A Publication of the
Jacobs Institute of Women's Health
September 1997 - Volume 5, Number 3
Prevention of unintended pregnancy is truly uncharted territory for managed care plans, but speakers at a Jacobs Institute symposium began mapping out the terrain for a packed house on July 30. The program, entitled "Managed Care and Unintended Pregnancy: Testing the Limits of Prevention," was the third in the series "Defining Issues and Monitoring Trends in Women's Health and Managed Care." Everyone agrees that unintended pregnancy is a problem, notes panel moderator Leo Dunn, MD, FACOG, but they then proceed to fight each other's solutions.
Representatives of managed care plans, county and public health departments, congressional staff, and national organizations contemplated some frightening statistics: 10% of adolescent girls become pregnant every year, and more than 85% of those pregnancies are unintended, according to Joan Fine, MD, an adolescent specialist with Medical West Associates, a Blue Cross Blue Shield of Massachusetts HMO. The United States still leads the industrialized world in the rate of teen pregnancies, she said, and it is estimated that the adolescent population will increase by 15% between 1995 and 2005, so the number of unintended pregnancies is likely to rise. Reductions in dependent coverage mean that the number of uninsured adolescents is also on the rise. And despite the preventive focus of managed care, there is little evidence that managed care has adopted and promoted contraceptive services to the same degree as other preventive services for women like the pap test and mammography screening.
Some progress in preventing unintended pregnancy has certainly been made under managed care, according to Rachel Benson Gold, senior public policy associate at The Alan Guttmacher Institute. She pointed out that whereas about half of traditional fee-for-service plans cover no reversible contraceptive method at all, only 7% of HMOs don't cover some form of reversible contraceptive method. Family planning clinics have dealt with the advent of managed care in two ways, Ms. Gold said: by leveraging existing relationships--"hooking up with a community health center, to subcontract for contraceptive services"--and by working in coalitions when negotiating with large managed care plans.
Dian Harrison, president and CEO of Planned Parenthood--Golden Gate, a merger of several smaller affiliates, described how Planned Parenthood became more attractive to large managed care organizations, both by merging individual clinics seen as too "fragmented" and by expanding their services into primary care. Planned Parenthood affiliates now have contracts with or are members of 11 managed health care systems in California.
"For reasons that escape me," said Ms. Gold, " most health plans make a distinction between prescription drugs in general and oral contraceptives." HMOs don't seem to make that distinction as often as other types of plans. Legislation has been introduced in the Senate and House to require coverage of contraceptive devices and methods; similar legislation is "perking along at the state level," she said. Cynthia Dailard, legislative assistant for health care issues in the office of Senator Olympia Snowe (R-Me.), co-sponsor of the federal bill, outlined the "simple principle" embodied in Senate bill S.766, in committee at the time of the symposium. The bill would ensure that (1) any insurance company that covers prescription drugs covers contraceptive drugs and (2) any insurance company that covers outpatient services covers contraceptive services. "The Equity Prescription Insurance Coverage bill is an argument for parity, not a mandate for coverage," Ms. Dailard said. The bill defines contraceptive services as consultations, examinations, and procedures provided on an outpatient basis to prevent unintended pregnancy.
Even when health plans cover contraceptives, they do so based on provision of such services to adult women, according to Dr. Fine: "For example, DepoProvera is a great contraceptive method for teens, but plans often require a co-payment equal to 5 years' worth of the pill, which teens can't afford." She pointed out that managed care plans could easily implement screening for teens at risk of unintended pregnancy but that the lack of age-appropriate practice guidelines and the time constraints typical in managed care environments hinder the implementation of such screening.
Lack of confidentiality and the difficulty teens have in getting access to appropriate care--that is, care appropriate to adolescents, rather than young girls or women--are major obstacles. She urged the adoption of policies to remove such obstacles: managed care plans should cover all costs of contraception for teens (an extremely cost-effective move), and plans should establish an adolescent health care coordinator, to improve delivery of appropriate pediatric and ob-gyn services.
Ms. Harrison, playing devil's advocate, said "If we wait until they enter the health care system, we may be too late; we need education in elementary school." Richard Younge, MD, MPH, vice president and chief medical officer at Bronx Health Plan, said "We need to figure out how to facilitate education so it doesn't only take place at a doctor's visit."
Medicaid covers 15% of reproductive-age women in the United States and provides $1 of every $2 spent on reproductive services in this country, according to Ms. Gold. Dr. Younge, noting that the Bronx Health Plan is a Medicaid managed care plan, expressed concern about legislative coverage mandates, pointing out that "it is an easy step from prescriptive to proscriptive mandates." He believes that women should expect their primary care providers (including adolescent care providers) to offer reproductive health services, and sees a larger impact to society: "When young women who are poor get pregnant, they remain poor," he reminded attendees.
In terms of "prevention after the fact"--emergency contraception--Dr. Fine brought up the fundamental problem of lack of awareness of the technique among providers and teens, despite a national hotline and web site and Dr. Younge described the collateral problem of accessibility to time-critical services. "We need to think about who gets informed," Ms. Gold pointed out. Many plans provide information to enrollees and expect them to pass that information on to dependent adolescents. "We need to think of creative ways to see that those who need services are informed directly," she said.
The symposium series is funded by a grant from The Commonwealth Fund, the Henry J. Kaiser Family Foundation, the Lilly Center for Women's Health (Eli Lilly Company), and Wyeth-Ayerst Laboratories. The fourth symposium, which will address STDs, will be held October 29, in Washington, DC. For more information, contact Elizabeth Markle at the Institute at 202-863-4990 or .
Researchers, health care purchasers, and managed care representatives discussed ways to make managed care more cost-effective and to improve preventive care services for women at "Players in the Marketplace," the second Women's Health Leadership Seminar, on June 25 in Oakland, Calif. The seminar was co-hosted by the Jacobs Institute of Women's Health and the Pacific Institute for Women's Health, and presented in conjunction with the Women's Health Collaborative, a statewide coalition whose mission is to improve the status of women's health in California. The program was sponsored by a grant from the James Irvine Foundation.
While managed care is generally believed to outperform traditional indemnity insurance in providing preventive care, one form of managed care, the looser PPO arrangement, actually fares worse than indemnity on many screening services important to women. Helen H. Schauffler, PhD, MSPH, associate professor of health policy at the University of California at Berkeley (UCB) presented data from the 1996 California Behavioral Risk Factor Survey and the 1996 UCB Survey of California Health Plans. Dr. Schauffler's findings revealed that HMO and point-of-service (POS) options were more likely to cover comprehensive clinical preventive services and offer comprehensive health promotion programs--although the data showed that most women are not using these programs.
Noting that the U.S. Deputy Assistant Secretary for Women's Health, Dr. Susan Blumenthal, has said that "changing her health-related behaviors should be a woman's chief health concern," Dr. Schauffler examined the data to determine the extent to which the health system was encouraging healthy behaviors. She found that the public health safety net was doing a better job than all types of private insurance in providing counseling services in areas such as smoking cessation, diet and exercise, alcohol use, STDs and HIV, and gun safety. Her data indicate a large number of missed opportunities, even among women with insurance.
Rhoda Nussbaum, MD, Kaiser Permanente's new Women's Health Leader, noted that Kaiser now serves one third of northern California residents. To focus the plan's efforts in women's health, a Kaiser task force in 1996 identified areas to emphasize in women's health delivery, including obstetrics and perinatal health, breast cancer, menopause, adolescence, and research. Its work led to the creation of the permanent Women's Health Leader position and an agenda focused on new models of care delivery, convenience for the consumer, partnership and trust, and an aggressive research agenda.
Rosaline Vasquez, MD, associate medical director for CIGNA HealthCare, described women's health initiatives in preventive health, specific therapies such as autologous bone marrow transplants for breast cancer, improved access to specialists such as ob-gyns, and new programs such as a 24-hour health information line. She elaborated the advantages of the independent practice association, or IPA, configuration, which allows the health plan to offer enrollees a variety of providers, settings, and locations. Dr. Vasquez added that public policy mandates are not the way to ensure quality health care and instead "drive up costs, which we all pay."
Catherine Brown, a consultant to the Pacific Business Group on Health (PBGH), discussed the health care purchasing strategies used by PBGH's 33 private and public members. PBGH negotiates both premiums and the reporting of performance data by health plans. Participating plans agree to put 2% of the premiums paid by PBGH members at risk for performance measurement against predetermined target rates negotiated by the plans and purchasers together. The initiative uses the HEDIS measures of the National Committee for Quality Assurance, but PBGH is looking to move "beyond HEDIS" to more outcomes-based measures.
"No payers have successfully privatized public health," said Gordon Norman, MD, regional medical director for PacifiCare, noting that Dr. Schauffler's data presented a "sobering" picture. He contrasted the fee-for-service system, characterized by "supply management," with the newer emphases on demand and care management and then outlined some specific responses by PacifiCare to four general areas of women's concern with managed care: a well-woman benefit and Express Referral program (access), female and male infertility diagnosis and treatment and the Healthy Pregnancy program (reproductive benefits), training, brochures, self-efficacy aids and risk assessments (communication), and strategic provider alliances and provider profiling (quality improvement).
An overall theme that has emerged in this seminar series is the health care consumer's need for assistance in learning the ways of managed care--in the form of consumer-friendly information, patient navigators, and ombudsman programs. Attendees' questions indicate that they are having to become fairly sophisticated managers of their own health care under managed care. Helen Rodriguez-Trias, MD, codirector of the Pacific Institute, enjoined attendees to bring women's health concerns to the remaining hearings of the Governor's
The difficulties of meshing patient satisfaction, physician reimbursement, and quality health care services in the managed care environment engrossed a packed house at a Jacobs Institute symposium on June 4. The program was the second in the series "Defining Issues and Monitoring Trends in Women's Health and Managed Care."
In her opening statement, Elizabeth McGlynn, PhD, joked, "I'll have communicated my point today if you walk out of here more confused than when you walked in, because that's the state health care is in." Dr. McGlynn is a health policy analyst at the RAND Corporation. A fundamental confusing element, she said, is the way in which benefits are packaged by health care plans. Because of the way benefits packages are designed, consumers often find themselves comparing apples to oranges in evaluating benefits. Dr. McGlynn recommended asking a few across-the-board questions: what services are covered? what are the rules for accessing services? what are the prices of different services? and finally--since twice as many women as men spend more than 10% of their income on out-of-pocket health care expenditures--are any services carved out?
Another variable element is the method by which physicians are reimbursed for services. A recent Commonwealth Fund survey found that physicians, on average, work under 10 different contracts. Fee-for-service insurance, Dr. McGlynn said, offers physicians an incentive to provide more services, because they will be paid for each service. Managed care reverses this incentive system. Although current data do not indicate that reimbursement mechanisms affect the quality of care delivered, the question becomes one of stretching reimbursements to cover services. "What can you do with $9 per member per month in terms of dealing with, say, pediatric needs?" she asked.
Ob-gyns have higher rates of participation in managed care contracts, especially in PPOs and HMOs, than do family practitioners and internists, although managed care contracts are not their major source of revenues. "Lots of obstetricians are paid a global fee for prenatal care, which is in effect a capitation. One might even think of it as a carveout," suggested Dr. McGlynn. A little more than half of managed care contracts for family practice and internal medicine are capitated. Capitation reduces utilization/resource use when compared with fee-for-service arrangements but shows no difference in outcomes. Interestingly, she pointed out, patients who face higher copayments and deductibles tend to use fewer services but, again, the data show no difference in outcomes, "which unfortunately suggests that much of what we do in health care has little effect on patient outcomes."
Ruth Brannon, director of rehabilitation and disability management at the Washington Business Group on Health (WBGH), offered some perspective on employers' motivations in selecting health care plans. In a survey of benefit managers at 200 WBGH companies, she said, one finding stood out: "Across the board, managed care options seemed to provide coverage for the widest array of services." Most of these large employers are self insured but still provide options to employees; many have education campaigns to encourage enrollment in managed care options. Ms. Brannon sees a move on the part of employers and physicians toward taking the consideration of outcomes measures "out of the clinical realm alone and considering other kinds of outcomes."
The average cost of managing disability and chronic illness, she said, is approximately 8% of total payroll costs. And up to 30% of all employer paid health care is related to unhealthy behavior. Many companies see a need to reduce the percentage of their health care expenses going to treat the effects of unhealthy behaviors on the part of employees, according to Ms. Brannon, "but these companies have realized that they can also affect turnover and retention of workers by providing support for the women who work for them."
Rosalyn Baxter-Jones, MD, FACOG, director of Women's Health Services, FPA Medical Management, Inc., and president of the Women's Health Pavilion (San Diego), described a pilot program of centers which offer primary care for women specifically in a setting open to both men and women, staffed with both male and female providers. Access and services outside urban areas is also changing, according to Maxine Brinkman, BSN, director of Women's Services at North Iowa Mercy Health Center and president of the National Association of Women's Health Professionals. Working in what she called "a true rural health area," she finds that in many plans only the most basic services are offered, and not always at the frequency desired. "Our incentives reward volumes and relative values," she pointed out. "For our patients these incentives are misaligned." Rural women's biggest complaint about health care is that their provider doesn't spend enough time with them. "Even if they just come in for a pap test," she said, "they've got a whole bunch of issues to discuss." The data presented by Dr. McGlynn and Ms. Brannon show that women do want education in primary-preventive care, but providers are not reimbursed for education services. "We need national outcome data to prove the value of educational programs such as these," said Ms. Brinkman. The challenge is to increase women's understanding of what quality health care is, and how they can get it.
How to get it, said Dolores L. Mitchell, executive director of the Massachusetts Group Insurance Commission, is clear: "You have to throw your weight around." As head of the state agency that provides state employee health benefits, she noted, "If you're a 900-pound gorilla like I am, that's easy. If you're not a 900-pound gorilla, join a coalition!" Purchasers can thus exert the leverage of the market to influence health plan behavior. She frankly appraised the "anti-managed care hysteria," as generated more by complaints from physicans than objections from consumers. "The motives and morals of the opposing sides, rather than the facts, have dominated the discussion," she said, arguing that "purchasers really do influence what providers offer." Ms. Mitchell stressed that the aging of the U.S. population means that, despite prevention-focused services, "health care is going to cost more in the future. All of us, if we don't get hit by a car, are going to get sick and need care."
Predicting the cost and outcome of care is going to become ever more tricky, said Robert St. Peter, MD, senior medical researcher at Mathematica Policy Research, Inc. and the Center for Studying Health System Change. There are not enough current data, he pointed out, and the data on preventive care use in managed care settings are old. "Very simple issues such as what services are included in the capitation amount are going to be very important," he said. "In my experience in researching how employers choose health plans, it's price, price, price. And after price, it's choice of providers." Dr. McGlynn pointed out that studies have revealed no relationship between patient satisfaction and receipt of high quality services. "We need to remember that they're not the same thing."
The symposium series is being underwritten entirely by the Commonwealth Fund, the Henry J. Kaiser Family Foundation, Wyeth-Ayerst Laboratories, and Eli Lilly & Company. The third symposium is covered in another article in this issue. The fourth symposium, addressing STD prevention and treatment under managed care, will be held October 29 in Washington, DC. For more information, contact Elizabeth Markle at the Jacobs Institute at 202-863-4990 or .