A Publication of the
Jacobs Institute of Women's Health
March 1997 - Volume 5, Number 1
Can women get better health care from a managed care system than they can from traditional fee-for-service? There are no simple answers, but as medicine continues its rapid shift from fee-for-service to managed care, those with an interest in women's health are beginning to assess how to take advantage of medical restructuring in order to ensure improved primary health care for women. In a symposium February 7 sponsored by the Jacobs Institute, the first of eight to be held as part of the project, "Women's Health and Managed Care: Defining Issues and Monitoring Trends," two presenters and four reactors discussed how managed care is treating women and what the future holds.
"These are tough problems to solve," said presenter Karen J. Carlson, MD, who in 1985 at Massachusetts General Hospital established a multidisciplinary unit for primary care for women, the first of its kind in the nation. Though "managed care does not provide a panacea," Dr. Carlson concluded, with its emphasis on primary care, incentives to improve coordination of care, ability to measure outcomes, and potential for a multidisciplinary approach, it offers advantages over traditional delivery systems. But, she added, some aspects of managed carefor example, the erosion of the physician-patient relationship and managed care's continued focus on the diseases of menare less optimistic signs for women.
As managed care evolves, however, it offers a unique opportunity "to use this very fluid situation to bring women's health care to a better place," said Eileen Hoffman, MD, associate director for education at the Mt. Sinai Women's Health Program and a founding board member of the American College of Women's Health Physicians, the second presenter. "Once managed care organizations follow through on reining in costs of specialty care, they will focus on decreasing the cost of primary care," Dr. Hoffman predicted. "Primary care will increasingly be delivered by teams that serve defined populations."
"It's interesting to think of women as a defined population," she noted. "Managed care organizations ask, as part of their business strategy, how can we best deliver primary care services to women? by what provider? in what setting? They can redress deficiencies in women's health care at the same time they are achieving their economic and organizational goals."
Dr. Hoffman defined a number of major problems, though, in considering women as a specific population. Fragmentation of care, what one article has referred to as "a patchwork quilt with gaps," is one, perhaps best illustrated by mental health carve-outs. "We have to think about how to bring mental health to the primary care setting," she said. "We need a cadre of mental health clinicians trained in short-term behavioral therapy."
Dr. Hoffman also emphasized shifting roles in managed care for health care providers, with nurse practitioners serving in a primary care/preventive care/gatekeeper role and able to apply the multidisciplinary biopsychosocial orientation that receives greater emphasis in nursing school than in medical school.
Carol Aschenbrener, MD, senior scholar in residence at the Association of Academic Health Centers, was the first reactor. She addressed the issue of physician training. "Changing curricula is a tough, slow, but possible process," she said. She emphasized the importance of understanding the existing system and power structure in order to effect change. Another important point, she said, is that "women are not a homogenous group. It is critical to understand and say at every opportunity that age and race and sexual orientation and socioeconomic status and education affect women's health status and how they seek health care."
Kaiser Permanente has been studying these issues, reported Carol Havens, MD, director of continuing medical education for the insurer in northern California. As primary care providers carry an increasingly heavy load in managed care systems, and another large component of primary care comes from nurse practitioners and physician's assistants, competency of providersincluding communications skillsis a critical issue, she added.
From the consumer point of view, said Cynthia Pearson, executive director of the National Women's Health Network, "if you look at the media, you'd think that all women want is their ob-gyn for primary care and longer hospital stays after childbirth." But the traditional issues of concern to womenaccess to care, quality of care, and information as a source of powercontinue to be issues in managed care systems. "Managed care can offer less fragmentation, and therefore a more holistic approach, less overuse, and the potential of better access to a full range of care," she said. "But it cannot solve problems of access to care for the uninsured. That must be solved by the states. A two-tier system is the peril of the future."
Myra C. Snyder, RN, EdD, president and CEO of the California Association of HMOs, put a political spin on the discussion. "What we really need to look at in the delivery of women's health care is the politics," she said. She sees the accreditation period for health plans is an opportunity for individuals to have an influence. "If you work at the employer and NCQA level," she suggested, "it's much easier to have an influence."
Audiocassettes of the symposium are available for $12 plus $3.50 shipping and handling. Copies of the papers commissioned from Drs. Hoffman and Carlson are available upon request from the Institute for $7.50 prepaid for copying and shipping. Copies of the first Insights background paper, "Women's Primary Care in Managed Care: Clinical and Provider Issues" are available by calling 202-863-4990.
Cross-culteral perspectives, hormone replacement therapy (HRT) decision-making, and alternative approaches shaped the discussion at the Jacobs Institute's January 29 breakfast seminar, "Healthy Approaches to Menopause." Key among the notes sounded by the three speakers was the fact that menopause is a natural process that does not cause problems for most women, regardless of nationality.
"Physicians need to approach HRT decisions with the idea that they are dealing by and large with normal women," said Anthony Scialli, MD, director of the ob-gyn residency program at Georgetown University Medical School and director of the Reproductive Toxicology Center. Providers have a public health responsibility to present the option of HRT to women as preventive medicine, he said, "because HRT decreases the incidence of atherosclerotic heart disease by about 30 percent and the risk of fracture by at least that much." But each provider treats only one woman at a time, he pointed out, and for that one woman, concerns about breast cancer risk may carry greater weight than avoiding heart disease.
The traditional approach to counseling women he described as "a scientific effort to lay out pros and cons and help the patient strike a balance between them, an effort that substitutes the physician's values for the patient's." Dr. Scialli urged a different approach, one that lays out the statistics but accommodates how the woman in question feels. "I make no bones about the fact that I personally think that HRT is a good idea; if I were a woman, I would choose it," Dr. Scialli said. "But at least half my patients choose not to take it, and their values are more important than mine in this case."
Physicians need to inform women of alternative medications and lifestyle changes that may suit them better than HRT, he said. But women taking non-pharmaceuticals need to recognize that they are still taking medications, he noted, saying that he points out to his patients that he prefers to use medications that have been tested.
Dr. Fugh-Berman has been a consultant with the NIH Office of Alternative Medicine; she is a medical officer in NIH's Contraceptive Development Branch and chair of the National Women's Health Network. In her general practice, she offers patients conventional and alternative therapies. She described the hormonal effects of various herbs, from evening primrose oil to ginseng, saint johnswort, and gingko, as well as soybean products, many of which contain phytoestrogens. "Women in Asia have a lower rate of breast cancer than western women," Dr. Fugh-Berman pointed out. "One theory to explain this is that Asian women eat a lot of phytoestrogens, effectively lowering their estrogen production by making their estrogen receptors perceive their needs as being met. It may be that these women have lower estrogen levels because of their lifetime intake of soy products, that they have in effect been ingesting a natural form of HRT."
Dr. Fugh-Berman also discussed other alternative therapies, from biofeedback in learning Kegel exercises for incontinence to the use of cranberry and blueberry juices and lactobacilli in fighting urinary tract infections. A question from the audience about calcitonin injections raised the issue of non-hormonal treatments for low bone density. Dr. Fugh-Berman pointed out that magnesium and boron are also very important for bone strength, and that high intakes of protein, phosphorus, sodium, and caffeine deplete calcium levels in the body. She suggested that bisphosphonates will probably replace calcitonin soon.
"In the social sciences, we think of menopause not so much as a physical fact but as a social construct," said Margaret Lock, PhD, professor of medical anthropology in the Department of Social Studies of Medicine at McGill University. The term "menopause," she pointed out, was invented in 1821 by a French physician.
Dr. Lock has conducted original research on menopause in Japan and East Africa. Her cross-cultural data show that hot flashes and night sweats are not equally distributed across women and that not all postmenopausal women are at equal risk for such problems as heart disease. Japanese women, for example, report a much lower incidence of trouble sleeping, depression, and night sweats than do Canadian and American women. And, significantly, she pointed out, there is no word for hot flash in Japanese, nor in two Indian languages.
There is a Japanese word for a long gradual life transition not unlike the old-fashioned term "climacteric"; but the end of menstruation plays only a small part. Nearly a third of the women she studied who had stopped menstruating said they had no menopausal symptoms. What symptoms the women reported might be unrecognizable to an American ob-gyn: shoulder stiffness, headaches, getting tired easily, worsening eyesight.
The Samburu women of Northern Kenya--"none of whom have eaten a single green leafy vegetable in their lives," Dr. Lock pointed out, "but who have a very calcium-rich diet"--report very few menopausal symptoms at all. Because they spend most of their reproductive lives either pregnant or lactating, it is impossible for them to tell at first when they have stopped menstruating.
The 19961997 breakfast seminar series is sponsored by The Monsanto Company and G.D. Searle. Audiocassettes are available for $12 plus $3.50 shipping and handling. Resource packets on menopause are also available for $15 plus $3.50 shipping and handling. For more information, call the Jacobs Institute at 202-863-4990 or e-mail .
The Jacobs Institute has received a $75,000 grant from the James Irvine Foundation to conduct a series of Women's Health and Managed Care Leadership Seminars in California. The purpose is to increase awareness of and disseminate information about managed care trends, policies, and practices to health care providers, researchers, community leaders, and women's health advocates in the state. Each seminar will explore the implications for women of changes in the health care delivery system. The Jacobs Institute will organize the seminars in partnership with the Pacific Institute of Women's Health, in Los Angeles, headed by Francine Coeytaux and Helen Rodriguez-Trias, MD. Jacobs Institute members and other interested persons will be invited to the seminars, which will be held this year in several locations throughout the state. To be put on the mailing list, call the Institute at 202-863-4990.