Women's Health: Officially a Top National Priority
The Well-Woman Visit is the most popular National Performance Measure (NPM) on the Maternal and Child Health Bureau’s (MCHB) recently revised list.
The MCHB’s newly transformed Title V Block Grant allows state programs to choose - from a list of 15 - the 8 measures most meaningful to their maternal and child health (MCH) populations. Forty-one states and all 9 federal jurisdictions chose Well-Woman Visit1 a service with access rates that have hovered at 65% for the past five years.2
“I’m not quite sure why there has been a lack of change [in the access rates],” said Ashley Hirai, an MCHB Health Scientist who oversees epidemiology training and served on the work group that revised the NPMs. “I think there just needs to be more done to promote the importance of preventive visits and address access barriers.”
THE SIGNIFICANCE OF THE WELL-WOMAN VISIT
The Well-Woman Visit NPM is associated with fourteen of the twenty-two national outcome measures (NOMs), which are indicative of the overall health of the country. While they have an obvious influence on maternal morbidity and mortality, they are also linked to a decrease in infant mortality and adverse birth outcomes (like low birth weight and preterm births)3 that put babies at risk for death or, for those who survive, an array of diseases including developmental delay, behavioral problems, and long-term disability.4,5
The well-woman visit is an opportunity for care providers to detect chronic conditions at a treatable stage, identify early risk factors, and offer information about preconception and healthy behaviors through screenings, lab tests, counseling, and a physical exam.
ACCESS VS QUALITY
While many of these services can be individually quantified2, the MCHB framed the NPM to monitor the access rather than the quality or content of the Well-Woman Visit3. Although there are content guidelines for well-woman visits from the American Congress of Gynecologists (ACOG), quality recommendations for family planning from the Center for Disease Control (CDC), and the Affordable Care Act’s (ACA) list of women's preventive services, Hirai explained: “There is no population-based source that can capture receipt of all recommended preventive services right now. That may be something we will assess as data systems evolve.”
But the MCHB believes the states that elected to improve access to well-woman visits can choose to incorporate content or quality measures. "We hope that access as well as content can be optimized," said Hirai, “Improving the content and quality of visits may increase demand.”
HOW STATES CAN SHOW PROGRESS TOWARD THE GOAL
As part of their State Action Plans, Title V programs will develop at least one evidence-based or evidence-informed strategy measure to assess the performance of each of their selected NPMs. States have the flexibility to address each NPM with as many strategies as they need to achieve change.
States may need to approach the issue from several angles. The ACA eliminated copayments and cost-sharing for women in states that expanded Medicaid, but many remain uninsured, ranging from 5% in Rhode Island to 22% in Texas.6,7 While cost discourages many women from seeking preventive care,8 they also have to contend with many, less tangible barriers: availability of time, childcare, transportation, health literacy, the understanding of disease, and the lack of awareness of accessible health services.9 Forty percent of U.S. women are unaware that Well-Woman Visits are covered under the ACA.10
“Some of the major approaches may be in promoting insurance outreach and enrollment,” said Hirai, “building public education campaigns around the importance of getting a well-woman visit and how it is covered by ACA, and partnering with providers to establish reminder-recall systems and address patient barriers.”
Hirai listed three resources that could assist states with strategy development: Innovation Station, a searchable database of best practices, CoIIN’s Pre-and Interconception Care Learning Network to reduce infant mortality, and the new Strengthen the Evidence project from Johns Hopkins. But, Hirai said, Title V programs might find more opportunities to advance the well woman visit through partnership with their state Medicaid agencies. The Center for Medicaid and Medicare Services (CMS) has developed evidenced-based best practices to promote post-partum visits, a related preventive service that has also been notoriously difficult to improve. “States may be able to leverage those activities more broadly to affect the problem in preconception,” Hirai explained.
States involved in the CMS initiative have outlined their quality improvement strategies which include collaborating with managed care plans to distribute education materials, conducting patient focus groups, implementing mobile messaging, and incorporating parental screenings into well-child visits11. Among other strategies, CMS encourages provider offices to be more involved with patients’ care: following up with phone calls and letters when appointments aren’t scheduled, explaining the importance of preventive visits, conducting home visits, providing transportation, and even using monetary incentives.12
Hirai named five states that reported increases in their rates of well-woman visits (by at least 5 percentage points) between 2011 and 2013: Hawaii, Michigan, Mississippi, Pennsylvania, and Texas. “Without a much deeper analysis, I can’t really say too much about responsible factors," said Hirai, "But it’s reassuring to know that significant progress within a short time frame is possible in every region of the country.” The popularity of the Well-Woman Visit among State Title V programs reflects the needs of the MCH population in the United States. “This is an essential measure that can really affect the health of the entire MCH population,” explained Hirai. “Having that optimal health well before pregnancy can set a positive trajectory for the health of infants and children.”
- Title V Maternal and Child Health Services Block Grant Program. Title V State Action Plans. Accessed November 30, 2015.↩
- Hirai A, Cornell A, McCoy C. The Well-Woman Visit in the Title V Performance Measurement Framework: Access, Content or Quality? Pulse: A Monthly Newsletter from the Association of Maternal & Child Health Programs. May/June 2015. . Accessed November 16, 2015.↩
- U.S. Department of Health and Human Services, Health Resources and Services Administration, Maternal and Child Health Bureau. Federally Available Data Resource Document ↩
- U.S. Department of Health and Human Services, Health Resources and Services Administration, Maternal and Child Health Bureau. Child Health USA 2014 . Accessed December 22, 2015.↩
- Saigal S, Doyle LW. An overview of mortality and sequelae of preterm birth from infancy to adulthood. Lancet. 2008 Jan 9;371(9608):261-9.↩
- U.S. Department of Health and Human Services. Affordable care act rules on expanding access to preventive services for women. Washington, DC: DHHS; 2013. http://www.hhs.gov/healthcare/facts/factsheets/2011/08/womensprevention0.... Accessed November 9, 2015.↩
- Kaiser Family Foundation. State Health Facts, Health Insurance Coverage of Women 19-64. Accessed December 22, 2015.↩
- U.S. Department of Health and Human Services, Health Resources and Services Administration, Maternal and Child Health Bureau. Women's Health USA 2013. Barriers to Care and Unmet Need for Care. Accessed November 16, 2015.↩
- Carrillo JE, Carrillo VA, Perez HR, Salas-Lopez D, Natale-Pereira A, Byron AT. Defining and targeting health care access barriers. Journal of Health Care for the Poor and Underserved. 2011;22(2):562-75. doi: 10.1353/hpu.2011.0037↩
- Salganicoff A, Ranji U, Beamesderfer A, Kurani N. Women and Health Care in the Early Years of the Affordable Care Act. https://kaiserfamilyfoundation.files.wordpress.com/2014/05/8590-women-an.... Key Findings from the 2013 Kaiser Women’s Health Survey. Published May 2014. Accessed December 2, 2015.↩
- The Centers for Medicaid and Medicare. Medicaid Summary of MCH Quality Improvement Projects by State http://www.medicaid.gov/medicaid-chip-program-information/by-topics/qual... Published January 2015. Accessed December 2, 2015.↩
- The Center for Medicaid and Medicare. Resources on Strategies to Improve Postpartum Care Among Medicaid and CHIP Populations. http://www.medicaid.gov/medicaid-chip-program-information/by-topics/qual.... Published February 2015. Accessed December 2, 2015.↩