Preventing Obesity in Midlife Women: A Recommendation From the Women's Preventive Services Initiative

DESCRIPTION

The Women's Preventive Services Initiative (WPSI), a national coalition of women's health professional organizations and patient advocacy representatives, developed a recommendation for counseling midlife women aged 40 to 60 years with normal or overweight body mass index (BMI; 18.5 to 29.9 kg/m²) to maintain weight or limit weight gain to prevent obesity with the long-term goals of optimizing health, function, and well-being. This recommendation is intended to guide clinical practice and coverage of clinical preventive health services for the Health Resources and Services Administration and other stakeholders. Clinicians providing preventive health care to women in primary care settings are the target audience for this recommendation.

METHODS

The WPSI developed this recommendation after evaluating results of a systematic review of the effectiveness and harms of interventions to prevent weight gain and obesity in women aged 40 to 60 years without obesity. Seven randomized clinical trials including 51 638 participants and using various counseling and behavioral interventions were included. Trials indicated favorable weight changes with interventions that were statistically significantly different from control groups in 4 of 5 trials of counseling, but not in 2 trials of exercise. Few harms were reported.

RECOMMENDATION

The WPSI recommends counseling midlife women aged 40 to 60 years with normal or overweight BMI (18.5 to 29.9 kg/m²) to maintain weight or limit weight gain to prevent obesity. Counseling may include individualized discussion of healthy eating and physical activity.

Screening and Intervention for Psychosocial Needs by U.S. Obstetrician-Gynecologists

Objectives: To determine the psychosocial needs screening and intervention practices of obstetrician-gynecologists (OBGYNs) and elucidate characteristics associated with screening and resource availability. Methods: We administered a cross-sectional paper and online survey to 6288 U.S. office-based OBGYNs from March 18 to September 1, 2020, inquiring about screening and intervention practices for intimate partner violence, depression, housing, and transportation. We analyzed associations between demographic/practice characteristics and screening/having resources for all four needs. Results: 1210 OBGYNs completed the survey. One hundred ninety-five OBGYNs (16%) reported their practices screened all patients for all four needs. Having resources to address all four needs (prevalence ratio [PR] = 4.39, 95% confidence interval [CI] = 3.04-6.34), working in health centers/clinics (PR = 2.22, 95% CI = 1.43-3.45), and seeing ≥50% Medicaid patients (PR = 1.62, 95% CI = 1.02-2.58) were associated with screening for all four needs. One hundred sixty-eight OBGYNs (14%) reported their practices had resources onsite to address all four needs. Working in health centers/clinics (PR = 3.99, 95% CI = 2.56-6.22), large practices (PR = 3.37, 95% CI = 1.63-6.95), Medicaid expansion states (PR = 2.60, 95% CI = 1.45-4.65), and practices with >11% uninsured patients (PR 2.30, 95% CI = 1.31-4.04) were associated with having resources onsite for all four needs. Conclusion: Most OBGYN practices appeared underresourced to address psychosocial needs within clinical care. Innovative financial models or collaborative care models may help incentivize this work.

Out-of-pocket spending for oral contraceptives among women with private insurance coverage after the Affordable Care Act

Objectives

We aimed to identify which types and brands of oral contraceptive pills have the largest shares of oral contraceptive users in large employer plans with out-of-pocket spending and which oral contraceptives have the highest average annual out-of-pocket costs.

Study design

We analyzed a sample of medical claims obtained from the 2003-2018 IBM MarketScan Commercial Claims and Encounters Database (MarketScan), which is a database with claims information provided by large employer plans. We only included claims for women between the ages of 15 and 44 years who were enrolled in a plan for more than half a year as covered workers or dependents. To calculate out-of-pocket spending, we summed copayments, coinsurance and deductibles for the oral contraceptive prescriptions.

Results

We found that 10% of oral contraceptive users in large employer plans still had out-of-pocket costs in 2018. Oral contraceptives with the largest share of users with annual out-of-pocket spending are brand-name contraceptives with generic alternatives. The three contraceptives with the highest average annual out-of-pocket spending were brand-name contraceptives without generic alternatives. Three of the 10 contraceptives with the largest shares of users who have annual out-of-pocket spending and 3 of the 10 contraceptives with the highest average annual out-of-pocket spending contain iron.

Conclusions

Women with health insurance are still paying out of pocket for oral contraception, and future research should investigate which health plans have fewer fully covered contraceptives and effective modes of educating providers and patients about how to maximize the no-cost coverage benefit that has been extended to women.

Implications

The Affordable Care Act eliminated out-of-pockets costs for contraception for most insured women. However, some women still pay out of pocket for certain oral contraceptive brands and types that may have covered alternatives. Providers and patients could benefit from more education on how to maximize the no-cost coverage benefit extended to women.

Screening for Anxiety in Adolescent and Adult Women: A Recommendation From the Women's Preventive Services Initiative

DESCRIPTION

The Women's Preventive Services Initiative (WPSI), a national coalition of women's health professional organizations and patient representatives, developed a recommendation on screening for anxiety in adolescent and adult women to improve detection; achieve earlier diagnosis and treatment; and improve health, function, and well-being. The WPSI's recommendations are intended to guide clinical practice and coverage of services for the Health Resources and Services Administration and other stakeholders. The target audience for this recommendation includes all clinicians providing preventive health care to women, particularly in primary care settings. This recommendation applies to women and adolescent girls aged 13 years or older who are not currently diagnosed with anxiety disorders, including pregnant and postpartum women.

METHODS

The WPSI developed this recommendation after evaluating results of a systematic review of the effectiveness of screening, accuracy of screening instruments, and benefits and harms of treatments in adolescent girls and adult women. No studies directly evaluated the overall effectiveness or harms of screening for anxiety. Twenty-seven screening instruments and their variations were moderately to highly accurate in identifying anxiety (33 individual studies and 2 systematic reviews; 171 studies total). Symptoms improved and relapse rates decreased with psychological therapies (246 randomized controlled trials [RCTs] in 5 systematic reviews) and with selective serotonin reuptake inhibitors or selective serotonin and norepinephrine reuptake inhibitors (126 RCTs in 3 systematic reviews). The WPSI also considered the effect of screening on symptom progression and identification of associated and underlying conditions, as well as implementation factors.

RECOMMENDATION

The WPSI recommends screening for anxiety in women and adolescent girls aged 13 years or older who are not currently diagnosed with anxiety disorders, including pregnant and postpartum women. Optimal screening intervals are unknown, and clinical judgment should be used to determine frequency. When screening suggests the presence of anxiety, further evaluation is necessary to establish the diagnosis and determine appropriate treatment and follow-up.

The Importance of Strengthening Workplace and Health Policies to Support Breastfeeding

In recent years, there has been renewed attention to the central role that clinicians and healthcare institutions can play to support women in initiating and sustaining breastfeeding through the first year of their infant's life. There has been, however, considerably less focus on how to support the breastfeeding needs of new mothers who return to work, particularly those who go back shortly after the birth of their infant. While many women intend to continue breastfeeding when they go back to work, about one-third report breastfeeding as a major challenge. For many women, the lack of paid family leave, limited flexibility with their work hours, and workplaces that offer few accommodations can make it especially hard for them to sustain breastfeeding. The Affordable Care Act (ACA) included many provisions that strengthened coverage for pregnant women and new mothers. In addition to coverage improvements, The ACA amended the Fair Labor Standards Act to require employers with 50 or more workers to provide reasonable break time and a private space that is not a bathroom for expressing milk. For women who breastfeed or who must express milk while they work, having health insurance benefits and Medicaid policies that cover the costs of lactation supplies and support services can make a difference in the decision to continue to provide their infants with breast milk through the first year of their lives and ultimately improve both maternal and infant outcomes in the long run.

Screening for Urinary Incontinence in Women: A Recommendation From the Women's Preventive Services Initiative

DESCRIPTION

Recommendation on screening for urinary incontinence in women by the Women's Preventive Services Initiative (WPSI), a national coalition of women's health professional organizations and patient representatives. The WPSI's recommendations are intended to guide clinical practice and coverage of services for the Health Resources and Services Administration and other stakeholders. The target audience for this recommendation includes all clinicians providing preventive health care for women, particularly in primary care settings. This recommendation applies to women of all ages, as well as adolescents.

METHODS

The WPSI developed this recommendation after evaluating evidence regarding the benefits and harms of screening for urinary incontinence in women. The evaluation included a systematic review of the accuracy of screening instruments and the benefits and harms of treatments. Indirect evidence was used to link screening and health outcomes in the chain of evidence that might support screening in the absence of direct evidence. The WPSI also considered the effect of screening on symptom progression and avoidance of costly and complex treatments, as well as implementation factors.

RECOMMENDATION

The WPSI recommends screening women for urinary incontinence annually. Screening ideally should assess whether women experience urinary incontinence and whether it affects their activities and quality of life. The WPSI recommends referring women for further evaluation and treatment if indicated.

Blueprint for action: steps toward a high-quality, high-value maternity care system

Childbirth Connection hosted a 90th Anniversary national policy symposium, Transforming Maternity Care: A High Value Proposition, on April 3, 2009, in Washington, DC. Over 100 leaders from across the range of stakeholder perspectives were actively engaged in the symposium work to improve the quality and value of U.S. maternity care through broad system improvement. A multi-disciplinary symposium steering committee guided the strategy from its inception and contributed to every phase of the project. The "Blueprint for Action: Steps Toward a High Quality, High Value Maternity Care System", issued by the Transforming Maternity Care Symposium Steering Committee, answers the fundamental question, "Who needs to do what, to, for, and with whom to improve the quality of maternity care over the next five years?" Five stakeholder workgroups collaborated to propose actionable strategies in 11 critical focus areas for moving expeditiously toward the realization of the long term "2020 Vision for a High Quality, High Value Maternity Care System", also published in this issue. Following the symposium these workgroup reports and recommendations were synthesized into the current blueprint. For each critical focus area, the "Blueprint for Action" presents a brief problem statement, a set of system goals for improvement in that area, and major recommendations with proposed action steps to achieve them. This process created a clear sightline to action that if enacted could improve the structure, process, experiences of care, and outcomes of the maternity care system in ways that when anchored in the culture can indeed transform maternity care.

Role of health insurance coverage in women's access to prescription medicines

OBJECTIVE

To examine the effects of health insurance coverage and other factors on access to prescription medicines for non-elderly women ages 18-64.

METHODS

Based on a nationally representative telephone survey of adult women in the United States, this study uses multiple logistic regression to determine the factors significantly associated with cost barriers among non-elderly women. The sample for the study includes 1,177 women ages 18-64 who use >or=1 prescription drug on a regular basis. Cost barriers are defined as not filling a prescription or skipping or splitting doses owing to cost. A composite variable of income and health insurance was created to examine the role of insurance in mitigating barriers for women of different income levels. Descriptive analyses report the share of subgroups of women who have faced any of these cost barriers, and logistic regression analyses were used to examine the role of health insurance, income, and other factors in predicting financial access to prescribed medications.

KEY FINDINGS

Over half (54%) of non-elderly women reported that they were taking a prescription medicine on a regular basis, and nearly one third (32%) of these women reported experiencing >or=1 affordability barrier in the prior year and had to either forgo or delay a prescription and/or reduce dosages to make medicines last longer because of costs. Uninsured women had the highest odds of facing a cost barrier, regardless of income level. Low-income, uninsured women were nearly 7 times as likely to face a cost barrier to prescription drugs, compared with higher income women with insurance. Even uninsured women with incomes >or=200% of the federal poverty level had 5 times the odds of facing a prescription medicine cost barrier, and low-income, insured women experienced 2 times the odds of a prescription medicine cost barrier, compared with their higher income, insured counterparts.

CONCLUSION

Lack of health insurance coverage was significantly associated with experiencing cost barriers, regardless of income level, underscoring the critical role that insurance coverage plays in protecting women from out-of-pocket costs and for accessing prescription medicines. Limiting out-of-pocket spending is also important for low-income women who have insurance, because even minimal costs can act as barriers for this group.

Five years later: poor women's health care coverage after welfare reform

The 1996 welfare reform law aims to increase poor women's participation in the work force and encourage their financial independence. Because women's ability to obtain and retain employment is affected by their health status, welfare reform's success is fundamentally tied to poor women's access to health care and to health insurance. Despite this, the rate of uninsurance among poor women with children has grown by half in recent years, leaving 37% of poor mothers uninsured in 2000. Coverage through employer-sponsored insurance has increased only slightly, and Medicaid participation has dropped. Although many factors contributed to this, welfare policies and procedures and low Medicaid eligibility levels had unintended yet significant negative effects on women's health care coverage. The sharp decline in poor women's health care coverage is likely to be one of several health-related issues that Congress will consider as it debates the reauthorization of the welfare law in 2002. Both public and private efforts will be necessary to improve coverage for poor women with children. Much progress has been made during the past 5 years in covering poor and near-poor children, but their parents have been left behind. The same efforts that proved successful for children, including broadening eligibility for coverage and simplifying the application process, can be used to improve the health and well-being of parents and to strengthen their ability to care for and support their families.

Access to care for low-income women: the impact of Medicaid

This study was undertaken to assess how low-income women with Medicaid, private insurance, or no insurance vary with regard to personal characteristics, health status, and health utilization. Data are from a telephone interview survey of a representative cross-sectional sample of 5,200 low-income women in Minnesota, Oregon, Tennessee, Florida, and Texas. On the whole, low-income women were found to experience considerable barriers to care; however, uninsured low-income women have significantly more trouble obtaining care, receive fewer recommended services, and are more dissatisfied with the care they receive than their insured counterparts. Women on Medicaid had access to care that was comparable with their low-income privately insured counterparts, but in general had significantly lower satisfaction with their providers and their plans. Future federal and state efforts should focus on expanding efforts to improve the scope and reach of health care coverage to low-income women through public or private means.

The key to the door: Medicaid's role in improving health care for women and children

Medicaid is the nation's major public financing program for providing health insurance coverage and long-term care services to the poor. This article assesses Medicaid's contributions over the last three decades to improving the coverage, access to care, and health of low-income children and women. The article reviews Medicaid's impact on the low-income population covered by this program, demonstrating both the role insurance plays and its limitations as a strategy for improving the health of vulnerable populations. Medicaid has shown over the last three decades that it is an important lever to help open the door to better health care, and ultimately to improved health for America's poor women and children, by substantially expanding coverage of the low-income population and helping to reduce differentials in access to care between the poor and the privately insured. Gaps in coverage and limitations in access persist, but overall the program has resulted in better coverage, access, and health care for millions of poor children and their parents.

Medicaid and managed care: meeting the reproductive health needs of low-income women

State Medicaid programs have increasingly turned to managed care with hopes of controlling spending while improving access to care. The move to managed care has significant implications for the provision of reproductive health services--family planning, abortion, sterilization, sexually transmitted diseases, and maternity care. However, the delivery of reproductive health services in a Medicaid managed care environment is wrought with many difficulties. The complexity inherent in Medicaid policy, the changing world of managed care, and the health and social needs of the Medicaid population are compounded by the sensitive nature of reproductive health needs.

Medicaid and managed care: implications for low-income women

This commentary reviews Medicaid's role for low-income women and examines the implications of Medicaid managed care on the delivery of health services to this vulnerable population. Today 40% of the Medicaid population, mostly poor women and their children, is enrolled in managed care. Medicaid agencies are hoping managed care will control spending and address longstanding problems with access to care. Low-income women have a number of characteristics that make them doubly vulnerable to access to care and place them at high risk of health problems. Furthermore, many beneficiaries have historically experienced nonfinancial barriers to care under fee-to-service Medicaid. While many look to managed care to overcome these obstacles, the evidence suggests that it does not offer a great improvement over fee-to-service in terms of improved access or reduced long-term costs for low-income women. For Medicaid managed care to realize its potential, it must assure that financing is adequate, resources for monitoring and oversight are sufficient, and systems and benefits are responsive to the complex and diverse health care needs of low-income women.

Commentary: Lessons from Medicaid--improving access to office-based physician care for the low-income population

Medicaid offers important lessons about providing access to office-based physician services for the poor. First, differentials in physician fees between Medicaid and other payers compromise access to care and are difficult to reverse. Second, managed care alone is not enough to attain equity in access, especially if differentials in payment rates between Medicaid and private patients in managed care settings are allowed to grow. Finally, financing strategies alone are not sufficient to resolve the shortage of health care providers in medically underserved areas. In these areas, payment policy must be combined with resource development to ensure that vulnerable populations have access to care.