doctor's hands holding stethoscope

Credit: Alex E. Proimos on Flickr, under Creative Commons (CC BY 2.0).

(WOMENSENEWS)–Half of all American women have skipped health visits, follow ups or treatments because they couldn’t afford to pay, according to a 2011 report by the Commonwealth Fund.

Women have also been paying higher health insurance premiums, with 92 percent of U.S. health plans practicing gender rating, according to a 2010 report from the National Women’s Law Center. The report added that 56 percent of plans charge non-smoking women more for coverage than male smokers.

All that should change as President Barack Obama’s reelection lowers the uncertainty about the Affordable Care Act and the new law continues its gradual implementation.

The predictable effect will be a major expansion of women’s preventive health care. More in doubt, however, is which doctors will provide that care.

Currently, many healthy women with adequate health coverage have two primary care doctors, in contrast to men, who generally have one. Women see a primary care doctor and an obstetrician-gynecologist, a specialist who often requires a referral under current systems.

But that could change since the new health law defines certain services as primary or preventive care but leaves open the matter of who provides that care. It could be a general practitioner or internist or another primary-care provider. Or it could be the physician who does a woman’s annual Pap smear, while she’s in the office for a regular visit.

Beginning this year, all new plans have been required to cover preventive services — including cervical cancer screenings, mammograms and contraceptives, among many other services –without co-pays, coinsurance or cost sharing. Existing plans will phase that in over time.

Medicaid expansion in most states and the mandate to buy health insurance will further expand coverage of women’s preventive care.

Many states already allow women direct (non-referral) access to specialists such as ob-gyns. The new law mandates this, so an increasing number of insured women means an increasing number of visits.

An Expanding Role

With all that looming, Dr. Michael Policar, a clinical professor of ob-gyn at University of California at San Francisco School of Medicine, suggests that ob-gyns prepare for an increased role as primary care providers.

In a 2012 lecture posted on the UCSF website he writes that ob-gyns should “welcome new revenue producing opportunities,” but stresses the need for ob-gyns to get more training and practice in providing non-reproductive primary care.

Many ob-gyns already provide preventive services that are not specific to women, such as complete physical exams, blood pressure readings and blood cholesterol tests, says Dr. Albert Strunk, a deputy executive vice president for the American Congress of Obstetricians and Gynecologists, called ACOG.

Strunk argues that ob-gyns–who are in short supply in many parts of the country–should be included in the new law’s program for increasing Medicaid primary care reimbursement rates, another facet of the law designed to address primary care needs for both sexes.

The Affordable Care Act includes some loan repayment programs to encourage medical students to go into primary care, but it is unclear what effect that could have on the shortage of ob-gyns.

If the new law encourages more women to see ob-gyns, Brietta Clark, a professor of law at Loyola Law School, Los Angeles, will approve. Clark, a researcher of access to health care issues, says all healthy women should see ob-gyns because they are able to “spot bigger problems” that often primary care physicians and other mid-level providers cannot. Clark herself suffered from fibroids that her primary care provider did not find during multiple exams, but after she switched to an ob-gyn, the problem was identified right away.

Since ob-gyns see women as their regular practice, they will be more in tune with potential problems, such as fibroids, cancer or anything else out of the ordinary. If the health care provider is not an ob-gyn, it is essential that the person “have ongoing training and experience; not someone who just did some rotations,” Clark says.

She applauds the Affordable Care Act for doing away with higher co-pays for ob-gyns because “gynecologists should not be treated as rare specialists.”

Keeping the Family Doc

Dr. Jeffrey Cain, chairman of the American Academy of Family Physicians, cautions against thinking that women can do away with their general practitioner.

Cain, based in Denver, says women benefit from the family physician’s “broader perspective” and coordination of care. Studies have shown that when people have a “first contact” provider, no matter what type, their overall costs decline and their health improves, Cain said.

“All family physicians are required to complete clinical training . . .  in prevention, counseling, detection, diagnosis and treatment of gender-specific disease in women and men,” says a spokesperson for the American Academy of Family Physicians, which has headquarters in Leawood, Kan.

Ob-gyns are educated in a surgical specialty designed to deal with problems such as reproductive system cancers and high-risk maternity care. They often provide more basic services as well.

While family physicians, general practitioners, internists, nurse practitioners and physician’s assistants are also qualified to provide women’s primary care, some of them refer patients to ob-gyns instead.

Some women say they’d rather have one physician instead of two for convenience sake.

Linda, 30, had a family physician providing all her care until she lost her job and health insurance three years ago. She has a new job now, with insurance, but has two doctors: a gynecologist and a general practitioner, who does not provide women’s primary care. She says, “I would LOVE to find one that does everything.”

ACOG has long said that ob-gyns have a tradition of providing preventive care to women and that the specialty knows how to provide women a point of entry to the health care system.

But some women say they never thought to ask their ob-gyns for general preventive health care.

While the Affordable Care Act provides some incentives for medical students to go into primary care and some incentives to incorporate mid-level providers, the current medical education system is still “incentivized to produce more specialists,” says Cain of the American Academy of Family Physicians. Ob-gyns, he says, are getting a “mixed message” about where they fall.

Cain expects ob-gyns to take an increasingly close place beside family doctors and other general practitioners as the system moves toward what he and others call “team-based care.”

The days of the solo practice are over, says law professor Clark: “The costs are too great.”

Hana Askren is a reporter by day and a doula by night. A Los Angeles native, she now lives in New York, where she works as an editor at Mergermarket, part of the Financial Times Group, and is a DONA-certified doula.

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