Payer Considerations in Women’s Reproductive Health

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Neil Minkoff, MD: Dr. Lopes, let me move on to you. We are fortunate to have someone like you on our panel who looks at things as a trained OB-GYN who has been practicing for a number of years, but also looks at things through the lens of a payer to through public health. They’re not a completely overlapping Venn diagram, but there’s enough overlap that it’s nice to get your perspective. When you think about this from your payer perspective as opposed to your OB-GYN perspective, what are the top priorities for payers when thinking about women of childbearing age?

Maria Lopes, MD, MS: In terms of priorities, fibroids are generally not a priority for most health plans. Typically, population-level payers will focus on quality metrics, which include HEDIS [Healthcare Effectiveness Data and Information Set] Medicare Star Ratings, and which focuses primarily on screening and prevention. For women, it’s mammography, colorectal screening, cervical cancer screening, and screening for osteoporosis and osteopenia. It’s also infertility, especially in states that have mandates for infertility benefits, and the cost associated with infertility and what it can mean, especially when it comes to assisted reproductive technologies.

In matters of procreation, emphasis can be placed on the prevention of caesarean sections and the prevention of premature births. But at a high level outside of childbirth, it is the prevention of testing that is linked to the US Task Force on Preventive Services. Along with this, payers lifted all restrictions on contraception. We will come back to this later.

But essentially, it’s having options. We are talking about options here in terms of alternative surgical options that meet the needs of the patient and are as individualized as the patients require. It’s not just about whether you want conservative options or not. Often it’s about what else has been tried. What is safe? What is effective? How long does a person have to take these treatments to potentially go into a menopausal state where they will be hypoestrogenic? This is all part of the considerations as a payer not only thinks about priorities, but how important the priority of some of these categories are in terms of alternative treatment options.

Transcripts edited for clarity.

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