Transforming Primary Healthcare for Women: A Framework for Addressing Gaps and Barriers

Health Update
 

By Laurie Zephyrin, Lisa Suennen, Pavitra Viswanathan, Jared Augenstein and Deborah Bachrach

Editor’s Note: The U.S. primary healthcare system does not effectively meet women’s needs during the teen and young adult years and/or as they age and transition through later stages of life. In a new report prepared in collaboration with and funded by the Commonwealth Fund (CMWF)—part 1 of our series—Manatt describes gaps and barriers in women’s primary healthcare and proposes a framework for transforming the system so that it can meet the needs of women of all ages, races/ethnicities and socioeconomic backgrounds. Findings are based on a review of academic literature, primary research, interviews with experts, and an all-day convening with primary healthcare innovators and industry leaders. Key points are summarized below. Click here to read the full two-part report—and watch your email for our summary of part 2.


Introduction

Primary healthcare plays an essential role in effectively addressing women’s unique health needs from puberty to reproduction through menopause and late life. Primary care should also be a lever to address critical health transitions as women age. Achieving the promise of comprehensive primary healthcare for women is critical to improving health outcomes, bending the cost curve and promoting health equity.

While women often require care from cardiologists, neurologists, obstetricians and gynecologists, and other specialists who address particular conditions, these providers are not oriented to comprehensively address women’s broad and intersecting health needs across the life course. Therefore, as women age and experience natural life transitions, such as menopause, they require the care and attention of a primary healthcare provider who can monitor their evolving needs, make connections across specialty services, and understand emerging patterns that may indicate future health risks.

Why Good Primary Healthcare Is So Important for Women

By promoting primary healthcare 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 often experience a decline in health, nutrition, education and economic outcomes. They also face a financial loss that may take generations to overcome.i

Women also make up nearly 60% of U.S. workers and represent 65% of the unpaid workforce of informal caregivers for children, elderly relatives and family members with disabilities. During the COVID-19 pandemic, healthcare organizations have depended heavily on women, who account for nearly four in five essential healthcare workers.ii

However, it is clear from our research that the U.S. primary healthcare system for women is inadequate. Health status indicators show that women in the United States have worse outcomes than women in other high-income countries and some areas of women’s health are fundamentally underserved due to lack of provider awareness.iii

Staggering disparities persist across women of different socioeconomic, racial and educational backgrounds. People of color are less likely to receive preventive health services regardless of income, neighborhood, comorbid illness or insurance type, and often receive lower-quality care.iv Income inequality also has a profound impact on health. Women in the top 1% of the income distribution have a life expectancy that is 10 years longer than that of women in the bottom 1%.v

A range of factors contribute to the underperformance of the primary healthcare system for women, including:

  • “Siloing” of reproductive health and maternal health from other key clinical and nonclinical services that are critical to women’s whole health
  • Insufficient attention to sex differences that affect disease progression and treatment

Studies have demonstrated notable sex differences in the symptoms and prevalence of neurological conditions between women and men. Adjusting for age, women are twice as likely to develop multiple sclerosis and two to three times as likely to experience migraines.vi As women have a longer life expectancy than men, they are more likely to experience age-related morbidities, disability and various forms of dementia.vii,viii

Gaps and Barriers in Women’s Primary Care

The current primary healthcare system in the United States 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 healthcare. Our research identified a variety of gaps and barriers in primary healthcare that include those related to education, financing, healthcare delivery, utilization and policy. (Click here to access the full white paper with a detailed description of these gaps and barriers.)

A Framework for Transforming Primary Care for Women

Manatt and CMWF developed a framework for transforming primary care for women based on findings from the literature review, research, stakeholder interviews and convening of experts. (Click here to access the white paper and view the full framework.) The framework describes a primary healthcare model for delivering comprehensive, integrated, high-quality primary healthcare that is optimized for women at all ages and stages of life. The model incorporates three types of healthcare services: those applicable to men and women, those unique to women, and those that women typically experience at different life stages.

Foundational Elements Applicable to Men and Women

Certain characteristics are essential for any comprehensive primary healthcare system, regardless of its intended patient base. A comprehensive primary healthcare system must be:

  • Accessible, affordable and accountable to create entry points outside the traditional health system and encourage better consumer engagement.
  • Highly integrated across physical health, behavioral health and social services to serve patients’ needs holistically in a coordinated manner.
  • Multidisciplinary, team-based and highly coordinated with specialty care resources to improve access to and coordination with specialty care when needed and prevent avoidable utilization.
  • Prevention-focused and proactive to prevent disease or delay its onset and progression.
  • Equitable, culturally competent and community-driven to respond to patients’ needs and preferences, promote engagement with the healthcare system, and eliminate disparities.
  • Evidence-based so that treatment approaches are tailored at the individual level.
  • Enhanced by performance data and seamless technology integration to improve digital access, coordinate care across the care team, and better equip clinicians and patients to make informed decisions.
  • Appropriately financed and incentivized to ensure that multidisciplinary primary healthcare providers—including those who coordinate the provision of social services—are able to meet patients’ needs in a manner that promotes high-value care.

Primary Healthcare Domains Unique to Women

These criteria can help primary healthcare systems optimally serve women of all ages and at all stages of life and deliver care in a manner that accounts for sex- and gender-specific distinctions:

  • Sex-specific care, related to health needs that are unique to women, such as pregnancy and menopause.
  • Sex-aware care, related to conditions that are diagnosed or treated differently in women as compared to men, such as heart disease and neurodegenerative diseases.
  • Gender-sensitive care, provided in ways that are inclusive of gender-specific preferences, including lesbian, gay, bisexual, transgender, queer, intersex and asexual (LGBTQIA) health needs.

Health Experiences Unique to Women by Life Stage

Primary care providers should develop sustained relationships with patients across stages of life so they can address or facilitate care for the vast majority of personal healthcare needs. Based on the specific health experience, primary healthcare teams may assume either primary or shared responsibility for delivering care:

  • Primary responsibility: A broad range of health conditions can be diagnosed and managed cost-effectively at the primary healthcare level, such as prevention and ongoing chronic disease management.
  • Shared responsibility: Conditions that cannot be adequately addressed at the primary healthcare level are managed by specialty, ancillary and social service providers with care coordination support from the primary healthcare system.

Conclusion

The primary healthcare system is particularly well positioned to play a vital and unique role in addressing women’s diverse physical health, behavioral health and social needs across the life course. However, major care gaps and structural barriers inhibit the primary healthcare system in its current form from meeting women’s needs. To optimally serve women of all ages and at all stages of life, the primary healthcare system must be comprehensive, prepared to deliver sex-specific, sex-aware, and gender-sensitive care, and adept at both managing and coordinating care for an array of health experiences.

In Light of the COVID-19 Pandemic: Considerations for Women’s Primary Healthcare

The fragility of the primary healthcare 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 healthcare system by drawing from lessons learned through the pandemic response.

Key Considerations Actions for the Primary Healthcare System Actions for Policymakers
Addressing delayed and unattended physical health, behavioral health, and social service needs
  • In the coming months, proactively identify and address gaps in women’s healthcare that occurred during the public health emergency (for example, missed Pap smears and mammograms, unattended mental health needs) as well as the impact of COVID-19 on preexisting chronic conditions.b
  • Integrate screenings for social determinants of 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
  • Create a flexible pool of funding to address social and medical needs through community initiatives, such as Accountable Communities for Health and Health Equity Zones.
  • Reimburse community health workers (CHWs) for connecting Medicaid patients to health-related social services at an increased Federal Medical Assistance Percentage rate.
Leveraging digital primary healthcare solutions
  • Adopt technologies to enable remote consultation and monitoring.d
  • Integrate health information and/or ask women about app-based care they may have used during the pandemic to address general health, contraceptive and mental health needs.e
  • Leverage the nonphysician workforce through digital solutions, especially during key transitions in a woman’s life, such as during the postpartum period.
  • Provide capital investments for states to advance telehealth in Medicaid for the full range of providers, including physicians, nurses, doulas and CHWs.
  • Include supplemental funds in COVID-19 relief and recovery efforts to bolster the primary healthcare workforce.
Strengthening women’s primary healthcare delivery during times of crisis
  • Identify flexibilities at the federal level that states can elect to exercise during a public health emergency to adapt coverage, benefits and payments.
  • Stratify populations into high-risk versus lower-risk patients and incorporate pregnancy status as a key priority indicator.
  • Depoliticize women’s healthcare to prevent gaps in care during public health emergencies, such as delayed abortions that result from these interventions being classified as elective procedures.f
  • Give priority and extra consideration to rural practices, practices serving underserved communities, practices serving areas with high COVID-19 incidence, and independent primary healthcare sites (such as physician-owned practices and sites with fewer than 250 physicians).
Developing standardized health equity approaches that address race, gender and income disparities
  • Adopt health equity approaches that ensure that care practices acknowledge intersectionality.
  • Design cross-cutting policies using a health equity framework to reduce disparities and promote equity in health outcomes.
 

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 Healthcare for Women,” Rolling Stone, Mar. 30, 2020.


i Patricia M. Davidson et al., “The Health of Women and Girls Determines the Health and Well-Being of Our Modern World: A White Paper From the International Council on Women’s Health Issues,” Healthcare for Women International 32, no. 10 (Oct. 2011): 870–86.

ii Campbell Robertson and Robert Gebeloff, “How Millions of Women Became the Most Essential Workers in America,” The New York Times, Apr. 18, 2020.

iii What Is the Status?, 2018.

iv Hostetter and Klein, “In Focus: Reducing Racial Disparities,” 2018.

v Dhruv Khullar and Dave A. Chokshi, “Health, Income & Poverty: Where We Are & What Could Help,” Health Policy Brief, Health Affairs, Oct. 4, 2018.

vi Janine Austin Clayton, “Sex Influences in Neurological Disorders: Case Studies and Perspectives,” Dialogues in Clinical Neuroscience 18, no. 4 (Dec. 2016): 357–60.

vii Janine Austin Clayton, “Sex Influences,” 2016; Centers for Disease Control and Prevention, “Minorities and Women Are at Greater Risk for Alzheimer’s Disease,” last updated Aug. 20, 2019; Centers for Disease Control and Prevention, “Older Persons’ Health,” last updated Jan. 19, 2017; and Guy C. Brown, “Living Too Long,” EMBO Reports 16, no. 2 (Feb. 2015): 137–41.

viii Harvard Health Publishing, “Gender Matters: Heart Disease Risk in Women,” last updated Mar. 25, 2017; and Katherine A. Liu and Natalie A. Dipietro Mager, “Women’s Involvement in Clinical Trials: Historical Perspective and Future Implications,” Pharmacy Practice 14, no. 1 (Jan.–Mar. 2016): 708.

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