out," she said.
"If advocates of competition want to put their recommendations where their mouths are," Dr. Feder continued, "we really do need a single, common benefit package or a standard benefit package in Medicare if that competition is going to promote us toward efficiency and not toward segmentation of the market."
Paul Cleary, PhD, professor of health care policy at Harvard University Medical School, presented an analysis of data captured through the Consumer Assessment of Health Plans (CAHPs). The CAHPs study provides the largest set of data from consumers on their experiences with managed care. Analyzing responses from Medicare beneficiaries, Dr. Cleary said he did not find significant differences overall between men and women in terms of their satisfaction with the care they received. Women did give more positive responses about their health care, but Dr. Cleary said thats common. "One interpretation is that...women are much more effective than men at using the medical care system, at precipitating or catalyzing meaningful communication," said Dr. Cleary.
Dr. Cleary says further data collection and comparison will help pinpoint where gender and access issues arise. He and his colleagues are constantly analyzing the survey and the responses, asking "What can we do now, instead of characterizing the consumers care, to really improve it?"
Arlene S. Bierman, MD, MS, senior research physician at the Center for Outcomes and Effectiveness Research of the Agency for Health Care Policy and Research, discussed the effects of capitation on Medicare. "Theres been a historic gender bias in Medicare payments," she noted, because the program was designed to cover acute care, while women disproportionately suffer from chronic diseases and disability. Further, Medicares capitation formula is based on traditional fee-for-service costs. Research by Dr. Bierman and her colleagues demonstrated that women had more functional impairment and comorbidity than men and used more ambulatory and less inpatient services than men, but "annual Medicare reimbursements and capitation rates are lower for women."
"Among women, the impact of this payment imbalance will be greater for low-income and minority women," she noted. "These findings raise the question of whether capitated Medicare will perpetuate existing inequities in financing care for chronic illness."
Dr. Bierman concluded, "We need to identify cost-effective ways to finance, organize, and deliver care and match payment with the needs [of older women]....We need to promote a health services research agenda that will really allow us to extend active life expectancy, which is achievable."
Joan Leiman, PhD, executive deputy vice president for health sciences and clinical professor of public health at Columbia University, offered her observations about the findings presented throughout the day. She suggested some "policy principles" that should be considered as a result:
"The Jacobs Institute of Womens Health is an independent, nonprofit membership organization dedicated to advancing the knowledge, practice, and understanding of womens health care." That sentence is what caught my eye as I was diligently searching for a place to intern this fall in Washington, DC.
As a student in the Washington Semester Program at American University, it was my job to find a place where I would be able to enjoy working and would have the opportunity to learn about the "real world," while using my skills to contribute to the organization and its work. The Jacobs Institute was the place for me.
What I found at Jacobs was exactly what I had envisioned. I became part of a small staff of dedicated individuals who work to improve health care for women in the United States. Although I had been at the Institute for a short time, I became a part of one of its important events. On September 16th, I was fortunate to be able to attend the "Women and Medicare: Agenda for Change" conference. It was there that I realized the importance of the Jacobs Institutes work. As I listened to distinguished speakers, experts in their respective fields from around the country, I became inspired and hopeful for the changes to come on behalf of women. This experience strengthened my commitment to contribute in whatever way I could to help Jacobs continue to address womens health needs.
Womens Health Issues is calling for entries for its 2000 Leadership Award manuscript prize. The topic is "Putting prevention into practice: closing the gap between what we know and what we do in womens health care." A $1,000 prize will be given for the best manuscript submission.
Findings from The Commonwealth Funds 1998 Survey of Womens Health demonstrate the need for continued effort in the area of prevention. The survey found there was little change in preventive health screening rates among women between 1993 and 1998. A majority of women do not receive counseling from their physicians on important health behaviors.
As general guidelines, the manuscript should not exceed 2,000 words and 20 references. The deadline for the award is March 31, 2000. Announcement of the winner will be made in June 2000. The winning manuscript, and others deemed acceptable for publication, will appear in upcoming issues of Womens Health Issues.
Address manuscripts to the Editor, Womens Health Issues, Jacobs Institute of Womens Health 409 12th Street, SW, Washington, DC 20024-2188. Please indicate that you wish your submission to be considered for the 2000 Leadership Award.
April 1314, International Conference on Womens Reproductive Health: Rights and Choices in 2000 and Beyond, Girton College, Cambridge, UK. For more information, contact Brenda Fearon at [email protected]
Health Notes: Womens Health, a monograph from the California State Board of Pharmacy, aims to "educate consumers to the fact that compliance to a prescribed drug regimen is one of the quickest ways to reduce the cost of health care while improving patients health and wellness." Free copies can be obtained by calling the Board at 916-445-5014.
Patients as Effective Collaborators in Managing Chronic Conditions, published by the Center for the Advancement of Health with the Milbank Memorial Fund, "summarizes the impact of efforts to increase collaboration among health professionals and their patients on health outcomes, patient satisfaction, and cost." The report is available at www.milbank.org, or call the Milbank Memorial Fund at 212-355-8400 or CFAH at 202-387-2829.
Managing Hyperlipidemia in Women, a new teaching module from the Association of Professors of Gynecology and Obstetrics, includes a study guide, self-assessment quiz, case studies, and support slides. It is available for $250; the monograph alone is $7. For more information, contact APGO at 202-863-2507.
Beneath the Averages: An Analysis of Medicare and Private Expenditures and Analysis of Benefits Offered by Medicare HMOs 1999: Complexities and Implications are two new reports available from the Kaiser Family Foundation through their request line at 800-656-4533 or web site at www.kff.org.
Welcome to the following new members of the Jacobs Institute, who joined from August 1 to September 30, 1999. To become a member, complete and return the order form. For more information on membership, call the Jacobs Institute at 202-863-4990.