Abstract
I
Midlife women participated in interviews as part of the Medical Expenditure Panel Survey (MEPS) between 2002 and 2012, providing data about the type of healthcare provider whom they saw in their office visits and the reasons for their use of services, including general checkup, diagnosis/treatment, or follow-up. Other reasons for seeking care were emergent care, counseling, immunizations and injections, vision examinations, and pregnancy or postoperative care. Each panel participated in five rounds of interviews encompassing 2 years.
Data from 44,830 women and 330,114 office visits were analyzed. Although the focus of the study was on type of physician provider, the investigators reported that women saw nonphysicians in 42% of office visits, with ∼3.5% women seeing mental health providers and another 6.2% women seeing nurse practitioners (NPs)/nurses or physician assistants (PAs), a noteworthy proportion of visits. “Other nonphysician providers” included laboratory technicians, chiropractors, and physical therapists. Visits involving both a physician and nonphysician provider were attributed to the physician, so it was difficult to determine the extent to which the nonphysician providers were involved in a particular visit. Thus the MEPS approach to data gathering was not sensitive to the contributions made by healthcare providers who were not physicians.
Women who participated in the MEPS and saw obstetrician/gynecology providers were more likely to be white, married, employed, and living in metropolitan areas, and enjoying higher incomes, private health insurance, and in better health than women who saw family physicians or internal medicine physicians. In addition, women seeing obstetrician/gynecology providers were more likely to live in the northeast. The investigators were careful to indicate that the sample was not representative of homeless women, those who were incarcerated, and those hospitalized for psychiatric disorders. When women made office visits to obstetrician/gynecology providers, they were most likely to receive a checkup (61%–63% from 2002 to 2012), whereas those who visited a family medicine or internal medicine provider were most likely to obtain a diagnosis or treatment (40%–50%). Thus there is a suggestion that patterns of care delivered varied for women seeing the obstetrician/gynecologist versus women seeing family medicine or internal medicine physicians.
Fragmentation Versus Comprehensive Care
Given past concerns about fragmentation of women's healthcare related to allocating reproductive and sexual healthcare to obstetric/gynecologic specialists and other nonreproductive healthcare to internal medicine or family medicine physicians, 4 it is important to note that 10%–20% of women obtained primary care solely from an obstetrician/gynecologist and a similar proportion received care from both an obstetrician/gynecologist and a family medicine or internal medicine physician. The proportion of midlife women who receive primary care from obstetrician/gynecologists or both obstetrician/gynecologists and family medicine/internal medicine in this MEPS study appears to have declined over the decade studied. Although this change may signal progress in reducing fragmentation of care, it also may alert us to the need to strengthen the preparation of primary care providers in sexual and reproductive healthcare as part of comprehensive primary care for women. 5
The delivery of comprehensive primary care to women is a goal not yet well supported in our current systems of healthcare and provider education and training in sexual and reproductive health. 6 Educational preparation of primary care providers currently emphasizes management of chronic conditions such as diabetes, hyperlipidemia, or chronic hypertension and limits preparation in sexual and reproductive healthcare, such as contraceptive technology, high-risk pregnancy, and hormone therapy, or preparation of obstetrician/gynecologists whose training emphasizes sexual and reproductive healthcare but not management of chronic conditions. As a result, women who see only one type of provider may not receive comprehensive services. Integration of women's healthcare in comprehensive primary care should include sexual and reproductive care as well as care for women experiencing chronic health problems uniquely experienced by women, more prevalent among women or treated differently in women versus men. This will require concerted effort to reform the educational system used to prepare primary care providers.
Understanding Who Provides Primary Care for Women
In addition to increasing emphasis on comprehensive primary care for women, understanding which professionals provide primary care for women is essential. Accounting for all primary care providers for women, especially in a nationally sponsored data resource such as the MEPS, is essential as a foundation for forecasting accurately the educational resources required to prepare the future women's healthcare workforce. What is missing from this otherwise informative analysis is a complete accounting of midlife women's primary healthcare as provided not only by physicians but also by advanced registered nurse practitioners (ARNPs) and PAs. In the United States, there are currently more than 222,000 licensed ARNPs, 83% with certification in an area of primary care. NPs hold prescriptive privileges, including for controlled substances, in all 50 states and the DC. 7 Family NPs, the largest group of practicing primary care NPs, account for ∼51% of NPs in the United States and are educated in providing primary care to women, including adults and late adolescents. In addition, ∼6% of NPs are certified in women's health and specialize in providing sexual and reproductive healthcare to women across the lifespan.
PAs also contribute significantly as primary care providers, although state laws leave most delegatory decisions to a supervising physician. 8 A majority of PAs engage in specialty practice. Of the nearly 102,000 PAs certified in 2014, ∼26% practice in primary care, 20% practice in family medicine/general practice, 1.4% in obstetrics and gynecology, and 7.6% in internal medicine subspecialties. 9
Lack of attention to these providers in the MEPS limits the ability to fully account for current women's healthcare and project educational resources to meet future needs. Moreover, just as physicians may elect a specialty, ARNPs and PAs also may elect specialty preparation. For example, ARNPs may obtain national certification in women's healthcare through the National Certification Corporation. 10
Differences in state licensure for healthcare providers make it difficult to track directly the number of patients and patient encounters per year. Thus, federally supported studies such as the MEPS could provide unique information about who cares for midlife women.
Primary Care Teams
Increasingly primary care is delivered by teams of health professionals. One example is the use of the Patient Aligned Care Team by the Veterans Administration (VA). The VA has carefully analyzed the contributions of registered nurses, physicians, NPs, social workers, pharmacists, mental health professionals such as psychologists, and other health professionals to identify critical elements of care delivered by each. 11 Providers (e.g., physicians and NPs) practice in collaboration with other team members to deliver carefully tailored services to veterans. Such arrangements are being adopted in other nongovernment organizations delivering health services, such as primary care clinics and federally qualified health centers. For midlife women, a team approach is useful to provide the full scope of menopause care.
What is evident is the complexity of providing comprehensive women's healthcare in a system of medical specialization based on organ systems. To date, gender-based primary care has received limited attention, with the noteworthy exception of Centers of Excellence in Women's Health Care funded by the Office of Women's Health of the Public Health Service and the Centers for Women's Health within the VA. 12
Nonetheless, the arrangements for the MEPS could be modified to help address the issues outlined here about comprehensive women's healthcare, inclusion of NPs and PAs as healthcare providers, and structural arrangements of teams in caring for women, such as outlined previously. Providing a much more complete picture of the arrangements for women's healthcare would include not only enumerating additional types of providers but also attending carefully to the scope of the practice and the structures in which care is delivered, for example, by teams.
Beginning data collection in the states in which both NPs and PAs have full authority for their practice should be a high priority for the MEPS. A decade from now, the readers of the Journal of Women's Health will be able to learn about who is REALLY providing women's healthcare and what services they provide.