A Publication of the
Jacobs Institute of Women's Health
Volume 7, Number 3, September 1999
Purchasers and Health Plans Come Together
"Good womens health is good business and good for the bottom line," said Nikki Heidepriem, JD, in her welcoming address at the Jacobs Institute conference "Value Purchasing: Investing in Womens Health." Heidepriem, a member of the Institutes Board of Governors, underscored the reason the Jacobs Institute, in conjunction with the Washington Business Group on Health, convened the meeting of health insurance purchasers: "We know you can purchase better value by taking into account the unique health care needs of women."
The participantshuman resources directors, medical directors, benefits managers, and others charged with negotiating contracts and services with health insurers for their companys employeesrepresented such corporations as the Coca Cola Company, Delta Air Lines, Ford Motor Company, Perdue Farms, Procter and Gamble, Sara Lee Corporation, the U.S. Postal Service, and the U.S. Office of Personnel Management. They came to Washington, DC, June 17 to learn what some companies and health plans are doing to better address the health care needs of women. (See "Investing in Womens Health: Models for Success.")
Mary Jane England, MD, president of the Washington Business Group on Health, noted her organization is helping businesses address the issue through such efforts as Business, Babies, and the Bottom Line, a publication that addresses womens reproductive health as it relates to workplace productivity.
"We need to look broadly at womens health in terms of the community, the environment, and the workplace," said England in an introductory address at the conference.
Keynote speaker Eileen Hoffman, MD, summed up the current situation this way: "If corporate America has decided that health care should be employer based, than employers have a financial and social responsibility for ensuring that costs are contained and quality is assured." The problem is that costs are rising and quality is questionable. The solution, she said, is gender-based medicine.
By "looking through a gender lens," Hoffman emphasized how such widespread health concerns as hypertension, asthma, diabetes, and depression affect women and men differently and in some cases require different treatments. This concept is relatively new, and physicians, insurers, purchasers, and consumers are only now beginning to consider its ramifications. For example, it was recently discovered that stress tests are an inexpensive and effective method for detecting heart disease in men but not in women.
Further, Hoffman noted, "Neutrality has kept us from identifying violence as a risk factor for disease." Victims of domestic violence are seen in emergency rooms for acute injuries, but Hoffman points out they often suffer from mental health conditions and chronic pain, are more likely to smoke, and are more likely to suffer obstetric complications as a result of abuse during pregnancy. "Violence is a stronger predictor of utilization of health services than age," said Hoffman.
Hoffman emphasized that direct and indirect costs of illness and disability among women affect a companys competitiveness. She notes employers have been reluctant to get involved in health care issues but asked, "In what other aspect of business would an employer not be involved in making sure the supplier provides a quality product?
"Employers have an opportunity to set the standard that insurers have to meet. When they do it with a gender-based approach, it will decrease the costs of programs and premiums and increase the quality of care, the value of care, and equityequal quality based on an appreciation of sex and gender differences," she concluded.
With a shrinking pool of young employees to draw on, employers increasingly use health insurance plans and health programs to attract and retain workers, said Mary Anne Hraba in the second keynote speech. Hraba represents Watson Wyatt, a consulting firm that works with employers choosing health care coverage.
Hraba identified many of the same problems as Hoffman, saying the health care market is in flux, health costs are rising, the quality of care is uneven, and consolidations among insurers are limiting consumer and purchaser choice. In addition, the workforce overall is aging, which means an increase in health care usage, and employees in general are dissatisfied with the status quo of health care coverage.
In addition to the rising costs, Hraba said her companys clients are concerned that "health plan administration is poor and getting worse, which impacts employers business results and employee satisfaction."
In response, Hraba and her colleagues recommend more companies, especially large corporations, establish long-term partnerships with insurers. For example, when companies agree to a multi-year contract with an insurer, the insurer has an incentive to improve care because the company will not be shopping around for the cheapest plan every year.
Employers who partner with plans "are more likely to see a health plan as an investment in human capital and use it as a tool to attract workers and increase retention," said Hraba.
Thoroughly and regularly evaluating health care benefitsthrough audits and performance standards, for examplecontributed to better employee satisfaction, as determined by a study of best practices, said Hraba. Companies who did these things found they incurred lower cost increases and productivity was improved.
More employers are sponsoring their own health programs for their employees, such as lactation centers and mammography and osteoporosis screening. "Usually theres a payoff, for example $2 saved for every $1 invested," said Hraba. "Even without the savings," she emphasized, "employees are better focused on productivity" when such programs are available.
Hraba concluded, "Improved health care will be a win-win situation for employers, employees, and health plans."
In breakout sessions, participants discussed more specific initiatives and barriers to improving womens health care in relation to cardiovascular disease, depression, domestic violence, and pregnancy. Each session featured brief presentations from an expert on the subject, a corporate purchasing representative, and a representative from a managed care organization, followed by group discussion led by a facilitator. Later in the day, facilitators presented a synopsis of all the discussions.
Many employers already know that "good womens health is good business." Following are some of the programs showcased at the Jacobs InstituteWashington Business Group on Health summit.
Delta Airlines employs 18,000 flight attendants, 95% of whom are female. Delta knows that flexibility and teamwork are key to ensuring healthy pregnancies among its women employees. Eighty percent of Deltas employees are covered by CIGNA Healthcare, and the two corporations work in partnership: CIGNA provides the care and Delta encourages employees to make use of the following:
CIGNA subcontracts with the March of Dimes Healthy Babies program to provide some of these services.
Through its work/life programs, Delta tries to accommodate pregnant flight attendants (who must stop flying at 26 weeks of gestation) and all employees who are new mothers in a number of ways. Flight attendants are given the option of moving into a ground job at the start of pregnancy (in order to reduce the fetus exposure to cosmic radiation), or they may work part-time, job share, or take unpaid leave. After the baby is born, employees can use a combination of sick leave and disability to stay home and care for their infants. Nursing mothers are able to take additional time off from work.
Recognizing both the direct and indirect costs of pregnancy, Delta understands that the company and its employees share an interest in ensuring mothers and babies health.
"Taking the First Step" was an innovative program designed by Sara Lee Corporation to address depression in female employees. The programs goals were to provide information and increase awareness about depression, provide confidential screening resources, encourage women to seek assistance, and demonstrate employer support.
All corporate office female employees were invited to attend a 1 1/2-hour educational luncheon. An off-site setting was chosen to make attendees feel more comfortable and safe in speaking. Expert presenters included the (female) president of the Illinois Psychiatric Society, informational hand-outs and take home gifts were distributed, and clinical social workers from a local hospital were available to do confidential screenings. A review of the program, which appeared on the front page of the next Sara Lee Corporation newsletter, provided key informational components of the seminar, highlighted the companys employee assistance program (with its toll-free number), and encouraged all employees to call for information or assistance.
Fifty of the 85 women who were invited attended the program. Fourteen attendees participated in confidential screenings, and several of these women were diagnosed as clinically depressed (more women would have participated in the screenings if there had been more time and more screeners). The program received strong support from senior management and positive employee feedback. For its next seminar, Sara Lee is considering a longer time frame and small break-out sessions to encourage more discussion and questions.
The fact that heart disease is the number one cause of death among women was one incentive for Anthem Blue Cross Blue Shield, Procter and Gamble, and Kroger to join forces to offer a comprehensive Healthy Woman program that utilized the resources of all three companies. This month-long initiative took place in 96 Kroger grocery stores and reached 100,000 women with screenings for heart health (as well as screenings for other conditions of concern to women, including skin cancer, breast cancer, and osteoporosis). Womens health kiosks in Kroger pharmacies offered a detailed risk assessment, including family history, cardiac risk factors, knowledge of cholesterol, and blood pressure readings. Twelve percent of the women screened for heart health were referred to their doctors for further evaluation.
Pepco, the Potomac Electric Power Company, focused on cardiovascular health among its employees for purely practical reasons: cardiovascular disease accounts for the single largest expenditure of health care costs by disease category among its indemnity plan enrollees, and high blood pressure was the primary diagnosis in two thirds of the cases. The solution was to work with the Network to Improve Community Healths Hypertension Project. Pepco employees were offered a preevaluation test, blood pressure screenings and education, and an information brochure with the blood pressure test results. When indicated, a referral letter was sent to a private physician for additional follow up.
A tragedy involving domestic violence claimed the life of a federal employee. In response, the federal Office of Personnel Management marshaled its resources to produce a guidebook, "Responding to Domestic Violence: Where Federal Employees Can Find Help," for employees who are victims of domestic abuse, as well as supervisors, coworkers, and other human resource professionals. Like a first aid manual, the guidebook helps users to assess the situation, find resources, and get skilled help. It builds on the personnel system and the various federal office resources available to victims and managers.
On September 1,1999, the Jacobs Institute will convene an expert panel to develop guidelines for health plans on counseling women on menopause. Jacobs interest in this project was sparked by discussions with the National Committee for Quality Assurance (NCQA), the Washington, DC-based organization that oversees the evolution of the Health Plan Employer Data and Information Set (HEDIS). Public and private purchasers of health care use HEDIS to compare the quality of care and services provided by managed care organizations. HEDIS 2000 will contain a new measure of how well health plans have counseled female members about their options for managing menopausal hormonal changes. The measure is based on a survey of a sample of women between 45 and 55 years old.
As soon as news of this measures inclusion reached health plans, they began to call NCQA for guidance on providing counseling. Many organizations involved in womens health have published guidelines for providers on menopausal counseling, but NCQA asked Jacobs to synthesize a new set specifically geared toward the HEDIS measure, which assesses the breadth of the counseling and the degree to which it was personalized for the woman receiving it. Through the generous support of The Commonwealth Fund, the Jacobs staff will be able to work with the expert panel members to finalize guidelines by the end of this year, which will make them available to health plans before they begin to implement the survey measure.
The panel will be chaired by Drs. Bill Andrews and Carol Weisman, members of the Jacobs board as well as co-chairs of NCQAs Womens Health Measurement Advisory Panel, the committee that developed the menopause counseling measure.
As she explains in her essay in this issue of In Touch, Kani Ilangovan, our summer intern, devoted her two months with us to an exhaustive search for published papers, professional guidelines, physician and patient educational materials, and decision aids. She synthesized her findings into a document that will help to inform the panels discussions. Not only were her dedication and the quality of her work exceptional, but Kani herself is a delightful person, and it was a pleasure to have her with us. We will miss her and we wish her the very best in medical school and beyond.
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." The article will be published in Womens Health Issues, the journal of the Jacobs Institute. Sambamoorthi and colleagues studied estrogen use among 4,365 elderly women. Overall, 13% of the women used estrogen during 1995. Age, race, income, health history, and whether the woman had seen a gynecologist in the previous year all affected estrogen use. Dr. Sambamoorthis work was funded in part by grants from the Agency for Health Care Policy and Research and the National Institute on Aging. The study, along with others submitted, will be published in the November/December 1999 issue of Womens Health Issues.
An Interns Experience: Two Months at the Jacobs Institute
The first time I read about the Jacobs Institute, I was surrounded by stacks of medical textbooks and illegible notes, midterm finals were ominously looming ahead, and I was taking a study break, imagining how I would spend my summer. As I write this, I am again surrounded by books (this time they involve menopause and patient counseling), the deadline for my fellowship paper is approaching, and I am taking a break to reflect on how my summer was spent.
It was an easy decision to choose Jacobs Institute of Womens Health as the site at which I wanted to work for the summer through the Washington Health Policy Fellowship Program sponsored by the American Medical Student Association. I have always been interested in womens health and, looking through the Jacobs Institutes web site, I was impressed by the breadth and the quality of the research that is performed here and at the nonpolitical, multipronged approach to educating society about significant issues in womens health.
My first day here was immediately before the conference on purchasing, so I was introduced to Jacobs in blazing glory, dealing head-on with difficult issues such as domestic violence, depression, cardiovascular health, and family planning in a practical, action-focused manner. I was inspired by the way the Jacobs Institute encouraged businesses to make the well-being of their employees a priority, provided them with tools and data, and gave them opportunities to brainstorm.
Since the conference, I have been researching materials for the panel discussion in September on developing guidelines on implementing the Health Plan Employer Data and Information Set (HEDIS) 2000 "Management of Menopause" measure, which requires health plans to provide menopause counseling to perimenopausal women. This project has been fascinating and well worth the many hours Ive poured into it. I have learned about the various types of patient counseling available, ranging from traditional health care providers to patient discussions to interactive CD-ROMs and tailored decision aids. I have also learned about womens attitudes, expectations, and experiences of menopause and how these vary from culture to culture.
One of the areas I found most intriguing was individualizing counseling for the patients needs. Doctors can write prescriptions, but ultimately its up to the patient to have them filled and take them. Ive learned about various methods of creating a decision-making partnership between patient and health professional in which both work together to identify the needs and goals of the patient and to achieve them in an atmosphere of mutual trust and respect. This is the kind of medicine I would like to practice one day, and I am very grateful that my time with the Jacobs Institute has given me, as it has for so many others, tools to accomplish my goals.
We are currently accepting applications for the 1999 Jacobs InstituteOrtho-McNeil Pharmaceutical Scholar award. Research that considers the changing health care environment, the unmet need for primary and preventive health services, the historic lack of research on womens health, and the importance of social, cultural, legal, economic, and behavioral factors influencing the financing and delivery of health care to women is eligible. The award is a one-year, $30,000 grant. The application deadline is October 15, 1999. For more information, click here.
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.
September 2225, Association of Reproductive Health Professionals Annual Meeting, Hotel Adolphus, Dallas, TX, covers a range of topics, including contraception, domestic violence, and cervical cancer, by and for womens health care providers. CME credits available. Preconference September 2223 addresses health care needs of teens. For more information, call ARHP toll-free at 877-444-ARHP or visit their web site at www.arhp.org.
October 912, National Conference on Women and HIV/AIDS, Los Angeles Convention Center, CA, provides a forum to exchange information among researchers, providers, policy makers, and individuals affected by HIV/AIDS. For more information, call the Talley Management Group at 609-423-7222, ext. 350, or e-mail [email protected]
October 2729, Contraceptive Technology Conference, Sheraton Colonial Square, Atlanta, GA, includes presentations and panel discussions on current research, new developments, and clinical strategies by and for physicians, nurses, and other health care providers. CME credits available. A one-day preconference on October 27 addresses adolescent health care. For more information, call Contemporary Forums, 925-828-7100, ext. 0, weekdays 8 am to 5 pm Pacific time.
Physicians Guide to Prevention and Treatment of Osteoporosis and the accompanying Pocket Guide to Prevention and Treatment of Osteoporosis were developed by the National Osteoporosis Foundation in concert with several national medical societies. For a free copy, contact NOFs Professional Education Order Fulfillment at 1150 17th Street, NW, Suite 500, Washington, DC, 20036, or www.nof.org.
Improving the Health of Adolescent Girls, a policy report from The Commonwealth Fund, discusses the findings of their 1997 survey on adolescent girls health and resulting goals for action. For more information, contact TCF at 212-606-3800 or visit their web site at www.cmwf.org.
Insurance Inequities: A State-by-State Review of Contraceptive Coverage, published by the National Abortion and Reproductive Rights Action Leagues Foundation, outlines current policies around the country. For more information, contact NARAL at 202-973-3000 or visit their web site at www.naral.org.
Welcome to the following new members of the Jacobs Institute, who joined from May 12 to July 31, 1999. To become a member, complete and return the form on page 3. For more information on membership, call the Jacobs Institute at 202-863-4990 or visit our web site at jiwh.org.
Theodore Barrett Jr