Risks and Opportunities
by Karen Carlson, MD
Managed care systems may offer real improvements in women's primary care over the current system of care fragmented between generalists (internists, family practitioners, and general practitioners) and obstetrician-gynecologists, as well as the fragmentation between the biomedical sciences and the psychosocial components to women's health. Among the potential solutions offered by managed care are: a strong focus on primary care, better access to ancillary services, and disease management programs for female-specific disorders.
However, problems with current managed care plans include:
inadequate coverage of mental health services, burdensome authorizations systems, and capitated organ-based disease"carve outs" that result in more, not less, fragmentation of care for women.
Comprehensive primary care for women includes four distinct elements - preventive care, episodic care, chronic disease care, and the doctor-patient relationship. Carlson highlighted strengths and weaknesses of managed care in all four areas. Managed care systems generally have better coverage and stronger organizational systems to assure consistent performance of preventive services. They also can have the capacity to develop practice guidelines for common episodic illnesses among women, although most such efforts to date have focused on acute conditions which affect men more than women.
Few managed care initiatives have targeted chronic diseases, although many women could potentially benefit from innovative disease management programs that integrate multiple disciplines and use psychoeducational support groups to improve outcomes, she concluded. For now, however, it appears that plans have less financial incentive to invest in these areas than in acute care. Managed care systems can improve doctor patient relationships through patient satisfaction surveys, physician training in communication skills, and systems that promote participatory decision-making. However, several factors tend to counteract these improvements.
Disruption in continuity of care occurs as a result of changing health plans, shorter office visits result from productivity pressures on physicians, and financial incentives that appear to affect clinical decision making undermine patients' trust.
Women's health advocates and managed care organizations have parallel interests, and the present fluid situation in the health care delivery system provides an opportunity to move women's health forward. Predicting that health care will continue to be highly organized with prospective payment increasingly dominant, Dr. Hoffman asserted that managed care organizations could utilize a new conception of the primary care team to serve the needs of defined populations, in this instance women, as part of their business strategy. She posited that the solution to the fragmentation outlined by Dr. Carlson was to transfer the structure of the delivery of primary care to a team of health care professionals, led by advanced practice nurses and comprising generalist and specialist physicians as well as mental health professionals and other ancillary care providers.
Dr. Hoffman predicted that primary care will be the next area in which managed care focuses on cutting costs, and that the team approach presented here would facilitate reduction in costs without sacrificing quality. She also stressed that it is impertative, particularly with women's health, to recognize the mental health etiology of patients' complaints, and that mental health competency must be integrated into primary care.
Dr. Hoffman's presentation also highlighted the following: trends in the health professions workforce conflict with trends towards team care (as the educational experiences of various providers are separate rather than integrated); the goal should be to move beyond multidisciplinary to interdisciplinary health care teams redesigning roles for health care teams serving a variety of defined populations maximizes human and educational resources adapting this strategy to women can advance delivery from women's health centers to women-centered health.
Carol Aschenbrener, MD responded by stating that changing medical education curricula is a "tough, slow, but possible process" and that change must occur both in curricula and in the attitudes of health professionals already in the field. In order to achieve the kind of interdisciplinary care described by Dr. Hoffman, Dr. Aschenbrener noted that providers cannot continue to be trained in "parallel tracks" but must have shared learning experiences.
Carol Havens, MD described the efforts of Kaiser Permanente to develop an adult primary care team by supplementing, rather than substituting, physicians with other health care providers. Kaiser has explicitly outlined areas of responsibility for its primary care physicians and provides additional training for those unprepared in certain areas.
Cindy Pearson agreed that older, non-profit HMOs such as Kaiser have been "progressive and visionary" and that managed care organizations hold the potential for more rational, holistic provision of care. She raised concerns, however, that newer for-profit health plans lack the same vision, and that while the traditional emphasis of the women's health movement had been on avoiding overtreatment, under managed care the concern has become restricted access to care.
Myra Snyder, EdD asserted that the managed care organizations themselves are not necessarily the locus of power, and that those seeking change should also try to influence the purchasers of health care and the consultants on whom they often rely, the federal and state governments, consumer demands, accreditation standards, and medical groups. She warned that expending "political capital" on narrow issues such as length of stay following childbirth was a less productive strategy than taking a broader approach to change.