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Primary care for women under managed care: Clinical issues
Primary Care for Women Under Managed Care: Clinical Issues Karen J. Carlson,
MD
Massachusetts General Hospital IHarvard Medical School 13oston, Massachusetts
M
anaged care has become a dominant force among systems for health care delivery in the United States. Over three quarters of persons obtaining health care through their employers do so under some form of managed care plan. Although resistance to managed care has surfaced, ’ there is no doubt that organizations to manage health care cost, quality, and accesswill proliferate in years to come. Women use health care services at higher rates than men.* For this reason alone, changes in health care delivery c’ould be said to have a disproportionate effect on women. It is noteworthy that among the earliest legislative efforts to regulate managed care practices was the restriction of “drive-through deliveries.” Recently “drive-through mastectomies” have come under scrutiny, and large settlements in litigation against health maintenance organizations (HMOs) that denied coverage of bone marrow transplants for breast cancer have made headlines.’ Women also use ambulatory services more frequently than men.’ Although management of expensive inpatient care was among the earliest initiatives of managed care, primary (care has received greater emphasis in recent years. This emphasis is congruent with a commitment among managed care organizations to controlling the costs of care and to improving health status at the population level. This article examines the clinical issues in primary care for women under managed care delivery systems, considering ways in which such systems present opportunities for addressing unmet needs in women’s health care, as well as potential threats to optimal care for women.
THE
CURRENT
SYSTEM: FRAGMENTATION HEALTH CARE
IN WOMEN’S
Fragmentation in women’s health care has existed at two levels. The first is at the level of delivery of basic clinical services to women. The second is in the conceptualization of women’s health, which has been defined according to a specialty-focused biomedical model, rather than a multidisciplinary biopsychosocial model.
C‘ARLSON:
0 lYY7 bv The Jacobs of Women’, Health Published by Elsevier 10~Y-~s~7/~7/g17.00 PII s1049-~~~7(97)00075-:1
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The delivery of primary care services to women has traditionally been divided between generalists (internists, family practitioners, and general practitioners) and obstetrician/gynecologists, with many areas of overlap.” In general, women have received medical care for episodic and chronic nonreproductive illness from the first group and gynecologic and obstetric care from the latter. The time-limited nature of pregnancy allows the two-provider model to function reasonably well for obstetric care. Gynecologic care, however, is an ongoing need for women throughout the life span. Given this reality, women have had three options for obtaining primary care. They could have the continuity and efficiency of seeing a single physician, but in so doing, risk neglecting their general health needs or their gynecologic needs (depending on whether the physician was an obstetrician/gynecologist or a generalist). Or they could have two physicians, ensuring that both reproductive and nonreproductive health needs would be addressed, but running the risk of contradictory recornmel7dations, duplication of efforts, a~~ti other inefficiencies. Each specialty rn‘ly have unique merits as primary care providers. Differences in the provision of certain types of preventive care to women by generalists and obstetrician/gynecologists have been reported. Obstetrician/ gynecologists provide a greater number of preventive services than generalists,’ and obstetrician/gynecologists have higher age-adjusted rates of Papanicolaou test screening than generalists” and are more likely to include breast and gynecologic exams in a general medical examination7 Overuse of Papanicolaou smears, however, has been more frequentlj? documented among gynecologists.” Generalists have been more broadly tra-ined in adult medicine and are almost certainly better able to met4 the “large majority of personal health care needs” that define the clinLca1domain of primary care providers.“ In addition, skills and attitudes essential to primary care practice (such as the practical application of clinical epidemiology, ,311 awareness of cost-effectiveness, and a tolerance for uncertainty) are more commonly addressed in the training of generalists than in that of specialists ~ch as obstctrician/gynccologists. Changes in the system of medical education are brginning to ameliorate the problem of fragmentation in wornen’s care. For over two decades, the specialty of family practice has trained physicians who can provide both general and gynecologic care (and (often obstetric care). Some residency programs in internal medicine have included training in primary care gynecology to enable their graduates to provide routine gynecologic care. Finally, since 1995, residency training for obstetrician/gynecologists has included a nonreproductive primary care component and postgraduate training programs in general primary care have proliferated. These initiatives in medical cducation ultimately should result in less fragmentation as more physicians are broadly trained to meet women’s general medic,>1care needs. The second way ~JI which women’s health care has been fragmented is in the conceptual model that has been the found,ltion for training physicians. Under the prevailing biomedical model, c,lre for women has been viewed as the province of multiple medical speci,llties. In this model, defined according to organ systems, the core disciplines concerned with women’s health have Ibeen obstetrics and gynecology, medicine, endocrjnology, and psychiatry. New conceptualizations of women’s health are based on a biopsychosocial model. This model emphasizes the importance of psychological and social factors as well asbiological factors in health and illness. There is some evidence that the difference in morbidity rates between women and men may be largely explained by nonbiologic factors, including acquired risks related to lifestyle, rcrleh, and socioeconomic variables, psychosocial factors, and health-reporting
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behavior.2 The biopsychosocial model has been proposed as a more appropriate model for women’s health.‘” A clinical example illustrates how the traditional specialty model has served women’s health needs poorly. Chronic abdominal pain is a problem commonly encountered in the primary care of women. Chronic abdominal pain can have many causes, including gastrointestinal disease, gynecologic disorders, and functional changes in bowel function related to the menstrual cycle, diet, and other environmental factors; it can also represent a somatic manifestation of previous sexual abuse. ” In the traditional system, a women presenting to a generalist would typically receive an evaluation aimed first at excluding a serious gastrointestinal disorder (sometimes including a referral to a gastroenterologist for testing), then a referral to a gynecologist to rule out disorders of the uterus or ovaries, and then a psychiatric referral to address psychosocial stressors implicated in functional bowel disorders and chronic pelvic pain syndromes. Under the new conceptualization of comprehensive women’s health, a skilled clinician would evaluate all of these diagnostic possibilities simultaneously, allowing more rapid assessment and initiation of treatment without the inefficiencies of multiple consultations and exhaustive, rather than targeted, testing. Only a comprehensive model informed by a knowledge of gender-specific disease tbpidcmiology will facilitate efficient, accurate management of illness in women.
Solutions
Under
Managed
Care
Managed care has to date prompted a number of changes in health care delivery that provide partial solutions to the problem of fragmentation in women’s health care. The focus c?npvirnury NW is the most important of these. Under ideal circumstances, the primary care physician as gatekeeper can coordinate care and make sure that a woman does not “fall between the cracks” if her problem does not fit neatly into the domain of a single specialty. The primary care provider also takes on the responsibility of ensuring that a woman receives appropriate preventive care. Accc~ss to RIZC~IIOY~~ suz~iccs is essential because psychosocial factors often have an important role in symptom severity and functional effects for women. For example, the common problem of mechanical back pain in a working mother juggling the strains of lifting children, work stress, and lack of time for preventive exercise will not be solved by an orthopedic evaluation, magnetic resonance imaging, or a nonsteroidal drug, but rather by a physical therapy evaluation and treatment plan tailored to her indi\ridual needs. LII’SIWSPnzanqc~~zt /~~o~~~r~znrs for female-specific disorders have the potential to improve women’s health care under managed care. Such programs provide the focal point for a much-needed integration of multidisciplinary expertise and stimulate the development of inno\,ative approaches to complex clmical problems. An example is the problem of chronic pelvic pain, widely acknowledged as a frustrating condition for both patients and physicians.” a randomized trial demonstrated that multidisciplinary management of pelvic p‘lin (integrating gynecology, psycholp?y, physical therapy, ;Ind nutrition) improved pelvic pain at 1 year signlflcantlv more often th‘ln a standard approach.” Such disease management prograins i,vill be most effective if they emphasize (1) disorders for which there is somt’ evidence that a multidisciplina~*y approach produces improved outcc~mes compared with :standard care; (2) time-limited treatment, with return to th(a primar) care physician for management based on recommendations of the multid~sciplinq~ group; (3) dl~\~c~lopmcnt of guidelines for use by primary care physicians in initial management, including indications for rl-ferral; and (3) ongoing evaluation of quCllitJf ,Ind cost outcomes.
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Problems
Under
Managed
Care
Primary care providers need basic skills (such as competent breast and pelvic exams) as well as broad knowledge to provide comprehensive care to women. Managed care cannot solve the problem of gaps in the knowledge base and skills qf practicing generalist physicians, particularly those trained outside of family practice or primary care medicine programs. Currently, many managed care plans have acknowledged the reality of fragmented provider competence b) allowing women access to gynecologic cart without authorization by the primary care provider. This is a sensible policy in the near term, although the existing evidence suggests that organizations that allow self-referral to gynecologists achieve no higher rates of preventive services such as Papanicolaou smears than organizations that do not.‘” Managed care organizations can, over the long term, require that generalists who wish to provide primary carle to women demonstrate competency in basic aspects of gynecologic care such as the breast and pehric examination, contraceptive management, and initial management of common gynecologic problems such as vaginitis and abnormal bleeding. They can also sponsor training in these areas for practicing generalists who desire to upgrade thei] competence in office gynecology. lrladequafc coverage qf mental kraltll sc17~ic~s is a problem in women’s health care that managed care has, if anything, compounded. Managed care organizations have generally implemented systems that tend to limit access to mental health services compared with tradi&nai fee-for-service care. There is little research evaluating the effects of such changes on mental health. Data on mental health outcomes from the Medical Outcomes Study suggest that the performance of managed care organization is Lrariable and site-specific relative to fee-for-service plans. ” ‘The gatekeeping requirements of some managed care organizations have resulted in a hwdcasorne autkorizafioll systcnl that increases administrative inefficiency while doing nothing to improve communication among physicians in\~olved in a woman’s care. When such systems impede appropriate access to cart’, their effects on the health of the population will be detrimental, although short-term cost savings may result. Finally, the capitatcd organ-based dis~rasc “cam’ auf” risks rr~i~~stit~~fj~)~za/i-7~7ti~~~~ of _fi,“S”‘L”ztation. The disease management concept ma\/ work well for some conditions, particularly those that occur in relatively young populations of women with a limited number of coexi,+ting conditions (for example, pregnancv), and those that, at least at initial diagnc~sis, requirt~ intensive and highly tcbchnical care (such as breast or ovarian cancer). Brcause, however, the primary care provider is almost always in the best position to o\.ersee the process of care in the long term, by virtue of his or her unique knowledge of the patient acquired over time, disease management programs must inform ,jnd involve the primary care physiclan ,It the earliest possible point in a patient’s course. It is vital that disease management programs do not disrupt primary care physicians’ relationships with patients by “carving out” management of chronic illnesses. Management of chronic riisordcrs, which often occur as one among many health problems (for example, osteoporosis and obesity), might use multidisciplinary specialty units in the development of guidelines for use in primary care and for individual clinical consultations to pro\.ide recommendations for implementation in the primarv c‘lre setting. They- should not be used as alternative sites for ongoing care. ihe cnmplexitv of the current health care svstem requires that processes promoting continuity of care receive hlghesi priority as management systems evolvc~. “’
COMPONENTS
OF COMPREHENSIVE CARE FOR WOMEN
PRIMARY
What constitutes comprehensive primary care for women? First, it includes expertise in evaluation and management of the range of medical problems commonly encountered in primary care practice-those that affect both men and women. These include both diseases (such as hypertension, coronary artery disease, diabetes, and human immunodeficiency virus infection) and conditions (such as headache, back pain, and fatigue) that may manifest differently, or respond differently to treatment, in women as compared with men. Comprehensive women’s primary care also includes management of medical problems that occur more commonly in women, such as osteoporosis, disorders. Reproductive thyroid disease, breast disease, and autoimmune health care, including preventive care as well as management of common gynecologic conditions, is a cornerstone of primary care for women. Mental health care and behavioral medicine, including issues related to depression, smoking, substance abuse, and domestic violence, are equally important elements of comprehensive care. Truly comprehensive care for women includes obstetric care. At the least, clinicians who do not themselves deliver obstetric care should understand the interaction of pregnancy with illness and management of common medical and psychiatric problems during and after pregnancy. In addition to these clinically defined components of care, we can also consider comprehensive care for women in terms of two broad domains: technical care and interpersonal care. Technical care includes both the provision of appropriate services and the skill with which appropriate care is performed. l7 Technical considerations apply to preventive care, episodic illness care, and chronic disease care. Interpersonal aspects of care encompass communications between physician and patient, as well as the physician’s emotion-handling skills, awareness of an individual patient’s values and preferences, and decision-making style.
PREVENTIVE
CARE
The inadequate emphasis on prevention for women in existing care systems has been abundantly documented.‘“*i“ Improving preventive care for women requires attention to all steps in the process: provision of services by clinicians, coverage of services by insurers, and use of services by women.
Solutions
Under
Managed
Care
Managed care has already had a positive impact in expanding provision of some preventive services by clinicianls. Greater use of preventive services in health maintenance organizations compared with fee-for-service practices has been documented20,21 and preventive care specific to women (Papanicolaou tests, breast examinations, and mammography) reflects a similar pattern.22 Managed care brings the potential for stronger ovganizafional strategies to ensure consistent performance of preventive services. These include clinical database systems to identify individual patients in need of preventive services and systems to monitor physician performance of recommended preventive services. Coverage of certain preventive services such as Papanicolaou smears and mammography under managed care generally is improved compared with the fee-for-service system. Coverage has often been limited by the lack of reliable outcome measures and cost-effectiveness data for specific screening interven-
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tions. Several screening interventions for specific subgroups of women deserve a critical review and development of guidelines for use within managed care organizations. These include screening of high-risk populations of women for chlamydial infection (based on recent data demonstrating that treatment can prevent pelvic inflammatory disease2’) and bone density testing for postmenopausal women (in light of the availability of bisphosphonates in addition to estrogen replacement therapy for treatment of osteoporosis). Use of services by women is another aspect of preventive care upon which managed care organizations can have a positive impact. Putiel?t and comrrzunify r~i~lcafio~z initiatives sponsored by /zenith care ovgarzizafions can be marketed to target specific subpopulations of members such as young unmarried women or perimenopausal women. Such initiatives can include live and televised seminars, print material, videotapes, and reminder cards. Collaboration with community organizations is desirable, and is essential in cases involving culturally sensitive health issues.
Problems
of Managed
Care
7’11~provision of preventive services takes fim, which is perceived by physicians and patients as increasingly limited as the influence of managed care grows. The preventive services explicitly covered by managed care (such as Papanicolaou smears, mammograms, and fecal occult blood tests) emphasize diagnostic testing rather than counseling. Screening women for specific health behaviors and exposures such as diet and exercise habits, risky sexual behavior, substance abuse, and domestic violence takes time within a face-toface doctor-patient interaction. Although complementary approaches using ancillary care providers and screening instruments can be valuable, there is a minimum irreducible quantity of time required for primary care clinicians to diagnose, assess, and counsel patients about thesca important health behaviors. For some motivated women, ancillary services (such as smoking cessation group) will be effective and these should be usc*d when appropriate. But for other women, only work with a primary care physician over time can lead to acknowledgement of the need to change and motivation to make changes in lifestyle factors which have a tremendous impact on their health. Managed care organizations that seek to improve preventive care for women must provide incentives for counselling as well as technic,4 screening interventions.
EPISODlC
CARE
The chief task within HMOs for primary care of episodic illnesses is to promote efficient use of the health care system. Several factors contribute to existing inefficiencies in primary care of episodic illnesses, including lack of accepted clinical guidelines for management of common problems, financial incentives promoting office visits rather than other approaches such as telephone management, and lack of systems and financial incentives for patient educatic)n in self-care.
Solutions
Under
Managed
Care
Managed care organizations have taken positive steps to address each of the factors just described. At the level of the health care system, dev~~lopnzcnt I$ f~l~&ic‘c~ pi&lines has helped clinicians to incorporate the latest researchinterpreted through the filters of expert judgment ,lnd consideration of c~ost-effectiveness-into their clinical management of common problems. Although to date such efforts have targeted primarily high-cost inpatient care,
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applications to ambulatory care are expanding. For clinicians, guidelines to reduce inappropriate use of services provide a method for rationing access to care that is far preferable to “blunt instruments” for controlling costs such as copayments.24 Common episodic problems in women that are appropriate for guideline use include acute dysuria, vaginitis symptoms, acute pelvic pain, irregular \,aginal bleeding, and fatigue as well as more general problems such as headache, back pain, abdominal pain, sore throat, and cough. Managed care organizations with capitated reimbursement systems have also remouedfinancial disincentives for telephone managementand judicious use qf rlonphysician personnel for some aspects of care. For example, management of uncomplicated urinary tract infection by telephone has become an accepted I standard of care for established adult female patients in primary care practices. / This form of care had been advocated by some physicians and desired by many patients during the years before managed care but has only become a standard practice with the realignment of financial incentives to promote efficient care. Finally, managed care has the potential to use membership databases to provide patient education in self-care, which can reduce inappropriate use of services for episodic illness. For example, the health needs of young adult women typically center around gynecologjc care (including contraceptive management and prevention of sexually transmitted diseases), modification of risky habits (such as smoking, substance abuse, and unsafe sexual practices), and care for minor illnesses such as allergic rhinitis and upper respiratory and urinary tract infections. A managed care organization can use its membership database and health education resources to provided targeted health information to this population that can complement face-to-face teaching by the primary care provider. Topics that could be targeted for Ihis age group would include the normal menstrual cycle, common concerns related to sexuality, availability of emergency contraception (that is, the “morning after pill”), strategies for smoking cessation, warning signs of depression, and self-care measures for common illnesses such ac. allergy, minor headaches, and respiratory infections, including guidelines for when to seek care. ‘This form of “demand management” for specific populations of women can provide reliable information on reproductive, nonreproductive, and mental health issues that promotes appropriate use of health resources. Demand m;lnagement initiatives are ideally undertaken in paraIlei with efforts to ensure continuity of care so that the outcomes of these initiatives can be assessedover time in a relatively stable member population.
Problems
Under
Managed
Care
The majority of managed care initiative:; to improve care for episodic illnesses have focused on high-cost or technology-intensive clinical scenarios such as asthma, chest pain, and acute myocardial infarction.. These conditions are those in which investment of management resources will yield high short-term returns (primarily in cost terms) in the form of reduced hospital use, With the exception of managed care initiatives in pnlnatal care and high-risk pregnantits, which clearly benefit both women and their children, these diseas(>rrurt~a~~cmerzt ejbrts have tcrrded tofoczrs OHxute t-onditiorzsthat afiect men mow t/~all 7/‘OllIi’l7.
CHRONIC
DISEASE
CARE
At a given age, men have higher mortality rates than women, and women have high rates of morbidity largely due to higher rates of acute illnesses and most
nonfatal chronic conditions.* For women, improved health over the life span requires reduction in morbidity and functional impairment associated with chronic conditions, such as arthritis, headaches, and chronic gastrointestinal disorders. Unfortunately, chronic diseases have received proportionally less attention as subjects of clinical research than acute disorders, so understanding of pathophysiology and development of effective treatments for many chronic conditions are limited. For example, there is no known medical or surgical therapy that can influence the course of osteoarthritis.“” Another element that limits effectlIve care for many chronic conditions is a lack of understanding of the role of nonbiologic factors in outcomes. New models of health-related quality of life, which link clinical and quality-of-life concepts in a way that facilitates empiric testing, emphasize the relationship of nonmedical factors (such as socioeconomic status, employment, and social support) and psychological factors (such ;IS motivation) to health outcomes2h; however, clinicians have at rudimentary understanding at best of the role of these factors in determining the health status of persons with chronic diseases.
Solutions
Under
Managed
Care
At this time in the evolution of managed care, relatively few initiatives have targeted chronic disease. There is, however, the potential for managed care to bring the strengths of its systems and population-based approach to improve care of chronic conditions in women. One potentially useful approach is in the intt>graGonof multiple disciplines to develop guidelines for care of chronic conditions that can be implemented in the primary care setting. In addition to the example of chronic pelvic pain cited earlier, other examples include type 11diabetes; chronic headaches; chronic rheumatologic conditions such as osteoarthritis, rheumatoid arthritis, and fibromyalgia; and obesity. For such conditions, a multidisciplinary approach integrating medicine, surgery, psychology, and other services such as physical therapy and nutrition may be more effective than standard care (though empiric data comparing these two approaches are lacking). Such multidisciplinary collaborations are certainly important for the development of clinical guidelines, even if care is provided in conventional settings. There is a large body of research evidence that indicates that psychoeducational groups for women with chronic conditions are associated with better health outcomes, including improvements in physical symptoms, social functioning, attitudes, compliance, and use of health care resources.2i’A randomized trial of group treatment for women with metastatic breast cancer demonstrated a doubling of survival time for group participants. ** Historically, the concept of the psychoeducational group has been institutionalized within women’s health care in the form of prenatal education groups to inform women (and their partners) about the physiology of pregnancy, expectations for physical and psychological changes over time, and specific techniques for managing these changes during pregnancy and delivery. Application of this concept of time-limited psychoeducational groups for women with conditions such as heart disease, diabetes, arthritis, irritable bowel syndrome, and asthma should be explored; there is evidence for improved health outcomes associated with psychoeducational groups in all these conditionsZ7 The ability of managed care systems to link multiple small practice units allows accessto a sizable population of women with similar chronic conditions. C’omputerized use and health status data on the member population permits evaluation and modification of the educational intervention.
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Problems
Under
Managed
Care
Thr -financial return from investments in innovative approaches to chronic disease n~anagement is likely to be less immediate than the cost savings resulting from targeting acute care. It is unclear whether the current competitive pressures on managed care organizations, coupled with high enrollee turnover over time, are compatible with the commitment of resources needed to develop better approaches to chronic disease care. Although chronic diseases are responsible for three quarters of direct medical care costs, it is uncertain whether changing delivery systems for chronic care will generate significant cost savings.2y
INTERPERSONAL
CARE
lnterpersonal care is an extremely important aspect of clinical care for all patients, and particularly for women. The positive effects of high-quality interpersonal care on health outcomes art’ well documented.“” Studies of aspects of provider behavior correlated with patient satisfaction identify the most important predictors as the amount of information given by the provider and partnership-building behavior.“’ A. participatory decision-making style has also been correlated with improved health outcomes.“.“’ Studies of gender differences in doctor-patient interactions show that female patients ask for and receive more health information, elicit more partnership-building behavior, and receive more health services than male patients.” There is some evidence that women are more likely than men to be dissatisfied with their doctors; 40% report they have switched doctors.“’ Lack of technical competence and lack of communication skills were the primary reasons cited by women for switching physicians. A hallmark of primary care, which is central to the current systems of managed care, is continuity of care. Returns in quality and cost terms of the investments of professionals’ time and other health resources in an individual member arc’ diminished if that member later changes to a new physician-particularly if she Ica\,cs her managed care plan to do so.
Solutions
Under
Managed
Care
Managed care has given a tremendous stimulus to the movement for quality measurement and improvement within health delivery systems. Methods of quality assessment have been developed to evaluate multiple aspects of the care process, including measures of patierlt satisjartiou. Data from such evaluations have been reported back to physicians, with the goal of influencing their behavior, including interpersonal care. Patient satisfaction has been used as a 1 ariable for determining physician reimlbursrment under capitated systems. [f physicians are being asked to improve their communication skills (which most were not taught formally during medical training), they also should be given instruction to improve those skills. Managed cure system should &;lc)tc resources to trailli,?Cy&sicinP7s iI1 ,.,c,n2/rlllllicatj~)~~~ skills ju5t as they offer educational programs to optimize drug prescribing or cost-effective use of di,lgnostic tests. Educational interventions to improve communication skills among physicians have been demonstrated to improve problem-defining and emotion-handling skills without increas.ing the length of the office visit.“r’ Other innovations m,ithin managed care include fi,rwal systems to prormfe pvfir:ip~for?y derision makirlCq to educate patients and improve their ability to take an active role in their care. An example is a series of interactive videodisc programs, known as Shared Decision-Making Programs, which are currently in LW on over 200 platforms (many in managed care systems) in the Unitcbd
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States.” These prog rams include a series on women’s health topics, including early stage breast cancer, benign uterine conditions, and hormone replacement therapy. By encouraging members di.agnosed with particular conditions to view such educational programs, managed care organizations can ensure that patients have had access to basic information needed to take an active role in decision making and can validate the importance of patient participation in the care process. Frcdback to physicin~s 011mviations in use of specific interventions is another strategy organizations can use to address the problem of lack of participatory decision making. A clinical example concerns treatment alternatives for women with early stage breast cancer. Large regional variations in rates of procedures such as breast-conserving surgery versus mastectomy are thought to reflect an excessive influence of the physician’s practice style in the surgical decision-making process.“’ Managed care organizations can address this problem of unwanted variation by using their clinical databases to provide participating surgeons with data on their own rates of procedures compared with that of their peers. There is somt: evidence that dissemination of population data on rates of these procedures does little to change physician brhavior;“s but feedback of information on practice patterns to individual physicians has been shown to have a positive effect.“’
Problems
Under
Managed
Care
Two trends now prevalent in managed care have the potential to offset the benefits for improving interpersonal cdre from initiatives such as those just described. The first is the disrupfion $ co22fint2ity (f cm. The duration of the physician-patient relationship is highly correlated with use of a participatory decision-making style, with the most participatory visits occurring among p,i tien ts who have seen their physician for at least 5 years.“” Competition in the marketplace among managed care plans has resulted in economic incentives to <>hangeplans frequently for purchasers Iof health services. From one year to the next, an individual woman may be required to choose a new physician as health benefits packages shift. Such pressures undermine the maintenance of a st,lble continuity relationship between doctor and patient-an investment that c.an reap major gains in both process and outcomes of care over the years. The second trend under managed cart’ that can negatively impact interpersonal care is the fwd fn7oard shorlt>r~fficc +i/s. L,ength of the office visit is a major determinant of participatory decision-making stvle. III analysis of data from the Medical Outcomes Study, Kaplan ct ~1.“’ f&d that visits of 15 minutes or less were significantly less participatory than those lasting more than 20 minutes. With current industrl: norms of a 15minutcl office visit in primary care practice, productivity presiurcxs on clinicians may be inconsistent with the time requirements for involving patients effectivelv in treatment decisions. .4lthough current standards ma)’ improve cost outcomes, they are likely to have a negative impact on qus,lity outcomes o\cr time. A third factor that can compromise interpersonal cart’ under managed care is the r~/~si~nofptic~~fs’ fvllsf fl~af TPSL~/~.S T~~UVI fi/ril/lciil/ ir7c~lwfiw.s q@f UY a~7pc~2 10 #‘ci c~inicu~ &‘isjo~l rnakin~~.Although managed care provides a great impetus for integration of systems, thereby decreasing fragmentation of care, capitated payment mechanisms also run the risk of rtaal or apparent withholding of care bv physicians, with tremendous t>ottbntial for damage to the trust inherent in the doctor-patient rclationshrp. Principle<; for the design of capitated systems that encourage better ‘md more efficient care for patients and comrnu nities have been proposed.J”
CONCLUSIONS lnnovations in managed care systems offer some important advantages over include an traditional systems for women’s primary care. These innovations incentives flor improved coordination of care and emphasis on primary care, communication among caregivers, the ability to disseminate guidelines and monitor performance of preventive and treatment interventions, and the potential for a more comprehensive multidisciplinary approach to complex problems in women’s health. Managed care systems also offer additional opportunities for physician training in the technical and interpersonal aspects of women’s care and have the potential for enhancing patient education by using population data to target subgroups of women. The current system of managed ca-re also poses some threats to efforts to improve the quality of women’s primary care. Chief among these is erosion of the doctor-patient relationship through productivity pressures, disincentives for maintenance of continuity, and real or apparent financial conflict-of-interest between physicians and patients. Innovationx in clinical practices under managed care have to date emphasized diseases and conditions that affect men rnore than women (with the exception of prenatal can: and high-risk pregnancy management programs). Managed care does not provide a panacea for all thr problems in delivery of primary care to women. It does nothing to solve the problem of access for uninsured women. High co-insurance within some managed care plans for basic preventive services can impede access to care. Data indicating that special populations including the poor and elderly chronically il I (both groups with a substantial majority of female members) fare less well in HMOs than in fee-for-service medicine are alarming. ” Finally, managed care cannot solve the problem of gaps in the training of primary care physicians to care for the comprehensive health needs of women and in the uneven foundation for clinical practice provided by our current sketchy knowledge base. With these limitations in mind, clinicians, health policy makers, insurers, ~ and the public must work together to make sure that our changing system of health care delivery is responsive to the real needs of women.
ACKNOWLEDGMENTS i The author gratefully acknowledges ~ MD, Isaac Schiff, MD, and Paulette earlier version of this manuscript.
Nancy Gagliano, MD, Anne Moulton, Thabault, RN, JD, for their review of an
REFERENCES 1. Bodenheimer T. The HMO backlash---righteous
or reactionary? N Engl J Med
1996;335:1601-3. 2.
3. 3. 5. 6.
Verbrugge LM. The twain meet: empirical explanations of sex differences in health and mortality. J Health Sot Behav 1989;30:282-304. National Ambulatory Medical Care Survey. Hyattsville (MD): National Center for Health Statistics, 1989. Clancy CM, Massion CT. American women’s health care: a patchwork quilt with gaps. JAMA 1992;268:1918 -20. Weisman CS. Women’s use of health ‘care. In: Falik MM, Collins KS. Women’s health-The Commonwealth Fund Survey. Baltimore (MD): Johns Hopkins University Press, 1996. Lurie N, Slater J, McGovern I’, Ekstrum J, Quam I,, Margolis K. Preventive care for women: does the sex of the physician matter? N Engl J Med 1993;329:478-82,
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BA, Weiss KB. Women’s health care in the ambulatory care setting. Clin Res 1991;39:595A. Cohen MM, Roos NP, MacWilliam L., Majda A. Assessing physicians’ compliance with guidelines for I’apanicolaou testing. Med Care 1992;30:514-28. Donaldson MS et al. Primary care: America’s health in a new era. Washington (DC): National specialty. J Johnson K. Women’s health: developiiig a new interdisciplinary Womens Health 1992;1:95-9. Wolf JL. Bowel function. In: Carlson KJ, Eisenstat SA. Primary care of women. St. Louis (MO): Mosby, 1995. Gambone JC, Reiter RC. Nonsurgical management of chronic pelvic pain: a multidisciplinary approach. Clin Obstet Gynecol 1990;33:205-11. Peters AAW, van Dorst E, Jellis 8, van Zuuren E, Hermans J, Trimbos JB. A randomized clinical trial to compaae two different approaches in women with chronic pelvic pain. Obstet Gynecol 1991;77:740-4. Harris JM. Papanicolaou smear recommendations, patient complaints, and patient satisfaction in managed-care medical organizations. Med Care 1995;33:272-9. Ware JE, Bayliss MS, Rogers WH, Kosinski M, Tarlov AR. Differences in &year health outcomes for elderly and poor, chronically ill patients treated in HMO and fee-for-service systems. JAMA 1996;276:1039-47. Blumenthal D. Origins of the quality of care debate. N Engl J Med 1996;335:1146-9. Palmer RH. Considerations in defining quality of health care. In: Palmer RH, Donabedian A, Povar GJ (eds). Striving for quality in health care: an inquiry into policy and practice. Ann Arbor (MI): Health Administration Press, 1991. Makuc DM, Freid VM, Kleinman JC. National trends in the use of preventive health care by women. Am J Public Health 198Y;79:21-6. Commonwealth Fund Commission on Women’s Health. Prevention and women’s health: a shared responsibility. New York (NY): The Commonwealth Fund, 1996. Udvarhelyi IS, Jennison K, Phillips RS, Epstein AM. Cotnparison of the quality of ambulatory care for fee-for-service and prepaid patients. Ann lnt Med 1991;115:
7. Rartman
8. 9. 10. 11. 12. 13.
14. 15.
16. 17.
18. 19. 20.
3946400. 21.
22.
23. 24. 25. 26. 27.
28.
29. 30.
31. 32. 33.
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Bernstein AB, Thompson GB, Harlan LC. ljifferences in rates of cancer screening by usual source of medical care. Med Care 1’391;29:196-209. Makuc DM, Freid VM, Parsons PE. Health insurance and cancer screening among women. Advance data no 254. Hy,jttsville (MD): National Center for Health Statistics, 1994. Hillis SD, Wasserheit JN. Screening for Chlamydia-a key to the prevention of pelvic inflammatory disease. N Engl _IMed lYY6;223:3399-400, Chassin MR. Improving the quality of care. N Engl J Med 1996;335:1060-3. Anderson RJ. Osteoarthritis. In: Carlson KJ, Eisenstat SA. Primary care of women. St. Louis (MO): Mosby, 1996. Wilson IB, Cleary PD. Linking clinical variables with health-related quality of life: a conceptual model of patient outcomes. ] AMA 1995;273:59-65. Ulman KH. Group psychotherapy with the medically ill. In: Kaplan HI, Sadock BJ (eds). Comprehensive group psychotherapy. Baltimore (MD): Williams and Wilkins, 1993. Spiegel D, Bloom JR, Kraemer HC, Gottheil E. The beneficial effect of psychosocial treatment on survival of metastatic breast cancer patients: a randomized prospec ti\re outcomes study. Lancet 1989;2:885. Hoffman C, Rice D. Sung H-Y. Persons wjith chronic conditions: their prevalence and costs. JAMA 1996;276:1473-9. Kaplan SH, Greenfield S, Ware JE. Impact of the doctor-patient relationship on the outcomes of chronic disease. In: Stewart M, Rotor D (eds). Communication with medical patients. Newbury Park (CA): Sage Publications,, 198Y. Hall JA, Roter DL, Katz NR. Meta-analysis of correlates of provider behavior in medical encounters. Med Care lY88;26:657-75. Greenfield S, Kaplan S, Ware JE. Expanding patient involvement in care: effects on patient outcomes. Ann Int Med 3985;102:520-8. Kaplan SH, Gandek B, Greenfield :S, Rogers W, Ware JE. Patient and visit characteristics related to physicians’ participatory decision-making style: results from the Medical Outcomes Study. MIJd Care lYY5;33:1176-87,
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34. Kaplan SH et al. In: Falik MM, Collins KS. Women’s Health-The Commonwealth Fund Survey. Baltimore (MD): Johns Hopkins University Press, 1996. 35. Roter DL, Hall JA, Kern DE, Barker LR, Cole KA, Rota RI’. Improving physicians’ interviewing skills and reducing patients’ emotional distress: a randomized clinical trial. Arch Intern Med 1995;155:1877-84. 36. Kasper JF, Fowler FJ. Responding to the challenge: a status report on shared decision-making programs. HMO Pratt 1993;7:176-81. 37. Nattinger AB, Gottlieb MS, Veum J, Yahnke D, Goodwin J. Geographic variation in the use of breast-conserving treatment for breast cancer. N Engl J Med 1992;326: 1102. 38. Nattinger AB, Gottlieb MS, Hoffman JIG, Walker AP, Goodwin JS. Minimal increase in use of breast-conserving surgery from 1986 to 1990. Med Care 1996;34:479--89. 39. Davis DA, Thomson MA, Oxman AD, Haynes RB. Changing physician performance: a systematic review of the effect of continuing medical education strategies. JAMA 1995;274:700-5. 40. Berwick DM. Payment by capitation and the quality of care. N Engl J Med 1996;335:1227-31.
CAIILSON:
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ISSLIES
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MD
Massachusetts General Hospital IHarvard Medical School 13oston, Massachusetts
M
anaged care has become a dominant force among systems for health care delivery in the United States. Over three quarters of persons obtaining health care through their employers do so under some form of managed care plan. Although resistance to managed care has surfaced, ’ there is no doubt that organizations to manage health care cost, quality, and accesswill proliferate in years to come. Women use health care services at higher rates than men.* For this reason alone, changes in health care delivery c’ould be said to have a disproportionate effect on women. It is noteworthy that among the earliest legislative efforts to regulate managed care practices was the restriction of “drive-through deliveries.” Recently “drive-through mastectomies” have come under scrutiny, and large settlements in litigation against health maintenance organizations (HMOs) that denied coverage of bone marrow transplants for breast cancer have made headlines.’ Women also use ambulatory services more frequently than men.’ Although management of expensive inpatient care was among the earliest initiatives of managed care, primary (care has received greater emphasis in recent years. This emphasis is congruent with a commitment among managed care organizations to controlling the costs of care and to improving health status at the population level. This article examines the clinical issues in primary care for women under managed care delivery systems, considering ways in which such systems present opportunities for addressing unmet needs in women’s health care, as well as potential threats to optimal care for women.
THE
CURRENT
SYSTEM: FRAGMENTATION HEALTH CARE
IN WOMEN’S
Fragmentation in women’s health care has existed at two levels. The first is at the level of delivery of basic clinical services to women. The second is in the conceptualization of women’s health, which has been defined according to a specialty-focused biomedical model, rather than a multidisciplinary biopsychosocial model.
C‘ARLSON:
0 lYY7 bv The Jacobs of Women’, Health Published by Elsevier 10~Y-~s~7/~7/g17.00 PII s1049-~~~7(97)00075-:1
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ISSUES
Imtitute Scwnct
Inc
OF MANAGFD
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The delivery of primary care services to women has traditionally been divided between generalists (internists, family practitioners, and general practitioners) and obstetrician/gynecologists, with many areas of overlap.” In general, women have received medical care for episodic and chronic nonreproductive illness from the first group and gynecologic and obstetric care from the latter. The time-limited nature of pregnancy allows the two-provider model to function reasonably well for obstetric care. Gynecologic care, however, is an ongoing need for women throughout the life span. Given this reality, women have had three options for obtaining primary care. They could have the continuity and efficiency of seeing a single physician, but in so doing, risk neglecting their general health needs or their gynecologic needs (depending on whether the physician was an obstetrician/gynecologist or a generalist). Or they could have two physicians, ensuring that both reproductive and nonreproductive health needs would be addressed, but running the risk of contradictory recornmel7dations, duplication of efforts, a~~ti other inefficiencies. Each specialty rn‘ly have unique merits as primary care providers. Differences in the provision of certain types of preventive care to women by generalists and obstetrician/gynecologists have been reported. Obstetrician/ gynecologists provide a greater number of preventive services than generalists,’ and obstetrician/gynecologists have higher age-adjusted rates of Papanicolaou test screening than generalists” and are more likely to include breast and gynecologic exams in a general medical examination7 Overuse of Papanicolaou smears, however, has been more frequentlj? documented among gynecologists.” Generalists have been more broadly tra-ined in adult medicine and are almost certainly better able to met4 the “large majority of personal health care needs” that define the clinLca1domain of primary care providers.“ In addition, skills and attitudes essential to primary care practice (such as the practical application of clinical epidemiology, ,311 awareness of cost-effectiveness, and a tolerance for uncertainty) are more commonly addressed in the training of generalists than in that of specialists ~ch as obstctrician/gynccologists. Changes in the system of medical education are brginning to ameliorate the problem of fragmentation in wornen’s care. For over two decades, the specialty of family practice has trained physicians who can provide both general and gynecologic care (and (often obstetric care). Some residency programs in internal medicine have included training in primary care gynecology to enable their graduates to provide routine gynecologic care. Finally, since 1995, residency training for obstetrician/gynecologists has included a nonreproductive primary care component and postgraduate training programs in general primary care have proliferated. These initiatives in medical cducation ultimately should result in less fragmentation as more physicians are broadly trained to meet women’s general medic,>1care needs. The second way ~JI which women’s health care has been fragmented is in the conceptual model that has been the found,ltion for training physicians. Under the prevailing biomedical model, c,lre for women has been viewed as the province of multiple medical speci,llties. In this model, defined according to organ systems, the core disciplines concerned with women’s health have Ibeen obstetrics and gynecology, medicine, endocrjnology, and psychiatry. New conceptualizations of women’s health are based on a biopsychosocial model. This model emphasizes the importance of psychological and social factors as well asbiological factors in health and illness. There is some evidence that the difference in morbidity rates between women and men may be largely explained by nonbiologic factors, including acquired risks related to lifestyle, rcrleh, and socioeconomic variables, psychosocial factors, and health-reporting
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behavior.2 The biopsychosocial model has been proposed as a more appropriate model for women’s health.‘” A clinical example illustrates how the traditional specialty model has served women’s health needs poorly. Chronic abdominal pain is a problem commonly encountered in the primary care of women. Chronic abdominal pain can have many causes, including gastrointestinal disease, gynecologic disorders, and functional changes in bowel function related to the menstrual cycle, diet, and other environmental factors; it can also represent a somatic manifestation of previous sexual abuse. ” In the traditional system, a women presenting to a generalist would typically receive an evaluation aimed first at excluding a serious gastrointestinal disorder (sometimes including a referral to a gastroenterologist for testing), then a referral to a gynecologist to rule out disorders of the uterus or ovaries, and then a psychiatric referral to address psychosocial stressors implicated in functional bowel disorders and chronic pelvic pain syndromes. Under the new conceptualization of comprehensive women’s health, a skilled clinician would evaluate all of these diagnostic possibilities simultaneously, allowing more rapid assessment and initiation of treatment without the inefficiencies of multiple consultations and exhaustive, rather than targeted, testing. Only a comprehensive model informed by a knowledge of gender-specific disease tbpidcmiology will facilitate efficient, accurate management of illness in women.
Solutions
Under
Managed
Care
Managed care has to date prompted a number of changes in health care delivery that provide partial solutions to the problem of fragmentation in women’s health care. The focus c?npvirnury NW is the most important of these. Under ideal circumstances, the primary care physician as gatekeeper can coordinate care and make sure that a woman does not “fall between the cracks” if her problem does not fit neatly into the domain of a single specialty. The primary care provider also takes on the responsibility of ensuring that a woman receives appropriate preventive care. Accc~ss to RIZC~IIOY~~ suz~iccs is essential because psychosocial factors often have an important role in symptom severity and functional effects for women. For example, the common problem of mechanical back pain in a working mother juggling the strains of lifting children, work stress, and lack of time for preventive exercise will not be solved by an orthopedic evaluation, magnetic resonance imaging, or a nonsteroidal drug, but rather by a physical therapy evaluation and treatment plan tailored to her indi\ridual needs. LII’SIWSPnzanqc~~zt /~~o~~~r~znrs for female-specific disorders have the potential to improve women’s health care under managed care. Such programs provide the focal point for a much-needed integration of multidisciplinary expertise and stimulate the development of inno\,ative approaches to complex clmical problems. An example is the problem of chronic pelvic pain, widely acknowledged as a frustrating condition for both patients and physicians.” a randomized trial demonstrated that multidisciplinary management of pelvic p‘lin (integrating gynecology, psycholp?y, physical therapy, ;Ind nutrition) improved pelvic pain at 1 year signlflcantlv more often th‘ln a standard approach.” Such disease management prograins i,vill be most effective if they emphasize (1) disorders for which there is somt’ evidence that a multidisciplina~*y approach produces improved outcc~mes compared with :standard care; (2) time-limited treatment, with return to th(a primar) care physician for management based on recommendations of the multid~sciplinq~ group; (3) dl~\~c~lopmcnt of guidelines for use by primary care physicians in initial management, including indications for rl-ferral; and (3) ongoing evaluation of quCllitJf ,Ind cost outcomes.
CARI
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Problems
Under
Managed
Care
Primary care providers need basic skills (such as competent breast and pelvic exams) as well as broad knowledge to provide comprehensive care to women. Managed care cannot solve the problem of gaps in the knowledge base and skills qf practicing generalist physicians, particularly those trained outside of family practice or primary care medicine programs. Currently, many managed care plans have acknowledged the reality of fragmented provider competence b) allowing women access to gynecologic cart without authorization by the primary care provider. This is a sensible policy in the near term, although the existing evidence suggests that organizations that allow self-referral to gynecologists achieve no higher rates of preventive services such as Papanicolaou smears than organizations that do not.‘” Managed care organizations can, over the long term, require that generalists who wish to provide primary carle to women demonstrate competency in basic aspects of gynecologic care such as the breast and pehric examination, contraceptive management, and initial management of common gynecologic problems such as vaginitis and abnormal bleeding. They can also sponsor training in these areas for practicing generalists who desire to upgrade thei] competence in office gynecology. lrladequafc coverage qf mental kraltll sc17~ic~s is a problem in women’s health care that managed care has, if anything, compounded. Managed care organizations have generally implemented systems that tend to limit access to mental health services compared with tradi&nai fee-for-service care. There is little research evaluating the effects of such changes on mental health. Data on mental health outcomes from the Medical Outcomes Study suggest that the performance of managed care organization is Lrariable and site-specific relative to fee-for-service plans. ” ‘The gatekeeping requirements of some managed care organizations have resulted in a hwdcasorne autkorizafioll systcnl that increases administrative inefficiency while doing nothing to improve communication among physicians in\~olved in a woman’s care. When such systems impede appropriate access to cart’, their effects on the health of the population will be detrimental, although short-term cost savings may result. Finally, the capitatcd organ-based dis~rasc “cam’ auf” risks rr~i~~stit~~fj~)~za/i-7~7ti~~~~ of _fi,“S”‘L”ztation. The disease management concept ma\/ work well for some conditions, particularly those that occur in relatively young populations of women with a limited number of coexi,+ting conditions (for example, pregnancv), and those that, at least at initial diagnc~sis, requirt~ intensive and highly tcbchnical care (such as breast or ovarian cancer). Brcause, however, the primary care provider is almost always in the best position to o\.ersee the process of care in the long term, by virtue of his or her unique knowledge of the patient acquired over time, disease management programs must inform ,jnd involve the primary care physiclan ,It the earliest possible point in a patient’s course. It is vital that disease management programs do not disrupt primary care physicians’ relationships with patients by “carving out” management of chronic illnesses. Management of chronic riisordcrs, which often occur as one among many health problems (for example, osteoporosis and obesity), might use multidisciplinary specialty units in the development of guidelines for use in primary care and for individual clinical consultations to pro\.ide recommendations for implementation in the primarv c‘lre setting. They- should not be used as alternative sites for ongoing care. ihe cnmplexitv of the current health care svstem requires that processes promoting continuity of care receive hlghesi priority as management systems evolvc~. “’
COMPONENTS
OF COMPREHENSIVE CARE FOR WOMEN
PRIMARY
What constitutes comprehensive primary care for women? First, it includes expertise in evaluation and management of the range of medical problems commonly encountered in primary care practice-those that affect both men and women. These include both diseases (such as hypertension, coronary artery disease, diabetes, and human immunodeficiency virus infection) and conditions (such as headache, back pain, and fatigue) that may manifest differently, or respond differently to treatment, in women as compared with men. Comprehensive women’s primary care also includes management of medical problems that occur more commonly in women, such as osteoporosis, disorders. Reproductive thyroid disease, breast disease, and autoimmune health care, including preventive care as well as management of common gynecologic conditions, is a cornerstone of primary care for women. Mental health care and behavioral medicine, including issues related to depression, smoking, substance abuse, and domestic violence, are equally important elements of comprehensive care. Truly comprehensive care for women includes obstetric care. At the least, clinicians who do not themselves deliver obstetric care should understand the interaction of pregnancy with illness and management of common medical and psychiatric problems during and after pregnancy. In addition to these clinically defined components of care, we can also consider comprehensive care for women in terms of two broad domains: technical care and interpersonal care. Technical care includes both the provision of appropriate services and the skill with which appropriate care is performed. l7 Technical considerations apply to preventive care, episodic illness care, and chronic disease care. Interpersonal aspects of care encompass communications between physician and patient, as well as the physician’s emotion-handling skills, awareness of an individual patient’s values and preferences, and decision-making style.
PREVENTIVE
CARE
The inadequate emphasis on prevention for women in existing care systems has been abundantly documented.‘“*i“ Improving preventive care for women requires attention to all steps in the process: provision of services by clinicians, coverage of services by insurers, and use of services by women.
Solutions
Under
Managed
Care
Managed care has already had a positive impact in expanding provision of some preventive services by clinicianls. Greater use of preventive services in health maintenance organizations compared with fee-for-service practices has been documented20,21 and preventive care specific to women (Papanicolaou tests, breast examinations, and mammography) reflects a similar pattern.22 Managed care brings the potential for stronger ovganizafional strategies to ensure consistent performance of preventive services. These include clinical database systems to identify individual patients in need of preventive services and systems to monitor physician performance of recommended preventive services. Coverage of certain preventive services such as Papanicolaou smears and mammography under managed care generally is improved compared with the fee-for-service system. Coverage has often been limited by the lack of reliable outcome measures and cost-effectiveness data for specific screening interven-
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tions. Several screening interventions for specific subgroups of women deserve a critical review and development of guidelines for use within managed care organizations. These include screening of high-risk populations of women for chlamydial infection (based on recent data demonstrating that treatment can prevent pelvic inflammatory disease2’) and bone density testing for postmenopausal women (in light of the availability of bisphosphonates in addition to estrogen replacement therapy for treatment of osteoporosis). Use of services by women is another aspect of preventive care upon which managed care organizations can have a positive impact. Putiel?t and comrrzunify r~i~lcafio~z initiatives sponsored by /zenith care ovgarzizafions can be marketed to target specific subpopulations of members such as young unmarried women or perimenopausal women. Such initiatives can include live and televised seminars, print material, videotapes, and reminder cards. Collaboration with community organizations is desirable, and is essential in cases involving culturally sensitive health issues.
Problems
of Managed
Care
7’11~provision of preventive services takes fim, which is perceived by physicians and patients as increasingly limited as the influence of managed care grows. The preventive services explicitly covered by managed care (such as Papanicolaou smears, mammograms, and fecal occult blood tests) emphasize diagnostic testing rather than counseling. Screening women for specific health behaviors and exposures such as diet and exercise habits, risky sexual behavior, substance abuse, and domestic violence takes time within a face-toface doctor-patient interaction. Although complementary approaches using ancillary care providers and screening instruments can be valuable, there is a minimum irreducible quantity of time required for primary care clinicians to diagnose, assess, and counsel patients about thesca important health behaviors. For some motivated women, ancillary services (such as smoking cessation group) will be effective and these should be usc*d when appropriate. But for other women, only work with a primary care physician over time can lead to acknowledgement of the need to change and motivation to make changes in lifestyle factors which have a tremendous impact on their health. Managed care organizations that seek to improve preventive care for women must provide incentives for counselling as well as technic,4 screening interventions.
EPISODlC
CARE
The chief task within HMOs for primary care of episodic illnesses is to promote efficient use of the health care system. Several factors contribute to existing inefficiencies in primary care of episodic illnesses, including lack of accepted clinical guidelines for management of common problems, financial incentives promoting office visits rather than other approaches such as telephone management, and lack of systems and financial incentives for patient educatic)n in self-care.
Solutions
Under
Managed
Care
Managed care organizations have taken positive steps to address each of the factors just described. At the level of the health care system, dev~~lopnzcnt I$ f~l~&ic‘c~ pi&lines has helped clinicians to incorporate the latest researchinterpreted through the filters of expert judgment ,lnd consideration of c~ost-effectiveness-into their clinical management of common problems. Although to date such efforts have targeted primarily high-cost inpatient care,
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applications to ambulatory care are expanding. For clinicians, guidelines to reduce inappropriate use of services provide a method for rationing access to care that is far preferable to “blunt instruments” for controlling costs such as copayments.24 Common episodic problems in women that are appropriate for guideline use include acute dysuria, vaginitis symptoms, acute pelvic pain, irregular \,aginal bleeding, and fatigue as well as more general problems such as headache, back pain, abdominal pain, sore throat, and cough. Managed care organizations with capitated reimbursement systems have also remouedfinancial disincentives for telephone managementand judicious use qf rlonphysician personnel for some aspects of care. For example, management of uncomplicated urinary tract infection by telephone has become an accepted I standard of care for established adult female patients in primary care practices. / This form of care had been advocated by some physicians and desired by many patients during the years before managed care but has only become a standard practice with the realignment of financial incentives to promote efficient care. Finally, managed care has the potential to use membership databases to provide patient education in self-care, which can reduce inappropriate use of services for episodic illness. For example, the health needs of young adult women typically center around gynecologjc care (including contraceptive management and prevention of sexually transmitted diseases), modification of risky habits (such as smoking, substance abuse, and unsafe sexual practices), and care for minor illnesses such as allergic rhinitis and upper respiratory and urinary tract infections. A managed care organization can use its membership database and health education resources to provided targeted health information to this population that can complement face-to-face teaching by the primary care provider. Topics that could be targeted for Ihis age group would include the normal menstrual cycle, common concerns related to sexuality, availability of emergency contraception (that is, the “morning after pill”), strategies for smoking cessation, warning signs of depression, and self-care measures for common illnesses such ac. allergy, minor headaches, and respiratory infections, including guidelines for when to seek care. ‘This form of “demand management” for specific populations of women can provide reliable information on reproductive, nonreproductive, and mental health issues that promotes appropriate use of health resources. Demand m;lnagement initiatives are ideally undertaken in paraIlei with efforts to ensure continuity of care so that the outcomes of these initiatives can be assessedover time in a relatively stable member population.
Problems
Under
Managed
Care
The majority of managed care initiative:; to improve care for episodic illnesses have focused on high-cost or technology-intensive clinical scenarios such as asthma, chest pain, and acute myocardial infarction.. These conditions are those in which investment of management resources will yield high short-term returns (primarily in cost terms) in the form of reduced hospital use, With the exception of managed care initiatives in pnlnatal care and high-risk pregnantits, which clearly benefit both women and their children, these diseas(>rrurt~a~~cmerzt ejbrts have tcrrded tofoczrs OHxute t-onditiorzsthat afiect men mow t/~all 7/‘OllIi’l7.
CHRONIC
DISEASE
CARE
At a given age, men have higher mortality rates than women, and women have high rates of morbidity largely due to higher rates of acute illnesses and most
nonfatal chronic conditions.* For women, improved health over the life span requires reduction in morbidity and functional impairment associated with chronic conditions, such as arthritis, headaches, and chronic gastrointestinal disorders. Unfortunately, chronic diseases have received proportionally less attention as subjects of clinical research than acute disorders, so understanding of pathophysiology and development of effective treatments for many chronic conditions are limited. For example, there is no known medical or surgical therapy that can influence the course of osteoarthritis.“” Another element that limits effectlIve care for many chronic conditions is a lack of understanding of the role of nonbiologic factors in outcomes. New models of health-related quality of life, which link clinical and quality-of-life concepts in a way that facilitates empiric testing, emphasize the relationship of nonmedical factors (such as socioeconomic status, employment, and social support) and psychological factors (such ;IS motivation) to health outcomes2h; however, clinicians have at rudimentary understanding at best of the role of these factors in determining the health status of persons with chronic diseases.
Solutions
Under
Managed
Care
At this time in the evolution of managed care, relatively few initiatives have targeted chronic disease. There is, however, the potential for managed care to bring the strengths of its systems and population-based approach to improve care of chronic conditions in women. One potentially useful approach is in the intt>graGonof multiple disciplines to develop guidelines for care of chronic conditions that can be implemented in the primary care setting. In addition to the example of chronic pelvic pain cited earlier, other examples include type 11diabetes; chronic headaches; chronic rheumatologic conditions such as osteoarthritis, rheumatoid arthritis, and fibromyalgia; and obesity. For such conditions, a multidisciplinary approach integrating medicine, surgery, psychology, and other services such as physical therapy and nutrition may be more effective than standard care (though empiric data comparing these two approaches are lacking). Such multidisciplinary collaborations are certainly important for the development of clinical guidelines, even if care is provided in conventional settings. There is a large body of research evidence that indicates that psychoeducational groups for women with chronic conditions are associated with better health outcomes, including improvements in physical symptoms, social functioning, attitudes, compliance, and use of health care resources.2i’A randomized trial of group treatment for women with metastatic breast cancer demonstrated a doubling of survival time for group participants. ** Historically, the concept of the psychoeducational group has been institutionalized within women’s health care in the form of prenatal education groups to inform women (and their partners) about the physiology of pregnancy, expectations for physical and psychological changes over time, and specific techniques for managing these changes during pregnancy and delivery. Application of this concept of time-limited psychoeducational groups for women with conditions such as heart disease, diabetes, arthritis, irritable bowel syndrome, and asthma should be explored; there is evidence for improved health outcomes associated with psychoeducational groups in all these conditionsZ7 The ability of managed care systems to link multiple small practice units allows accessto a sizable population of women with similar chronic conditions. C’omputerized use and health status data on the member population permits evaluation and modification of the educational intervention.
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Problems
Under
Managed
Care
Thr -financial return from investments in innovative approaches to chronic disease n~anagement is likely to be less immediate than the cost savings resulting from targeting acute care. It is unclear whether the current competitive pressures on managed care organizations, coupled with high enrollee turnover over time, are compatible with the commitment of resources needed to develop better approaches to chronic disease care. Although chronic diseases are responsible for three quarters of direct medical care costs, it is uncertain whether changing delivery systems for chronic care will generate significant cost savings.2y
INTERPERSONAL
CARE
lnterpersonal care is an extremely important aspect of clinical care for all patients, and particularly for women. The positive effects of high-quality interpersonal care on health outcomes art’ well documented.“” Studies of aspects of provider behavior correlated with patient satisfaction identify the most important predictors as the amount of information given by the provider and partnership-building behavior.“’ A. participatory decision-making style has also been correlated with improved health outcomes.“.“’ Studies of gender differences in doctor-patient interactions show that female patients ask for and receive more health information, elicit more partnership-building behavior, and receive more health services than male patients.” There is some evidence that women are more likely than men to be dissatisfied with their doctors; 40% report they have switched doctors.“’ Lack of technical competence and lack of communication skills were the primary reasons cited by women for switching physicians. A hallmark of primary care, which is central to the current systems of managed care, is continuity of care. Returns in quality and cost terms of the investments of professionals’ time and other health resources in an individual member arc’ diminished if that member later changes to a new physician-particularly if she Ica\,cs her managed care plan to do so.
Solutions
Under
Managed
Care
Managed care has given a tremendous stimulus to the movement for quality measurement and improvement within health delivery systems. Methods of quality assessment have been developed to evaluate multiple aspects of the care process, including measures of patierlt satisjartiou. Data from such evaluations have been reported back to physicians, with the goal of influencing their behavior, including interpersonal care. Patient satisfaction has been used as a 1 ariable for determining physician reimlbursrment under capitated systems. [f physicians are being asked to improve their communication skills (which most were not taught formally during medical training), they also should be given instruction to improve those skills. Managed cure system should &;lc)tc resources to trailli,?Cy&sicinP7s iI1 ,.,c,n2/rlllllicatj~)~~~ skills ju5t as they offer educational programs to optimize drug prescribing or cost-effective use of di,lgnostic tests. Educational interventions to improve communication skills among physicians have been demonstrated to improve problem-defining and emotion-handling skills without increas.ing the length of the office visit.“r’ Other innovations m,ithin managed care include fi,rwal systems to prormfe pvfir:ip~for?y derision makirlCq to educate patients and improve their ability to take an active role in their care. An example is a series of interactive videodisc programs, known as Shared Decision-Making Programs, which are currently in LW on over 200 platforms (many in managed care systems) in the Unitcbd
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States.” These prog rams include a series on women’s health topics, including early stage breast cancer, benign uterine conditions, and hormone replacement therapy. By encouraging members di.agnosed with particular conditions to view such educational programs, managed care organizations can ensure that patients have had access to basic information needed to take an active role in decision making and can validate the importance of patient participation in the care process. Frcdback to physicin~s 011mviations in use of specific interventions is another strategy organizations can use to address the problem of lack of participatory decision making. A clinical example concerns treatment alternatives for women with early stage breast cancer. Large regional variations in rates of procedures such as breast-conserving surgery versus mastectomy are thought to reflect an excessive influence of the physician’s practice style in the surgical decision-making process.“’ Managed care organizations can address this problem of unwanted variation by using their clinical databases to provide participating surgeons with data on their own rates of procedures compared with that of their peers. There is somt: evidence that dissemination of population data on rates of these procedures does little to change physician brhavior;“s but feedback of information on practice patterns to individual physicians has been shown to have a positive effect.“’
Problems
Under
Managed
Care
Two trends now prevalent in managed care have the potential to offset the benefits for improving interpersonal cdre from initiatives such as those just described. The first is the disrupfion $ co22fint2ity (f cm. The duration of the physician-patient relationship is highly correlated with use of a participatory decision-making style, with the most participatory visits occurring among p,i tien ts who have seen their physician for at least 5 years.“” Competition in the marketplace among managed care plans has resulted in economic incentives to <>hangeplans frequently for purchasers Iof health services. From one year to the next, an individual woman may be required to choose a new physician as health benefits packages shift. Such pressures undermine the maintenance of a st,lble continuity relationship between doctor and patient-an investment that c.an reap major gains in both process and outcomes of care over the years. The second trend under managed cart’ that can negatively impact interpersonal care is the fwd fn7oard shorlt>r~fficc +i/s. L,ength of the office visit is a major determinant of participatory decision-making stvle. III analysis of data from the Medical Outcomes Study, Kaplan ct ~1.“’ f&d that visits of 15 minutes or less were significantly less participatory than those lasting more than 20 minutes. With current industrl: norms of a 15minutcl office visit in primary care practice, productivity presiurcxs on clinicians may be inconsistent with the time requirements for involving patients effectivelv in treatment decisions. .4lthough current standards ma)’ improve cost outcomes, they are likely to have a negative impact on qus,lity outcomes o\cr time. A third factor that can compromise interpersonal cart’ under managed care is the r~/~si~nofptic~~fs’ fvllsf fl~af TPSL~/~.S T~~UVI fi/ril/lciil/ ir7c~lwfiw.s q@f UY a~7pc~2 10 #‘ci c~inicu~ &‘isjo~l rnakin~~.Although managed care provides a great impetus for integration of systems, thereby decreasing fragmentation of care, capitated payment mechanisms also run the risk of rtaal or apparent withholding of care bv physicians, with tremendous t>ottbntial for damage to the trust inherent in the doctor-patient rclationshrp. Principle<; for the design of capitated systems that encourage better ‘md more efficient care for patients and comrnu nities have been proposed.J”
CONCLUSIONS lnnovations in managed care systems offer some important advantages over include an traditional systems for women’s primary care. These innovations incentives flor improved coordination of care and emphasis on primary care, communication among caregivers, the ability to disseminate guidelines and monitor performance of preventive and treatment interventions, and the potential for a more comprehensive multidisciplinary approach to complex problems in women’s health. Managed care systems also offer additional opportunities for physician training in the technical and interpersonal aspects of women’s care and have the potential for enhancing patient education by using population data to target subgroups of women. The current system of managed ca-re also poses some threats to efforts to improve the quality of women’s primary care. Chief among these is erosion of the doctor-patient relationship through productivity pressures, disincentives for maintenance of continuity, and real or apparent financial conflict-of-interest between physicians and patients. Innovationx in clinical practices under managed care have to date emphasized diseases and conditions that affect men rnore than women (with the exception of prenatal can: and high-risk pregnancy management programs). Managed care does not provide a panacea for all thr problems in delivery of primary care to women. It does nothing to solve the problem of access for uninsured women. High co-insurance within some managed care plans for basic preventive services can impede access to care. Data indicating that special populations including the poor and elderly chronically il I (both groups with a substantial majority of female members) fare less well in HMOs than in fee-for-service medicine are alarming. ” Finally, managed care cannot solve the problem of gaps in the training of primary care physicians to care for the comprehensive health needs of women and in the uneven foundation for clinical practice provided by our current sketchy knowledge base. With these limitations in mind, clinicians, health policy makers, insurers, ~ and the public must work together to make sure that our changing system of health care delivery is responsive to the real needs of women.
ACKNOWLEDGMENTS i The author gratefully acknowledges ~ MD, Isaac Schiff, MD, and Paulette earlier version of this manuscript.
Nancy Gagliano, MD, Anne Moulton, Thabault, RN, JD, for their review of an
REFERENCES 1. Bodenheimer T. The HMO backlash---righteous
or reactionary? N Engl J Med
1996;335:1601-3. 2.
3. 3. 5. 6.
Verbrugge LM. The twain meet: empirical explanations of sex differences in health and mortality. J Health Sot Behav 1989;30:282-304. National Ambulatory Medical Care Survey. Hyattsville (MD): National Center for Health Statistics, 1989. Clancy CM, Massion CT. American women’s health care: a patchwork quilt with gaps. JAMA 1992;268:1918 -20. Weisman CS. Women’s use of health ‘care. In: Falik MM, Collins KS. Women’s health-The Commonwealth Fund Survey. Baltimore (MD): Johns Hopkins University Press, 1996. Lurie N, Slater J, McGovern I’, Ekstrum J, Quam I,, Margolis K. Preventive care for women: does the sex of the physician matter? N Engl J Med 1993;329:478-82,
C4KlSON:
CL.INICAI.
ISSlXS
OF MANAGEI)
CARE
359
BA, Weiss KB. Women’s health care in the ambulatory care setting. Clin Res 1991;39:595A. Cohen MM, Roos NP, MacWilliam L., Majda A. Assessing physicians’ compliance with guidelines for I’apanicolaou testing. Med Care 1992;30:514-28. Donaldson MS et al. Primary care: America’s health in a new era. Washington (DC): National specialty. J Johnson K. Women’s health: developiiig a new interdisciplinary Womens Health 1992;1:95-9. Wolf JL. Bowel function. In: Carlson KJ, Eisenstat SA. Primary care of women. St. Louis (MO): Mosby, 1995. Gambone JC, Reiter RC. Nonsurgical management of chronic pelvic pain: a multidisciplinary approach. Clin Obstet Gynecol 1990;33:205-11. Peters AAW, van Dorst E, Jellis 8, van Zuuren E, Hermans J, Trimbos JB. A randomized clinical trial to compaae two different approaches in women with chronic pelvic pain. Obstet Gynecol 1991;77:740-4. Harris JM. Papanicolaou smear recommendations, patient complaints, and patient satisfaction in managed-care medical organizations. Med Care 1995;33:272-9. Ware JE, Bayliss MS, Rogers WH, Kosinski M, Tarlov AR. Differences in &year health outcomes for elderly and poor, chronically ill patients treated in HMO and fee-for-service systems. JAMA 1996;276:1039-47. Blumenthal D. Origins of the quality of care debate. N Engl J Med 1996;335:1146-9. Palmer RH. Considerations in defining quality of health care. In: Palmer RH, Donabedian A, Povar GJ (eds). Striving for quality in health care: an inquiry into policy and practice. Ann Arbor (MI): Health Administration Press, 1991. Makuc DM, Freid VM, Kleinman JC. National trends in the use of preventive health care by women. Am J Public Health 198Y;79:21-6. Commonwealth Fund Commission on Women’s Health. Prevention and women’s health: a shared responsibility. New York (NY): The Commonwealth Fund, 1996. Udvarhelyi IS, Jennison K, Phillips RS, Epstein AM. Cotnparison of the quality of ambulatory care for fee-for-service and prepaid patients. Ann lnt Med 1991;115:
7. Rartman
8. 9. 10. 11. 12. 13.
14. 15.
16. 17.
18. 19. 20.
3946400. 21.
22.
23. 24. 25. 26. 27.
28.
29. 30.
31. 32. 33.
360
Bernstein AB, Thompson GB, Harlan LC. ljifferences in rates of cancer screening by usual source of medical care. Med Care 1’391;29:196-209. Makuc DM, Freid VM, Parsons PE. Health insurance and cancer screening among women. Advance data no 254. Hy,jttsville (MD): National Center for Health Statistics, 1994. Hillis SD, Wasserheit JN. Screening for Chlamydia-a key to the prevention of pelvic inflammatory disease. N Engl _IMed lYY6;223:3399-400, Chassin MR. Improving the quality of care. N Engl J Med 1996;335:1060-3. Anderson RJ. Osteoarthritis. In: Carlson KJ, Eisenstat SA. Primary care of women. St. Louis (MO): Mosby, 1996. Wilson IB, Cleary PD. Linking clinical variables with health-related quality of life: a conceptual model of patient outcomes. ] AMA 1995;273:59-65. Ulman KH. Group psychotherapy with the medically ill. In: Kaplan HI, Sadock BJ (eds). Comprehensive group psychotherapy. Baltimore (MD): Williams and Wilkins, 1993. Spiegel D, Bloom JR, Kraemer HC, Gottheil E. The beneficial effect of psychosocial treatment on survival of metastatic breast cancer patients: a randomized prospec ti\re outcomes study. Lancet 1989;2:885. Hoffman C, Rice D. Sung H-Y. Persons wjith chronic conditions: their prevalence and costs. JAMA 1996;276:1473-9. Kaplan SH, Greenfield S, Ware JE. Impact of the doctor-patient relationship on the outcomes of chronic disease. In: Stewart M, Rotor D (eds). Communication with medical patients. Newbury Park (CA): Sage Publications,, 198Y. Hall JA, Roter DL, Katz NR. Meta-analysis of correlates of provider behavior in medical encounters. Med Care lY88;26:657-75. Greenfield S, Kaplan S, Ware JE. Expanding patient involvement in care: effects on patient outcomes. Ann Int Med 3985;102:520-8. Kaplan SH, Gandek B, Greenfield :S, Rogers W, Ware JE. Patient and visit characteristics related to physicians’ participatory decision-making style: results from the Medical Outcomes Study. MIJd Care lYY5;33:1176-87,
WOMEN’S
HEALTH
ISSUES
VOL.. 7, NO. h NOVIIMBtll:DE(:~MBEK
19’17
34. Kaplan SH et al. In: Falik MM, Collins KS. Women’s Health-The Commonwealth Fund Survey. Baltimore (MD): Johns Hopkins University Press, 1996. 35. Roter DL, Hall JA, Kern DE, Barker LR, Cole KA, Rota RI’. Improving physicians’ interviewing skills and reducing patients’ emotional distress: a randomized clinical trial. Arch Intern Med 1995;155:1877-84. 36. Kasper JF, Fowler FJ. Responding to the challenge: a status report on shared decision-making programs. HMO Pratt 1993;7:176-81. 37. Nattinger AB, Gottlieb MS, Veum J, Yahnke D, Goodwin J. Geographic variation in the use of breast-conserving treatment for breast cancer. N Engl J Med 1992;326: 1102. 38. Nattinger AB, Gottlieb MS, Hoffman JIG, Walker AP, Goodwin JS. Minimal increase in use of breast-conserving surgery from 1986 to 1990. Med Care 1996;34:479--89. 39. Davis DA, Thomson MA, Oxman AD, Haynes RB. Changing physician performance: a systematic review of the effect of continuing medical education strategies. JAMA 1995;274:700-5. 40. Berwick DM. Payment by capitation and the quality of care. N Engl J Med 1996;335:1227-31.
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CLINICAl.
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