Transforming Primary Healthcare for Women: The Path Forward

By Laurie Zephyrin, Lisa Suennen, Pavitra Viswanathan, Jared Augenstein and Deborah Bachrach

Editor’s Note: An array of care gaps and structural barriers inhibits the U.S. primary healthcare system from fully meeting the needs of women across the life course. Recently, new models of technology-enabled primary healthcare have emerged, some of which seek to address these gaps and barriers. While these innovations have promise, many operate outside the traditional healthcare system and are only accessible to a narrow segment of consumers.

In a new report prepared in collaboration with and funded by The Commonwealth Fund—part 2 of our series—Manatt identifies innovative care models, business models and technologies for improving primary healthcare for women across ages, races/ethnicities and socioeconomic backgrounds. The report also recommends ways that policymakers, payers, entrepreneurs, clinical leaders and investors can accelerate reform. Findings are based on a review of academic literature, primary research, interviews with experts and an all-day meeting between primary healthcare innovators and industry leaders. Key points are summarized below. Click here to read our full part 2 report on The Path Forward—and here if you missed part 1 of the series, describing the gaps and barriers in women’s primary healthcare and proposing a framework for transforming the system.

Introduction

The fragility of the primary healthcare system has become markedly apparent in the wake of the COVID-19 pandemic. (See part 1 of our report.) Promising models of technology-enabled primary healthcare have emerged to address current gaps and barriers, but many are only accessible, in their current form, to a limited group of consumers.

The ability to design and scale proven innovations and models across different geographies and demographic groups will require significant changes to how primary healthcare is designed, delivered and financed. At the same time, the absence of diverse women’s perspectives in leadership discussions hampers the development of care models and approaches that are responsive to women’s needs.¹

Achieving a Comprehensive Primary Healthcare System

Policymakers, payers, entrepreneurs, clinical leaders and investors can advance five key reforms to meaningfully improve the primary healthcare system for women in the next ten years:

• Prepare primary healthcare providers to deliver comprehensive care that directly addresses women’s unique needs.
• Build integrated primary healthcare teams equipped with the expertise to respond to women’s health needs.
• Embrace primary healthcare visits as opportunities to build trusted relationships between women and providers and to effectively facilitate linkages to specialty and social services.
• Adopt care models and digital health innovations to expand access to integrated care for women across race/ethnicity, age and socioeconomic status.
• Prioritize racial/ethnic and gender diversity in leadership across the healthcare industry.

Training for Primary Healthcare Providers to Meet the Unique Needs of Women

Primary healthcare training programs can be redesigned to ensure that providers are adequately prepared to:

• Comprehensively address women’s primary healthcare needs.
• Partner with specialists to deliver integrated care.
• Deliver care in a culturally competent and age-sensitive manner.

In a report on women’s health curricula, the U.S. Department of Health & Human Services emphasizes that medical training should take a life course approach to ensure that women’s evolving needs and changing professional and personal obligations are met throughout their lives. Medical curricula can highlight sex-specific differences in care by interweaving case studies and clinical simulations that focus on women; historically, these have disproportionately featured men.² Medical training should emphasize empathy toward all patients and acknowledge systemic racism, the intersectionality between gender and race/ethnicity, and pervasive misconceptions in diagnosis and treatment (for instance, a mistaken belief in women’s high pain tolerance) to improve awareness of and responses to implicit and explicit bias.³

Transforming Primary Healthcare Practices for Women

While women often require care from cardiologists, neurologists, ob-gyns and other specialists, these providers may not have the bandwidth or incentives to comprehensively address broad and intersecting health needs across the life course. Therefore, as women age and experience natural life transitions, they require the care and attention of a primary healthcare provider—possibly in consultation with other specialists—who can monitor their evolving needs.

Preparing Students and Clinicians to Provide Appropriate Care for Women

Research shows that integrated, team-based primary healthcare is associated with shorter hospital stays, better management of certain chronic conditions, higher-quality care and lower costs to the health system.⁴ Primary healthcare teams should be multidisciplinary and able to integrate and coordinate specialty care, behavioral health, nutrition and social supports. This may require multiple provider types, including nurses, physician assistants and community health workers.

Such efforts will require practice and culture change to designate roles and underscore the value of sharing responsibilities across provider types. Primary healthcare practices should also prioritize gender diversity in recruitment, as many women prefer to see female providers.⁵

To improve access to primary healthcare, practices must identify new entry points and co-locate services in more convenient locations such as work- and school-based clinics and retail settings. Providing services before and after business hours on weekdays and during the weekends is essential to improving service utilization.

Reimagining Annual Visits for Women as Opportunities to Deliver Integrated Primary Healthcare

Primary healthcare providers must be equipped to offer women’s health services as part of a care team, ensuring each encounter is a positive, engaging experience. The care team should include providers who are prepared to address reproductive healthcare, chronic conditions, behavioral health and health-related social needs.

Primary healthcare visits should include timely conversations with women prior to the onset of key life transitions, such as menopause, as well as routine screenings for nonclinical needs, such as food and housing insecurity, interpersonal violence and other social needs. In addition to an annual in-person visit, women should have opportunities to receive care throughout the year by leveraging virtual care. To enable primary healthcare teams to spend adequate time with women during visits, broad adoption of delivery system and payment reforms is needed.

Expanding the Use of Digital Innovations in Primary Healthcare

Rapid and continuing advancements in digital technology are enabling a fundamental transformation in how primary healthcare is delivered. Developments in health information exchange, interoperability, mobile sensors and apps, and telemedicine, coupled with increasing adoption rates of smartphones and broadband Internet access, are allowing for the design and implementation of digitally enabled primary healthcare models that are more accessible, convenient and connected than ever before.

The perception and adoption of digital technology among primary healthcare providers have improved in recent years. A study found that nearly 90 percent of primary healthcare providers view digital health solutions as advantageous in enhancing their ability to care for patients.⁶

As of May 7, 2020, all states plus Washington, D.C., have issued guidance to expand the use of telemedicine in their Medicaid programs during the COVID-19 pandemic.⁷ These types of digital tools can help primary healthcare providers deliver comprehensive care to women.

Telehealth solutions can increase access to primary healthcare providers regardless of where the patient may be located. Telehealth can also enhance access to specialists, such as psychiatrists, cardiologists, neurologists and others. Remote monitoring tools can enable primary healthcare providers to deliver more continuous care to patients with chronic conditions, such as diabetes, heart failure and chronic obstructive pulmonary disease. Digital tools can increase patient engagement in care, which has been shown to lower costs and improve health outcomes.⁸

Opportunities for Policymakers, Payers, Entrepreneurs, Clinical Leaders and Investors

As novel care models and technology-enabled solutions emerge, policymakers, payers, entrepreneurs, clinical leaders and investors each have a unique role to play in accelerating the development and adoption of comprehensive primary healthcare approaches that meet the unique needs of women across the life course.

Policymakers and Payers

Medicaid provides coverage for 25 million women ages 18 and older, and is the largest source of coverage for births in the United States.⁹ Of the population over age 65 who rely on Medicare coverage, 56 percent are women; among enrollees over age 85, two-thirds are women.¹⁰ Federal and state programs, therefore, have a significant responsibility to ensure that women have access to age-sensitive care from appropriately trained clinicians.

Policymakers and payers should:

• Expand Medicaid and create new, targeted coverage pathways or eligibility groups (for example, postpartum care) that focus on improving coverage among women.
• Invest in Federally Qualified Health Centers to develop and deliver integrated women’s health and primary healthcare models.
• Augment and restructure primary healthcare reimbursement to pay providers for assessing and responding to social determinants of health.
• Require increased representation of women in clinical trials and increase federal grant funding for research on sex differences in disease progression and treatment.

Entrepreneurs and Clinical Leaders

Entrepreneurs and clinical leaders can enhance the primary healthcare system for women by designing and scaling solutions that respond to gaps and barriers.

Entrepreneurs and clinical leaders should:

• Recruit teams that are diverse in gender and race/ethnicity and that reflect the communities they serve.
• Engage female patients across races/ethnicities in the co-creation and design of solutions for women.
• Leverage technology to enhance integration across physical health, behavioral health and social support services.
• Broaden the number and types of entry points that individuals can use to seek primary healthcare, including through the use of virtual primary healthcare models.
• Measure primary healthcare access on the basis of race/ethnicity, income and first language, and tailor models to ensure inclusion.
• Commit to ensuring that innovations will reach women of all income levels, races/ethnicities and socioeconomic backgrounds at each age and stage of life, including developing business road maps that identify pathways to reach women who are enrolled in Medicaid.
• Measure and demonstrate the return on investment of new care models and technologies in achieving positive health outcomes, and disseminate lessons learned to encourage adoption of and continued investment in novel approaches across the industry.

Investors

Though women are the fastest-growing group of entrepreneurs in the United States, women receive less than 5 percent of small-business lending. Some venture funds have recognized a particular disparity in the investments made in ventures directed by low- to moderate-income women and women of color.¹¹ Beginning in 2015, venture capital investment in women’s health began to trend upward at a rapid pace, totaling $354 million in 2017.¹² By 2025, the global market potential for femtech is projected to reach $50 billion.¹³ It will be essential for investors in healthcare venture funds to recognize that funding products and services for women is as important as funding female founders and female founders of color.

Investors should:

• Aggressively hire diverse investment professionals to achieve gender parity across venture capital leadership.¹⁴
• Train investors to be more aware of gender-specific differences in health outcomes and experiences.
• Require diverse leadership and management teams at the healthcare companies they invest in.

Defining Success

Policymakers, payers, entrepreneurs, clinical leaders and investors should set the following targets in working toward a primary healthcare system that optimally meets women’s needs:

• Achieving equity in primary healthcare visit attendance and routine screenings across women of all racial/ethnic and socioeconomic backgrounds
• Minimizing the number of women who do not have a primary healthcare provider
• Adopting telehealth solutions across all primary healthcare practices
• Augmenting medical school and residency curricula to include women’s health topics
• Achieving parity in venture capital investments in women’s and men’s health solutions
• Evolving healthcare leadership teams so that diverse women represent at least half of the decision makers

Conclusion

Today’s primary healthcare system is not designed or operated in a manner that fully meets the physical health, behavioral health or social needs of women, particularly as those needs evolve as women transition through various stages of life. Policymakers, payers, entrepreneurs, clinical leaders and investors all have roles to play in bringing about much-needed reforms and in achieving a primary healthcare system that optimally serves women in the next ten years.

_{¹ Michelle Stohlmeyer Russell et al., Women Dominate Healthcare—Just Not in the Executive Suite (Boston Consulting Group, Jan. 7, 2019).}

_{² Women’s Health Curricula, 2013.}

_{³ Michelle DallaPiazza et al., “Exploring Racism and Health: An Intensive Interactive Session for Medical Students,” MedEdPortal: Journal of Teaching and Learning Resources (Dec. 2018); and Rachel R. Hardeman, “Developing a Medical School Curriculum on Racism: Multidisciplinary, Multiracial Conversations Informed by Public Health Critical Race Praxis (PHCRP),” Ethnicity & Disease 28, Suppl. 1 (Aug. 2018): 271–78.}

_{⁴ Brenda Reiss-Brennan et al., “Association of Integrated Team-Based Care with Healthcare Quality, Utilization, and Cost,” JAMA 316, no. 8 (Aug. 23/30, 2016): 826–34; and Molly Candon and Melissa E. Ostroff, “Beyond Physicians: Interdisciplinary Teams in Integrated Care,” Health Policy$ense (blog), University of Pennsylvania Leonard Davis Institute of Health Economics, Sept. 23, 2019.}

_{⁵ Jamie Ballard, “Nearly Half of Women Prefer Being Treated by a Female Doctor,” YouGov, Aug. 21, 2018.}

_{⁶ AMA Digital Health Research, “Physicians’ Motivations and Requirements for Adopting Digital Health—Adoption and Attitudinal Shifts from 2016 to 2019,” presentation, American Medical Association, Feb. 2020.}

_{⁷ Jared Augenstein et al., Executive Summary: Tracking Telehealth Changes State-by-State in Response to COVID-19 (Manatt, updated June 26, 2020).}

_{⁸ Thomas Bodenheimer et al., “Patient Self-Management of Chronic Disease in Primary Care,” JAMA 288, no. 19 (Nov. 20, 2002): 2469–75; and Russell E. Glasgow, “Self-Management Aspects of the Improving Chronic Illness Care Breakthrough Series: Implementation with Diabetes and Heart Failure Teams,” Annals of Behavioral Medicine 24, no. 2 (Spring 2002): 80–87.}

_{⁹ Henry J. Kaiser Family Foundation, Medicaid’s Role for Women, fact sheet (KFF, Mar. 28, 2019); and Kathy Gifford et al., Medicaid Coverage of Pregnancy and Perinatal Benefits: Results from a State Survey (Henry J. Kaiser Family Foundation, Apr. 27, 2017).}

_{¹⁰ Henry J. Kaiser Family Foundation, Medicare’s Role for Older Women (KFF, May 16, 2013).}

_{¹¹ “CNote Launches Wisdom Fund to Close Lending Gap for Women,” CNote (blog), Mar. 20, 2019.}

_{¹² Dana Olsen, “The Top 13 VC Investors in Femtech Startups,” PitchBook, Nov. 2, 2018.}

_{¹³ Frost & Sullivan, “Femtech: Digital Revolution in Women’s Health,” 2018.}

_{¹⁴ Claire Liu, Megan Zweig, and Natalie Yu, The State of Gender Equity at Healthcare Startups and VCs in 2019 (Rock Health, 2019).}