Understanding Barriers, Gaps in Women’s Primary Care Quality

July 27, 2020 - Improving primary care access and quality for women will require an allover approach to providing sex-specific, sex-aware, and gender-sensitive care that is coordinated across a woman’s lifetime, according to a new report published by the Commonwealth Fund and Manatt Health.

Primary care is foundational to health and wellness, serving as a key place for patients to receive preventive screenings, early interventions, and health coaching that will ultimately keep them well in the long run.

For women, the role of primary care is enhanced. Although women see a number of specialists to attend to their normal health needs — an OBGYN, for example — primary care serves as the epicenter for all of this care.

It’s for that reason that, although primary care needs a boost for every patient, examining the barriers and gaps for women specifically is of high importance.

“Achieving the vision of comprehensive primary health care for women is critical to improving health outcomes, bending the cost curve, and promoting health equity,” the report authors said. “However, it is clear from our research that the U.S. primary health care system for women is inadequate. Health status indicators show that women in the U.S. have worse outcomes than women in other high-income countries.”

“Staggering disparities persist across women of different socioeconomic, racial, and educational backgrounds,” they continued. “People of color are less likely to receive preventive health services irrespective of income, neighborhood, comorbid illness, or insurance type, and often receive lower-quality care.”

Factors like income inequality also have an impact on women’s health and primary care, the researchers pointed out. That is not to mention the fact that many of those social determinants of health are interrelated; a woman who is part of a racial minority is also more likely to live in a low-income neighborhood of be low-income herself.

Through a literature review, interviews with industry experts, and a roundtable with payers, primary care providers, policymakers, and healthcare advocates, the researchers identified a series of barriers limiting primary care for women.

Sources of women’s health limitations largely fell into one of three buckets: policy, the primary care delivery system, and primary care utilization among women.

Education, financing, and policy

This bucket refers to the institutional challenges that can hinder primary care for women.

For example, inadequate medical education and training can keep clinicians from understanding the best way to treat the unique health needs women face. Training largely does not address gender, although gender plays a key role in disease progression — for example, how heart disease can manifest in a man compared to a woman.

Additionally, there is a lack of investment in women’s health and a lack of female leadership on health boards.

Importantly, primary care for women is weakened because women’s health, and particularly reproductive health, is heavily politicized.

Primary healthcare delivery system

High-quality primary care for women is also hampered within the actual delivery system.

Providers face time constraints, have access to inadequate clinical guidelines, and must work in siloed specialties, which fragments care across a women’s life.

Women’s primary care also comes with stigma attached and does not do a great job of addressing social determinants of health or inequity and racism.

Sex or gender bias, limited care coordination, and women’s health specialist shortages also hamper primary care for women.

Primary care utilization for women

Challenges in primary care utilization among women can largely be attributed to the social determinants of health. Many women experience language or cultural barriers with their primary care providers, or do not trust their primary care providers or healthcare in general.

Others face healthcare coverage barriers when seeking primary care. Some women do not have a regular source of primary care.

Principles for quality primary care for women

In order for key healthcare stakeholders, including patients, providers, payers, and policymakers, to begin to revamp women’s health, they must first understand the key principles to quality women’s health.

Of course, there are some principles that overlap with quality healthcare for all patients, including men. Primary care principles that are important in men’s health are also usually important in women’s health. Those principles may include:

• Accessibility, affordability, accountability
• Focus on preventive care and early intervention
• Use of performance data and seamless technology use or integration
• Leaning on integrated care models
• Health equity and cultural competency
• Appropriate financial and incentive structures
• Multidisciplinary care and care coordination
• Use of evidence-based care interventions

However, there are a handful of principles specific to women’s health that will be essential for ensuring primary care access and utilization is equitable between women and men. Those principles may include:

• Sex-specific care, or care that addresses health needs that are unique to women, like pregnancy or menopause.
• Sex-aware care, or treating healthcare ailments that are treated differently in women than they are in men.
• Gender-sensitive care, or care that is delivered in ways that account for and respect preferences common among a certain gender. That means care is also delivered in such a way that is sensitive to members of the LGBTQIA community.

Importantly, the sex-specific health needs for women will change over the course of her lifetime. A patient entering adolescence will need care specific to starting menstruation, for example, while a woman in her 40s or 50s will need more pre-menopausal care.

Strong team-based care and care coordination will be necessary to create a longitudinal care pathway for women that spans their whole lives.

“To optimally serve women of all ages and at all stages of life, the primary health care system must be comprehensive, prepared to deliver sex-specific, sex-aware, and gender-sensitive care, and adept at both managing and coordinating care for an array of health experiences,” the researchers concluded.

This report was the first of two the Commonwealth Fund published on primary care for women. The second report focused on the actionable steps healthcare industry leaders can take to address gaps and barriers in primary care for women within the next 10 years.