WOMEN'S HEALTH
Poor Need More Preventive Care
Even though women enrolled in Medicaid and similar government-funded insurance programs may believe they receive good care, two recent studies show that poor and low-income women are not receiving adequate preventive care and in some cases are not receiving appropriate treatment.
To learn how effective the Medicaid program is, the Washington, DC-based Campaign for Women's Health (CWH) sponsored a telephone survey of 1,300 women Medicaid recipients in California, Arkansas, Georgia, and Michigan. In a separate study Jennifer S. Haas, MD, and colleagues of Boston's Brigham and Women's Hospital analyzed all Massachusetts in-hospital, single-gestation births in 1984 and 1987. They wanted to know whether women enrolled in the state's Healthy Start insurance program for low-income, pregnant women had better health than uninsured women.
Of those responding to the CWH survey, more than 80 percent in each of the four states rated the care they receive from Medicaid physicians as good or excellent. However, only 11 percent (the low) of Arkansas recipients and only 17 percent (the high) of California recipients said they would leave Medicaid as is.
The CWH study points out that many women enrolled in Medicaid do not receive five routine screenings that could lead to the prevention or early detection of diseases and thus "make a critical difference to the health of the patient and the cost of medical treatment." CWH reports:
- High blood pressure, a leading cause of heart disease, can be easily detected during any healthcare facility visit. However, one out of four women said she had not had her blood pressure checked during the past year.
- Another indicator of heart disease is high blood cholesterol levels. Barely half the respondents had had their cholesterol levels checked in the past year.
- Diabetes affects twice as many women as men, yet in Arkansas only 45 percent (the low) of respondents and in Michigan only 53 percent (the high) had had their blood sugar levels checked in the past year.
- One in three women on Medicaid had not had either a Pap smear or a breast examination in the past year, and only 54 percent had had both.
On a more positive note, CWH found that 80 percent of survey respondents who received regular prenatal care carried their babies to full term. But of the 20 percent of women on Medicaid who did not receive regular prenatal care, less than half carried to full term.
Not only are poor and low-income women often receiving inadequate preventive care, many are not receiving appropriate treatment. Structural barriers such as lack of child and elder care and transportation mean women who are ill do not get immediate care and often become more ill. As many as 52 percent of respondents from California and from Arkansas said their health deteriorated as a result of not being able to get healthcare services from a physician.
In addition, many respondents reported getting inappropriate treatment because they were unable to procure medications their physicians had prescribed. According to CWH, at least one in four respondents said they had been denied medications that Medicaid did not cover. In California as many as one in three respondents reported being refused a physician-prescribed medication.
In the study of mothers who are enrolled in Healthy Start, Haas and colleagues report in JAMA that in the state of Massachusetts the provision of health insurance alone does not improve maternal health but is associated with an increase in the rate of cesarean surgeries.
Although Haas and colleagues do not speculate whether the increase is an improvement or decrement in the quality of care, they suggest that "payer is a determinant of cesarean section use independent of clinical circumstance." They hypothesize that "physicians may be more willing to perform a cesarean delivery on patients with insurance because they perceive them as a 'higher' social class" or that they treat insured women more aggressively because they are concerned about medical malpractice liability.
Provision of health insurance may not reduce maternal morbidity and mortality associated with pregnancy and childbirth, note Haas et al. But the researchers emphasize that pregnancy may be the only time a woman has contact with the healthcare system and therefore "may be an important time for interventions directed at improving women's health overall."
CATHOLIC HEALTH ASSOCIATION
What Leaders Expect from CHA
Leaders in Catholic healthcare look to the Catholic Health Association (CHA) to plan and organize its meetings primarily to address, and provide opportunities to discuss, the Catholic perspective on healthcare issues, according to a survey we recently completed.
About one-fourth (25.2 percent) of survey respondents—who included hospital and long-term care chief executive officers (CEOs), as well as representatives from Catholic healthcare systems—ranked national healthcare reform as the topic they most wanted CHA to explore. The issue was ranked as one of the three most important topics by 43.8 percent of respondents.
Ethical issues, especially those concerning right-to-die questions and rationing of healthcare, were another prominent concern for Catholic healthcare leaders, with 10.8 percent ranking them as the most important area for CHA to address and 26.3 percent placing them among their top three issues. Various management issues (e.g., employee relations, strategic planning, evaluations and assessments, information technology, and marketing) were also cited as important (10.4 percent, most important; 25 percent, among the three most important), as were mission and margin issues (9.8 percent; 21.7 percent) and CHA's healthcare reform proposal (7.3 percent; 14.8 percent).
We also asked respondents to identify five annual professional and association meetings they would likely attend because of the meetings' relevance, ranking them in order of importance. Thirty-eight percent cited the CHA assembly as among the five most important meetings they attended, and 10.2 percent indicated it was their most important meeting. Only the American College of Healthcare Executives (ACHE) annual meeting and American Hospital Association (AHA) and state hospital association meetings were mentioned more frequently.
Our survey revealed some significant differences between respondents based on the type of organization with which they were affiliated. For example, hospital CEOs were much more likely to attend ACHE's annual meetings than were healthcare system staff, who more often cited the CHA, AHA, and American Association of Homes for the Aging (AAHA) annual meetings as important. Not surprisingly, the AAHA meeting was the most important for long-term care administrators, who also said they hoped future CHA assemblies would have more sessions that focused on long-term care issues.
Responding to an open-ended question about what they expected from CHA's annual assembly, many of those surveyed said they expect to gain a perspective on healthcare issues they cannot get at other professional or association meetings. For respondents who indicated they look to CHA for inspiration and renewal, as well as for those who expect CHA to promote Catholic identity in healthcare, the current assembly format is generally acceptable.
Sr. Susan Sanders, RSM, PhD
Assistant Professor
Susan F. Bennett, PhD
Assistant Professor
Management of Public Affairs Department
DePaul University
Chicago
HEALTHCARE DELIVERY
St. Louis Providers Form an IDN
In a move that anticipates President Clinton's healthcare reform proposal, four major St. Louis-area healthcare organizations have announced they are forming an integrated delivery network (IDN).
Participants in the new network include DePaul Health Center, a member of the Daughters of Charity National Health System; Missouri Baptist Medical Center, a member of Missouri Baptist Health Care System; Saint Louis University Health Sciences Center; and the following members of the SSM Health Care System: St. Mary's Health Center, St. Joseph Health Center, St. Joseph Hospital West, Cardinal Glennon Children's Hospital, and the SSM Rehabilitation Institute.
The IDN's objective will be to enhance efficiency and effectiveness in healthcare delivery and to improve access and quality of care by bringing hospitals, physicians, managed care companies, and other components together. William Schoenhard, SSM Health Care System's executive vice president and chief operating officer and current chairperson of the IDN, empnhasizes that participants will maintain their identities and sponsorship. "The network will be built on the strengths of the individual institutions and their medical staffs," he said.
More than 4,000 physicians are currently affiliated with the IDN participants. The medical staff at each network hospital will be "highly involved in providing input and direction regarding the future development of the network," Schoenhard stressed. There are 2,855 licensed beds and 12,378 employees at participating facilities.
As the network develops, it will negotiate managed care contracts on behalf of participants, develop a unified patient information system, coordinate services to gain economies of scale and increased efficiency, and develop common measures of quality and network performance.
The organizations involved in the network have come together because they have compatible missions, values, and management philosophies. According to Schoenhard, "The network will actively seek additional participants who share its ideals and who seek to expand their service mission without giving up their unique identities."