REPORT JULY 2020 TRANSFORMING PRIMARY HEALTH CARE FOR WOMEN Part 1: A Framework for Addressing Gaps and Barriers Laurie Zephyrin, Lisa Suennen, Pavitra Viswanathan, Jared Augenstein, and Deborah Bachrach ABSTRACT TOPLINES ISSUE: The U.S. primary health care system does not effectively meet Major gaps and structural barriers inhibit the current women’s needs as they age and transition through stages of life. primary health care system from GOAL: Describe gaps and barriers in women’s primary health care and meeting women’s needs. propose a framework for transforming the system so that it can meet the needs of women of all ages, races/ethnicities, and socioeconomic Women require comprehensive, backgrounds throughout their lives. high-quality primary health care that is designed for women at all METHODS: Literature review, expert interviews, and an all-day expert ages and stages of life and can convening with innovators, primary care providers, advocates, deliver sex-specific, sex-aware, policymakers, and payers. and gender-sensitive care. FINDINGS: Major gaps and barriers inhibit the primary health care system from meeting the physical, behavioral, and social needs of women across the life course, including: gaps in medical training; barriers to utilization and delivery, including biases, time constraints, lack of focus on social factors, and competing professional and personal obligations; access barriers related to language, culture, and lack of a regular source of primary care; underrepresentation of women in health care leadership and policymaking; and the politicization of women’s health issues. CONCLUSION: We propose a framework for transforming primary health care for women of all ages and at all stages of life that provides comprehensive care, delivers sex-specific, sex-aware, and gender- sensitive care, and adeptly manages and coordinates care for an array of health experiences. Transforming Primary Health Care for Women — Part 1: A Framework for Addressing Gaps and Barriers 2 INTRODUCTION Primary health care plays an essential role in responding Recently, the vital role that primary health care plays in to women’s unique health needs through advanced age the U.S. health system has received renewed attention. and in bridging care during life transitions, from puberty Primary health care is associated with positive health and reproduction to menopause. Achieving the vision of comprehensive primary health care for women is critical outcomes; regions that have more primary health to improving health outcomes, bending the cost curve, and care providers are associated with lower rates of promoting health equity. hospitalization, cancer mortality, heart disease, and stroke. Experts estimate that 130,000 U.S. deaths per year While women often require care from cardiologists, could be saved by improving primary health care access. 1 neurologists, obstetricians and gynecologists (ob/gyns), A comprehensive primary health care system delivers and other specialists who address particular conditions, accessible and high-quality services that are prevention- these providers may not have the expertise or bandwidth to focused, integrated with behavioral comprehensively address women’s broad and intersecting health needs across the life course. Therefore, as women age health care and social services, and experience natural life transitions, such as menopause, equitable, and effective. they require the care and attention of a primary health care provider who can monitor their evolving needs, make connections across specialty services, and understand emerging patterns that may indicate future health risks.2 In the first of two reports, we examine the array of care gaps and structural barriers that inhibit primary health care in the United States from meeting the needs of women of all ages and socioeconomic backgrounds. Our findings are based on a review of academic literature, interviews with experts, and an all-day meeting between primary health care innovators and industry leaders. In the second report, we explore existing and emerging care models, technology- enabled solutions, and business approaches that have the potential to close the gaps and barriers in primary health care for women within the next decade. WHY GOOD PRIMARY HEALTH CARE IS SO IMPORTANT FOR WOMEN By promoting primary health care for women, we help promote the health and economic well-being of the population as a whole. Studies show that, when a mother dies, her children and her community of family and friends experience a decline in health, nutrition, education, and economic outcomes; they also face a financial loss that may take generations to overcome.3 Given that the rate of maternal mortality is two to three times higher among Black A “graphic recording” of national experts’ views on the mothers than white mothers, this impact is amplified in current primary health care system, which was uniformly perceived to be inadequately meeting women’s needs. communities of color.4 commonwealthfund.org Report, July 2020 Transforming Primary Health Care for Women — Part 1: A Framework for Addressing Gaps and Barriers 3 Women also play an indispensable role in the labor force. They make up nearly 60 percent of U.S. workers5 and represent 65 percent of the unpaid workforce of informal caregivers for children, elderly relatives, and family members with disabilities.6 During the COVID-19 pandemic, health care organizations have depended heavily on women, who account for nearly four in five essential health care workers.7 Good primary health care for women is not only vital for promoting economic stability but also critical to limiting costs across the health care system: 90 percent of national health care expenditures are attributed to treating chronic and mental health conditions, both of which Another significantly impact adult women.8 challenge However, it is clear from our research that the U.S. is the primary health care system for women is inadequate. insufficient Health status indicators show that women in the U.S. attention across have worse outcomes than women in other high-income medical specialties countries. For example, the U.S. maternal mortality rate given to sex differences is higher than the rate in any other high-income country in disease progression and continues to rise.9 and treatment. For example, cardiovascular disease, the Staggering disparities persist across women of different leading cause of death among socioeconomic, racial, and educational backgrounds. women, often presents and People of color are less likely to receive preventive health progresses differently in women than services irrespective of income, neighborhood, comorbid it does in men. illness, or insurance type, and often receive lower-quality care.10 Income inequality also has a profound impact Similarly, studies have demonstrated notable sex on health; women in the top 1 percent of the income differences in the prevalence of neurological conditions distribution have a life expectancy that is 10 years longer between women and men. Adjusting for age, women are twice as likely to develop multiple sclerosis and two to than that of women in the bottom 1 percent, a difference three times as likely to experience migraines.12 As women that equates to the health impact of a lifetime of smoking.11 have a longer life expectancy than men, they are more It is paramount for an effective primary health care likely to experience age-related morbidities, disability, system to incorporate strategies of caring for low-income and dementia. For example, as women age, they are populations and address racial/ethnic disparities. twice as likely to be diagnosed with Alzheimer’s disease A range of factors contributes to the underperformance and are more likely than men to experience strokes that of the primary health care system for women. One are associated with worse outcomes.13 Despite these barrier is the historic “siloing” of reproductive health and differences, commonly used treatment approaches were maternal health from other key clinical and nonclinical developed predominantly through research on men and services that are critical to women’s whole health. are not as successful when administered to women.14 commonwealthfund.org Report, July 2020 Transforming Primary Health Care for Women — Part 1: A Framework for Addressing Gaps and Barriers 4 GAPS AND BARRIERS IN WOMEN’S PRIMARY CARE The current primary health care system in the U.S. could be much more responsive to the needs of all individuals, regardless of their sex and gender. But women experience unique challenges when seeking primary health care. Our research identified three categories of gaps and barriers in primary health care (Exhibit 1). In the Appendix, we describe these gaps and barriers in detail and highlight those that are specific to or disproportionately affect women. A FRAMEWORK FOR TRANSFORMING Foundational Elements Applicable to Men PRIMARY CARE FOR WOMEN and Women The following framework was developed based on findings Certain characteristics are essential for any comprehensive from the literature review, stakeholder interviews, and primary health care system, regardless of its intended convening of experts. It describes a primary health care model for delivering comprehensive, high-quality primary patient base. A comprehensive primary health care system health care that is enhanced for women at all ages and must be: stages of life (Exhibit 2). The model incorporates three types of health care services: those applicable to men and women, • Accessible, affordable, and accountable to create entry those unique to women, and those that women typically points outside the traditional health system and experience at different life stages. encourage better consumer engagement. Exhibit 1. Three Categories of Gaps and Barriers in Primary Health Care EDUCATION, FINANCING, PRIMARY HEALTH CARE PRIMARY HEALTH CARE AND POLICY DELIVERY SYSTEM UTILIZATION • Inadequacy of medical • Time constraints • Inconsistent or no regular education and training • Sex- and gender-based bias source of primary health care addressing gender • Language, culture, and trust • Inequity and structural racism • Underinvestment in primary • Health care coverage barriers to health care models that target • Inadequate clinical guidelines seeking primary health care women • Lack of focus on addressing • Lack of gender diversity across social determinants of health industry leadership • Lack of care coordination • Politicization of women’s health • Siloed care resulting from health transitions across the life course • Confidentiality and stigma • Undersupply of women’s health specialists Data: Adapted from Lu Ann Aday and Ronald Andersen, “A Framework for the Study of Access to Medical Care,” Health Services Research 9, no. 3 (Fall 1974): 208–220. commonwealthfund.org Report, July 2020 Transforming Primary Health Care for Women — Part 1: A Framework for Addressing Gaps and Barriers 5 Exhibit 2. Framework for Transforming Primary Health Care for Women Health Care Applicable to Accessible, affordable, and Enhanced by performance data and Comprehensive Primary Prevention-focused and proactive accountable seamless technology integration Men and Women Elements of Equitable, culturally competent, and Appropriately financed and Highly integrated community-driven incentivized Multidisciplinary, team-based, and Evidence-based highly coordinated Primary Health Care Domains Sex-Specific Care Sex-Aware Care Gender-Sensitive Care Unique to Women Care for conditions that are Care provided in ways Care related to health needs diagnosed or treated in that reflect gender-specific that are sex-specific sex-specific ways preferences Adolescence Early Adulthood Middle Adulthood Advanced Adulthood Ages 12–17 Ages 18–44 Ages 45–64 Ages 65+ Social Stressors that Impact Health (e.g., Social Isolation, Role in Caregiving, Economic Inequality, Trust in Health Care System) PCP Primary Responsibility Prevention Common Health Experience of Women by Life Stage Sexual and Reproductive Health Rising Chronic Disease Risk Pre Early Late Post Menopauase Behavioral Health PCP Shared Responsibility with Specialist(s) Fertility & Maternal Health Cardiovascular Health Osteoporosis Diabetes Neurological Health Cancer (Reproductive and Nonreproductive) Palliative Care commonwealthfund.org Report, July 2020 Transforming Primary Health Care for Women — Part 1: A Framework for Addressing Gaps and Barriers 6 • Highly integrated across physical health, behavioral Health Experiences Unique to Women by health, and social services to serve patients’ needs Life Stage holistically in a coordinated manner. Primary health care providers should develop sustained • Multidisciplinary, team-based, and highly coordinated relationships with patients across stages of life so they can with specialty care resources to improve access to and address or facilitate care for the vast majority of personal coordination with specialty care when needed and health care needs.16 To fulfill this role, primary health care prevent avoidable utilization. teams, through technology and team-based care, must • Prevention-focused and proactive to prevent disease or be organized and equipped to address diverse physical delay its onset and progression. health, behavioral health, and social service needs.17 Based on the specific health experience, primary health care • Equitable, culturally competent, and community- teams may either assume primary or shared responsibility driven to respond to patients’ needs and preferences, for delivering care: promote engagement with the health care system, and eliminate disparities. • Primary responsibility: A broad range of health • Evidence-based so that treatment approaches are conditions can be diagnosed and managed cost tailored at the individual level. effectively at the primary health care level, such as prevention and ongoing chronic disease management. • Enhanced by performance data and seamless technology integration to improve digital access, • Shared responsibility: Conditions that cannot be coordinate care across the care team, and better equip adequately addressed at the primary health care clinicians and patients to make informed decisions. level are managed by specialty, ancillary, and social • Appropriately financed and incentivized to ensure that service providers — including nurses, ob/gyns, and multidisciplinary primary health care providers — community health workers — with care coordination including those who coordinate the provision of support from the primary health care system. social services — are able to meet patients’ needs in a manner that promotes high-value care. CONCLUSION Primary Health Care Domains Unique to Women The primary health care system is particularly well The criteria listed above can help primary health care positioned to play a vital and unique role in addressing systems optimally serve women of all ages and at all stages women’s diverse physical health, behavioral health, and of life and deliver care in a manner that accounts for sex- social needs across the life course. However, major care and gender-specific distinctions. Three critical domains gaps and structural barriers inhibit the primary health include:15 care system in its current form from meeting women’s • Sex-specific care: Care related to health needs that are needs. To optimally serve women of all ages and at all unique to women, such as pregnancy and menopause. stages of life, the primary health care system must be comprehensive, prepared to deliver sex-specific, sex-aware, • Sex-aware care: Care for conditions that are diagnosed and gender-sensitive care, and adept at both managing and or treated differently in women as compared to men, coordinating care for an array of health experiences. such as heart disease and neurodegenerative diseases. • Gender-sensitive care: Care provided in ways that are In the second of our two reports, we contemplate the inclusive of gender-specific preferences, including concrete steps that policymakers, payers, entrepreneurs, lesbian, gay, bisexual, transgender, queer, intersex, and clinical leaders, and investors can take to materially enhance asexual (LGBTQIA) health needs. primary health care for women in the next 10 years. commonwealthfund.org Report, July 2020 Transforming Primary Health Care for Women — Part 1: A Framework for Addressing Gaps and Barriers 7 In Light of the COVID-19 Pandemic: Considerations for Women’s Primary Health Care The fragility of the primary health care system has become markedly apparent in the wake of the COVID-19 outbreak. Some primary care practices have closed; some have adopted telehealth and other digital health technologies to care for patients remotely.a To date, the pandemic has affected women’s health in a range of ways. Key considerations are highlighted in the following table. In the coming months, clinical leaders have the opportunity to reengineer and fortify the primary health care system by drawing from lessons learned through the pandemic response. Key Considerations Actions for the Primary Health Care System Actions for Policymakers Addressing delayed and • In the coming months, proactively identify • Create a flexible pool of funding to address unattended physical and address gaps in women’s health care that social and medical needs through community health, behavioral health, occurred during the public health emergency (for initiatives, such as Accountable Communities for and social service needs example, missed Pap smears and mammograms, Health and Health Equity Zones. unattended mental health needs) as well as the impact of COVID-19 on preexisting chronic • Reimburse community health workers (CHWs) for conditions.b connecting Medicaid patients to health-related social services at an increased Federal Medical • Integrate screenings for social determinants of Assistance Percentage rate. health (for example, domestic violence, food insecurity) and facilitate linkages to support services, recognizing that needs have been exacerbated by the COVID-19 outbreak.c Leveraging digital primary • Adopt technologies to enable remote consultation • Provide capital investments for states to advance health care solutions and monitoring.d telehealth in Medicaid for the full range of providers, including physicians, nurses, doulas, • Integrate health information and/or ask women and CHWs. about app-based care they may have used during the pandemic to address general health, • Include supplemental funds in COVID-19 relief contraceptive, and mental health needs.e and recovery efforts to bolster the primary health care workforce. • Leverage the nonphysician workforce through digital solutions, especially during key transitions in a woman’s life, such as during the postpartum period. Strengthening women’s • Identify flexibilities at the federal level that states • Give priority and extra consideration to rural primary health care can elect to exercise during a public health practices, practices serving underserved delivery during times emergency to adapt coverage, benefits, and communities, practices serving areas with of crisis payments. high COVID-19 incidence, and independent primary health care sites (such as physician- • Stratify populations into high-risk versus lower- owned practices and sites with fewer than 250 risk patients and incorporate pregnancy status as physicians). a key priority indicator. • Depoliticize women’s health care to prevent gaps in care during public health emergencies, such as delayed abortions that result from these interventions being classified as elective procedures.f Developing standardized • Adopt health equity approaches that ensure that • Design cross-cutting policies using a health health equity approaches care practices acknowledge intersectionality. equity framework to reduce disparities and that address, race, gender, promote equity in health outcomes. and income disparities a Noam N. Levey, “Widening Coronavirus Crisis Threatens to Shutter Doctors’ Offices Nationwide,” Los Angeles Times, Mar. 24, 2020. b Timothy Hoff, “COVID-19 Fallout: How Will Other Needed Care Be Provided During the Pandemic?,” Medical Economics Blog, Mar. 24, 2020. c Anna North, “When Home Isn’t Safe: What the Coronavirus Pandemic Means for Domestic Violence Survivors,” Vox, Mar. 26, 2020; and Caroline G. Dunn et al., “Feeding Low-Income Children During the COVID-19 Pandemic,” New England Journal of Medicine, published online Mar. 30, 2020. d Jared Augenstein et al., Executive Summary: Tracking Telehealth Changes State-by-State in Response to COVID-19 (Manatt, updated June 26, 2020). e Kari Dequine Harden, “A ‘Seismic Shift’ Moves Medicine Online During COVID-19 Crisis Through Telehealth Technology,” Steamboat Pilot & Today, Mar. 30, 2020. f Alex Morris, “States Are Using the Cover of COVID-19 to Restrict Abortion and Health Care for Women,” Rolling Stone, Mar. 30, 2020. commonwealthfund.org Report, July 2020 The Commonwealth Transforming PrimaryFund Health Care for Women — Part 1: A Framework How High for Addressing Is America’s Gaps Health and Barriers Care Cost Burden? 8 APPENDIX. GAPS AND BARRIERS IN WOMEN’S PRIMARY HEALTH CARE Gaps in Training the majority of respondents were not only more likely to Inadequacy of medical education and training addressing be satisfied with care from their ob/gyn than from their gender. Most primary health care training programs do not primary health care provider but also were more likely equip providers to address women’s unique needs. Less to be open and honest with their ob/gyn than with their than 30 percent of medical schools incorporate gender- primary health care provider.25 This is problematic given specific topics in their curriculum and only 9 percent of that many ob/gyns do not consider themselves primary medical schools offer women’s health courses or electives.18 health care providers and do not offer comprehensive Across medical specialties, there is poor awareness of primary health care services.26 the sex differences in disease progression and treatment and a lack of awareness of pivotal health experiences that Did You Know? Only 20 percent of ob/gyn residencies women encounter. For example, despite the far-reaching offer training on menopause, and 80 percent of medical impact menopause has on women’s health, providers are residents report feeling “barely comfortable” discussing or largely ill-equipped to initiate important conversations treating menopause.27 around this transition with patients.19 Underutilization of primary health care. Recent data Medical training also insufficiently prepares providers to indicate that the trend of underutilization of primary deliver care that recognizes an array of experiences and health care is worsening. This decline is attributed to a life paths. For example, though nearly 80 percent of physi- number of factors, including rising out-of-pocket costs, cians believe addressing social needs is as important as decreased real or perceived needs, and increasing use medical care, most do not feel prepared to address them; of some alternative sources of care, such as urgent care correspondingly, studies suggest that providers often avoid clinics.28 asking about social issues.20 Pandemics and other public health emergencies can Did You Know? More than 70 percent of primary health further exacerbate underutilization. For example, as a care providers report not feeling well-informed on result of social distancing orders and other aspects of the LGBTQIA health needs and clinical management of response to the COVID-19 outbreak, ambulatory practice LGBTQIA care, and almost 80 percent of primary health visits sharply fell by nearly 60 percent.29 care providers are unsure of how and where to refer patients with LGBTQIA-specific needs.21 Many providers Did You Know? Between 2008 and 2016, primary health assume heterosexuality when interacting with patients, care utilization among adults under age 65 dropped by 25 which can cause patient discomfort and deter open percent; this decline was particularly marked for lower communication between patients and providers.22 income and younger adults.30 Barriers to Primary Health Care Utilization Shortage of primary health care providers. Another major factor is the growing shortage of health care providers Inconsistent or no regular source of primary health care. to serve a rapidly aging population. The U.S. is expected Nearly 20 percent of adult women report not having a to see a shortage of up to 50,000 primary health care primary health care provider. This rate is higher among providers by 2032, with rural areas facing the greatest some racial/ethnic minorities, including Hispanic (33%) shortages.31 Though retail health clinics, such as those and American Indian/Alaska Native (26%) women.23 operated by Walmart and CVS, have the potential to help Twenty percent of women consider their ob/gyn to be mitigate these shortages, practice-related regulations and their primary health care provider, a perception that is licensing policies may limit their reach in some states.32 more common among women who are pregnant, have Language, culture, and trust. Language and cultural newborns, and do not have a chronic condition.24 A recent barriers, mistrust, and perceptions that health care survey of women between the ages of 18 and 44 found that commonwealthfund.org Report, July 2020 The Commonwealth Transforming PrimaryFund Health Care for Women — Part 1: A Framework How High for Addressing Is America’s Gaps Health and Barriers Care Cost Burden? 9 providers are not listening to patients’ concerns can deter Sex- and gender-based bias. Frequently, women’s concerns primary health care utilization and engagement. Multiple are dismissed or perceived as being less severe than studies have shown that higher levels of perceived men’s. Negative encounters with the health system — discrimination and lower levels of trust in the health care from inconvenience to disrespect and abuse — have system among women from underrepresented communi- been shown to suppress a willingness to seek care in ties are associated with lower utilization of preventative the future.37 Notably, clinicians respond differently to and routine services.33 women’s reports of pain or discomfort than men’s and observe different treatment practices, such as prescribing Professional/personal barriers to seeking primary health sedatives to women and narcotics for men.38 Women are care. Women are more likely than men to delay self-care more likely than men to receive referrals to psychologists as a result of their professional and personal obliga- to address nondescript symptoms and are less likely than tions. Caregiving, in particular, has a profound impact on men to receive pain medication or interventions. Women women’s ability to attend to their own health. 60 percent who present with heart attack symptoms are often sent of unpaid, informal caregivers in the U.S. are women.34 home with a diagnosis of stress or panic disorder rather Frontline and essential workers battling the COVID-19 than being given the full cardiovascular diagnostic outbreak are not only more likely to be women and people workup that is more consistently offered to men.39 of color but also more likely to live at or below the federal poverty line and have children at home, which creates additional and novel burdens with respect to caregiving.35 Did You Know? More than 80 percent of women with chronic pain report experiencing some form of gender While caregiving is a challenge across the age continuum, discrimination from their health care providers, who may the physical, emotional, and financial burden imposed attribute their symptoms to ephemeral diagnoses like by this role becomes particularly pronounced when “stress” when, in fact, more serious medical conditions middle-aged caregivers enter the “sandwich generation,” exist; moreover, women reporting pain are more likely a period during which they may assume simultane- than men to be prescribed sedatives rather than pain ous caregiving responsibilities for young children and medication.40 aging parents. The burden of this dual role compels the majority of working caregivers to adjust their careers to Racial/ethnic disparities. Troubling racial/ethnic dispari- accommodate caregiving duties and can inhibit them ties exist in health outcomes for women of color, including from attending to their own health and well-being. 36 For the following: women who balance several roles at home and at work, finding time to go to a primary health care visit during • Though the rate of breast cancer is similar among Black business hours can be a challenge. and white women, the rate of breast cancer mortality is 40 percent higher among Black women. Breast cancer Barriers to Delivering Comprehensive Primary is also more likely to be detected at an earlier stage in Health Care white women.41 Latinas are less likely than non-Latinas to receive preventative care, such as regular mammo- Time constraints. On average, primary health care visits last 11 to 15 minutes, which is woefully insufficient to gain grams and pap tests.42 a holistic understanding of a patient’s medical and social • The rate of maternal mortality among Black women in needs, build a relationship of trust to encourage open the U.S. is two to three times greater than that of white dialogue, and effectively monitor the specialty, ancillary, women.43 and social services that a given patient may be receiving. Shorter visits are incentivized by the typical primary • Blacks and Hispanics are more likely than whites to health care reimbursement model, which rewards the lack a usual source of care when sick other than the number of visits conducted rather than the types of emergency department, signaling a major gap in access services delivered. to primary health care.44 commonwealthfund.org Report, July 2020 The Commonwealth Transforming PrimaryFund Health Care for Women — Part 1: A Framework How High for Addressing Is America’s Gaps Health and Barriers Care Cost Burden? 10 • Primary health care practices that serve minority the many factors that predict mortality and morbidity, communities tend to be poorly resourced, underfund- approximately 40 percent are socioeconomic and include ed, and responsible for serving more medically needy education, employment, safety, and income.53 Having at patients compared to clinics that mostly serve white least one unmet social need is associated with increased patients.45 rates of depression, diabetes, hypertension, emergency department overuse, and clinic “no-shows.”54 • Racial bias has been well documented among all types of health care providers and specialties and is most The ways in which nonmedical factors impact women’s frequently associated with negative patient-provider health can vary by age. For example: interactions.46 • Factors like financial stability, housing security, • During pregnancy, Black women are less likely to nutrition, and exposure to domestic violence during feel that they were encouraged to make their own a woman’s reproductive years significantly affect her decisions and more likely to feel pressured into ability to have a pregnancy free of complications.55 receiving medical interventions.47 • In the U.S., Black and Hispanic families have a median Economic inequity. Income inequality and insurance wealth that is about one-tenth of white families. coverage also have a profound impact on health. Women Disparities in wealth persist regardless of education, in the top 1 percent of the income distribution have a life marital status, age, or income. Many long-standing expectancy that is 10 years longer than that of women factors drive these differences, including systematic in the bottom 1 percent.48 The rate of screenings, such as labor and mortgage market discrimination.56 mammograms, colon cancer screenings, and Pap tests are lower among uninsured women.49 In states that did not • Over one quarter of women ages 65 to 74 and over half expand Medicaid and have a larger uninsured popula- of women ages 85 and older live alone.57 As the elderly tion, preventable diseases like cervical cancer are more population continues to rapidly grow, the demand common. For example, in Alabama, which did not expand for critical social supports (such as transportation or Medicaid, women who develop cervical cancer have a personal care), as well as interventions to mitigate higher mortality rate than women in other states, in part social isolation, are increasing, yet they are rarely because women without insurance coverage do not have attended to in the primary health care system.58 These access to early screenings and care is delayed until the needs are likely to be experienced more acutely by onset of more serious symptoms.50 older women than older men as women have longer life expectancies. Inadequate clinical guidelines. Evidence-based guidelines have historically not accounted fully for sex differences in To address patients’ needs holistically, the primary health disease progression, in part due to the underrepresenta- care system must address social needs that can serve as tion of women in clinical trials.51 Evidence-based guide- barriers to health. While significant new funding and lines are particularly inadequate for vulnerable popu- energy is being dedicated to this area, more attention lations, such as women with disabilities. For instance, must be focused on developing models that address social despite pervasive misperceptions among providers, determinants of health through community partnerships women with disabilities are equally likely to be sexually and integration with primary health care. active as their peers without disabilities. However, women Lack of integrated care teams. Primary health care with disabilities are less likely to be offered information providers are well suited to effectively coordinate care by providers on contraception and sexually transmitted across specialty, ancillary, and social services through- infection (STI) prevention and are less likely to receive out a woman’s life. Primary health care providers should screenings for sexual violence or reproductive cancers.52 proactively conduct timely conversations prior to key life Inadequate focus on addressing social determinants of transitions and provide warm handoffs to other providers health. Social determinants of health play a particularly such as ob/gyns, behavioral health specialists, medical salient role in predicting women’s health outcomes. Of specialists, geriatricians, and others across the life course. commonwealthfund.org Report, July 2020 The Commonwealth Transforming PrimaryFund Health Care for Women — Part 1: A Framework How High for Addressing Is America’s Gaps Health and Barriers Care Cost Burden? 11 One of the main factors that inhibits the current primary great demand for and low supply of key women’s health health care system from serving this role is that integrated, specialty services. For example, despite the prevalence of multidisciplinary primary health care teams — typically behavioral health conditions among women and the fact including physicians, nurse practitioners and/or physician that the physiological changes associated with pregnancy assistants, behavioral health specialists, care coordina- can significantly impact mental health, some states have tors, and social service providers — have not been widely as few as one certified, practicing perinatal psychiatrist adopted. Practices that have implemented integrated in residence. Similarly, although an average of 27 million primary health care teams have not done so in a standard- women experience menopause each year,65 studies show ized fashion. that medical residents and practitioners have signifi- cant knowledge gaps that inhibit their ability to address Confidentiality and stigma. Confidentiality persists as menopausal symptoms.66 Though a menopause certifica- a major concern that deters women across ages from tion is available to close those knowledge gaps, fewer than seeking health care services. 1,000 providers practicing in the U.S. have undergone this special training and are menopause-certified. This paucity Did You Know? Thirteen percent of sexually experienced of specialists makes it even more crucial that primary adolescents on a parent’s health insurance plan reported health care providers are equipped to offer baseline care not seeking sexual and reproductive health care because for women. of concerns that their parent might learn that they sought Lack of racial/ethnic diversity among women’s health care.59 This is particularly significant given that 50 percent specialists. Only 5 percent of physicians across medical of new STIs and over 20 percent of new HIV diagnoses are specialties identify as Black or African American.67 Black reported among adolescents and young adults.60 women make up just 3 percent of all medical provid- ers.68 Among medical specialties, ob/gyn has the highest Among adult women, confidentiality is of particular number of women and women of color (61.9 percent concern in the context of behavioral health. Women ages women and 8 percent Black women).69 18 to 44 are more likely than men to develop a mental illness and are twice as likely as men to develop an anxiety Of the members of the American College of Nurse- disorder.61 In recent years, the number of women with Midwives, only 7 percent identify as people of color. opioid use disorder at labor and delivery quadrupled.62 However, the specialty is becoming more diverse. In 2014, 14.5 percent of nurse-midwives undergoing certification However, despite the high prevalence of mental health for the first time identified as people of color and 10.3 conditions among women, harmful stigmas endure in the percent of midwifery students identified as Black.70 community and in the workplace that discourage women from openly seeking behavioral health services or request- Lack of comprehensive primary health care and digital ing time off from work for behavioral health appoint- innovations. Although a wave of novel care models and ments.63 Interestingly, when women do seek help for digital solutions have emerged in recent years that have behavioral health needs, they are more likely than men to the potential to address discrete gaps in today’s primary confide in their primary health care providers as opposed health care system for women, no single innovation or to behavioral health specialists.64 validated combination of innovations comprehensively addresses women’s physical health, behavioral health, Undersupply of women’s health specialists. Women’s health and social needs. Emerging innovations that could materi- specialists include primary health care providers with ally improve access to care, such as telehealth/telemedi- women’s health training, ob/gyns, and medical special- cine technologies, have not been uniformly adopted by ists with women’s health training, including oncologists, primary health care practices and cater largely to commer- cardiologists, psychiatrists, and neurologists. There is cially insured populations in their present form. commonwealthfund.org Report, July 2020 The Commonwealth Transforming PrimaryFund Health Care for Women — Part 1: A Framework How High for Addressing Is America’s Gaps Health and Barriers Care Cost Burden? 12 One much needed digital innovation is integrated and CEOs were white.79 Nationwide, over 60 percent of longitudinal electronic health records (EHRs). Effective full-time medical faculty are white, 20 percent are Asian longitudinal EHRs present a comprehensive snapshot American, 5 percent are Hispanic, and less than 4 percent of each patient’s medical and social needs, and can are Black.80 Across medical school faculty, the proportion facilitate early diagnosis, reduce errors, and support of female faculty members decreases as the faculty rank better patient outcomes.71 However, there is significant increases in seniority; this is particularly pronounced room for improvement to ensure that EHRs effectively among non-white women.81 advance health care delivery. A recent study revealed that some primary health care physicians spend more While several female-focused and female-led companies time documenting in their EHRs than providing clinical recently launched, new primary health care startups tend care.72 Forty percent of primary health care providers to have largely male leadership. Notably, in 2019, only 12 feel that EHRs present more challenges than benefits, and percent of partners at venture funds active in digital health nearly 60 percent feel that significant improvements are were women. Improving gender diversity is inherently required to derive clinical value from EHRs.73 According to beneficial to health care businesses; one study demon- primary health care providers, some of the key improve- strated that diverse management teams are more innova- ments that must be made to EHRs over the next decade tive and generate 19 percent higher financial returns.82 As include improving interoperability, enhancing predictive new primary health care models emerge and seek venture analytics, integrating financial information and data on capital support, it will be critical to promote gender social determinants of health, and enabling patients to diversity among investors to ensure that investments are access and share their own records.74 directed towards women’s health-focused companies. Male venture partners tend to back women’s health companies very infrequently and often overlook the issue Did You Know? As of May 7, 2020, all states plus of gender diversity when evaluating potential investments. Washington, D.C., have issued guidance to expand the use of telemedicine in their Medicaid programs during the COVID-19 pandemic.75 Politicization of Women’s Health Women’s reproductive health across the life course is highly politicized. The harmful stigmas that result can Underrepresentation in Health System deter women’s willingness to seek health care on a regular Leadership and Policymaking basis, discourage open dialogue between women and Lack of gender and racial/ethnic diversity across industry their physical and behavioral health care providers, and leadership and academia. Though the presence of women profoundly impact long-term health and well-being. in leadership and decision-making roles across the health The impact of politicization is most acutely felt by lower- care industry is slowly increasing, women are still signifi- income women, who disproportionately rely on publicly cantly unrepresented as compared with men. As of 2018, funded health care coverage and, therefore, have fewer only 4 percent of CEOs and 21 percent of board members options for receiving comprehensive women’s health of Fortune 500 health care companies were women.76 services.83 For example, enrollment in Texas’ family Hospital leadership in 2019 demonstrated slightly better planning program decreased by 25 percent after the gender diversity, with women assuming approximately 37 state prohibited the participation of providers who offer percent of leadership roles;77 however, only 16 percent of comprehensive reproductive health services, including deans and department chairs at academic medical centers birth control and abortion, in the program. This decrease are women.78 in access to comprehensive reproductive health care was Inadequate gender diversity in both the health care associated with a 26 percent increase in the birth rate industry and academia is further compounded by limited among Medicaid enrollees and a spike in the number of racial/ethnic diversity. In 2015, 91 percent of all hospital teen pregnancies.84 commonwealthfund.org Report, July 2020 The Commonwealth Transforming PrimaryFund Health Care for Women — Part 1: A Framework How High for Addressing Is America’s Gaps Health and Barriers Care Cost Burden? 13 Did You Know? Eighteen states impose abortion-related restrictions on the allocation of public funds for health care. Nine states restrict federal Title X family planning funds from being used to reimburse providers who perform abortions and/or offer counseling on reproductive health. Fifteen states prohibit state funds from financing providers who perform abortions and/or offer counseling on reproductive health, and 12 states restrict public funding for STI testing and treatment as well as sex education.85 In the wake of the COVID-19 pandemic, state officials in at least nine states have classified abortions as elective procedures and have taken measures to stop performing these interventions during the public health emergency, despite the American College of Obstetricians and Gynecologists’ guidance that abortions are essential and time-sensitive.86 commonwealthfund.org Report, July 2020 Transforming Primary Health Care for Women — Part 1: A Framework for Addressing Gaps and Barriers 14 NOTES 1. American Academy of Family Physicians, “Why 11. Dhruv Khullar and Dave A. Chokshi, Health, Income Primary Care Matters,” n.d. & Poverty: Where We Are & What Could Help, Health Policy Brief, Health Affairs, Oct. 4, 2018. 2. 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Harris Poll, “How Doctors Feel,” 2018. commonwealthfund.org Report, July 2020 Transforming Primary Health Care for Women — Part 1: A Framework for Addressing Gaps and Barriers 18 HOW WE CONDUCTED THIS STUDY Jared Augenstein is a director at Manatt Health and has extensive experience assisting large health systems, Manatt Health reviewed current academic literature academic medical centers, and children’s hospitals on primary health care and conducted interviews with strategic planning and implementation efforts with 15 multidisciplinary industry leaders and subject related to delivery system transformation, population matter experts representing innovators, payers, health health infrastructure development, and organizational systems, and academia. Learnings from this preliminary restructuring. He also advises health care start-ups on investigation informed a robust, all-day meeting in business planning strategies. December 2019 that the Commonwealth Fund convened with 17 innovators and national experts on opportunities Deborah Bachrach is a partner at Manatt Health to transform primary health care for women. The and previously served as Medicaid director and convening participants were selected for their deep deputy commissioner of health for the New York State expertise, the breadth of organizations they represent Department of Health’s Office of Health Insurance across the health care industry, and their professional Programs. She uses her significant experience with both and personal perspectives on primary health care for public- and private-sector health policy and financing to women. See the Acknowledgments for a complete list of help states, providers, insurers, and foundations analyze individuals who contributed to this work. and implement the Affordable Care Act. ABOUT THE AUTHORS Editorial support was provided by Maggie Van Dyke. Laurie Zephyrin, M.D., M.P.H., M.B.A., joined the Commonwealth Fund in 2019 as vice president, Health Care Delivery System Reform. Dr. Zephyrin is a board-certified physician and has extensive experience leading the vision, For more information about this brief, please contact: design, and delivery of innovative health care models across Laurie Zephyrin, M.D. national health systems. Vice President, Delivery System Reform The Commonwealth Fund Lisa Suennen is group lead of the digital and technology lzcmwf.org practice and managing director at Manatt Health. She also leads the Manatt venture fund. With more than 30 years’ experience as an entrepreneur, venture capitalist, board member, and strategic advisor, she has spent much of her career helping companies adopt and leverage digital technologies, develop strategies for growth through innovation and investment, and build strong collaborations between established and emerging market entrants. Pavitra Viswanathan is a consultant at Manatt Health and works closely with federal and state agencies, payers, health systems, and foundations on efforts to expand access to high-quality care. She focuses on issues related to Medicaid policy, women’s health, care coordination, and chronic disease management. commonwealthfund.org Report, July 2020 Transforming Primary Health Care for Women — Part 1: A Framework for Addressing Gaps and Barriers 19 ACKNOWLEDGMENTS The Commonwealth Fund Stakeholder Interview Participants • Yaphet Getachew, Program Associate • Molly Coye, Executive in Residence, AVIA • Corinne Lewis, Senior Research Associate • Joia Crear Perry, National Birth Equity Collaborative • Eric Schneider, Senior Vice President for Policy and • Susan Edgman-Levitan, Executive Director, John Research D. Stoeckle Center for Primary Care Innovation, Massachusetts General Hospital Convening Participants • Mary Langowski, Founder and CEO, Rising Tide • Adimika Arthur, HealthTech for Medicaid • Emily Maxson, Chief Medical Officer, Aledade, Inc. • Sydney Etheredge, Planned Parenthood Federation • Sharon Vitti, Senior Vice President and Executive of America Director, CVS Health/MinuteClinic • Seth Feuerstein, Yale School of Medicine • Jeanette Waxmonsky, Vice President Integrated • Ann Garnier, Lisa Health Care, Product Development at New Directions • Margaret Laws, HopeLab Behavioral Health • Debra Ness, National Partnership for Women • Elizabeth Yano, Director, VA Center for the Study of and Families Healthcare Innovation, Implementation & Policy • Neil Patel, Iora Health Manatt Health Subject Matter Experts • Ileana L. Piña, Wayne State University/American • Jocelyn Guyer, Managing Director, Manatt Health Heart Association • Brenda Pawlak, Managing Director, Manatt Health • Christine Ritchie, Massachusetts General Hospital • Carol Raphael, Senior Advisor, Manatt Health • Evan Schnur, Walmart • Edith Coakley Stowe, Director, Manatt Health • Lisa Simpson, AcademyHealth • Sharon Woda, Managing Director, Manatt Health • Leah Sparks, Wildflower Health • Emily Stewart, Community Catalyst Graphic Recording • Deneen Vojta, UnitedHealth Group • Sasha Brito, ImageThink • Jane Weldon, CommonSpirit Health commonwealthfund.org Report, July 2020 About the Commonwealth Fund The mission of the Commonwealth Fund is to promote a high-performing health care system that achieves better access, improved quality, and greater efficiency, particularly for society’s most vulnerable, including low-income people, the uninsured, and people of color. Support for this research was provided by the Commonwealth Fund. The views presented here are those of the authors and not necessarily those of the Commonwealth Fund or its directors, officers, or staff.