In Her Own Right The Institute of Medicine's Guide to Women's Health Issues (1997) / Chapter Skim
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8 Women in the Health Care System
8 Women in the Health Care System
Pages 153-176
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From page 153... ...
Yet our people meanwhile suffer some of the worst rates of infant mortality and cervical cancer, among other preventable tragedies, in the industrialized world. Our talented medical professionals perform at the peak of their art while many ordinary citizens go without routine care.
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From page 154... ...
Large numbers of women now practice medicine, but men still predominate in such prestigious posts as those of professors and deans. Women throng the lesser-paying fields as nurses; allied health professionals like technicians, audiologists, and occupational therapists; and low-skilled workers like nurses aides and home health care aides.
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From page 155... ...
Women's experience differs from men's "in each of these dimensions," Woods notes, but finance "looms as the critical issue for the decade." As a group, women are far less able than men to pay for all the health care they need.5 One of the reasons is obvious: women simply earn less than men -- 72 cents for every male dollar in 1991, giving them less money to spend on both bills and insurance premiums.6 More than three-quarters of all Americans -- and a slightly higher percentage of women than men -- nonetheless have some form of coverage. But women less often use private plans and more often depend on public assistance programs like Medicaid, which drastically curtail options because many providers refuse publicly funded patients.7 155
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From page 156... ...
Fewer female workers get insurance as a job benefit, with the disproportionately female holders of part-time and unskilled jobs least likely to enjoy this valuable "perk." Even among the overwhelmingly female health care workforce, many employees lack health coverage. Some 6% of those staffing doctors' offices, for instance, have no health insurance, and 52% get no employer contribution toward their premiums.11 And even in this age of two-paycheck families, many mothers still cut back their work hours or leave the labor force altogether, at least temporarily.
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From page 157... ...
(However, the recent Kennedy-Kassebaum Health Insurance Bill prohibits denying insurance coverage based on medical conditions. -- ED.) More than 80% of family physicians offer family planning, but most private plans consider it unreimbursable preventive care, leaving patients to pay for office visits and birth control supplies out of their own pockets.
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From page 158... ...
Lack of prevention thus creates a deadly class discrepancy. Breast cancer strikes African American women less often than whites, for example -- 96.6 cases per 100,000 women as opposed to 112.9 per 100,000 -- but kills them more often -- 27 per 100,000 versus 23 per 100,000.18 In poor areas, tumors are 20% more likely to have reached the lethal late stages by the time they are found than in more affluent locales.
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From page 159... ...
A Pap test even once every five years slashes mortality by 84%, once every two years by 93%. In the early 1970s, African Americans had largely lethal late-stage diagnoses about as often as whites, but twice as often by the late 1980s.22 So large a "relative difference in late-stage cancer among different groups is an important clue to the existence of problems with access and, potentially, with subsequent treatment," notes the IOM committee on access.23 Nor is cancer screening the only routine care whose lack disproportionately kills poor and nonwhite Americans.
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From page 160... ...
"Battering," the access committee stated, "is a major factor in injury and illness among women" -- indeed, their commonest reason for visiting emergency rooms -- "but it is often overlooked by medical professionals." Though violence may occasion up to a quarter of those trips, "emergency care providers typically identify less than 5 percent of the women with injuries or illnesses suggestive of abuse."28 And if the abusing husband or boyfriend controls an abused woman's money, insurance, or car keys, she may never get to see a doctor about her injuries at all. A similar kind of blind spot has kept many women from getting appropriate care for another "secret" disorder, alcohol and drug abuse.
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From page 161... ...
Problems often begin with inadequate or nonexistent insurance. Mothers between 16 and 24 account for 40% of American births, but a quarter of them lack any private coverage.32 "Once an affordable service on a middle-class income," maternity care is now, in the access committee's words, "an almost unthinkable expense without health insurance."33 Under a third of the uninsured therefore get proper prenatal care, as opposed to 81% of the insured.34 But neither Medicaid nor even a private policy guarantees a woman what she needs.
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From page 162... ...
Almost three dozen states have areas with fewer than 20 OB/GYNs per 100,000 women of childbearing age, almost a score have areas with fewer than 10 per 100,000, and 400,000 women in 22 states live in areas with no OB/GYNs at all.38 In the populous Northeast, few family doctors take obstetrical cases. In more sparsely settled regions like the North Central plains, delivering babies has long formed a routine part of general practice, and family physicians account for two-thirds of those providing private rural obstetrical care.
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From page 163... ...
Along with the size and probability of judgments, the cost and difficulty of buying malpractice insurance have also risen rapidly. Doctors who remain in the field, whether OB/GYN specialists or family practitioners, often find that escalating insurance premiums can make delivering babies a prohibitively expensive business proposition.
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From page 164... ...
on an individual basis," the committee suggests.46 So, by default, community and migrant health centers provide much of the prenatal care that poor women do manage to obtain. But even they, in the blunt words of one center director, "are often unable to provide on-site or contract off-site prenatal care and delivery services because of the high cost of malpractice insurance."47 For those that do treat pregnant women, paying for premiums can use up the funds needed to recruit and retain insurable OB/GYNs.
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From page 165... ...
, deliver a baby without medical malpractice insurance, or cease furnishing prenatal care altogether," the liability committee observes. "Terminating care of a patient at the time of delivery not only places the patient in jeopardy and the physician into an ethical dilemma, it also creates potential liability for the physician who ultimately performs the delivery with no prior knowledge of the patient."49 In a cruel and dangerous irony, then, "the very factors that call for increased access to care can also intensify a physician's sense of risk when caring for low-income patients," the committee goes on.
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From page 166... ...
Though permitted to practice in all 50 states and entitled to Medicaid reimbursement since 1980, they, too, have found insurance increasingly unobtainable. Certified nurse-midwives have a good record of safe deliveries, but nonetheless, "the difficulties in obtaining professional liability insurance in many states have made it virtually impossible for nurse-midwives to practice other than as the employees of physicians.
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From page 167... ...
In today's less personal atmosphere, as women hunt for physicians to accept them and doctors scrutinize patients as potential courtroom adversaries, "erosion of trust is both one of the causes and one of the consequences of the medical professional liability crisis," the committee believes. On the one hand, fewer and fewer Americans have longstanding family physicians whom they feel they know personally.
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From page 168... ...
Blue Cross, Medicaid, and other insurers began reimbursing without question. Eight out of nine randomized clinical trials of EFM, however, have found little basis for the early enthusiasm.
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From page 169... ...
among women who have continuous electronic fetal monitoring, the reason being that they are unable to walk," Thacker suggests. "They are therefore less able to tolerate labor and require more sedation."67 In addition, the liability committee observes that "the frequency of operative deliveries, primarily cesarean sections, has been linked statistically to the use of EFM," increasing both costs and mothers' risk of injury.68 This rising rate of cesarean births in fact constitutes the other major change in obstetrical practice over recent decades.
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From page 170... ...
With so few vaginal breech deliveries, there is less opportunity to educate residents; we have therefore an increasing pool of physicians with little or no experience in performing such deliveries."69 Nor do today's residents have either incentive or encouragement to learn older techniques to use in tricky situations. "For many years," the head of an obstetrics department told the liability committee, "a standard part of my teaching to medical students and residents had been to perform only medically and obstetrically indicated cesarean sections, uninfluenced by other considerations such as inconvenience, time of the day or night, interference with office hours, monetary gain, or threat of malpractice.
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From page 171... ...
Three-quarters of men over 65, but only a bit over one-third of their female contemporaries, live in a married couple. By 85, one-third of men but only 8% of women still have a living spouse.75 "More women than men," Woods notes, therefore must "hire someone to provide their care."76 Eighty-four percent of the seniors in nursing homes are not currently married, as opposed to only 64% of the similarly impaired persons able to remain outside of institutions.77 "The typical nursing home resident is an 80-year-old white widow who has several chronic medical conditions," according to the committee.
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From page 172... ...
"There is little status, recognition or compensation for this key role."83 Not surprisingly, aides change jobs frequently, and nursing homes report increasing difficulty finding suitable staff. As the nation's elderly population increases, so will the demand for these key front-line workers, as well as for other allied health personnel who deal with the ailments of aging, including professionals such as physical and occupational therapists and audiologists.84 Exacerbating the tight market for competent aides are the 172
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From page 173... ...
."85 But as the elderly population continues to grow, "if current morbidity, disability and functional dependence rates and patterns continue," the allied health committee predicts, "by the year 2000 about 50 percent more noninstitutionalized elderly people will require the help of others in daily living activities than required such help in 1977."86 With more people living longer, with increasing numbers of three- and even four-generation families, and with more middle-aged women in paying jobs, the prospects for informal caregivers providing the needed help look increasingly grim. These forces may all combine to force the nation toward "a more formalized system of care," surmises IOM's Committee to Design a Strategy for Quality Review and Assurance in Medicare.87 Despite converging trends and hopeful forecasts, though, "the nation's stock of nursing home beds is not keeping pace with the growth in demand -- let alone probable need," warns the allied health committee.
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From page 174... ...
This would entail "interdisciplinary research to address the gaps in our knowledge of how women's reproductive and endocrine cycles affect health and disease," Woods believes. In addition, "medical students would learn how to identify themselves across gender lines, all specialties would become more user friendly to women, and the medical profession would rectify its past inequities in its conceptualization of women and the denial of leadership opportunities to women.
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From page 175... ...
34. Medical Professional Liability and the Delivery of Obstetrical Care, Vol.
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From page 176... ...
58. Thacker in Medical Professional Liability, Vol.
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