A national survey finds that many women are not getting preventive care or even birth control counseling at annual gynecological exams and that some women are skipping them altogether. For them, such visits are. . . : Hardly Routine
For women, the annual visit to the gynecologist has long been considered essential to good health. But many women are forgoing their annual checkups or, when they do get to the doctor, are not receiving basic preventive care recommended by medical experts.
A new national survey has found that among women who visited their gynecologist during the last two years, a startling 94% do not receive all the tests and counseling recommended for their age group.
That women often do not get all the care recommended by national guidelines is not surprising considering this: About half of those surveyed said they spent only 15 minutes or less with their doctor or other provider.
One in three women said they had not even had a routine gynecological exam in the last 12 months, while 16% have not had an exam in the last two years. Lack of insurance and time constraints were most often cited as the reasons for delaying care.
The results come from a nationwide poll conducted by the Henry J. Kaiser Family Foundation and the Los Angeles Times, with Essence and Latina magazines.
The telephone survey, conducted between Jan. 6 and Feb. 10, polled 2,241 women, ages 18 to 64, about reproductive health issues. The poll included interviews with 603 Latinas and 601 black women.
Health experts who analyzed the data for The Times said the gaps in care are likely explained by the large numbers of women without insurance, a lack of awareness among women about which services they should expect of their doctors, and frustration among gynecologists over the payment system used by many health insurers.
“What this survey points out is the amount of time that is spent with these women on such critical issues is a problem,” says Julia Scott, president of the National Black Women’s Health Project. She adds: “Women don’t know what to expect or what particular concerns can be addressed by who.”
Major groups, such as the American Medical Assn. and the American College of Obstetricians and Gynecologists, recommend an annual exam and have detailed guidelines specifying what should be covered. The survey, for example, showed that most women received a Pap smear and breast exam (94% and 88%, respectively).
But the poll also showed conflicts between what doctors aim to accomplish and what women say they want.
Only 42% of those surveyed were counseled on calcium to prevent bone loss, while a dismal 35% of women of childbearing age said they received counseling on birth control. Less than one-third of the women said they received counseling or screenings for sexually transmitted diseases.
Despite the well-known health benefits provided by hormone replacement therapy, only 66% of women ages 40 to 64 said they discussed menopause and hormone therapy with their doctors during their most recent exam.
“You would hope that for preventive services and routine services, women would have higher levels of care,” said Alina Salganicoff, director of women’s health policy for the Kaiser Family Foundation, a nonprofit national health care charity based in Menlo Park. (The foundation is not affiliated with Kaiser Permanente, the giant health care corporation.)
“I think women need to be more educated and informed about their health care and less afraid to ask their doctors questions,” she said. “But we also have a system right now where doctors are under discounted service plans. They are paid to spend much less time with women.”
HMO Payment System Is Cited
While the survey data indicate that doctors are not delivering all the recommended care to women, gynecologists have a different perspective. Many blame the payment system used by HMOs and other managed care plans in which doctors often are paid a fixed amount for taking care of patients--instead of being paid separately for each exam, test or procedure performed. They blame managed care for dramatically curtailing the services they can offer during the traditional gynecological visit.
“There is a tremendous discrepancy between what is ideal and what is practical,” says Dr. Philip G. Brooks, a Los Angeles gynecologist and clinical professor at UCLA. “Insurers no longer demand, no longer expect and no longer reward physicians for being comprehensive. The reimbursements today are such that if you are not efficient and fast, you can have trouble covering your overhead.”
Many health insurance plans offer an annual gynecological exam to women, sometimes called a “well woman” visit. But some plans will pay a gynecologist to provide only the essentials, such as a Pap smear and breast exam, says Dr. James Heaps, an assistant clinical professor at UCLA School of Medicine.
“The problem is: What is the definition of the annual exam? Insurance companies have introduced new terms, such as the ‘well woman’ or ‘gynecological checkup,’ which is very different from what a woman expects in an annual exam,” Heaps says.
Many women, for example, schedule a well-woman visit but have other issues or problems to discuss, he notes. While the doctor may go ahead and discuss those matters with the patient, the visit is still viewed--and reimbursed--as a well-woman visit.
“It ends up being a problem-oriented consultation for which a doctor is not reimbursed,” Heaps says. “For example, a woman may complain of pelvic pain. When we bill for that, the insurance company says, ‘No, the patient came in for her well-woman visit.’ That’s $15 [reimbursement] whether you spent five minutes or 50 minutes.”
Gynecologists can either accept the low reimbursement or advise the patient to make another appointment to discuss issues that are not part of the typical well-woman exam.
“The doctor is supposed to say, ‘Well, I understand you want to talk about that, but you have to make another visit.’ But patients really want to receive more than that. They want a [comprehensive] annual exam,” Heaps says.
Women believe that the annual gynecological exam should be much more than a checkup of the female organs. Fifty-nine percent of those surveyed said they discussed diet, exercise and nutrition with their doctors; 33% discussed vitamin and herb supplements, and 25% discussed alcohol or drug use.
“It’s important that women are able to get all their questions answered. They not only have a breast, uterus and ovaries; they are also a person,” says Dr. Aliza Lifshitz, a Los Angeles internist.
Heaps says he and some of his colleagues have chosen another option to deal with the confusion created by low insurance reimbursement: They are refusing to provide the annual gynecological exam as it is defined by managed care companies. Heaps refers women who simply need a well-women visit to a nurse-practitioner.
This trend is a disturbing one for consumers, many of whom supported legislation allowing women to choose a gynecologist as their “primary care physician” to oversee their medical care. A new California law, effective last Jan. 1, allows women to book an appointment directly with their gynecologist without first seeing a primary-care doctor. Sometimes referred to as “one-stop shopping,” this means a woman can go to her gynecologist once a year for a comprehensive checkup.
But, in reality, that is not what is happening, according to the Kaiser survey data and interviews with health experts. It’s more likely that women will be unable, in a single office visit, to get all the services they need and ask all the questions they have. That is, unless they are willing to settle for a no-frills annual gynecological exam.
Plan Determines Second Visit
Depending on the plan and the doctor, women may be able to go for a second visit and only make a small co-payment, Lifshitz says.
“But the doctor may say, ‘You already had a well-woman exam. Why do you need a visit?’ It’s very complicated.”
A few medical schools are attempting to address the need for more comprehensive services by developing specialized training, or sub-specialties, in women’s health, Salganicoff says.
And patients might benefit by making clear their reasons for seeing the doctor when booking an appointment, says Don White, a spokesman for the American Assn. of Health Plans, a Washington-based trade group for the managed health care industry.
“It may be a matter of better communication. People need to talk to their doctors about what they expect. It may mean making two appointments back to back; one for a well-woman visit and a primary care appointment to handle some of your other questions,” he says.
White dismisses the contention of some doctors that managed care is to blame for shorter doctor visits. He cites a 1997 study by the American Medical Assn. that shows the amount of time doctors spend with their patients didn’t change significantly between 1986 and 1997.
Time Varies With Coverage
The Kaiser survey showed that Medicaid patients tended to get the most time with their doctors, while uninsured women got the least. Moreover, 22% of Medicaid patients received all the recommended tests and counseling contrasted with 4% of the women in fee-for-service and managed care plans.
Recipients of Medicaid, the federal-state health program for the poor, may receive more care because they are more likely to be pregnant or to be in worse health by the time they see a doctor. Medicaid providers are also governed by stringent rules specifying which services should be provided to women, Salganicoff says.
Insurance coverage alone, however, doesn’t completely dictate the quality of the visit. Patients with traditional fee-for-service health insurance reported spending similar amounts of time with their providers as those in managed care plans but said they received fewer of the recommended tests and counseling. Only 6% of women in fee-for-service plans--which are not as likely to pay for preventive services--received the recommended tests and counseling.
And while the percentage of Americans without health insurance continues to rise, the inability to pay was not the sole reason that one-third of the women delayed getting an annual exam. About one-quarter blamed lack of money or insurance coverage, while others said they didn’t have time, didn’t know where to go for care or that it took too long to get an appointment.
“Sometimes women assume they are fine,” Salganicoff says. “Or they are afraid about what they could find out and delay care. Or they find it’s too hard to make an appointment. Women have complex lives.”
Despite obvious gaps in care, most of the women surveyed expressed satisfaction with their annual gynecological exam: 85% gave their care a grade of A or B.
“Women think they are getting good care,” Scott says. “But when we start ticking off what they should get, they often say, ‘Well, no, I didn’t get that.’ ”
Women’s satisfaction with their gynecological exam is not surprising because most women are healthy, says Adrienne Hahn, legislative counsel for the Consumer’s Union. Women with health problems typically don’t find their health care as satisfactory, she says. For example, the survey showed that fewer older women gave their care a grade of A.
“If they’re older,” she says, “they probably have an increased contact with the health care system.”
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How the Poll Was Conducted
The survey of women’s reproductive health care was conducted by the Henry J. Kaiser Family Foundation and the Los Angeles Times, with Latina magazine and Essence magazine.
Results are from a national survey of 2,241 women, ages 18 to 64. The survey included interviews with 601 African American women and 603 Latina women. The overall survey was weighted to represent women nationally based on race, age, education and region. The results for Asian American women were not broken out separately due to a small sample.
The margin of sampling error for the overall survey is plus or minus 4 percentage points. The error margin is plus or minus 6 percentage points for the African American subgroup and 5 percentage points for the Latina subgroup.
The telephone survey was carried out by Princeton Survey Research Associates between Jan. 6 and Feb. 10.
The Kaiser Family Foundation, based in Menlo Park, is a national health care philanthropy that conducts research into health care and other public policy issues. It is not associated with Kaiser Permanente or Kaiser Industries.
A summary of the survey findings and a copy of the questionnaire are available from the Kaiser Family Foundation by calling (800) 656-4533.
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Male or Female Doctor?
More than half of the women in the survey said they saw a female doctor, nurse or other provider for their last routine gynecological exam. Younger women and African American women are most likely to receive care from a female provider.
Percentage of women who saw a female provider:
Women 18-29: 56%
Women 50-64: 34%
Women 18-29: 60%
Women 50-64: 41%
Women 18-29: 52%
Women 50-64: 50%
Women 18-29: 55%
Women 50-64: 30%
Source: Kaiser Family Foundation
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What Women Talk About
Some topics women discuss with their doctors during annual gynecological exam.
18-29 30-49 60-64 Diet/exercise 53% 59% 62% Birth control options 52% N/A N/A Cancers, such as breast, ovarian or uterine 45% 47% 46% Menopause/hormone replacement therapy N/A 31% 79% Calcium to prevent bone loss N/A 38% 59% HIV prevention 45% N/A N/A Vitamin/herbal supplement N/A 32% 45%
Source: Kaiser Family Foundation
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What’s Not Being Discussed
Even women who have had a gynecological exam within the past two years reported that they didn’t receive all the tests and counseling recommended by major medical organizations. While most women underwent a Pap smear and breast exam, less than half were counseled on such important matters as birth control and sexually transmitted diseases.
Percent of women who say that at their last routine gynecological exam they. . .
* Had a Pap smear (18-64 yrs.): 94%
* Had a breast exam (18-64 yrs.): 88%
* Had or were advised to get mammogram (40-64 yrs.): 86%
* Were counseled on menopause and hormone replacement therapy (40-64 yrs.): 66%
* Were counseled on calcium to prevent bone loss (18-64 yrs.): 42%
* Were counseled on birth control options (when applicable): 35%
* Were counseled on HIV prevention and/or were advised to get or had HIV test (sexually active women 18-44 yrs.): 33%
* Were counseled on STD prevention and/or were advised to get or had STD test (sexually active women 18-44 yrs.): 30%
Source: Kaiser Family Foundation