CLINICAL OBSTETRICS AND GYNECOLOGY Volume 58, Number 2, 320–322 Copyright r 2015 Wolters Kluwer Health, Inc. All rights reserved.
Changes in Obstetrics and Gynecologic Care REBEKAH E. GEE, MD, MPH,* and GEORGE R. SAADE, MDw *Departments of Obstetrics and Gynecology and Health Policy and Management, Schools of Public Health and Medicine, Louisiana State University, New Orleans, Louisiana; and w Department of Obstetrics and Gynecology, The University of Texas Medical Branch, Galveston, Texas
Foreword
This month’s series of articles focuses on ‘‘changes in obstetrics and gynecologic care.’’ There has not been a time of greater change in health care in the United States (US) for decades, and these articles are diverse and focus on a host of issues that specialists in obstetrics and gynecology will encounter in their practice. We hope they will provide a roadmap for you to help navigate your way through some of these complex issues. We begin with an article by Joanne Armstrong on the Patient Protection and Affordable Care Act (ACA). Of course this is because ACA represents the most sweeping change affecting women’s health and our profession in a generation. The goal of the legislation is to increase access to both public and private insurance, and to improve the affordability and quality of care. Many provisions of the bill have direct impact on the women’s health care services. This paper provides an overview of the bill’s provisions that have the largest impact on women’s health care and provides data on the impact of the bill to date. One of the major provisions of ACA and also one of the most politically controversial ones was the expansion of the Medicaid program. Kay Johnson, Mary Applegate, and Rebekah Gee write about the history of Medicaid and provide an overview on changes in women’s health policy at the federal level. They outline a 30-year history of advocacy for and success in achieving women and children’s health coverage expansions. Obstetricians and gynecologists serve on the front lines of women’s health care, and our active participation in providing health care services is essential to their access. Several key components of the ACA hang in the balance as states decide whether or not to expand Medicaid. The authors discuss the impact of Medicaid on women’s health. In order for health care reform to be successful, the United States must learn to deal with increasing costs and strive toward greater value. Dr Levy and Mukherjee introduce us to
Correspondence: Rebekah Gee, MD, MPH, Departments of Obstetrics and Gynecology and Health Policy and Management, Louisiana State University, New Orleans, LA. E-mail: [email protected] The authors declare that they have nothing to disclose. CLINICAL OBSTETRICS AND GYNECOLOGY
320 | www.clinicalobgyn.com
/
VOLUME 58
/
NUMBER 2
/
JUNE 2015
Foreword the Triple Aim framework by the Institute for Healthcare Improvement. The Triple Aim purpose is to improve value of care by improving access to care, systems of care delivery, and quality of care while reducing overall expenditure, basically improving health care cost-effectiveness. The US health care system, overall, and OBGYN, in particular, need to address these aims. In this very well written piece, the authors provide clear steps to accomplish these aims from the health care value chain to the ratio of quality plus service to cost, all along emphasizing patient needs and desires. Associated with the need to improve value in health care is the new focus on quality and safety. Quality improvement collaboratives have grown in scope over the past few decades and increasingly are focused on improvements in perinatal care. Judette Louis describes the contours of quality improvement collaboratives and discusses how they have been used to address quality and safety gaps. She describes national interest in maternal health collaboratives with 31 states now engaged in a statewide perinatal quality collaborative in some form. Although these efforts have demonstrated significant improvement in some areas, in other areas they have only shown promise or data remain limited on effectiveness. Departing from a global overview of health care policy, we focus on opioid dependence in pregnancy, which is of growing national concern. Elizabeth Krans and colleagues discuss the fact that pregnancy is an opportune time to identify opioid dependence, facilitate conversion to opioid maintenance treatment, and coordinate care with specialists in addiction medicine, behavioral health, and social services. They argue for the need for comprehensive and multispecialty care and stress the need for development of strong patient-provider relationships that can facilitate the ability to deliver efficient and effective health care during pregnancy.
321
An important emerging change in obstetrical clinical practice is the shift from discrete office visits as the necessary vehicle for delivering medical care to the use of group visits. Amy Picklesimer and colleagues discuss the use of group prenatal care, which has been shown to result in lower rates of preterm birth, higher rates of breastfeeding, and higher rates of participation in postpartum family planning. They discuss the cost savings that can be realized through the use of this model as well as the research gaps that remain on outcomes and best settings for group care. Several articles in this journal address some of the trends in family planning. Cori Schreiber and Sarah Traxler provide a thoughtful overview on the state of family planning and reproductive health services in the United States. They outline the literature on our understanding of contraceptive use in various populations and remind us of threats to contraceptive and abortion access. They remind us that much work remains to improve reproductive health and that the overall rate of unintended pregnancy in the United States has not changed over the past 20 years. They urge us to continue to work to prevent unplanned pregnancy and stress that these efforts should focus on access to contraception for all women, principally long-acting reversible contraceptives. Dr Block-Abraham and colleagues address the issue of Medicaid consent to sterilization form and the various requirements that should be met, including the window during pregnancy when the form should be signed. Although the original intent of these requirements was to protect vulnerable populations from coerced sterilization, the authors convince us that in the form is currently preventing access to sterilization to the same patients it was intended to protect. They provide strong ethical arguments for change in the requirements, providing specific points where the form can be improved to address the current unintended consequences. www.clinicalobgyn.com
322
Gee and Saade
Finally, Lisa Peacock and colleagues nicely cover office-based procedures in obstetrics and gynecology, a topic that is very timely as practice is progressively shifting from the hospital to the office. They cover the safety, efficacy, cost, and feasibility of these office-based procedures, with specific attention to the most commonly performed
www.clinicalobgyn.com
ones. The manuscript is a must read to anyone contemplating these procedures as it is an easy–to-follow how-to-do-it manual. We hope you enjoy reading these manuscripts and find them as practical and useful as much as we did in navigating some of the myriad changes in obstetrics and gynecology.
Changes in Obstetrics and Gynecologic Care REBEKAH E. GEE, MD, MPH,* and GEORGE R. SAADE, MDw *Departments of Obstetrics and Gynecology and Health Policy and Management, Schools of Public Health and Medicine, Louisiana State University, New Orleans, Louisiana; and w Department of Obstetrics and Gynecology, The University of Texas Medical Branch, Galveston, Texas
Foreword
This month’s series of articles focuses on ‘‘changes in obstetrics and gynecologic care.’’ There has not been a time of greater change in health care in the United States (US) for decades, and these articles are diverse and focus on a host of issues that specialists in obstetrics and gynecology will encounter in their practice. We hope they will provide a roadmap for you to help navigate your way through some of these complex issues. We begin with an article by Joanne Armstrong on the Patient Protection and Affordable Care Act (ACA). Of course this is because ACA represents the most sweeping change affecting women’s health and our profession in a generation. The goal of the legislation is to increase access to both public and private insurance, and to improve the affordability and quality of care. Many provisions of the bill have direct impact on the women’s health care services. This paper provides an overview of the bill’s provisions that have the largest impact on women’s health care and provides data on the impact of the bill to date. One of the major provisions of ACA and also one of the most politically controversial ones was the expansion of the Medicaid program. Kay Johnson, Mary Applegate, and Rebekah Gee write about the history of Medicaid and provide an overview on changes in women’s health policy at the federal level. They outline a 30-year history of advocacy for and success in achieving women and children’s health coverage expansions. Obstetricians and gynecologists serve on the front lines of women’s health care, and our active participation in providing health care services is essential to their access. Several key components of the ACA hang in the balance as states decide whether or not to expand Medicaid. The authors discuss the impact of Medicaid on women’s health. In order for health care reform to be successful, the United States must learn to deal with increasing costs and strive toward greater value. Dr Levy and Mukherjee introduce us to
Correspondence: Rebekah Gee, MD, MPH, Departments of Obstetrics and Gynecology and Health Policy and Management, Louisiana State University, New Orleans, LA. E-mail: [email protected] The authors declare that they have nothing to disclose. CLINICAL OBSTETRICS AND GYNECOLOGY
320 | www.clinicalobgyn.com
/
VOLUME 58
/
NUMBER 2
/
JUNE 2015
Foreword the Triple Aim framework by the Institute for Healthcare Improvement. The Triple Aim purpose is to improve value of care by improving access to care, systems of care delivery, and quality of care while reducing overall expenditure, basically improving health care cost-effectiveness. The US health care system, overall, and OBGYN, in particular, need to address these aims. In this very well written piece, the authors provide clear steps to accomplish these aims from the health care value chain to the ratio of quality plus service to cost, all along emphasizing patient needs and desires. Associated with the need to improve value in health care is the new focus on quality and safety. Quality improvement collaboratives have grown in scope over the past few decades and increasingly are focused on improvements in perinatal care. Judette Louis describes the contours of quality improvement collaboratives and discusses how they have been used to address quality and safety gaps. She describes national interest in maternal health collaboratives with 31 states now engaged in a statewide perinatal quality collaborative in some form. Although these efforts have demonstrated significant improvement in some areas, in other areas they have only shown promise or data remain limited on effectiveness. Departing from a global overview of health care policy, we focus on opioid dependence in pregnancy, which is of growing national concern. Elizabeth Krans and colleagues discuss the fact that pregnancy is an opportune time to identify opioid dependence, facilitate conversion to opioid maintenance treatment, and coordinate care with specialists in addiction medicine, behavioral health, and social services. They argue for the need for comprehensive and multispecialty care and stress the need for development of strong patient-provider relationships that can facilitate the ability to deliver efficient and effective health care during pregnancy.
321
An important emerging change in obstetrical clinical practice is the shift from discrete office visits as the necessary vehicle for delivering medical care to the use of group visits. Amy Picklesimer and colleagues discuss the use of group prenatal care, which has been shown to result in lower rates of preterm birth, higher rates of breastfeeding, and higher rates of participation in postpartum family planning. They discuss the cost savings that can be realized through the use of this model as well as the research gaps that remain on outcomes and best settings for group care. Several articles in this journal address some of the trends in family planning. Cori Schreiber and Sarah Traxler provide a thoughtful overview on the state of family planning and reproductive health services in the United States. They outline the literature on our understanding of contraceptive use in various populations and remind us of threats to contraceptive and abortion access. They remind us that much work remains to improve reproductive health and that the overall rate of unintended pregnancy in the United States has not changed over the past 20 years. They urge us to continue to work to prevent unplanned pregnancy and stress that these efforts should focus on access to contraception for all women, principally long-acting reversible contraceptives. Dr Block-Abraham and colleagues address the issue of Medicaid consent to sterilization form and the various requirements that should be met, including the window during pregnancy when the form should be signed. Although the original intent of these requirements was to protect vulnerable populations from coerced sterilization, the authors convince us that in the form is currently preventing access to sterilization to the same patients it was intended to protect. They provide strong ethical arguments for change in the requirements, providing specific points where the form can be improved to address the current unintended consequences. www.clinicalobgyn.com
322
Gee and Saade
Finally, Lisa Peacock and colleagues nicely cover office-based procedures in obstetrics and gynecology, a topic that is very timely as practice is progressively shifting from the hospital to the office. They cover the safety, efficacy, cost, and feasibility of these office-based procedures, with specific attention to the most commonly performed
www.clinicalobgyn.com
ones. The manuscript is a must read to anyone contemplating these procedures as it is an easy–to-follow how-to-do-it manual. We hope you enjoy reading these manuscripts and find them as practical and useful as much as we did in navigating some of the myriad changes in obstetrics and gynecology.
