Women's health during health care transformation.

In the complex dynamic of today’s health care transformation, an essential component is the promise and potential to improve women’s health and health care. Moreover, women’s vital roles as decision makers, providers, and caregivers mean that the transformation in progress is certain to enhance access to and quality of care for individual women, as well as their families and extended social networks. The driving force for health care transformation is the Affordable Care Act of 2010 (ACA). Many physicians are already familiar with provisions in the ACA to expand health care insurance coverage to women and their families. In 2014, it will be illegal for insurance companies to deny coverage to anyone with a pre-existing condition, including pregnancy. In addition, sex will no longer be a pre-existing condition: insurers will not be able to charge women higher premiums than they charge men. Some provisions have already been enacted, such as providing coverage for dependent children through age 26 and no longer allowing coverage of children to be denied because of a pre-existing condition. It is especially exciting that expanded coverage for women’s health explicitly includes preventive services. The law requires new health plans to cover recommended preventive services, including vaccinations, cost-free. Regular well-baby and well-child visits are also covered from birth through age 21. These services do not require a co-pay or co-insurance when offered by providers in the insurer’s network. Preventive services include evidence-based services rated “A” or “B” by the U.S. Preventive Services Task Force; for example, depression screening, flu shots and colorectal cancer screening for adults over 50. In addition, there are over 20 services targeted to women such as annual well-woman visits to obtain the recommended preventive services, domestic and interpersonal violence screening and counseling, contraception and contraceptive counseling, and chlamydia infection screening for younger women and other women at higher risk. When coverage increases, how will access and coordinated care follow? Expanding access and coverage is absolutely necessary to improve health and health care, but it is not sufficient. Our current system is highly fragmented as well as costly, so improving care delivery and enhancing coordination across settings are important to assure better access that result in improved health. The Affordable Care Act thus includes numerous provisions focused on improving quality of healthcare services. One model that has captured the attention of the primary care community is the patient-centered medical home (PCMH). This approach, with its strong focus on coordination and integration of services has enormous potential for women’s health since historically, even primary care for women has too often represented a patchwork quilt with gaps.1 PCMH is particularly relevant to women’s role as health care coordinators for families. Effective, meaningful use of health information technology (IT) is vital to translating this exciting model into reality. Developing effective PCMH models will require significant workforce development, teamwork enhancement and fundamental payment reform. Of the key features of PCMH, providing “comprehensive” care is probably the most challenging, particularly the urgency of addressing medical and behavioral health needs. Traditional primary care settings are comfortable with care coordination for healthy patients or those with a mild or common illness such as osteoarthritis or simple hypertension. However, treatment options have increased in both number and complexity. Patients increasingly have multiple morbidities, each needing more “specialized” or comprehensive care. Often, the specialized care relates to a behavioral-health morbidity. AHRQ-supported researchers have outlined programmatic and policy actions that are needed to facilitate integration of behavioral health care within a PCMH. These include: develop a strategy to normalize mental health into mainstream medical practice, integrate reimbursement mechanisms, create a roadmap for implementation, determine mechanisms to address the needs of those with complex mental health problems, and disseminate the tools needed by primary care providers.2 Promoting mental health of women and their families is an important strategy to address access and health disparities issues. Achieving equity in health requires two things. First, addressing the root causes of health inequities and second, resource allocation and interventions to specifically address the unique needs of disadvantaged populations. Disparities in care must be described and considered. Every year since 2003, AHRQ reports to the Congress on the state of healthcare quality and healthcare disparities. During that period, we have documented steady, albeit slow, improvements in quality and safety, especially for acute conditions. However, though there are a few areas for optimism with respect to reducing disparities associated with race, ethnicity, gender, income and education, disparities remain pervasive across numerous domains. Specifically: Overall, improvement in the quality of care remains suboptimal and access to care is not improving (yet!). Few disparities in quality are getting smaller and almost no disparities in access are getting smaller. Particular problem areas include cancer screening and management of diabetes. Quality of care varies not only across types of care but also across parts of the country. In terms of women’s health, measures show a mixed picture of health care quality and disparities. A few examples3: In all years, females were more likely than males to be unable to get or delayed in getting needed medical care, dental care or prescription medicines. In 2009, adult females with a major depressive episode were more likely than their male counterparts to receive any treatment for depression in the last 12 months (67.4 % vs. 59 %). However, since 2008, the rate for females has decreased, while the rate for males has increased. From 2000 to 2008, the percentage of women ages 50–74 who reported they had a mammogram in the past 2 years did not change significantly. From 2000 to 2007, the rate of advanced stage breast cancer in women ages 50–64 decreased from 106 to 96 per 100,000 women. Rates among women ages 40–49 and age 65 and over did not change significantly.