Getting Low-Income Women the Primary Care They Need
Posted on August 28, 2014
The value of the Medicaid program in ensuring care for low income women and families cannot be overstated. Nearly one out of every five woman in the US (19%) is insured by Medicaid. Yet the importance of the Medicaid program is undercut by the current biased payment system.
When treating Medicaid patients, physicians generally receive a lower reimbursement rate than they do for Medicare or private insurance patients. Nationally, Medicaid pays just 73% of Medicare rates for most primary care services. The difference in reimbursement rates means that many physicians can only accept a limited number of Medicaid patients. This makes it hard for low-income patients to find providers and get access to the health care they need, especially primary care, which is so important for improving health and reducing health care costs.
The Affordable Care Act acknowledged the importance of this issue. It created a “pay bump” for family physicians, internists, and pediatricians to Medicare levels when providing certain primary care services to Medicaid patients. However, this pay bump missed the mark by excluding ob-gyns.
Many ob-gyns provide primary care services in their practices. In fact, 60% of ob-gyn Medicaid billing is for primary care services. Well-woman visits and pregnancy check-ups often include primary care services such as vaccinations, diabetes screening, nutrition counseling, family planning, and smoking cessation advice. A woman’s ob-gyn is often the only doctor she sees regularly. And ob-gyns know the importance of preventive care. Healthier women have healthier pregnancies, which lead to healthier babies and families.
In addition, the pay bump was not permanent and it is set to expire this year. That’s why ACOG strongly supports legislation introduced this summer by US Reps. Frank Pallone (D-NJ) and Henry Waxman (D-CA) and Sens. Murray (D-WA) and Brown (D-OH). HR 5364, the Children’s Health Insurance Program (CHIP) Extension and Improvement Act of 2014, extends the pay bump through 2019. S 2694, the Ensuring Access to Primary Care for Women & Children Act, extends it through 2016, and both bills apply it to ob-gyns. Please contact your legislators and ask them to cosponsor the bills today.
With as many as 7 million low income women entering Medicaid due to the recent expansion, demand for services will only increase. This bill would help more low-income patients get the preventive services they need and eliminate inequality in the health care system. In order to best optimize our resources for women’s health, parity in payment is critical.
Those Who Ignore History Are Doomed to Repeat It
Posted on August 25, 2014
For most of my career, I have been able to care for women without fear of major complications or death from abortion. However, I have not forgotten those days when safe abortion was generally unavailable. I was delighted when I delivered my first baby in 1968. But at that time in our history, the exciting events of bringing babies into this world were often countered by the tragedies of illegal abortion.
Enough time has passed since the legalization of abortion in the US that it appears much of our society has forgotten the dangers of unsafe pregnancy termination and the desperation of women encountering an unplanned, unwanted pregnancy. It is estimated that approximately 13% of maternal deaths worldwide are due to unsafe abortion. The death rates are even higher in some countries where abortion has been totally banned.
No one has a greater appreciation for the value of human life than those of us who dedicate our lives to the wellbeing of mothers and the delivery of their babies. No other profession has a better knowledge of the complexity of the reproductive process, the potential complications, and the tragic circumstances that can sometimes accompany pregnancy than obstetrics and gynecology. We understand the current science of embryology and factors associated with both normal and abnormal human development. We know and deeply appreciate when a human embryo reaches a stage of fetal development where survivability outside the mother becomes a possibility. We know that a safely performed outpatient pregnancy termination in the first trimester has a complication rate of approximately 0.3%, of which most are minor.
We also know that in many cases, pregnancy termination any time prior to fetal viability is far safer than proceeding with the pregnancy. We respect the ethnic, cultural, religious, social, and moral differences that might factor into a decision to end a pregnancy. Termination of any pregnancy is difficult, but under many circumstances, it is the best alternative for a woman. She has that freedom of choice.
During one of my many trips to Washington, DC, my wife and I took a walk to the Jefferson Memorial. After you enter the memorial, you can read Thomas Jefferson’s passionate words on religious freedom. His words prompt questions that may be answered differently according to the reader’s perspective. Was Jefferson’s expression of separation of church and state intended to entitle persons to make their own religious choices and beliefs within the moral framework of society? Should government interfere in such a personal choice as whether or not to bear a child? A birth certificate legally records our day of birth, but should the government even attempt to arbitrate the debate of scientific versus religious interpretation of the beginning of life?
Somehow, I believe Jefferson would be greatly offended by the current legislative and judicial interference into the highly personal patient-physician relationship. Our specialty of obstetrics and gynecology ardently supports the dignity, rights, and autonomy of all women. I also believe all of us who deliver babies have an intense reverence for life. However, we must not ignore or misinterpret our country’s history of personal freedom and the history of tragic consequences of illegal, unsafe abortion. Those who ignore history are doomed to repeat it.
Protecting Women’s Access to Birth Control
Posted on August 19, 2014
Ob-gyns know the critical role contraception plays in preventive care for women. When patients need a prescription for contraception, we expect that they will be able to fill it without hassle. Unfortunately for many women, that isn’t the case. All too often, pharmacists insert their own personal beliefs into the health care equation, refusing to fill prescriptions for birth control or emergency contraception.
Last month, Sen. Cory Booker (D-NJ) reintroduced the Access to Birth Control Act, S 2625. The bill is designed to prevent interference from pharmacists and ensure that patients get the prescriptions they need. ACOG fully supports this important legislation.
Unintended pregnancy continues to be a major public health issue in the US, accounting for approximately 50% of all pregnancies. An unplanned pregnancy can have negative consequences for mother and child. It can worsen any preexisting health conditions the mother may have, such as diabetes, hypertension, or coronary artery disease. And short spacing between pregnancies is associated with low birth weight and premature birth. Family planning, including contraception, is the key to healthy mothers and babies.
Contraceptives are also used for medical purposes beyond birth control. Contraceptives can be used to regulate menstrual cycles, treat bleeding due to uterine fibroids, and manage pain due to endometriosis. Combined hormonal contraceptives have also been shown to decrease the risk of endometrial and ovarian cancer. For more on the importance of access to contraception, see ACOG’s Committee Opinion Over-the-Counter Access to Oral Contraceptives.
Decisions about contraception should be made by a woman and her doctor. Women should not have to face harassment from pharmacists—or anyone else—when filling a prescription. Please ask your US House Representative to support S 2625, the Access to Birth Control Act.
The Urgent Need to Reform Graduate Medical Education Funding
Posted on August 7, 2014
This year there were over 20,000 graduates of US medical schools who applied to the National Resident Matching Program. Many of them, including over 100 who applied to ob-gyn, were without a residency position on Match Day.
It’s no surprise. While the number of US medical school graduates is growing through increased class sizes and new medical schools, the number of graduate medical education (GME) residency slots has not increased proportionately. Indeed, there has been no significant increase in the number of obstetrics and gynecology resident positions since the mid-1990’s.
Simply graduating more medical students will not solve the problem of the growing physician workforce shortage. Beyond medical school, GME is absolutely necessary to generate the finished-product physicians who practice high-quality patient-centered care and perform effectively in multidisciplinary, integrated teams.
One basic problem is funding mechanisms are simply not in place.
On July 29, 2014, the Institute of Medicine (IOM) released a committee report recommending significant changes in the methodology of GME funding. The report criticized the current funding mechanisms, now largely dependent on Medicare dollars. It also cited the lack of accountability and transparency, the inconsistency with workforce needs, and the favoring of specialty care over primary care.
The IOM proposal includes reformation of Medicare funding formulas and distribution mechanisms by phasing out direct and indirect GME payments and transitioning into a performance-based system over a 10 year period. The report recommends establishment of a GME Policy Council which would be charged with studying geographic workforce needs to guide policy and funding decisions.
The largest portion of GME costs are paid through Medicare, which directly reimburses teaching hospitals a pro-rata share of costs. Medicaid funding also plays a role, although it is linked to state workforce policy goals and varies dramatically from state to state. Other lesser sources include the Department of Defense, Veterans Affairs, Health Resources and Services Administration, and the National Institutes of Health. Some third party payers give indirect GME support through higher reimbursement for teaching hospitals, but the majority of insurers, while benefitting from the GME pipeline, do not contribute directly to financing GME.
The number of resident positions funded by Medicare was “capped” in 1997 by the Balanced Budget Act. These direct GME payments for residency are intended to compensate for costs including resident and faculty salaries. Indirect Medical Education (IME) payments are partial compensation to teaching hospitals for higher patient care costs associated with medical education. Although the amount of funding provided through Medicare IME has been steadily declining, the current Medicare Payment Advisory Committee now suggests a further cut by 50%.
The rationale for cuts in IME is based upon decreasing the uninsured population through the Affordable Care Act with a resultant increase in patient revenue to teaching hospitals. This becomes problematic for non-hospital GME-sponsoring institutions in that IME funding is basically de-identified and the funds go into teaching hospital’s general operational revenue, rather than being specifically designated for GME. The accredited sponsoring institutions for a large number of residency programs in the US are not hospitals, but rather universities or other educational entities. In the absence of a specific educational designation, GME funding is a direct competition to the other operational needs of hospitals. The potential unintended consequences of this change in funding streams is to create less incentive for teaching hospitals to cover the balance of unreimbursed GME costs and a disincentive to create new resident positions.
If that is not complex enough, there are different perspectives on how GME funding should be changed. The federal government is in favor of substantial reductions. The Council on Graduate Medical Education has recommended that current levels of GME funding be preserved and 3000 new GME positions be established to meet rural and urban underserved communities and to satisfy unmet needs in primary care, surgery, and psychiatry. The Association of American Medical Colleges recommends an additional 15,000 positions with no limitations. Although there is general agreement that GME financing is too focused on Medicare as the major payor, the medical education community has presented no cohesive message as to how financial support for GME can be expanded.
The time has come to re-engineer funding of GME. The current hospital-based GME financing mechanism does not reflect the diversity of needs of our population. The educational community recognizes the need to shift more of the training of physicians into ambulatory settings and facilities where the majority of their practice will take place. This implies that resident physicians should no longer be primarily employed by teaching hospitals with their education largely confined to in-patient service duties in a tertiary center.
The ACGME Sponsoring Institutions of resident education should have unrestricted flexibility to rotate trainees into alternative settings where they might later choose to practice. Hospital-based educational experiences remain important, but changes in GME funding must reflect the reality of an evolving health care system. To make this happen is going to require a thoughtful effort on the part of obstetricians/gynecologists and all stakeholders involved in medical education.
It’s worth the effort: The fulfillment of health care needs for women is dependent upon on an adequate supply of obstetricians and gynecologists.
Making the Tough Calls: Unmet—and Overmet—Needs
Posted on July 31, 2014
As physicians who care for women, ob-gyns must recognize the unmet needs of some of our patients—and the over-met needs of others. Carefully evaluating the needs of each of our patients will help improve care and reduce costs.
Every woman deserves health care that is necessary and appropriate for her. She also deserves a health care system that doesn’t burden everyone with unnecessary costs. In the changing healthcare environment, optimizing resources is critical for the continued improvement of women’s health care.
Many women in the U.S. have health care needs that are unmet. The ob-gyn workforce is dramatically mal-distributed over geographic areas. According to a 2008 study published in the New England Journal of Medicine, four out of five new physicians begin practice in regions where the physician supply is already high.
As a profession, we must make sure we provide services in areas of greatest need. We must not leave behind communities with long-standing deficits in health and well-being. ACOG continues to advocate for these women through the activities of the department on Health Care for Underserved Women. We stand by the principal that all women deserve access to health care.
Physicians also play a major role in controlling health care costs. Recent improvements in research and technology have given physicians many additional diagnostic and treatment options, but not every new option is appropriate for every patient. It is critical for ob-gyns to connect value to cost to reduce inefficient care.
A great example is ACOG’s partnership with Choosing Wisely. The Choosing Wisely campaign was designed to promote conversation between doctors and patients to encourage only appropriate and necessary treatment. By following the guidelines from Choosing Wisely, physicians can make sure that they are not “over-meeting” the needs of patients.
As the only group of physicians whose primary role is to provide care for women, ob-gyns have a unique leadership role to play in making these tough calls. Our goal is to make sure every women in the U.S. gets the care she needs. No more, and no less.
ACOG’s Executive Board is Working for You
Posted on July 17, 2014
In my role as ACOG President, I have the opportunity to work with many talented and dedicated people who serve on the Executive Board. The Board consists of national officers, district chairs, members at large, subspecialty representatives, and a public member. Our purpose is to carry out the objectives of ACOG by conducting the general management of the organization.
The recent meeting on July 12-14 was particularly productive.
The Board accepted the soon-to-be-published report from Immediate Past President Dr. Jeanne Conry’s Women’s Wellness Task Force. The task force worked to update and define key components of the well-woman visit, including age-specific recommendations for screening studies and other preventive health measures. The report also supports the value of offering pelvic examination as a component of the well-woman visit. This thoughtful and scientifically-based report supports the important role that obstetricians and gynecologists play in health care throughout a woman’s lifetime.
The Board also approved a strategic action plan for promoting global women’s health. The Global Operations Advisory Group was initiated by past president Dr. Jim Martin and has made remarkable progress since 2009. This new strategic plan is designed to organize and strengthen resources for health care efforts in other countries. ACOG members interested in global health affairs will have better opportunities to serve and learn from these structured programs. ACOG is the premier organization for women’s health and the Board’s support for global operations is a source of pride for all ACOG Fellows.
Another important responsibility of the Board is to approve and reaffirm policies of the organization. In an effort to insure transparency of all ACOG policies, the Board voted to provide access to policies through the ACOG website. This will let the public as well as members know where ACOG stands on important issues
The Board is busy in many other areas as well. We received reports from working groups assigned to address needs of our Fellows related to practice transformation associated with health reform, and to promote leadership of women’s health care teams. Additionally, the Council of District Chairs is exploring ways to expand direct communications with our membership.
It was an honor to preside over this meeting. The Executive Board and all of our leadership are working hard to meet the needs of our Fellows and the women we serve!
Help Prevent Group B Strep this Month
Posted on July 11, 2014
July is International Group B Strep Awareness Month. Group B Strep (GBS), found in 10–30% of pregnant women, is the leading cause of sepsis and meningitis in newborns, according to the US Centers for Disease Control and Prevention (CDC).
Ob-gyns have long been aware that preventing GBS is a key part of our commitment to protecting the health of newborns. Now we have the tools at our fingertips—literally—to be more effective.
In 2010, the CDC released new guidelines for GBS prevention. To help clinicians better implement them, the CDC worked with ACOG, the American Academy of Pediatrics, the American College of Nurse-Midwives, and the American Academy of Family Physicians to develop an app called “Prevent Group B Strep.”
The app debuted in September 2013. It is designed specifically for obstetricians and other health care professionals who provide obstetric or neonatal care. The app creates customized guidelines based on your patient’s characteristics. “Prevent Group B Strep” is free and available for Apple and Android devices.
If you haven’t already, download the app and implement it in your practice in this month. You can also help to educate your patients about the importance of GBS prevention by sharing ACOG’s patient education FAQ: Group B Strep and Pregnancy.
Spread the word about Group B Strep this month. Your efforts can help save more babies.
ACOG as a World Partner in Women’s Health
Posted on June 24, 2014
I am proud of what ACOG is doing in so many areas of women’s health, but I have particular pride in our global health initiatives. On June 13-14, I participated with a very dedicated group of ACOG Fellows in the Global Operations Advisory Group meeting to develop a strategic plan for our global operations. For two rewarding days, we created plans to help extend ACOG’s contributions to our ob-gyn colleagues in other countries and the women in those countries who are so in need of improvements in health care.
Yes, we do have our own problems within the United States, but our problems pale in comparison with those of many countries. As we work to strengthen women’s health care in our own country, we also have the opportunity to share those strengths. If we are truly leaders in women’s health care, we must consider the plight of women across the world and share our knowledge and expertise for the betterment of women everywhere.
ACOG is respected internationally for our educational materials and our leadership in all aspects of women’s health. A significant number of our Fellows already are dedicating time and effort to directly working with existing resources in other countries to improve obstetrical and gynecologic care. We also have many young physicians who are willing to offer their skills to help underserved populations at home and abroad. In exchange, ACOG Fellows are learning valuable lessons about basic issues in women’s health care that hold true across international boundaries.
As an organization, ACOG has the ability to convene individual ACOG Fellows and our affiliate organizations who want to do global work, and to collaborate with academic institutions in the United States with global health programs. Simply stated, our vision is to engage members and global partners to mobilize resources for support of best practices in women’s health care worldwide through education, information-sharing, training, quality improvement, advocacy, and delivery of care.
As the world has gotten smaller, our vision has grown larger. All of us can be proud of the participation by ACOG in global affairs.
ACOG Fellow Dr. Robert M. Wah Becomes Leader of AMA
Posted on June 12, 2014
I recently returned from Chicago, where I attended the 2014 American Medical Association Annual Meeting from June 6-11. It was a busy meeting! ACOG and the AMA have a long history of productive collaboration. This year, with the inauguration of ACOG Fellow Dr. Robert M. Wah as AMA President, our mutual relationship can only grow stronger.
On Friday, ACOG leadership met with representatives from the American Academy of Family Physicians, the American Academy of Pediatrics, and the American College of Physicians. The meeting allowed us to work together to review the policies and resolutions to be presented at the AMA House of Delegates.
Later on Friday, ACOG leadership participated in a Section Council Handbook Review meeting to provide feedback on the proposed policies and resolutions to be considered by the House of Delegates.
One important function of the ACOG AMA Section Council is to interview the candidates for AMA office. These interviews provide an opportunity to assess the AMA candidates’ stance on ACOG issues such as legislative interference and access to women’s health care options.
Tuesday evening was very special for all ACOG Fellows in attendance. I was honored to be on stage as Dr. Wah was inaugurated as the 169th President of the AMA. Dr. Wah has served on the ACOG Executive Board, Health Care Commission, and other committees. In fact, he got his start in leadership at ACOG as the chair of the Junior Fellow Congress Advisory Council! Dr. Wah is also the first Asian American to be president of AMA.
In his inaugural address, Dr. Wah discussed how tradition can serve as the foundation for innovation. He joined me in calling for physicians to adapt to the changes and opportunities in the evolving health care market. Watch Dr. Wah’s speech.
I am looking forward to a year of great collaboration with Dr. Wah and the AMA.
Why Ob-Gyns Must Lead in Medicine, Business, and Politics
Posted on May 22, 2014
The Danish physicist Niels Bohr said that “Prediction is very difficult, especially about the future.” While it’s true we can’t predict the future, it is clear that the health care marketplace in the US is changing rapidly. To ensure that health care becomes what women deserve, individual ob-gyns must step into new leadership positions.
The changes in health care are increasingly calling on ob-gyns to become “doctor business persons.” Some analysts predict that in the future, up to 85% of physicians will be employed by integrated health systems or very large multispecialty groups. As this occurs, it will become more important than ever for ob-gyns to develop skills in communication, negotiation, finances, team building, conflict resolution, and strategic thought.
In addition, ob-gyns now also need to be “doctor politicians.” Recently, there has been an increase in legislation that attempts to infringe on the patient-physician relationship. These laws are often based on political agendas, not scientific evidence. Physicians need to be able to determine the best treatment for their patients without interference from politicians. It is critical that individual ob-gyns work with ACOG and other medical organizations to fight these types of laws. For more, read ACOG’s Statement of Policy: Legislative Interference With Patient Care, Medical Decisions, and the Patient-Physician Relationship.
Finally, ob-gyns must be leaders because we are best suited to tackle the issues that are increasing the cost and affecting the quality of health care for women. If ob-gyns do not step up to leadership, our practices will be run by administrators, businessmen and lawyers. They will be people who have never counseled a patient, delivered a baby, or witnessed the distress of an unplanned pregnancy.
Women's health care is expanding beyond the exam room. So, too, must our roles. By becoming leaders in new areas, we can be sure to provide quality care to our patients now and into the future.
Our Patients Deserve Our Patience
Posted on May 14, 2014
Recent reports of rising cesarean delivery rates in the United States are a significant concern, both to the public and to those of us who are practicing obstetrics. Cesarean delivery rates vary dramatically across geographic areas of the country but also from one neighboring hospital to the next.
Certainly the variations in cesarean delivery rates are multi-factorial. It is easy to understand if a tertiary care hospital receiving high-risk pregnancies from a broad referral area would have an elevated cesarean delivery rate. However, it is disturbing to see that some hospitals with a high percentage of low-risk deliveries have higher cesarean delivery rates than the tertiary care hospitals in their referral area.
ACOG and the Society for Maternal-Fetal Medicine released a consensus statement in March on Safe Prevention of the Primary Cesarean Delivery. The statement addresses multiple modifiable considerations to reduce the cesarean delivery rate. I suggest that every obstetrician carefully read this document, paying particular attention to the discussion of labor dystocia and labor arrest as the most common cause of primary cesarean delivery.
Simply stated, current evidence according to the Consortium on Safe Labor indicates the diagnosis of labor arrest should not strongly be considered until the cervix has reached 6 centimeters dilated in both primiparous and multiparous women. This is in contrast to the standards proposed by the Friedman curve that have been operational in most labor and delivery units.
Waiting, observing, having another cup of coffee, and even pacing the floor until the cervix reaches 6 cm dilated can make the difference between a vaginal delivery and a cesarean delivery. Normal labor can be a relatively slow process, but our patients do deserve our patience.
How Ob-gyns Can Celebrate National Women's Health Week
Posted on May 9, 2014
National Women’s Health Week, led by the U.S. Department of Health and Human Services’ Office on Women's Health, starts on Mother’s Day, May 11. The goal is to empower women to make their health a priority.
For ob-gyns, it’s a great opportunity to help our patients and communities learn more about what it means to be a well woman.
The campaign encourages women to get regular checkups and preventive screenings, get physical activity, eat healthfully, improve mental health, and avoid risky behaviors such as smoking or texting while driving.
So what can ob-gyns do to celebrate National Women's Health Week?
- Encourage your patients to schedule an annual visit on May 12, which is National Women’s Checkup Day
- Promote and encourage screening for breast and gynecologic cancers and STDs
- Take advantage of continuing education courses offered by ACOG
- Share ACOG’s patient education resources in your clinic or office and on social media (Use the hashtag #NWHW hashtag in your tweets)
- Be a role model by embodying the behaviors you’d like your patients to adopt, such as regular physical activity, healthy eating, and living smoke-free
Let’s take advantage of this great opportunity to promote healthy behaviors for our patients.
Optimizing Resources for Women’s Health Care
Posted on May 1, 2014
This is an exciting time to be an ob-gyn. I begin my term as president of the American Congress of Obstetricians and Gynecologists at an opportune time, with ob-gyns at the forefront of change in women’s health care.
The scientific and technological advances in women’s health are arriving very quickly, with tremendous impact. We are enormously more effective in our ability to prevent, diagnose and treat disease. And there is every reason to believe that our capabilities will continue to improve.
I believe how we respond to change will be critical for continuing improvement of women’s health. There are a variety of ways individual ob-gyns can respond to the changing health care environment, including:
- Assuming leadership roles in a variety of settings
- Reducing the price of health care by connecting value to costs
- Recognizing patients’ unmet and over-met needs
- Utilizing technology based on clinical knowledge and outcomes research
- Understanding how patients measure quality care
ACOG is also involved in a number of key collaborations focused on improving women’s health care. ACOG’s partnerships with organizations such as the Women’s Health Registry Alliance, the Choosing Wisely campaign, and the Patient Centered Primary Care Collaborative all contribute to the optimization of resources in women’s health.
In addition to all of ACOG’s current efforts, I will be targeting certain important areas in the coming year. I am appointing a task force on collaborative care, a working group on women’s health care team leadership, and a working group on practice transitions.
In this time of change, we must assume a conscientious and deep commitment to creating the future of women’s health care. Obstetricians and gynecologists care for women—exclusively. As such, the future of women’s health care is in our hands. Together we can make it happen.