A Publication of the
Jacobs Institute of Women's Health
The Jacobs Institute and the American Association of Health Plans convened the first National Summit on Women's Health and Managed Care to build on and incorporate the lessons learned from the Jacobs Institute's recent managed care seminar series. About 50 representatives of health plans, including medical directors, quality assessment personnel, and program-oriented staff met for two days at the Swissotel/The Watergate in Washington, DC, March 10 and 11.
One goal of the summit was to bring together managed care representatives to contribute their expertise to an action plan on improving managed care's approach to women's health care. A draft of the plan was based on the commissioned papers, seminars, panel discussions, and Insights briefing papers that made up the managed care series. It covers primary and preventive care for women, reproductive health, mental health, and chronic conditions. Participants worked in break-out sessions to revise the draft and presented their changes to the whole group at the end of the summit.
Carolyn Clancy, MD, director of the Center for Outcomes and Effectiveness Research at the Agency for Health Care Policy and Research, delivered the keynote address at the summit. Dr. Clancy explained why the need exists to focus on improving managed care practices related to women's health. She pointed out that health researchers who had focused on health problems unique to women had to reevaluate their approach when it became clear, for example, that the number one killer of women is heart disease, which is not unique to women. Still, women's health research and prevention efforts continue to place more emphasis on reproductive issues than other conditions.
Attention to women's health issues has increased dramatically in the past few years, said Dr. Clancy, and recent milestones are the mandatory inclusion of women subjects in medical research, a reexamination of medical school curricula, and more studies evaluating the influence of a patient's gender on disease risk and progression as well as on physician practice patterns.
Managed care has been an important part of the solution in providing women access to preventive health care on a par with men, said Dr. Clancy. Women in health maintenance organizations are more likely to get preventive care, such as Pap tests and physical exams, than women in traditional plans. The summit is one way for health care advocates and researchers to look more closely at the kinds of strategies used to effect such changes so they can replicate them more broadly. "As more women are enrolled, we need to understand these things pretty quickly," said Dr. Clancy.
In closing, Dr. Clancy pointed out challenges still to be addressed, such as accessibility and affordability of health care, accountability on the part of health care systems, better coordination of different aspects of patient care, and new approaches to chronic illness. About half the people currently enrolled in medical school are women, said Dr. Clancy, "But that still does not speak to cultural and socioeconomic dynamics. We have not really thought about what it means to provide culturally competent care." She noted that improving these areas are all part of the health care agenda for the coming years.
After a day of smaller group discussions, summit participants reconvened for a presentation of each group's suggestions and a panel discussion of issues raised during the summit, facilitated by Rita Menitoff of Women's Health Management Solutions.
Derek van Amerongen, MD, national medical director of Anthem Blue Cross/Blue Shield, presented the group consensus on primary care. The group felt it is important to identify responsibility for various aspects of patient care because, as Dr. van Amerongen put it, "If it's everybody's job, it also becomes nobody's job." Managed care should establish a stronger relationship between responsibility and accountability, he said.
Among the suggestions for improving primary care were establishing realistic cost-sharing models for primary care, for example, affordable copayments for prescriptions; expanding opportunities for health care counseling outside of clinics; providing financial and other incentives for patients to seek preventive services; and focusing on special populations.
One specific suggestion was to create standard codes for reimbursement to cover counseling, such as genetic counseling. The group acknowledged it was difficult to document the content of a conversation with a patient but felt providers should be compensated for taking the time to counsel patients.
In addition, the group felt there should be some accountability for physician competence in primary care, and the role of obstetrician-gynecologists in providing primary care needs to be further discussed.
Arnold Cohen, MD, corporate medical director for women's health care at Aetna/U.S. Health Care, presented recommendations on reproductive health. The group concluded that one major clinical issue in this area is the high rate of unintended pregnancies (46-56%). Only about 20% of unintended pregnancies occur among teenagers, and yet efforts to address the issue have always focused on teenagers and underserved and minority populations. The group offered some solutions to decreasing the number of unintended pregnancies among the whole population.
For example, managed care should provide more and better coverage of contraception, which might include offering incentives or even reimbursements for condoms, the only commonly used form of contraception that also protects against sexually transmitted diseases (STDs). Dr. Cohen pointed out that to get more information on protection against pregnancy and STDs to teenagers, insurers should enhance communication with parents and encourage them to educate their children about these issues.
In addition, managed care organizations should develop programs to increase chlamydia screening and treatment. Such efforts will encourage more young women to see practitioners, where they will have more access to counseling and education about pregnancy and STDs.
Dr. Cohen also pointed out that community-based providers may be particularly helpful in underserved urban areas. Community-based clinics should be encouraged to forge good working relationships with managed care organizations, he said.
Robin Richman, MD, vice president and medical director for quality improvement/women's health for Tufts Health Plan, gave the recommendations from the group focused on mental health. Dr. Richman noted that we should learn from some of the successes of managed care in the field of mental health. However, "Education does not always produce change," she said. Successful health plan programs need champions in key positions and on a local level to ensure they reach their goals.
Also, researchers need to develop more ways to measure outcomes. Instead of looking only at recidivism, data should tell us "who feels better and who we have helped," said Dr. Richman.
The group felt all primary care-related specialists should have basic mental health training. For example, pediatricians should be able to spot the signs of postpartum depression, because they are likely to see new mothers. Professional societies should develop algorithms on primary care treatment versus referral for mental health conditions, which should include information on medications and the length of time needed to see results of treatment.
Among other suggestions, the group recommended primary care providers receive more education on drug interactions and side effects, especially with the introduction of many new medications to treat mental health conditions, because, for example, most antidepressants are prescribed by non-mental-health providers.
Cheryl Warner, MD, clinical consultant for Harvard Pilgrim Health Care, offered the recommendations of the group looking at chronic conditions. As an introduction, Dr. Warner presented a list of the key attributes of most good programs, which included using multidisciplinary teams and guidelines, allowing patients to direct their own care whenever possible, establishing outcome measures at the beginning of the program, and allowing the program enough time to show results.
A multidisciplinary approach to health care was seen as the most important element of successfully treating chronic conditions. In addition, the group felt that to address the lack of access to appropriate health care, managed care organizations should make efforts to know who its members are, their cultural needs, and how it can promote sensitivity through diversity training, disability access, etc.
Participants then joined in a discussion of the recommendations, including the role of the employer/payer in providing health care coverage for specific conditions and treatments, which was the topic of the closing keynote address by Mary Anne Hraba of Watson Wyatt, a consulting firm that works with employers choosing health coverage.
Ms. Hraba pointed out that her firm recommends employers develop long-term partnerships with managed care organizations. She felt that the country's changing demographics, changing corporate landscape, and changing health care needs represent three forces that are coming together to bring about changes in women's health care.
More women are working than ever before, and as the pool of young workers decreases, corporations are more concerned with both employee retention and with providing benefits that enhance their workers' quality of life. Employers are incorporating women's issues into current wellness programs, said Ms. Hraba, by educating employees about health risks and health-related social issues, such as stress from juggling work and home life. They're providing on-site mammography screening and establishing programs such as "managed maternity," which includes occasional phone calls from nurses.
Such efforts are making a difference. Ms. Hraba cited one study of on-site lactation centers that showed they decreased employee absenteeism because the employees' children were sick less frequently. Another company provided on-site osteoporosis screening and found 10% of their employees had signs of osteoporosis, including some who were in their twenties.
Ms. Hraba emphasized the need for more education and more conversation between employers and insurers. "Not everyone is there yet," said Ms. Hraba, "It's a slow road to partnership."
The summit was made possible through generous grants from The Commonwealth Fund, CIGNA HealthCare, Eli Lilly and Company, Merck and Company, Inc., and Wyeth-Ayerst Laboratories. A summary report on the Summit will be published this summer.
In their efforts to improve women's health, the honorees at the Jacobs Institute's 1999 Excellence in Women's Health Awards Luncheon-all physicians-represented the fields of federal oversight, lay media, and academic medicine. The honorees were Jane E. Henney, MD, the first woman Commissioner of the US Food and Drug Administration, who helped establish the Office on Women's 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, FACOG, Professor Emeritus at Harvard Medical School, biochemist, ob-gyn, and bioethicist, whose leadership of national commissions has helped establish ethical guidelines for human research subjects. Jacobs Institute board members presented the excellence awards, while Warren H. Pearse, MD, presented the lifetime achievement award to Dr. Ryan. In a welcoming address, W. Allen Schaffer, MD, Senior Vice President of Managed Care Operations for CIGNA, the event underwriter, praised the Jacobs Institute for its work "at the intersection of science, medicine, and social policy." Dr. Schaffer also acknowledged the recipients of this year's Excellence Awards, saying each was "a pioneer and advocate for better health for all women."
The Jacobs Institute of Women's Health would like to thank the following individuals, corporations, and foundations for support of the 1999 Excellence in Women's Health Awards, made possible through the generous support of CIGNA HealthCare.
Friends of Warren
In February we said good-bye 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. She is continuing to collaborate with us on the second phase of our long-term managed care project. We wish her all the best in her new position.
We welcome Emily Schifrin, our new project director, who directs our work on women's health and managed care, including the national summit for purchasers in June. She is also coordinating two monographs from the managed care project and arranging the first annual Commonwealth Fund/Jacobs Institute meeting in September, which will focus on women and Medicare. Emily comes to us from the National Committee for Quality Assurance. She has a master's degree in health policy and management from Harvard University's School of Public Health.
On March 14, 1999, Elizabeth Markle, MPH, CHES, passed away at Children's Hospital in Washington, DC, surrounded by her family and friends. She fought a courageous battle against cystic fibrosis, and she was always pleasant and optimistic no matter how she was feeling. Beth had been with the Jacobs Institute of Women's Health for over 3 years as our program assistant. Her primary responsibilities were organizing the Jacobs Institute of Women's Health-Ortho-McNeil Research Award and the Institute's breakfast seminar series. She was a delight to work with, and we will miss her tremendously.
Welcome to the following new members of the Jacobs Institute, who joined from January 21, 1999, to May 11, 1999. To become a member, complete and return the form on page 3. For more information on membership, click here or call the Jacobs Institute at 202-863-4990.
Linda Applegarth, EdM, EdD
June 27-30, Second National Conference on Women, presented by the Substance Abuse and Mental Health Services Administration in partnership with several other federal agencies, at the Wilshire Grand in Los Angeles, CA. The conference will focus on women's issues within the social service arenas. For more information or to register, call 202-973-8657 or toll free at 1-877-279-1539 or visit the group's web site at www.samhsa.gov.
July 17-23, Annual Meeting of the National Wellness Coalition in Stevens Point, WI. For more information, contact the Coalition at 800-243-8694 or visit its web site the www.wellnessnwi.org.
August 2-4, National Conference on Health Statistics: Health in the New Millennium: Making Choices, Measuring Impact, Washington, DC. Conference provides a national forum for discussion about uses of data, data needs, presentation of new information about National Center for Health Statistics programs and resources, and information on state and local initiatives. For information, visit the NCHS web site at www.cdc.gov/nchswww/nchshome.htm.
August 2-4, National Healthy Mothers, Healthy Babies Coalition Tenth Biennial Conference, Seattle, WA. Conference will explore new opportunities to close the gaps in health care disparities for ethnic and racial groups and showcase innovations for improving access to health care and quality of service. For information, call 703-836-6110 or e-mail [email protected]
Vive la Difference! a video and comprehensive guide to biologic differences between men and women, from the Society for the Advancement of Women's Health Research, provides health professionals important information about gender differences affecting the brain, heart, liver, and immune system. The Society recently distributed 700 copies to medical schools. To order a copy of the $35-video, call Connie Tomber at the Society at 202-223-8224.
Clinical Management of Breastfeeding for Health Professionals, a two-part video teaching course developed by Vida Health Communications with the Association for Women's Health, Obstetric, and Neonatal Nurses (AWHONN), covers the fundamentals of lactation and breastfeeding, presenting clinical pathways for successful management of lactation. Continuing education credits are available for nurses who complete the course. The cost is $395 for both videos. To order, call Vida Health Communications at 617-864-4334 or e-mail [email protected]
Scholars Program in Women's Health, research grants from Pfizer and the Society for the Advancement of Women's Health Research, will award nearly $600,000 over the next three years to medical school faculty to advance scientific research on women and cardiovascular disease, mental health, or reproductive biology. Awards will go to physicians who have completed clinical training, are appointed to a university faculty, and will conduct original research. For information and an application, call 800-201-1214.
The Robert Wood Johnson Community Health Leadership Program annually provides ten $100,000 awards to outstanding individuals to create or enhance health care programs for unserved or underserved communities. Nominations are due September 16, 1999. For more information, write to CHLP, 30 Winter Street, Suite 920, Boston, MA 02108.