Managed Care: Listening to Women
April 25, 1997
By Julianna S. Gonen, PhD
Sarah Samuels of the Pacific Institute for Womens Health and Martha Romans of the Jacobs Institute of Womens Health opened the program and described the overall goals of the seminar series, which include focusing public and health plan attention on key issues around womens health as the delivery system moves into managed care. The series is intended to elicit what women are saying about managed care, to discern their goals and their areas of satisfaction and dissatisfaction. Helen Rodriguez-Trias, also of the Pacific Institute, stressed that as the main consumers of health care, women have the most to gain and lose under managed care. This series provides one avenue for women to speak out and shape what happens within managed care, and she also noted that womens health consumers and advocates should attend the public hearings being held to form recommendations to the Governor via his new health care task force.
The Evolution of Managed Care
Bobbie Wunsch, MBA, President of Health Care Consulting and Management Services, provided an introduction to the program with an overview of the development of managed care. There is indeed hope in managed care for women, as it presents opportunities for delivering comprehensive womens health care, even if this is not yet being fully realized. As much as 75% of the insured population of California is enrolled in managed care, so clearly a large majority of the insured in the state are affected by managed care practices. The managed care concept dates back to the 1920s and was picked up on in earnest by Kaiser around World War II. We are currently in a time defined by intensified price competition, a situation Wunsch dubbed "the War of the Managed Care Networks." She envisions that this stage will give way to a time of cooperation between health plans, purchasers, and providers, with more of a focus on quality as a result of consumer action. Even further down the line, managed care organizations (or MCOs) will indeed be the only existing delivery systems, and they will come to assume greater responsibility for community health as they realize the resulting benefits to their profitability.
The first thing that managed care attempts to affect is cost, by influencing both consumers and providers of care, moving then to the amount of services used and the manner of service delivery. Managed care coverage is highly linked to a womans marital status, a further reason why the stakes for women in managed care are particularly high. Managed care coverage of many services has proven better than under indemnity insurance, but the view of womens health held by managed care executives has been too limited, focusing on issues such as abortion, mammography, and prenatal care. Consumer pressure has proven effective in some areas, such as gaining direct access to reproductive health services within managed care plans. Downsides in the reproductive health arena still exist however, including confidentiality issues (especially for teens), prior authorization requirements, and conscience clauses. As a firm consensus is currently lacking as to what constitutes womens comprehensive care, this is an opportunity for providers and consumers to develop and provide to MCOs our definition of what is comprehensive primary care for women. This would include special training in womens health for medical students and multidisciplinary practices. At present primary care providers are not equipped to provide this comprehensive care, no MCOs in California have specified gender-specific primary care competencies, and ob-gyns have straddled the fence on whether they want to be considered PCPs. Physicians assistants and nurse practitioners are currently poised to assume more of these responsibilities.
While most HMOs offer a range of preventive services, many women do not in fact utilize them. For this reason, MCOs need to track the actual receipt of services to determine whether enrollees are in fact benefitting from available services. MCOs must also allow patients to spend sufficient time with providers, must provide women the full range of contraceptive options, and provide adequate mental health services. In addition, MCOs must recognize the critical work of essential community providers. Legislation, however, is not the way to ensure standards of health for women.
Experiences of Low-Income Women
Roberta Wyn, PhD, of the UCLA Center for Health Policy Research, presented some preliminary results of a focus group study of low-income women in managed care in California.1. Data were gathered during 10 focus groups conducted between September 1996 and February 1997, with a total sample of 69 women who ranged in age from 25-64 and were members of varied racial/ethnic groups. The participants were recruited via telephone or through community organizations, and were low income or poor and covered by health insurance and in a managed care plan. Beginning with data on sources of health insurance coverage by poverty level and by ethnicity, 4 key issue areas of womens concerns with managed care were identified. These were gaps in covered services, access to care (both financial and non-financial barriers), coordination of care and specialty referrals, and ways to improve care.
Gaps in coverage were identified in the areas of dental care, mental health treatment, eye care, medication, and nutritional and other health promotion activities. While managed care plans are often covering these areas better than indemnity insurance, coverage for these services were nonetheless often found to be incomplete, and mere availability does not always translate into access. For example, many providers fail to remind enrollees about needed preventive services. Financial barriers encountered by these women included co-payments, uncovered services, and inadequately covered services or restrictions in coverage. The effects of these barriers are delayed, interrupted, or foregone care. Additional access barriers identified were time constraints, transportation issues, administrative difficulties (particularly in scheduling appointments), and cultural barriers (including provider location, language barriers, and gender issues). Women revealed that they in fact had to become sophisticated managers of their own care under managed care arrangements, learning to navigate the plans systems.
In the area of referrals and specialty care, the women in the focus groups identified delays in the referral process, concerns about who makes referral decisions, difficulties going outside of plan, and having doctors in one location among the key issue areas. Women expressed concern that those deciding whether to allow enrollees access to procedures or medication were not in fact physicians and were making these decisions based on financial, rather than medical, factors. The reliance on primary care gatekeepers to control access to specialists also raises concerns about these PCPs potentially assuming more responsibility than they should, particularly for women, for whom primary care includes reproductive health and mental health needs.
Los Angeles area data were also presented from a 1994 Commonwealth Fund survey of women which compared managed care and fee-for-service on aspects of access and doctor selection. More respondents rated managed care as fair or poor in the areas of office location convenience and hours, availability of telephone advice, waiting time for appointments, and access to specialty care, while managed care was rated better than fee-for-service on range of services, reasonableness of out-of-pocket fees, and premium amount paid. Choice of doctors and ease of changing doctors was rated fair or poor much more among the managed care respondents than those in fee-for-service.
Focus group participants were asked about aspects of the provider-patient relationship that were of particular importance to them. Responses included spending sufficient time, listening and answering questions completely, taking the patient seriously, knowing the patients history, treating the patient with respect, and emphasizing preventive care. Women expressed concern about what they termed "assembly-line medicine" under managed care that undermines the above features. In addition, these women reported consciousness of a perceived stigmatization of welfare and Medi-Cal recipients, and felt that this stigma undermined their care in some instances.
Dr. Wyn concluded her presentation by identifying several general areas that would improve care for women in managed care plans, as reported by the low-income women in the focus groups. These included greater benefits, removal of access barriers, and preservation of the patient-provider relationship.
Responding to Population Needs
Three panelists provided follow-up presentations after Dr. Wyn discussed the results of her research. Lark Galloway-Gilliam, MPA, Executive Director of Community Health Councils, Inc., stressed the need to overlay population needs on an organizational model in order to ensure that delivery systems are responsive to the gender, cultural, socioeconomic, and age differences and needs of those they serve. California has turned to managed care organizations to help solve the access problems that had developed under Medi-Cal, turning the women and children getting care through Medi-Cal into the "experimental case." But it is not possible to create one template that will work for everyone enrolled in a system, in large part because of cultural differences. While health plans receive a $75 per month capitation rate for Medi-Cal enrollees, only $10 makes its way down the primary care provider. As populations are being "defaulted" into managed care, it will be necessary to monitor utilization down the line to assess whether access to care has been reduced.
Ellen Severoni, RN, President and co-founder of California Health Decisions, a non-profit organization dedicated to involving the public in health choices, described CHDs activities during the debates over national health reform and its current projects. Seven key values were identified through engaging the public in discussion about health care: affordability, accountability, fairness, choice, dignity and respect, personal responsibility, and quality. These values drive decisions around delivering quality care, choosing health plans and physicians, providing and evaluating treatment options, making end-of-life choices, and evaluating health reform efforts. CHDs approach is to bring all of the important stakeholders around the same table and engage them in what is termed a "feedback loop," with CHD acting as the facilitator. The major issue under managed care identified by consumers, and particularly by women, has been specialty referral. Severoni described an example in which CHD facilitated a dialogue among consumers and a major purchaser and health plan to increase the number of "pass-throughs," or services for which referrals from a primary care provider are not required. By identifying specific concerns and engaging all interested parties with the ability to effect changes, a workable solution satisfactory to all was achieved - the number of pass-throughs was increased from 71 to 106. Getting consumers to identify their concerns and providers to acknowledge them is critical, as providers often believe that they understand consumer concerns when in fact they do not.
Cultural and Linguistic Competence
Carmela Castellano, founder and Executive Director of the Latino Coalition for a Healthy California, focused on the needs of non-English speaking Medi-Cal clients, particularly the need to enhance cultural and linguistic competence. After identifying Latino/a language-based access problems with HMOs in 1992, the Coalition developed a set of standards dubbed the Cultural Index of Accessibility to Care. The Coalition then approached health plans with the standards, where it found the most resistance at the medical group level. Their next step was the state of California, which ended up including the Index as part of the Medi-Cal two-plan model. Components of the Index are a needs assessment and availability of linguistic services at key access points within the health plan. Operational challenges have included lack of a solid state enforcement mechanism. Current efforts include linking the Index to assessments of patient satisfaction and outcomes. Implementation of the Index requires the cooperation of providers, and HMO medical directors are now beginning to "see the light" and come to the table. The Coalition hopes to expand use of the Index beyond Medi-Cal plans to all health plans serving diverse populations. Like the work of California Health Decisions with individual health plans and purchasers, the Coalitions success in implementing the Cultural Index of Accessibility to Care demonstrates that consumers can indeed influence the process of health care delivery within managed care.
Following the speaker presentations, the program was opened up for questions and comments from the audience, and many topics and concerns emerged. Discussion at the outset centered around the role of individual health care consumers in their own care and the level of personal responsibility that can reasonably be expected from various populations who may lack sufficient education and resources. Some participants asserted that individuals need to assume more responsibility, while others countered that women in particular already do this and that institutions such as managed care organizations must reflect the needs of those they serve.
It was suggested that there may be a need for a neutral agency to respond to consumer concerns, particularly in the present environment of intense competition between health plans that leads to individuals "signing away their rights" upon enrollment without full understanding. There is also a great need for basic information for consumers to foster better understanding of just what managed care is and how it works. It was suggested by the panelists that issues such as these be raised at the forthcoming public hearings of the Governors task force.
The issues raised around managed care also led to some discussion of possible alternatives to the system of employer-based managed care and possibilities for universal coverage. Bobbie Wunsch asserted that indeed this search is going on, and that ultimately we will have a national health program but one that is delivered through managed care organizations.
Finally, there were questions about the implications of managed cares focus on cost reduction - the fear that health care decisions are being made by business managers rather than clinicians. Panelists noted that cost was the first area of focus because it was the concern of those with power - the purchasers. Now that costs have been reigned in to some extent, there is more of an opportunity to focus on quality, as employers are paying more attention to employee dissatisfaction, and this provides an important consumer leverage point.
The seminar was attended by a range of participants, including representatives of consumer and community-based organizations, independent providers, government agencies, managed care organizations, universities/academic health centers, and others. Attendees were involved in education, advocacy, administration, research, clinical care, policy analysis, and many other occupations. Many reported that they found the information applicable to and useful in their own work, both for overall context and for the practical lessons on dealing with managed care on an individual and institutional level.
Managed care does hold significant potential for improving comprehensive care for women, although that promise has not yet been fully realized. At present a firm consensus as to what constitutes womens comprehensive care is still lacking; the current fluid situation in the health care market presents an opportunity for providers and consumers to develop and present to MCOs a definition of womens comprehensive primary care.
Managed care coverage of many services has been better than under indemnity insurance, but the view of womens health held by MCO executives has been too limited, focusing on mammography, prenatal care, and abortion.
While most MCOs offer a range of preventive services, many women do not avail themselves of these services. MCOs need to track actual utilization to determine whether enrollees are benefitting from available services.
The major areas of concern under managed care for low-income women are:
Availability of services does not translate automatically into access. Women have had to become sophisticated managers of their own care under managed care, as the new systems are often confusing and difficult to navigate. This can be problematic for consumers with less education and resources.
Low-income women are conscious of and often perceive the stigmatization of welfare and Medi-Cal recipients, and they often felt that this negative perception undermined the quality of care that they received.
Women place a great deal of value on the physician-patient relationship, and desire sufficient time with the provider, being listened to and having questions answered, being taken seriously, having their history known, and being treated with respect.
It is important to overlay the needs of the population being served on any organizational model in order to ensure that the delivery system designed is responsive to the varying needs of those served.
One of the biggest issues under managed care identified by consumers, and particularly by women, is specialty referral.
In order to effect changes in a system, it is important to involve all stakeholders, particularly those with the power to make the changes desired. By using effective strategies, consumers can indeed influence the process of health care delivery within managed care systems.
There may be a role for a neutral agency to respond to consumer concerns about managed care, particularly in an environment of intense competition between MCOs.
Now that costs have been reigned in to some extent, there is more of an opportunity, or even an impetus, for health plans to focus on quality; employers are also paying more attention to enrollee satisfaction levels. This provides an important consumer leverage point.
1. The complete report is now available. Wyn R, Leslie J, Glik D, Soliz B. Low-Income Women and Managed Care in California. UCLA Center for Health Policy Research and the Pacific Institute for Womens Health. August 1997.