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Women make an astounding 80 percent of health care decisions for themselves and their families. But there’s a disconnect between what women need and how providers have organized health care for them. While Value-Based Health Care (VBHC) is struggling to achieve more value for every health care dollar spent, providers are simultaneously sabotaging women in their customer base.
How? This might surprise you: through promotion of “women’s health” services. While providers may have good intentions for offering a dedicated place for women’s health needs, those services have actually fragmented care for women, especially those with more complex conditions.
Let’s evaluate how dedicated women’s health services can actually do a disservice for women as well as men, and can negatively affect the women that providers hope to reach.
Women’s Health Initiatives Focus Mainly on Women’s Reproductive Biology
To understand the limitations of how women’s health is defined, we’ll start with the World Health Organization (WHO). Among the top ten major health issues for women, half are directly related to sexuality, gender or reproduction: reproductive health, maternal health, HIV, sexually transmitted infections, and violence against women.
While these issues are important global status indicators for women’s health, note that cardiovascular disease, the leading cause of death for women in the U.S., is not even separately targeted as a women’s health issue—even though women often have a variant form of the disease with different symptoms that are harder to diagnose.
WHO identifies cancer as the top issue for women. Breast and lung cancer have the highest cancer incidence among women. And, indeed, breast health is commonly covered by providers who market women’s health, with mammogram screenings often part of the service mix. That’s because it falls into the classification scheme of gynecology and reproductive health.
WHO also calls out mental health and non-communicable diseases as important health priorities, along with “getting older” and “being young.” These catch-all categories may cover important conditions, such as women’s heart disease, but fail to identify or prioritize them.
By effectively equating women’s health to the status of reproductive organs, WHO sets the parameters for how women’s health is targeted globally. This affects funding, government policy and grants, and how areas of research are delineated. We see the same set of priorities across the spectrum of public health and the health care industry. Because of this world-view, some women’s health issues get showcased, while others—reflecting non-reproductive areas like cardiovascular or autoimmune diseases—get sidelined.
Like most organizations, the WHO women’s health priorities were determined by health care members on the executive committee, only a handful of whom are women. A similar gender composition exists on boards and among decision-makers in health plans, health systems and their providers. Women themselves are not well represented in determining their most vital health needs.
Women Have Lost Trust in U.S. Health Care
In a recent survey of women’s health care and health status, the Commonwealth Fund highlighted how women in the U.S. continue to lag behind women who live in other high income countries. American women have significant issues accessing and affording care, and less trust in the health care system.
Of 11 countries studied, American women also carry the heaviest burden of chronic disease, yet they have the highest rates of skipping needed care because of affordability. And they are the least satisfied with their care. The U.S. has the highest rate of maternal mortality among developed countries, and, potentially related, one of the highest rates of caesarean sections. Fewer women in the U.S. rate the quality of their health care as excellent or very good, compared to women in other countries studied. These findings are consistent with our examination of multiple clinical areas where both lack of clinical research supporting biological differences, coupled with cultural biases toward women, stymie good health care for women.
Are Women’s Health Care Centers Better or Worse for Value-Based Health Care?
Health care services can be organized for reasons of marketing, or in accord with the belief that specialization can deliver higher quality. From a marketing standpoint, a women’s health center can deliver a few frequently sought-after features:
- Primary care, especially female physicians;
- One-stop shopping for primary plus reproductive services;
- A “storefront” with a more woman-friendly appearance.
However, early studies of women’s health centers demonstrated unremarkable results regarding distinctive quality. Taking patient age, health risks, and outcome measures into account, results showed that women’s health centers, in general, catered to younger women with fewer chronic conditions, with older and more complex patients receiving care at general medicine clinics instead. Also, while women at women’s health centers were reported with higher mammography and cholesterol screenings, their rate of reported colorectal screening was lower. Patient satisfaction did not differ between the two settings.
Given their targeting of younger patients, women’s health centers, as a rule, don’t necessarily focus on post-reproductive-years risk factors, such as the increased cardiovascular risk caused by preeclampsia during pregnancy. Likewise, needs of women that emerge years after delivering children—such as uterine or vaginal prolapse or other pelvic floor issues—affect as much as one-third of women and is a frequently neglected area of patient care. Many older women, typically not women’s center patients, access services from different specialties to avoid associated incontinence, pain and infections. How health systems integrate protocols and processes across specialists is a significant issue that affects patient outcomes.
Fragmenting health care affects all patients. Some providers and advocates make a case for specializing women’s services based on the fact that women have been victims of delay and experienced gender-disparate care, and that a jump-start is needed to correct the imbalance. A contradictory argument can be made for improving care for both men and women, recognizing unique biology and risks, and integrating, rather than dividing, resources. One thing is certain: for men and women to achieve their best health status will require more than most gender-specific programs can now provide.
How VBHC Should Reevaluate Women’s Health Services
But in view of current Value-Based Health Care implementation, we should examine women’s health services from a different set of expectations. Consideration of women’s health centers should take place on a case-by-case basis, where the reasons and preferences (with women’s input) are tallied against the downsides of gender-specific care. Here are key questions to ask when making those assessments:
- Do we need a women’s health center to organize care for women, and how do we ensure that it addresses more than reproductive health as well as women of all ages? Or, are we trying to isolate services for women because we haven’t designed processes for identifying gender-specific conditions, treatments or care plans?
- Are all providers included in efforts to appreciate gender-specific needs of women, biological differences, as well as to foster research?
- Will a women’s health center create better care for women through integration and coordination of services—and how is this different than what should happen for men or for all patients?
- How do women’s health centers fit into an accountable health care system design, for delivery of specialized services for women beyond reproductive health services and gynecology? How do we address, for example, women’s cardiovascular disease?
- How do women of all ages fit into the model of women’s health services?
Founded as ICLOPS in 2002, Roji Health Intelligence guides health care systems, providers and patients on the path to better health through Solutions that help providers improve their value and succeed in Risk. Roji Health Intelligence is a CMS Qualified Clinical Data Registry.
Image: Viktor Forgacs