Lucia DiVenere, MA

Real progress was achieved in 2018 in the effort to reduce the US maternal mortality rate, the highest of any developed nation and where women of color are 3 to 4 times more likely than others to die of childbirth-related causes. Importantly, the United States is the only nation other than Afghanistan and Sudan where the rate is rising.¹

In May 2019, the Centers for Disease Control and Prevention (CDC) published a Vital Signs document focused on preventable maternal deaths.² It affirmed that about 60% of the 700 pregnancy-related deaths that occur annually in the United States are preventable, and it provided important information on when and why these deaths occur.

Among the CDC findings, about:

• one-third of deaths (31%) occurred during pregnancy (before delivery)
• one-third (36%) occurred at delivery or in the week after
• one-third (33%) occurred 1 week to 1 year postpartum.

In addition, the CDC highlighted that:

• Heart disease and stroke caused more than 1 in 3 deaths (34%). Infections and severe bleeding were other leading causes of death.
• Black and American Indian/Alaska Native women were about 3 times as likely to die from a pregnancy-related cause as white women.

The American College of Obstetricians and Gynecologists (ACOG), under the leadership of President Lisa Hollier, MD, MPH (2018–2019), fully embraced the challenge and responsibility of meaningfully improving health care for every mom. In this article, I review some of the critical steps taken in 2018 and preview ACOG’s continued commitment for 2019 and beyond.

Efforts succeed: Bills are now laws of the land

ACOG and our partner organizations, including the Society for Maternal-Fetal Medicine and the March of Dimes, have long recognized the value of state-based maternal mortality review committees (MMRCs) in slowing and reversing the rate of maternal mortality. An MMRC brings together local experts to examine the causes of maternal deaths—not to find fault, but to find ways to prevent future deaths. With the right framework and support, MMRCs already are providing us with data and driving policy recommendations.

Supporting MMRCs in all states. With this in mind, ACOG helped pass and push to enactment HR 1318, the Preventing Maternal Deaths Act of 2018 (Public Law No. 115-344), a bipartisan bill designed to help develop and provide support for MMRCs in every state. The bill was introduced in the US House of Representatives by Rep. Jaime Herrera Beutler (R-WA) and Rep. Diana DeGette (D-CO) and in the US Senate by Sen. Heidi Heitkamp (D-ND) and Sen. Shelley Moore Capito (R-WV). ACOG Fellow and US Rep. Michael Burgess, MD (R-TX), also was instrumental in the bill’s success. The CDC is actively working toward implementation of this law, and grantees are expected to be announced by the end of September.

Continue to: In addition, ACOG worked with Congress...

In addition, ACOG worked with Congress to secure $50 million in federal funding to reduce maternal mortality, allocated thusly:

• $12 million to support state MMRCs
• $3 million to support the Alliance for Innovation on Maternal Health
• $23 million for State Maternal Health Innovation Program grants
• $12 million to address maternal mortality in the Healthy Start program.

As these federal congressional initiatives worked their way into law, the states actively supported MMRCs as well. As of this writing, only 3 states—North Dakota, South Dakota, and Wyoming—have not yet developed an MMRC.³

Filling the gaps in ObGyn care. Another key ACOG-sponsored bill signed into law will help bring more ObGyns into shortage areas. Sponsored by Rep. Burgess, Rep. Anna Eshoo (D-CA), and Rep. Lucille Roybal-Allard (D-CA) and by Sen. Tammy Baldwin (D-WI) and Sen. Lisa Murkowski (R-AK), the Improving Access to Maternity Care Act (Public Law No. 115-320) requires the Department of Health and Human Services to identify maternity health professional target areas for use by the National Health Service Corps to bring ObGyns to where they are most needed.

Following up on that new law, ACOG currently is working closely with the American Academy of Family Physicians (AAFP) and the National Rural Health Association (NRHA) on the unique challenges women in rural areas face in accessing maternity and other women’s health care services. In June, Dr. Hollier represented ACOG at the Rural Maternal Health forum, which was convened by the Centers for Medicare and Medicaid and sponsored by ACOG, AAFP, and NRHA.⁴ We are pursuing policies designed to increase the number of ObGyns and other physicians who choose to train in rural areas and increase the clinical use of telehealth to help connect rural physicians and patients with subspecialists in urban areas.

Projects in the works

Congress is ready to do more. Already, 5 ACOG-supported bills have been introduced, including bills that extend women’s Medicaid coverage to 12 months postpartum (consistent with coverage for babies), support state perinatal quality collaboratives, and more. This interest is augmented by the work of the recently formed congressional Black Maternal Health Caucus, focused on reducing racial disparities in health care. In July, ACOG joined 12 members of Congress in a caucus summit to partner with these important congressional allies.

ACOG is expanding support for these legislative efforts through our work with another important ally, the American Medical Association (AMA). ACOG’s delegation to the 2019 Annual Meeting of the AMA House of Delegates in June scored important policy wins, including AMA support for Medicaid coverage for women 12 months postpartum and improving access to care in rural communities.

There is momentum on Capitol Hill to take action on these important issues, and ACOG’s priority is to ensure that any legislative package complements the important work many ObGyns are already doing to improve maternal health outcomes. ACOG has an important seat at the table and will continue to advocate each and every day for your practices and your patients as Congress deliberates legislative action.

Continue to: Your voice matters...

Your voice matters

Encourage your representatives in the House and the Senate to support ACOG-endorsed legislation and be sure they know the importance of ensuring access to women’s health care in your community. Get involved in advocacy; start by visiting the ACOG advocacy web page (www.acog.org/advocacy). Also note that members of Congress are back in their home states during seasonal breaks and many hold town halls and constituent meetings. The health of moms and babies is always an important issue, and you are the expert.

ACOG’s commitment to ensuring healthy moms and babies, and ensuring that our members can continue providing high-quality care, runs through everything we do.

Acknowledgments

The author thanks ACOG former Vice President for Health Policy Barbara Levy, MD, ACOG Senior Director Jeanne Mahoney, and ACOG Federal Affairs Director Rachel Tetlow for their helpful review and comments.

Real progress was achieved in 2018 in the effort to reduce the US maternal mortality rate, the highest of any developed nation and where women of color are 3 to 4 times more likely than others to die of childbirth-related causes. Importantly, the United States is the only nation other than Afghanistan and Sudan where the rate is rising.¹

In May 2019, the Centers for Disease Control and Prevention (CDC) published a Vital Signs document focused on preventable maternal deaths.² It affirmed that about 60% of the 700 pregnancy-related deaths that occur annually in the United States are preventable, and it provided important information on when and why these deaths occur.

Among the CDC findings, about:

• one-third of deaths (31%) occurred during pregnancy (before delivery)
• one-third (36%) occurred at delivery or in the week after
• one-third (33%) occurred 1 week to 1 year postpartum.

In addition, the CDC highlighted that:

• Heart disease and stroke caused more than 1 in 3 deaths (34%). Infections and severe bleeding were other leading causes of death.
• Black and American Indian/Alaska Native women were about 3 times as likely to die from a pregnancy-related cause as white women.

The American College of Obstetricians and Gynecologists (ACOG), under the leadership of President Lisa Hollier, MD, MPH (2018–2019), fully embraced the challenge and responsibility of meaningfully improving health care for every mom. In this article, I review some of the critical steps taken in 2018 and preview ACOG’s continued commitment for 2019 and beyond.

Efforts succeed: Bills are now laws of the land

ACOG and our partner organizations, including the Society for Maternal-Fetal Medicine and the March of Dimes, have long recognized the value of state-based maternal mortality review committees (MMRCs) in slowing and reversing the rate of maternal mortality. An MMRC brings together local experts to examine the causes of maternal deaths—not to find fault, but to find ways to prevent future deaths. With the right framework and support, MMRCs already are providing us with data and driving policy recommendations.

Supporting MMRCs in all states. With this in mind, ACOG helped pass and push to enactment HR 1318, the Preventing Maternal Deaths Act of 2018 (Public Law No. 115-344), a bipartisan bill designed to help develop and provide support for MMRCs in every state. The bill was introduced in the US House of Representatives by Rep. Jaime Herrera Beutler (R-WA) and Rep. Diana DeGette (D-CO) and in the US Senate by Sen. Heidi Heitkamp (D-ND) and Sen. Shelley Moore Capito (R-WV). ACOG Fellow and US Rep. Michael Burgess, MD (R-TX), also was instrumental in the bill’s success. The CDC is actively working toward implementation of this law, and grantees are expected to be announced by the end of September.

Continue to: In addition, ACOG worked with Congress...

In addition, ACOG worked with Congress to secure $50 million in federal funding to reduce maternal mortality, allocated thusly:

• $12 million to support state MMRCs
• $3 million to support the Alliance for Innovation on Maternal Health
• $23 million for State Maternal Health Innovation Program grants
• $12 million to address maternal mortality in the Healthy Start program.

As these federal congressional initiatives worked their way into law, the states actively supported MMRCs as well. As of this writing, only 3 states—North Dakota, South Dakota, and Wyoming—have not yet developed an MMRC.³

Filling the gaps in ObGyn care. Another key ACOG-sponsored bill signed into law will help bring more ObGyns into shortage areas. Sponsored by Rep. Burgess, Rep. Anna Eshoo (D-CA), and Rep. Lucille Roybal-Allard (D-CA) and by Sen. Tammy Baldwin (D-WI) and Sen. Lisa Murkowski (R-AK), the Improving Access to Maternity Care Act (Public Law No. 115-320) requires the Department of Health and Human Services to identify maternity health professional target areas for use by the National Health Service Corps to bring ObGyns to where they are most needed.

Following up on that new law, ACOG currently is working closely with the American Academy of Family Physicians (AAFP) and the National Rural Health Association (NRHA) on the unique challenges women in rural areas face in accessing maternity and other women’s health care services. In June, Dr. Hollier represented ACOG at the Rural Maternal Health forum, which was convened by the Centers for Medicare and Medicaid and sponsored by ACOG, AAFP, and NRHA.⁴ We are pursuing policies designed to increase the number of ObGyns and other physicians who choose to train in rural areas and increase the clinical use of telehealth to help connect rural physicians and patients with subspecialists in urban areas.

Projects in the works

Congress is ready to do more. Already, 5 ACOG-supported bills have been introduced, including bills that extend women’s Medicaid coverage to 12 months postpartum (consistent with coverage for babies), support state perinatal quality collaboratives, and more. This interest is augmented by the work of the recently formed congressional Black Maternal Health Caucus, focused on reducing racial disparities in health care. In July, ACOG joined 12 members of Congress in a caucus summit to partner with these important congressional allies.

ACOG is expanding support for these legislative efforts through our work with another important ally, the American Medical Association (AMA). ACOG’s delegation to the 2019 Annual Meeting of the AMA House of Delegates in June scored important policy wins, including AMA support for Medicaid coverage for women 12 months postpartum and improving access to care in rural communities.

There is momentum on Capitol Hill to take action on these important issues, and ACOG’s priority is to ensure that any legislative package complements the important work many ObGyns are already doing to improve maternal health outcomes. ACOG has an important seat at the table and will continue to advocate each and every day for your practices and your patients as Congress deliberates legislative action.

Continue to: Your voice matters...

Your voice matters

Encourage your representatives in the House and the Senate to support ACOG-endorsed legislation and be sure they know the importance of ensuring access to women’s health care in your community. Get involved in advocacy; start by visiting the ACOG advocacy web page (www.acog.org/advocacy). Also note that members of Congress are back in their home states during seasonal breaks and many hold town halls and constituent meetings. The health of moms and babies is always an important issue, and you are the expert.

ACOG’s commitment to ensuring healthy moms and babies, and ensuring that our members can continue providing high-quality care, runs through everything we do.

Acknowledgments

The author thanks ACOG former Vice President for Health Policy Barbara Levy, MD, ACOG Senior Director Jeanne Mahoney, and ACOG Federal Affairs Director Rachel Tetlow for their helpful review and comments.

Real progress was achieved in 2018 in the effort to reduce the US maternal mortality rate, the highest of any developed nation and where women of color are 3 to 4 times more likely than others to die of childbirth-related causes. Importantly, the United States is the only nation other than Afghanistan and Sudan where the rate is rising.¹

In May 2019, the Centers for Disease Control and Prevention (CDC) published a Vital Signs document focused on preventable maternal deaths.² It affirmed that about 60% of the 700 pregnancy-related deaths that occur annually in the United States are preventable, and it provided important information on when and why these deaths occur.

Among the CDC findings, about:

• one-third of deaths (31%) occurred during pregnancy (before delivery)
• one-third (36%) occurred at delivery or in the week after
• one-third (33%) occurred 1 week to 1 year postpartum.

In addition, the CDC highlighted that:

• Heart disease and stroke caused more than 1 in 3 deaths (34%). Infections and severe bleeding were other leading causes of death.
• Black and American Indian/Alaska Native women were about 3 times as likely to die from a pregnancy-related cause as white women.

The American College of Obstetricians and Gynecologists (ACOG), under the leadership of President Lisa Hollier, MD, MPH (2018–2019), fully embraced the challenge and responsibility of meaningfully improving health care for every mom. In this article, I review some of the critical steps taken in 2018 and preview ACOG’s continued commitment for 2019 and beyond.

Efforts succeed: Bills are now laws of the land

ACOG and our partner organizations, including the Society for Maternal-Fetal Medicine and the March of Dimes, have long recognized the value of state-based maternal mortality review committees (MMRCs) in slowing and reversing the rate of maternal mortality. An MMRC brings together local experts to examine the causes of maternal deaths—not to find fault, but to find ways to prevent future deaths. With the right framework and support, MMRCs already are providing us with data and driving policy recommendations.

Supporting MMRCs in all states. With this in mind, ACOG helped pass and push to enactment HR 1318, the Preventing Maternal Deaths Act of 2018 (Public Law No. 115-344), a bipartisan bill designed to help develop and provide support for MMRCs in every state. The bill was introduced in the US House of Representatives by Rep. Jaime Herrera Beutler (R-WA) and Rep. Diana DeGette (D-CO) and in the US Senate by Sen. Heidi Heitkamp (D-ND) and Sen. Shelley Moore Capito (R-WV). ACOG Fellow and US Rep. Michael Burgess, MD (R-TX), also was instrumental in the bill’s success. The CDC is actively working toward implementation of this law, and grantees are expected to be announced by the end of September.

Continue to: In addition, ACOG worked with Congress...

In addition, ACOG worked with Congress to secure $50 million in federal funding to reduce maternal mortality, allocated thusly:

• $12 million to support state MMRCs
• $3 million to support the Alliance for Innovation on Maternal Health
• $23 million for State Maternal Health Innovation Program grants
• $12 million to address maternal mortality in the Healthy Start program.

As these federal congressional initiatives worked their way into law, the states actively supported MMRCs as well. As of this writing, only 3 states—North Dakota, South Dakota, and Wyoming—have not yet developed an MMRC.³

Filling the gaps in ObGyn care. Another key ACOG-sponsored bill signed into law will help bring more ObGyns into shortage areas. Sponsored by Rep. Burgess, Rep. Anna Eshoo (D-CA), and Rep. Lucille Roybal-Allard (D-CA) and by Sen. Tammy Baldwin (D-WI) and Sen. Lisa Murkowski (R-AK), the Improving Access to Maternity Care Act (Public Law No. 115-320) requires the Department of Health and Human Services to identify maternity health professional target areas for use by the National Health Service Corps to bring ObGyns to where they are most needed.

Following up on that new law, ACOG currently is working closely with the American Academy of Family Physicians (AAFP) and the National Rural Health Association (NRHA) on the unique challenges women in rural areas face in accessing maternity and other women’s health care services. In June, Dr. Hollier represented ACOG at the Rural Maternal Health forum, which was convened by the Centers for Medicare and Medicaid and sponsored by ACOG, AAFP, and NRHA.⁴ We are pursuing policies designed to increase the number of ObGyns and other physicians who choose to train in rural areas and increase the clinical use of telehealth to help connect rural physicians and patients with subspecialists in urban areas.

Projects in the works

Congress is ready to do more. Already, 5 ACOG-supported bills have been introduced, including bills that extend women’s Medicaid coverage to 12 months postpartum (consistent with coverage for babies), support state perinatal quality collaboratives, and more. This interest is augmented by the work of the recently formed congressional Black Maternal Health Caucus, focused on reducing racial disparities in health care. In July, ACOG joined 12 members of Congress in a caucus summit to partner with these important congressional allies.

ACOG is expanding support for these legislative efforts through our work with another important ally, the American Medical Association (AMA). ACOG’s delegation to the 2019 Annual Meeting of the AMA House of Delegates in June scored important policy wins, including AMA support for Medicaid coverage for women 12 months postpartum and improving access to care in rural communities.

There is momentum on Capitol Hill to take action on these important issues, and ACOG’s priority is to ensure that any legislative package complements the important work many ObGyns are already doing to improve maternal health outcomes. ACOG has an important seat at the table and will continue to advocate each and every day for your practices and your patients as Congress deliberates legislative action.

Continue to: Your voice matters...

Your voice matters

Encourage your representatives in the House and the Senate to support ACOG-endorsed legislation and be sure they know the importance of ensuring access to women’s health care in your community. Get involved in advocacy; start by visiting the ACOG advocacy web page (www.acog.org/advocacy). Also note that members of Congress are back in their home states during seasonal breaks and many hold town halls and constituent meetings. The health of moms and babies is always an important issue, and you are the expert.

ACOG’s commitment to ensuring healthy moms and babies, and ensuring that our members can continue providing high-quality care, runs through everything we do.

Acknowledgments

The author thanks ACOG former Vice President for Health Policy Barbara Levy, MD, ACOG Senior Director Jeanne Mahoney, and ACOG Federal Affairs Director Rachel Tetlow for their helpful review and comments.

The Affordable Care Act (ACA) was enacted on March 23, 2010. Controversies, complaints, and detractors have and continue to abound. But the ACA’s landmark women’s health gains are unmistakable. Contraceptive coverage, maternity coverage, Medicaid coverage of low-income women, coverage for individuals with preexisting conditions, and gender-neutral premiums are now a part of the fabric of our society. For most.

Many physicians and patients—many lawmakers, too—do not remember the serious problems people had with their insurance companies before the ACA. Maternity coverage was usually a free-standing rider to an insurance policy, making it very expensive. Insurance plans did not have to, and often did not, cover contraceptives, and none did without copays or deductibles. Women were routinely denied coverage if they had ever had a cesarean delivery, had once been the victim of domestic violence, or had any one of many common conditions, like diabetes. The many exclusionary conditions are so common, in fact, that one study estimated that around 52 million adults in the United States (27% of those younger than age 65 years) have preexisting conditions that would potentially make them uninsurable without the ACA’s protections.¹

Before the ACA, it also was common for women with insurance policies to find their coverage rescinded, often with no explanation, even though they paid their premiums every month. And women with serious medical conditions often saw their coverage ended midway through their course of treatment. That placed their ObGyns in a terrible situation, too.

The insurance industry as a whole was running rough-shod over its customers, and making a lot of money by creatively and routinely denying coverage and payment for care. People were often insured, but not covered. The ACA halted many of these practices, and required insurers to meet high medical loss ratios, guaranteeing that 80% of the premiums’ for individual and small market insurers (and 85% for large insurers) are returned to patients in care payments or even in checks. In fact, nearly $4 billion in premiums have been rebated to insured individuals over the last 7 years under the ACA.²

The commitment of the American College of Obstetricians and Gynecologists (ACOG) to women’s health and to our members’ ability to provide the best care has centered on preserving the critical gains of the ACA for women, improving them when we can, and making sure politicians don’t turn back the clock on women’s health. We have been busy.

In this article, we will look at what has happened to these landmark gains and promises of improved women’s health, specifically preexisting condition protections and contraceptive coverage, under a new Administration. What happens when good health care policy and political enmity collide?

Preexisting coverage protections

The 1996 Health Insurance Portability and Accountability Act (HIPAA) defines a preexisting condition exclusionas a “limitation or exclusion of benefits relating to a condition based on the fact that the condition was present before the date of enrollment for the coverage, whether or not any medical advice, diagnosis, care, or treatment was recommended or received before that date.” HIPPA prohibited employer-sponsored health plans from discriminating against individuals through denying them coverage or charging them more based on their or their family members’ health problems. The ACA expanded protections to prohibit the insurance practice of denying coverage altogether to an individual with a preexisting condition.³

Continue to: Under Congress...

Under Congress

Republicans held the majority in both chambers of the 115th Congress (2017–2018), and hoped to use their majority status to get an ACA repeal bill to the Republican President’s desk for speedy enactment. It was not easy, and they were not successful. Four major bills—the American Health Care Act, the Better Care Reconciliation Act, the Health Care Freedom Act, and the Graham-Cassidy Amendment—never made it over the finish line, with some not even making it to a vote. The Health Care Freedom Act was voted down in the Senate 51-49 when Senator John McCain came back from brain surgery to cast his famous thumbs-down vote.⁴ These bills all would have repealed or hobbled guaranteed issue, community rating, and essential health benefits of the ACA. Of all the legislative attempts to undermine the ACA, only the 2017 Tax Cuts and Jobs Act (TCJA) was signed into law, repealing the ACA individual mandate.

Handling by the courts

The TCJA gave ACA opponents their opening in court. Twenty Republican state attorneys general and governors brought suit in February 2018 (Texas v Azar), arguing that because the ACA relies on the mandate, and the mandate has been repealed, the rest of the ACA also should be struck down. A federal district judge agreed, on December 15, 2018, declaring the entire ACA unconstitutional.⁵

That decision has been limited in its practical effect so far, and maybe it was not altogether unexpected. What was unexpected was that the US Department of Justice (DOJ) refused to defend a federal law, in this case, the ACA. In June 2018, the DOJ declined to defend the individual mandate, as well as guaranteed issue, community rating, the ban on preexisting condition exclusions, and discrimination based on health status in the ACA. The DOJ at that time, however, did not agree with the plaintiffs that without the mandate the entire ACA should be struck down. It said, “There is no reason why the ACA’s particular expansion of Medicaid hinges on the individual mandate.” Later, after the December 15 ruling, the DOJ changed its position and agreed with the judge, in a two-sentence letter to the court, that the ACA should be stricken altogether—shortly after which 3 career DOJ attorneys resigned.⁶

A legal expert observed: “The DOJ’s decision not to defend the ACA breaks with the Department’s long-standing bipartisan commitment to defend federal laws if reasonable arguments can be made in their defense. Decisions not to defend federal law are exceedingly rare. It seems even rarer to change the government’s position mid-appeal in such a high-profile lawsuit that risks disrupting the entire health care system and health insurance coverage for millions of Americans.”⁷

Regulatory tactics

What a policy maker cannot do by law, he or she can try to accomplish by regulation. The Administration is using 3 regulatory routes to undercut the ACA preexisting coverage protections and market stability.

Route 1: Short-Term Limited Duration (STLD) plans. These plans were created in the ACA to provide bridge coverage for up to 3 months for individuals in between health insurance plans. These plans do not have to comply with ACA patient protections, can deny coverage for preexisting conditions, and do not cover maternity care. In 2018, the Administration moved to allow these plans to be marketed broadly and renewed for up to 3 years. Because these plans provide less coverage and often come with high deductibles, they can be marketed with lower premiums, skimming off healthier younger people who do not expect to need much care, as well as lower-income families. This destabilizes the market and leaves people insured but not covered, exactly the situation before the ACA. Seven public health and medical groups sued to challenge the Administration’s STLD regulation; the lawsuit is presently pending.

Continue to: Route 2: Association Health Plans (AHPs)...

Route 2: Association Health Plans (AHPs). The Administration also has allowed the sale of AHPs, marketed to small employers and self-employed individuals. These plans also do not have to comply with ACA consumer protections. They often do not cover maternity care or other essential benefits, and can charge women higher premiums for the same insurance. This regulation, too, resulted in litigation and a federal judge enjoined the rule, but the case is now on appeal.

Route 3: ACA Section 1332 waivers. These waivers were created in the ACA to encourage state innovation to increase access to health coverage, under certain guardrails: states must ensure coverage is at least as comprehensive as the Essential Health Benefits; cost sharing protections must be at least as affordable as under the ACA; the plan must cover at least a comparable number of its residents; and the plan must not increase the federal deficit.

The Adminstration has come under fire for approving 1332 waiver plans that do not meet these guardrails, and allow insurers to exclude coverage for individuals with preexisting conditions, as well as skirt other important ACA patient protections. In response, Seema Verma, Administrator of the Centers for Medicare & Medicaid Services, promised as recently as April 23, that the Administration will not allow any weakening of the ACA preexisting coverage guarantee.⁸ So far, however, we do not know what action this means, and not surprisingly, House Democrats, now in the majority, are waiting to see those assurances come true. Consistent polling shows that a large majority of Americans, across political parties, think preexisting coverage protections are very important.⁹

Already, the House passed HR986, to repeal the Administration’s changes to the 1332 waiver rules. The bill won only 4 Republican votes in the House and now waits a Senate vote.

The House is ready to vote on HR1010, which returns the STLD rules to the original ACA version. The Congressional Budget Office has determined that this bill will reduce the federal deficit by $8.9 billion over 10 years, in part by reestablishing a large risk pool. Lower ACA premiums would mean lower federal subsidies and small federal outlays.

Contraceptive coverage

Since 2012, the ACA has required non-grandfathered individual and group health plans to cover, with no copays or deductibles, women’s preventive services, as determined by the Health Resources and Services Administration (HRSA). HRSA asked the National Academy of Medicine (the Institute of Medicine [IOM] at the time) to develop these coverage guidelines based on clinical and scientific relevance. The IOM relied heavily on ACOG’s testimony and women’s health guidelines. The guidelines are updated every 5 years, based on extensive review by the Women’s Preventive Services Initiative, led by ACOG. By law and regulation, covered services include:

• well-woman visits
• contraceptive methods and counseling, including all methods approved for women by the FDA
• breast and cervical cancer screening
• counseling for sexually transmitted infections
• counseling and screening for HIV
• screening for gestational diabetes
• breastfeeding support, supplies, and counseling
• screening and counseling for interpersonal and domestic violence.

Continue to: The previous administration offered a narrow exemption...

The previous administration offered a narrow exemption—an accommodation—for churches, religious orders, and integrated auxiliaries (organizations with financial support primarily from churches). That accommodation was expanded in the Supreme Court’s decision in Hobby Lobby, for closely held for-profit organizations that had religious objections to covering some or all contraceptives. Under the accommodation, the entity’s insurer or third-party administrator was responsible for providing contraceptive services to the entity’s plan participants and beneficiaries.

In October 2017, the Trump administration acted to greatly expand the ability of any employer, college or university, individual, or insurer to opt out of the ACA’s contraceptive coverage requirement. You will read more about this later.

ACOG’s business case for contraception

Early in the Trump Administration, the White House released a statement saying, “Ensuring affordable, accessible, and quality healthcare is critical to improving women’s health and ensuring that it fits their priorities at any stage of life.”¹⁰ ACOG could not agree more, and we encouraged the President to accomplish this important goal by protecting the landmark women’s health gains of the ACA. Our call to the President and the US Congress was: “Don’t turn back the clock on women’s health.”

We made a business case for continued contraceptive coverage:

Contraception reduces unintended pregnancies and saves federal dollars.

• Approximately 45% of US pregnancies are unintended.¹¹
• No-copay coverage of contraception has contributed to a dramatic decline in the unintended pregnancy rate in the United States, now at a 30-year low.¹²
• When cost is not a barrier, women choose more effective forms of contraception, such as intrauterine devices and implants.¹³
• Unintended pregnancies cost approximately $12.5 billion in government expenditures in 2008.¹⁴
• Private health plans spend as much as $4.6 billion annually in costs related to unintended pregnancies.¹⁵

Contraception means healthier women and healthier families.

• Under the ACA, the uninsured rate among women ages 18 to 64 almost halved, decreasing from 19.3% to 10.8%.¹⁶
• More than 55 million women gained access to preventive services, including contraception, without a copay or a deductible.¹⁶
• Women with unintended pregnancies are more likely to delay prenatal care. Infants are at greater risk of birth defects, low birth weight, and poor mental and physical functioning in early childhood.¹⁷

Increased access to contraception helps families and improves economic security.

• Women saved $1.4 billion in out-of-pocket costs for contraception in 1 year.¹⁸
• Before the ACA, women were spending between 30% and 44% of their total out-of-pocket health costs just on birth control.¹⁹
• The ability to plan a pregnancy increases engagement of women in the workforce and improves economic stability for women and their families.²⁰

Administration expands religious exemptions to contraception coverage

Still, on October 6, 2017, the Trump Administration moved to curtail women’s access to and coverage of contraception with the Religious Exemptions and Accommodations for Coverage of Certain Preventive Services under the Affordable Care Act and Moral Exemptions and Accommodations for Coverage of Certain Preventive Services Under the Affordable Care Act. In November 2018, the Administration published a revised rule, to take effect in January 2019.²¹ The rule immediately was taken to court by more than a dozen states and, 1 month later, was subject to an injunction by the US Court of Appeals for the Ninth Circuit, blocking the rules from going into effect in those states.

Continue to: The rule vastly expands the Obama Administration’s religious accommodation...

The rule vastly expands the Obama Administration’s religious accommodation to include “nonprofit organizations, small businesses, and individuals that have nonreligious moral convictions opposing services covered by the contraceptive mandate.” The covered entities include²¹:

• churches, integrated auxiliaries, and religious orders with religious objections
• nonprofit organizations with religious or moral objections
• for-profit entities that are not publicly traded, with religious or moral objections
• for-profit entities that are publicly traded, with religious objections
• other nongovernmental employers with religious objections
• nongovernmental institutions of higher education with religious or moral objections
• individuals with religious or moral objections, with employer sponsored or individual market coverage, where the plan sponsor and/or issuer (as applicable) are willing to offer them a plan omitting contraceptive coverage to which they object
• issuers with religious or moral objections, to the extent they provide coverage to a plan sponsor or individual that is also exempt.

The Administration says women losing coverage can get contraceptives through Title X clinics or other government programs. Of course, many women losing coverage are employed, and earn above the low income (100% of the federal poverty level) eligibility requirement for Title X assistance. To address that, the Administration, through its proposed Title X regulations, broadens the definition of “low income” in that program to include women who lose their contraceptive coverage through the employer-base health insurance plan. This move further limits the ability of the Title X program to adequately care for already-qualified individuals.

The Administration’s rule also relied on major inaccuracies, which ACOG corrected.²² First, ACOG pointed out that, in fact, FDA-approved contraceptive methods are not abortifacients, countering the Administration’s contention that contraception is an abortifacient, and that contraceptives cause abortions or miscarriages. Every FDA-approved contraceptive acts before implantation, does not interfere with a pregnancy, and is not effective after a fertilized egg has implanted successfully in the uterus.²³ No credible research supports the false statement that birth control causes miscarriages.²⁴

Second, ACOG offered data proving that increased access to contraception is not associated with increased unsafe sexual behavior or increased sexual activity.^25,26 The facts are that:

• The percentage of teens who are having sex has declined significantly, by 14% for female and 22% for male teenagers, over the past 25 years.²⁷
• More women are using contraception the first time they have sex. Young women who do not use birth control at first sexual intercourse are twice as likely to become teen mothers.²⁸
• Increased access to and use of contraception has contributed to a dramatic decline in rates of adolescent pregnancy.²⁹
• School-based health centers that provide access to contraceptives are proven to increase use of contraceptives by already sexually active students, not to increase onset of sexual activity.^30,31

Third, ACOG made clear the benefits to women’s health from contraception. ACOG asserted: As with any medication, certain types of contraception may be contraindicated for patients with certain medical conditions, including high blood pressure, lupus, or a history of breast cancer.^32,33 For these and many other reasons, access to the full range of FDA-approved contraception, with no cost sharing or other barriers, is critical to women’s health. Regarding VTE, the risk among oral contraceptive users is very low. In fact, it is much lower than the risk of VTE during pregnancy or in the immediate postpartum period.³⁴

Continue to: Regarding breast cancer: there is no proven increased risk...

Regarding breast cancer: there is no proven increased risk of breast cancer among contraceptive users, particularly among those younger than age 40. For women older than 40, health care providers must consider both the risks of becoming pregnant at advanced reproductive age and the risks of continuing contraception use until menopause.³⁵

ACOG has 2 clear messages for politicians

ACOG has remained steadfast in its opposition to the Administration’s proposals to block access to contraception. ACOG expressed its strong opposition to political interference in medical care, saying “Every woman, regardless of her insurer, employer, state of residence, or income, should have affordable, seamless access to the right form of contraception for her, free from interference from her employer or politicians.”²²

ACOG’s voice has been joined by 5 other major medical associations—American Academy of Family Physicians, American Academy of Pediatrics, American Psychiatric Association, American Academy of Pediatrics, and American Osteopathic Association—together representing more than 560,000 physicians and medical students, in urging the Administration to immediately withdraw its proposals. This broad coalition unequivocally stated³⁶:

Contraception is an integral part of preventive care and a medical necessity for women during approximately 30 years of their lives. Access to no-copay contraception leads to healthier women and families. Changes to our healthcare system come with very high stakes – impacting tens of millions of our patients. Access to contraception allows women to achieve, lead and reach their full potentials, becoming key drivers of our Nation’s economic success. These rules would create a new standard whereby employers can deny their employees coverage, based on their own moral objections. This interferes in the personal health care decisions of our patients, and inappropriately inserts a patient’s employer into the physician-patient relationship. In addition, these rules open the door to moral exemptions for other essential health care, including vaccinations.

These are challenging days for women’s health policy and legislation federally, and in many states. ACOG has two clear messages for politicians: Don’t turn back the clock on women’s health, and stay out of our exam rooms.

The Affordable Care Act (ACA) was enacted on March 23, 2010. Controversies, complaints, and detractors have and continue to abound. But the ACA’s landmark women’s health gains are unmistakable. Contraceptive coverage, maternity coverage, Medicaid coverage of low-income women, coverage for individuals with preexisting conditions, and gender-neutral premiums are now a part of the fabric of our society. For most.

Many physicians and patients—many lawmakers, too—do not remember the serious problems people had with their insurance companies before the ACA. Maternity coverage was usually a free-standing rider to an insurance policy, making it very expensive. Insurance plans did not have to, and often did not, cover contraceptives, and none did without copays or deductibles. Women were routinely denied coverage if they had ever had a cesarean delivery, had once been the victim of domestic violence, or had any one of many common conditions, like diabetes. The many exclusionary conditions are so common, in fact, that one study estimated that around 52 million adults in the United States (27% of those younger than age 65 years) have preexisting conditions that would potentially make them uninsurable without the ACA’s protections.¹

Before the ACA, it also was common for women with insurance policies to find their coverage rescinded, often with no explanation, even though they paid their premiums every month. And women with serious medical conditions often saw their coverage ended midway through their course of treatment. That placed their ObGyns in a terrible situation, too.

The insurance industry as a whole was running rough-shod over its customers, and making a lot of money by creatively and routinely denying coverage and payment for care. People were often insured, but not covered. The ACA halted many of these practices, and required insurers to meet high medical loss ratios, guaranteeing that 80% of the premiums’ for individual and small market insurers (and 85% for large insurers) are returned to patients in care payments or even in checks. In fact, nearly $4 billion in premiums have been rebated to insured individuals over the last 7 years under the ACA.²

The commitment of the American College of Obstetricians and Gynecologists (ACOG) to women’s health and to our members’ ability to provide the best care has centered on preserving the critical gains of the ACA for women, improving them when we can, and making sure politicians don’t turn back the clock on women’s health. We have been busy.

In this article, we will look at what has happened to these landmark gains and promises of improved women’s health, specifically preexisting condition protections and contraceptive coverage, under a new Administration. What happens when good health care policy and political enmity collide?

Preexisting coverage protections

The 1996 Health Insurance Portability and Accountability Act (HIPAA) defines a preexisting condition exclusionas a “limitation or exclusion of benefits relating to a condition based on the fact that the condition was present before the date of enrollment for the coverage, whether or not any medical advice, diagnosis, care, or treatment was recommended or received before that date.” HIPPA prohibited employer-sponsored health plans from discriminating against individuals through denying them coverage or charging them more based on their or their family members’ health problems. The ACA expanded protections to prohibit the insurance practice of denying coverage altogether to an individual with a preexisting condition.³

Continue to: Under Congress...

Under Congress

Republicans held the majority in both chambers of the 115th Congress (2017–2018), and hoped to use their majority status to get an ACA repeal bill to the Republican President’s desk for speedy enactment. It was not easy, and they were not successful. Four major bills—the American Health Care Act, the Better Care Reconciliation Act, the Health Care Freedom Act, and the Graham-Cassidy Amendment—never made it over the finish line, with some not even making it to a vote. The Health Care Freedom Act was voted down in the Senate 51-49 when Senator John McCain came back from brain surgery to cast his famous thumbs-down vote.⁴ These bills all would have repealed or hobbled guaranteed issue, community rating, and essential health benefits of the ACA. Of all the legislative attempts to undermine the ACA, only the 2017 Tax Cuts and Jobs Act (TCJA) was signed into law, repealing the ACA individual mandate.

Handling by the courts

The TCJA gave ACA opponents their opening in court. Twenty Republican state attorneys general and governors brought suit in February 2018 (Texas v Azar), arguing that because the ACA relies on the mandate, and the mandate has been repealed, the rest of the ACA also should be struck down. A federal district judge agreed, on December 15, 2018, declaring the entire ACA unconstitutional.⁵

That decision has been limited in its practical effect so far, and maybe it was not altogether unexpected. What was unexpected was that the US Department of Justice (DOJ) refused to defend a federal law, in this case, the ACA. In June 2018, the DOJ declined to defend the individual mandate, as well as guaranteed issue, community rating, the ban on preexisting condition exclusions, and discrimination based on health status in the ACA. The DOJ at that time, however, did not agree with the plaintiffs that without the mandate the entire ACA should be struck down. It said, “There is no reason why the ACA’s particular expansion of Medicaid hinges on the individual mandate.” Later, after the December 15 ruling, the DOJ changed its position and agreed with the judge, in a two-sentence letter to the court, that the ACA should be stricken altogether—shortly after which 3 career DOJ attorneys resigned.⁶

A legal expert observed: “The DOJ’s decision not to defend the ACA breaks with the Department’s long-standing bipartisan commitment to defend federal laws if reasonable arguments can be made in their defense. Decisions not to defend federal law are exceedingly rare. It seems even rarer to change the government’s position mid-appeal in such a high-profile lawsuit that risks disrupting the entire health care system and health insurance coverage for millions of Americans.”⁷

Regulatory tactics

What a policy maker cannot do by law, he or she can try to accomplish by regulation. The Administration is using 3 regulatory routes to undercut the ACA preexisting coverage protections and market stability.

Route 1: Short-Term Limited Duration (STLD) plans. These plans were created in the ACA to provide bridge coverage for up to 3 months for individuals in between health insurance plans. These plans do not have to comply with ACA patient protections, can deny coverage for preexisting conditions, and do not cover maternity care. In 2018, the Administration moved to allow these plans to be marketed broadly and renewed for up to 3 years. Because these plans provide less coverage and often come with high deductibles, they can be marketed with lower premiums, skimming off healthier younger people who do not expect to need much care, as well as lower-income families. This destabilizes the market and leaves people insured but not covered, exactly the situation before the ACA. Seven public health and medical groups sued to challenge the Administration’s STLD regulation; the lawsuit is presently pending.

Continue to: Route 2: Association Health Plans (AHPs)...

Route 2: Association Health Plans (AHPs). The Administration also has allowed the sale of AHPs, marketed to small employers and self-employed individuals. These plans also do not have to comply with ACA consumer protections. They often do not cover maternity care or other essential benefits, and can charge women higher premiums for the same insurance. This regulation, too, resulted in litigation and a federal judge enjoined the rule, but the case is now on appeal.

Route 3: ACA Section 1332 waivers. These waivers were created in the ACA to encourage state innovation to increase access to health coverage, under certain guardrails: states must ensure coverage is at least as comprehensive as the Essential Health Benefits; cost sharing protections must be at least as affordable as under the ACA; the plan must cover at least a comparable number of its residents; and the plan must not increase the federal deficit.

The Adminstration has come under fire for approving 1332 waiver plans that do not meet these guardrails, and allow insurers to exclude coverage for individuals with preexisting conditions, as well as skirt other important ACA patient protections. In response, Seema Verma, Administrator of the Centers for Medicare & Medicaid Services, promised as recently as April 23, that the Administration will not allow any weakening of the ACA preexisting coverage guarantee.⁸ So far, however, we do not know what action this means, and not surprisingly, House Democrats, now in the majority, are waiting to see those assurances come true. Consistent polling shows that a large majority of Americans, across political parties, think preexisting coverage protections are very important.⁹

Already, the House passed HR986, to repeal the Administration’s changes to the 1332 waiver rules. The bill won only 4 Republican votes in the House and now waits a Senate vote.

The House is ready to vote on HR1010, which returns the STLD rules to the original ACA version. The Congressional Budget Office has determined that this bill will reduce the federal deficit by $8.9 billion over 10 years, in part by reestablishing a large risk pool. Lower ACA premiums would mean lower federal subsidies and small federal outlays.

Contraceptive coverage

Since 2012, the ACA has required non-grandfathered individual and group health plans to cover, with no copays or deductibles, women’s preventive services, as determined by the Health Resources and Services Administration (HRSA). HRSA asked the National Academy of Medicine (the Institute of Medicine [IOM] at the time) to develop these coverage guidelines based on clinical and scientific relevance. The IOM relied heavily on ACOG’s testimony and women’s health guidelines. The guidelines are updated every 5 years, based on extensive review by the Women’s Preventive Services Initiative, led by ACOG. By law and regulation, covered services include:

• well-woman visits
• contraceptive methods and counseling, including all methods approved for women by the FDA
• breast and cervical cancer screening
• counseling for sexually transmitted infections
• counseling and screening for HIV
• screening for gestational diabetes
• breastfeeding support, supplies, and counseling
• screening and counseling for interpersonal and domestic violence.

Continue to: The previous administration offered a narrow exemption...

The previous administration offered a narrow exemption—an accommodation—for churches, religious orders, and integrated auxiliaries (organizations with financial support primarily from churches). That accommodation was expanded in the Supreme Court’s decision in Hobby Lobby, for closely held for-profit organizations that had religious objections to covering some or all contraceptives. Under the accommodation, the entity’s insurer or third-party administrator was responsible for providing contraceptive services to the entity’s plan participants and beneficiaries.

In October 2017, the Trump administration acted to greatly expand the ability of any employer, college or university, individual, or insurer to opt out of the ACA’s contraceptive coverage requirement. You will read more about this later.

ACOG’s business case for contraception

Early in the Trump Administration, the White House released a statement saying, “Ensuring affordable, accessible, and quality healthcare is critical to improving women’s health and ensuring that it fits their priorities at any stage of life.”¹⁰ ACOG could not agree more, and we encouraged the President to accomplish this important goal by protecting the landmark women’s health gains of the ACA. Our call to the President and the US Congress was: “Don’t turn back the clock on women’s health.”

We made a business case for continued contraceptive coverage:

Contraception reduces unintended pregnancies and saves federal dollars.

• Approximately 45% of US pregnancies are unintended.¹¹
• No-copay coverage of contraception has contributed to a dramatic decline in the unintended pregnancy rate in the United States, now at a 30-year low.¹²
• When cost is not a barrier, women choose more effective forms of contraception, such as intrauterine devices and implants.¹³
• Unintended pregnancies cost approximately $12.5 billion in government expenditures in 2008.¹⁴
• Private health plans spend as much as $4.6 billion annually in costs related to unintended pregnancies.¹⁵

Contraception means healthier women and healthier families.

• Under the ACA, the uninsured rate among women ages 18 to 64 almost halved, decreasing from 19.3% to 10.8%.¹⁶
• More than 55 million women gained access to preventive services, including contraception, without a copay or a deductible.¹⁶
• Women with unintended pregnancies are more likely to delay prenatal care. Infants are at greater risk of birth defects, low birth weight, and poor mental and physical functioning in early childhood.¹⁷

Increased access to contraception helps families and improves economic security.

• Women saved $1.4 billion in out-of-pocket costs for contraception in 1 year.¹⁸
• Before the ACA, women were spending between 30% and 44% of their total out-of-pocket health costs just on birth control.¹⁹
• The ability to plan a pregnancy increases engagement of women in the workforce and improves economic stability for women and their families.²⁰

Administration expands religious exemptions to contraception coverage

Still, on October 6, 2017, the Trump Administration moved to curtail women’s access to and coverage of contraception with the Religious Exemptions and Accommodations for Coverage of Certain Preventive Services under the Affordable Care Act and Moral Exemptions and Accommodations for Coverage of Certain Preventive Services Under the Affordable Care Act. In November 2018, the Administration published a revised rule, to take effect in January 2019.²¹ The rule immediately was taken to court by more than a dozen states and, 1 month later, was subject to an injunction by the US Court of Appeals for the Ninth Circuit, blocking the rules from going into effect in those states.

Continue to: The rule vastly expands the Obama Administration’s religious accommodation...

The rule vastly expands the Obama Administration’s religious accommodation to include “nonprofit organizations, small businesses, and individuals that have nonreligious moral convictions opposing services covered by the contraceptive mandate.” The covered entities include²¹:

• churches, integrated auxiliaries, and religious orders with religious objections
• nonprofit organizations with religious or moral objections
• for-profit entities that are not publicly traded, with religious or moral objections
• for-profit entities that are publicly traded, with religious objections
• other nongovernmental employers with religious objections
• nongovernmental institutions of higher education with religious or moral objections
• individuals with religious or moral objections, with employer sponsored or individual market coverage, where the plan sponsor and/or issuer (as applicable) are willing to offer them a plan omitting contraceptive coverage to which they object
• issuers with religious or moral objections, to the extent they provide coverage to a plan sponsor or individual that is also exempt.

The Administration says women losing coverage can get contraceptives through Title X clinics or other government programs. Of course, many women losing coverage are employed, and earn above the low income (100% of the federal poverty level) eligibility requirement for Title X assistance. To address that, the Administration, through its proposed Title X regulations, broadens the definition of “low income” in that program to include women who lose their contraceptive coverage through the employer-base health insurance plan. This move further limits the ability of the Title X program to adequately care for already-qualified individuals.

The Administration’s rule also relied on major inaccuracies, which ACOG corrected.²² First, ACOG pointed out that, in fact, FDA-approved contraceptive methods are not abortifacients, countering the Administration’s contention that contraception is an abortifacient, and that contraceptives cause abortions or miscarriages. Every FDA-approved contraceptive acts before implantation, does not interfere with a pregnancy, and is not effective after a fertilized egg has implanted successfully in the uterus.²³ No credible research supports the false statement that birth control causes miscarriages.²⁴

Second, ACOG offered data proving that increased access to contraception is not associated with increased unsafe sexual behavior or increased sexual activity.^25,26 The facts are that:

• The percentage of teens who are having sex has declined significantly, by 14% for female and 22% for male teenagers, over the past 25 years.²⁷
• More women are using contraception the first time they have sex. Young women who do not use birth control at first sexual intercourse are twice as likely to become teen mothers.²⁸
• Increased access to and use of contraception has contributed to a dramatic decline in rates of adolescent pregnancy.²⁹
• School-based health centers that provide access to contraceptives are proven to increase use of contraceptives by already sexually active students, not to increase onset of sexual activity.^30,31

Third, ACOG made clear the benefits to women’s health from contraception. ACOG asserted: As with any medication, certain types of contraception may be contraindicated for patients with certain medical conditions, including high blood pressure, lupus, or a history of breast cancer.^32,33 For these and many other reasons, access to the full range of FDA-approved contraception, with no cost sharing or other barriers, is critical to women’s health. Regarding VTE, the risk among oral contraceptive users is very low. In fact, it is much lower than the risk of VTE during pregnancy or in the immediate postpartum period.³⁴

Continue to: Regarding breast cancer: there is no proven increased risk...

Regarding breast cancer: there is no proven increased risk of breast cancer among contraceptive users, particularly among those younger than age 40. For women older than 40, health care providers must consider both the risks of becoming pregnant at advanced reproductive age and the risks of continuing contraception use until menopause.³⁵

ACOG has 2 clear messages for politicians

ACOG has remained steadfast in its opposition to the Administration’s proposals to block access to contraception. ACOG expressed its strong opposition to political interference in medical care, saying “Every woman, regardless of her insurer, employer, state of residence, or income, should have affordable, seamless access to the right form of contraception for her, free from interference from her employer or politicians.”²²

ACOG’s voice has been joined by 5 other major medical associations—American Academy of Family Physicians, American Academy of Pediatrics, American Psychiatric Association, American Academy of Pediatrics, and American Osteopathic Association—together representing more than 560,000 physicians and medical students, in urging the Administration to immediately withdraw its proposals. This broad coalition unequivocally stated³⁶:

Contraception is an integral part of preventive care and a medical necessity for women during approximately 30 years of their lives. Access to no-copay contraception leads to healthier women and families. Changes to our healthcare system come with very high stakes – impacting tens of millions of our patients. Access to contraception allows women to achieve, lead and reach their full potentials, becoming key drivers of our Nation’s economic success. These rules would create a new standard whereby employers can deny their employees coverage, based on their own moral objections. This interferes in the personal health care decisions of our patients, and inappropriately inserts a patient’s employer into the physician-patient relationship. In addition, these rules open the door to moral exemptions for other essential health care, including vaccinations.

These are challenging days for women’s health policy and legislation federally, and in many states. ACOG has two clear messages for politicians: Don’t turn back the clock on women’s health, and stay out of our exam rooms.

The Affordable Care Act (ACA) was enacted on March 23, 2010. Controversies, complaints, and detractors have and continue to abound. But the ACA’s landmark women’s health gains are unmistakable. Contraceptive coverage, maternity coverage, Medicaid coverage of low-income women, coverage for individuals with preexisting conditions, and gender-neutral premiums are now a part of the fabric of our society. For most.

Many physicians and patients—many lawmakers, too—do not remember the serious problems people had with their insurance companies before the ACA. Maternity coverage was usually a free-standing rider to an insurance policy, making it very expensive. Insurance plans did not have to, and often did not, cover contraceptives, and none did without copays or deductibles. Women were routinely denied coverage if they had ever had a cesarean delivery, had once been the victim of domestic violence, or had any one of many common conditions, like diabetes. The many exclusionary conditions are so common, in fact, that one study estimated that around 52 million adults in the United States (27% of those younger than age 65 years) have preexisting conditions that would potentially make them uninsurable without the ACA’s protections.¹

Before the ACA, it also was common for women with insurance policies to find their coverage rescinded, often with no explanation, even though they paid their premiums every month. And women with serious medical conditions often saw their coverage ended midway through their course of treatment. That placed their ObGyns in a terrible situation, too.

The insurance industry as a whole was running rough-shod over its customers, and making a lot of money by creatively and routinely denying coverage and payment for care. People were often insured, but not covered. The ACA halted many of these practices, and required insurers to meet high medical loss ratios, guaranteeing that 80% of the premiums’ for individual and small market insurers (and 85% for large insurers) are returned to patients in care payments or even in checks. In fact, nearly $4 billion in premiums have been rebated to insured individuals over the last 7 years under the ACA.²

The commitment of the American College of Obstetricians and Gynecologists (ACOG) to women’s health and to our members’ ability to provide the best care has centered on preserving the critical gains of the ACA for women, improving them when we can, and making sure politicians don’t turn back the clock on women’s health. We have been busy.

In this article, we will look at what has happened to these landmark gains and promises of improved women’s health, specifically preexisting condition protections and contraceptive coverage, under a new Administration. What happens when good health care policy and political enmity collide?

Preexisting coverage protections

The 1996 Health Insurance Portability and Accountability Act (HIPAA) defines a preexisting condition exclusionas a “limitation or exclusion of benefits relating to a condition based on the fact that the condition was present before the date of enrollment for the coverage, whether or not any medical advice, diagnosis, care, or treatment was recommended or received before that date.” HIPPA prohibited employer-sponsored health plans from discriminating against individuals through denying them coverage or charging them more based on their or their family members’ health problems. The ACA expanded protections to prohibit the insurance practice of denying coverage altogether to an individual with a preexisting condition.³

Continue to: Under Congress...

Under Congress

Republicans held the majority in both chambers of the 115th Congress (2017–2018), and hoped to use their majority status to get an ACA repeal bill to the Republican President’s desk for speedy enactment. It was not easy, and they were not successful. Four major bills—the American Health Care Act, the Better Care Reconciliation Act, the Health Care Freedom Act, and the Graham-Cassidy Amendment—never made it over the finish line, with some not even making it to a vote. The Health Care Freedom Act was voted down in the Senate 51-49 when Senator John McCain came back from brain surgery to cast his famous thumbs-down vote.⁴ These bills all would have repealed or hobbled guaranteed issue, community rating, and essential health benefits of the ACA. Of all the legislative attempts to undermine the ACA, only the 2017 Tax Cuts and Jobs Act (TCJA) was signed into law, repealing the ACA individual mandate.

Handling by the courts

The TCJA gave ACA opponents their opening in court. Twenty Republican state attorneys general and governors brought suit in February 2018 (Texas v Azar), arguing that because the ACA relies on the mandate, and the mandate has been repealed, the rest of the ACA also should be struck down. A federal district judge agreed, on December 15, 2018, declaring the entire ACA unconstitutional.⁵

That decision has been limited in its practical effect so far, and maybe it was not altogether unexpected. What was unexpected was that the US Department of Justice (DOJ) refused to defend a federal law, in this case, the ACA. In June 2018, the DOJ declined to defend the individual mandate, as well as guaranteed issue, community rating, the ban on preexisting condition exclusions, and discrimination based on health status in the ACA. The DOJ at that time, however, did not agree with the plaintiffs that without the mandate the entire ACA should be struck down. It said, “There is no reason why the ACA’s particular expansion of Medicaid hinges on the individual mandate.” Later, after the December 15 ruling, the DOJ changed its position and agreed with the judge, in a two-sentence letter to the court, that the ACA should be stricken altogether—shortly after which 3 career DOJ attorneys resigned.⁶

A legal expert observed: “The DOJ’s decision not to defend the ACA breaks with the Department’s long-standing bipartisan commitment to defend federal laws if reasonable arguments can be made in their defense. Decisions not to defend federal law are exceedingly rare. It seems even rarer to change the government’s position mid-appeal in such a high-profile lawsuit that risks disrupting the entire health care system and health insurance coverage for millions of Americans.”⁷

Regulatory tactics

What a policy maker cannot do by law, he or she can try to accomplish by regulation. The Administration is using 3 regulatory routes to undercut the ACA preexisting coverage protections and market stability.

Route 1: Short-Term Limited Duration (STLD) plans. These plans were created in the ACA to provide bridge coverage for up to 3 months for individuals in between health insurance plans. These plans do not have to comply with ACA patient protections, can deny coverage for preexisting conditions, and do not cover maternity care. In 2018, the Administration moved to allow these plans to be marketed broadly and renewed for up to 3 years. Because these plans provide less coverage and often come with high deductibles, they can be marketed with lower premiums, skimming off healthier younger people who do not expect to need much care, as well as lower-income families. This destabilizes the market and leaves people insured but not covered, exactly the situation before the ACA. Seven public health and medical groups sued to challenge the Administration’s STLD regulation; the lawsuit is presently pending.

Continue to: Route 2: Association Health Plans (AHPs)...

Route 2: Association Health Plans (AHPs). The Administration also has allowed the sale of AHPs, marketed to small employers and self-employed individuals. These plans also do not have to comply with ACA consumer protections. They often do not cover maternity care or other essential benefits, and can charge women higher premiums for the same insurance. This regulation, too, resulted in litigation and a federal judge enjoined the rule, but the case is now on appeal.

Route 3: ACA Section 1332 waivers. These waivers were created in the ACA to encourage state innovation to increase access to health coverage, under certain guardrails: states must ensure coverage is at least as comprehensive as the Essential Health Benefits; cost sharing protections must be at least as affordable as under the ACA; the plan must cover at least a comparable number of its residents; and the plan must not increase the federal deficit.

The Adminstration has come under fire for approving 1332 waiver plans that do not meet these guardrails, and allow insurers to exclude coverage for individuals with preexisting conditions, as well as skirt other important ACA patient protections. In response, Seema Verma, Administrator of the Centers for Medicare & Medicaid Services, promised as recently as April 23, that the Administration will not allow any weakening of the ACA preexisting coverage guarantee.⁸ So far, however, we do not know what action this means, and not surprisingly, House Democrats, now in the majority, are waiting to see those assurances come true. Consistent polling shows that a large majority of Americans, across political parties, think preexisting coverage protections are very important.⁹

Already, the House passed HR986, to repeal the Administration’s changes to the 1332 waiver rules. The bill won only 4 Republican votes in the House and now waits a Senate vote.

The House is ready to vote on HR1010, which returns the STLD rules to the original ACA version. The Congressional Budget Office has determined that this bill will reduce the federal deficit by $8.9 billion over 10 years, in part by reestablishing a large risk pool. Lower ACA premiums would mean lower federal subsidies and small federal outlays.

Contraceptive coverage

Since 2012, the ACA has required non-grandfathered individual and group health plans to cover, with no copays or deductibles, women’s preventive services, as determined by the Health Resources and Services Administration (HRSA). HRSA asked the National Academy of Medicine (the Institute of Medicine [IOM] at the time) to develop these coverage guidelines based on clinical and scientific relevance. The IOM relied heavily on ACOG’s testimony and women’s health guidelines. The guidelines are updated every 5 years, based on extensive review by the Women’s Preventive Services Initiative, led by ACOG. By law and regulation, covered services include:

• well-woman visits
• contraceptive methods and counseling, including all methods approved for women by the FDA
• breast and cervical cancer screening
• counseling for sexually transmitted infections
• counseling and screening for HIV
• screening for gestational diabetes
• breastfeeding support, supplies, and counseling
• screening and counseling for interpersonal and domestic violence.

Continue to: The previous administration offered a narrow exemption...

The previous administration offered a narrow exemption—an accommodation—for churches, religious orders, and integrated auxiliaries (organizations with financial support primarily from churches). That accommodation was expanded in the Supreme Court’s decision in Hobby Lobby, for closely held for-profit organizations that had religious objections to covering some or all contraceptives. Under the accommodation, the entity’s insurer or third-party administrator was responsible for providing contraceptive services to the entity’s plan participants and beneficiaries.

In October 2017, the Trump administration acted to greatly expand the ability of any employer, college or university, individual, or insurer to opt out of the ACA’s contraceptive coverage requirement. You will read more about this later.

ACOG’s business case for contraception

Early in the Trump Administration, the White House released a statement saying, “Ensuring affordable, accessible, and quality healthcare is critical to improving women’s health and ensuring that it fits their priorities at any stage of life.”¹⁰ ACOG could not agree more, and we encouraged the President to accomplish this important goal by protecting the landmark women’s health gains of the ACA. Our call to the President and the US Congress was: “Don’t turn back the clock on women’s health.”

We made a business case for continued contraceptive coverage:

Contraception reduces unintended pregnancies and saves federal dollars.

• Approximately 45% of US pregnancies are unintended.¹¹
• No-copay coverage of contraception has contributed to a dramatic decline in the unintended pregnancy rate in the United States, now at a 30-year low.¹²
• When cost is not a barrier, women choose more effective forms of contraception, such as intrauterine devices and implants.¹³
• Unintended pregnancies cost approximately $12.5 billion in government expenditures in 2008.¹⁴
• Private health plans spend as much as $4.6 billion annually in costs related to unintended pregnancies.¹⁵

Contraception means healthier women and healthier families.

• Under the ACA, the uninsured rate among women ages 18 to 64 almost halved, decreasing from 19.3% to 10.8%.¹⁶
• More than 55 million women gained access to preventive services, including contraception, without a copay or a deductible.¹⁶
• Women with unintended pregnancies are more likely to delay prenatal care. Infants are at greater risk of birth defects, low birth weight, and poor mental and physical functioning in early childhood.¹⁷

Increased access to contraception helps families and improves economic security.

• Women saved $1.4 billion in out-of-pocket costs for contraception in 1 year.¹⁸
• Before the ACA, women were spending between 30% and 44% of their total out-of-pocket health costs just on birth control.¹⁹
• The ability to plan a pregnancy increases engagement of women in the workforce and improves economic stability for women and their families.²⁰

Administration expands religious exemptions to contraception coverage

Still, on October 6, 2017, the Trump Administration moved to curtail women’s access to and coverage of contraception with the Religious Exemptions and Accommodations for Coverage of Certain Preventive Services under the Affordable Care Act and Moral Exemptions and Accommodations for Coverage of Certain Preventive Services Under the Affordable Care Act. In November 2018, the Administration published a revised rule, to take effect in January 2019.²¹ The rule immediately was taken to court by more than a dozen states and, 1 month later, was subject to an injunction by the US Court of Appeals for the Ninth Circuit, blocking the rules from going into effect in those states.

Continue to: The rule vastly expands the Obama Administration’s religious accommodation...

The rule vastly expands the Obama Administration’s religious accommodation to include “nonprofit organizations, small businesses, and individuals that have nonreligious moral convictions opposing services covered by the contraceptive mandate.” The covered entities include²¹:

• churches, integrated auxiliaries, and religious orders with religious objections
• nonprofit organizations with religious or moral objections
• for-profit entities that are not publicly traded, with religious or moral objections
• for-profit entities that are publicly traded, with religious objections
• other nongovernmental employers with religious objections
• nongovernmental institutions of higher education with religious or moral objections
• individuals with religious or moral objections, with employer sponsored or individual market coverage, where the plan sponsor and/or issuer (as applicable) are willing to offer them a plan omitting contraceptive coverage to which they object
• issuers with religious or moral objections, to the extent they provide coverage to a plan sponsor or individual that is also exempt.

The Administration says women losing coverage can get contraceptives through Title X clinics or other government programs. Of course, many women losing coverage are employed, and earn above the low income (100% of the federal poverty level) eligibility requirement for Title X assistance. To address that, the Administration, through its proposed Title X regulations, broadens the definition of “low income” in that program to include women who lose their contraceptive coverage through the employer-base health insurance plan. This move further limits the ability of the Title X program to adequately care for already-qualified individuals.

The Administration’s rule also relied on major inaccuracies, which ACOG corrected.²² First, ACOG pointed out that, in fact, FDA-approved contraceptive methods are not abortifacients, countering the Administration’s contention that contraception is an abortifacient, and that contraceptives cause abortions or miscarriages. Every FDA-approved contraceptive acts before implantation, does not interfere with a pregnancy, and is not effective after a fertilized egg has implanted successfully in the uterus.²³ No credible research supports the false statement that birth control causes miscarriages.²⁴

Second, ACOG offered data proving that increased access to contraception is not associated with increased unsafe sexual behavior or increased sexual activity.^25,26 The facts are that:

• The percentage of teens who are having sex has declined significantly, by 14% for female and 22% for male teenagers, over the past 25 years.²⁷
• More women are using contraception the first time they have sex. Young women who do not use birth control at first sexual intercourse are twice as likely to become teen mothers.²⁸
• Increased access to and use of contraception has contributed to a dramatic decline in rates of adolescent pregnancy.²⁹
• School-based health centers that provide access to contraceptives are proven to increase use of contraceptives by already sexually active students, not to increase onset of sexual activity.^30,31

Third, ACOG made clear the benefits to women’s health from contraception. ACOG asserted: As with any medication, certain types of contraception may be contraindicated for patients with certain medical conditions, including high blood pressure, lupus, or a history of breast cancer.^32,33 For these and many other reasons, access to the full range of FDA-approved contraception, with no cost sharing or other barriers, is critical to women’s health. Regarding VTE, the risk among oral contraceptive users is very low. In fact, it is much lower than the risk of VTE during pregnancy or in the immediate postpartum period.³⁴

Continue to: Regarding breast cancer: there is no proven increased risk...

Regarding breast cancer: there is no proven increased risk of breast cancer among contraceptive users, particularly among those younger than age 40. For women older than 40, health care providers must consider both the risks of becoming pregnant at advanced reproductive age and the risks of continuing contraception use until menopause.³⁵

ACOG has 2 clear messages for politicians

ACOG has remained steadfast in its opposition to the Administration’s proposals to block access to contraception. ACOG expressed its strong opposition to political interference in medical care, saying “Every woman, regardless of her insurer, employer, state of residence, or income, should have affordable, seamless access to the right form of contraception for her, free from interference from her employer or politicians.”²²

ACOG’s voice has been joined by 5 other major medical associations—American Academy of Family Physicians, American Academy of Pediatrics, American Psychiatric Association, American Academy of Pediatrics, and American Osteopathic Association—together representing more than 560,000 physicians and medical students, in urging the Administration to immediately withdraw its proposals. This broad coalition unequivocally stated³⁶:

Contraception is an integral part of preventive care and a medical necessity for women during approximately 30 years of their lives. Access to no-copay contraception leads to healthier women and families. Changes to our healthcare system come with very high stakes – impacting tens of millions of our patients. Access to contraception allows women to achieve, lead and reach their full potentials, becoming key drivers of our Nation’s economic success. These rules would create a new standard whereby employers can deny their employees coverage, based on their own moral objections. This interferes in the personal health care decisions of our patients, and inappropriately inserts a patient’s employer into the physician-patient relationship. In addition, these rules open the door to moral exemptions for other essential health care, including vaccinations.

These are challenging days for women’s health policy and legislation federally, and in many states. ACOG has two clear messages for politicians: Don’t turn back the clock on women’s health, and stay out of our exam rooms.

Illustration: Paul Zwolak for OBG Management

The American Board of Medical Specialties (ABMS) has decided to trade the phrase “maintenance of certification” (MOC) for “continuing board certification,” a seemingly minor change that has an important backstory. This is the story of how the physician community flexed its collective muscle and how the American College of Obstetricians and Gynecologists (ACOG) helped broker an important détente and pathway in a highly contentious issue.

Founded in 1933 as a nonprofit organization dedicated to maintaining high uniform standards among physicians, the ABMS and many of its specialty boards have found themselves, for more than a decade, under heavy fire from physicians (especially family physicians, internists, and surgeons), their 24 subspecialties, and the state medical societies representing them.

The ObGyn experience with the American Board of Obstetrics and Gynecology (ABOG), however, is better for a number of reasons. Historically, ABOG and ACOG have worked closely together, which is an anomaly among boards as many boards have an arms-length or even an antagonistic relationship with their specialty society.

The discussion below outlines physician concerns with the ABMS and related boards and describes efforts to address and rebuild the continuing board certification process.

Direct and indirect costs

Physicians are very concerned with the costs involved in MOC. Measurable costs include testing fees, while indirect costs include time, stress, travel to test centers, and threats to livelihood for failing a high-stakes examination. Physicians want the high-stakes exam eliminated.

Relevance to practice

Physicians often feel that the MOC has little relevance to their practice, which fuels a sense of resentment toward boards that they believe are dominated by physicians who no longer practice. Subspecialists feel farther away from general practice and the base exams. Generalists feel that the exams miss the points of their daily practice.

Lack of data to show improved quality of care

Physicians want to know that the MOC is worth their time, effort, and money because it improves patient care. To date, however, empirical or clinical data on patient outcomes are absent or ambiguous; most studies lack high-level data or do not investigate the MOC requirements. Physicians want to know what the best MOC practices are, what improves care, and that practices that make no difference will be discarded. In addition, they want timely knowledge alerts when evidence changes.

Relationship to licensing, employment, privileging, credentialing, and reimbursement

Hospitals, insurers, and states increasingly—and inappropriately—use board certification as the primary (sometimes only) default measure of a physician’s fitness for patient care. Physicians without board certification often are denied hospital privileges, inclusion in insurance panels, and even medical licenses. This changes certification from a voluntary physician self-improvement exercise into a can’t-earn-a-living-without-it cudgel.

Variation

Boards vary significantly in their MOC requirements and costs. The importance of an equal standard across all boards is a clear theme among physician concerns.

Role and authority of the ABMS and related boards

Many physicians are frustrated with the perceived autocratic nature of their boards—boards that lack transparency, do not solicit or allow input from practicing physicians, and are unresponsive to physician concerns.

According to Susan Ramin, MD, ABOG Associate Executive Director, ABOG is leading in a number of these areas, including:

• rapidly disseminating clinical information on emerging topics, such as Zika virus infection and opioid misuse
• offering physician choice of testing categories
• exempting high scorers from the secured written exam, which saved physicians a total of $881,000 in exam fees
• crediting physicians for what they already are doing, including serving on maternal mortality review committees, participating in registries, and participating in the Alliance for Innovation on Maternal Health (AIM)
• providing Lifelong Learning and Self-Assessment (LLSA) articles that, according to 90% of diplomates surveyed, are beneficial to their clinical practice (FIGURE).^1,2

Our colleague physicians are not so lucky. In a 2015 New England Journal of Medicine Perspective, one physician called out the American Board of Internal Medicine as “a private, self-appointed certifying organization,” a not-for-profit organization that has “grown into a $55-million-per-year business.”³ He concluded that “many physicians are waking up to the fact that our profession is increasingly controlled by people not directly involved in patient care who have lost contact with the realities of day-to-day clinical practice.”³

State and society responses to MOC requirements

Frustration with an inability to resolve these concerns has grown steadily, bubbling over into state governments. The American Medical Association developed “model state legislation intended to prohibit hospitals, health care insurers, and state boards of medicine and osteopathic medicine from requiring participation in MOC processes as a condition of credentialing, privileging, insurance panel participation, licensure, or licensure renewal.”⁴

Some states are proposing or have enacted legislation that prohibits the use of MOC as a criterion for licensure, privileging, employment, reimbursement, and/or insurance panel participation. Eight states (Arizona, Georgia, Kentucky, Maryland, Maine, Missouri, Oklahoma, Tennessee) have enacted laws to prohibit the use of MOC for initial and renewal licensure decisions. Many states are actively considering MOC-related legislation, including Alaska, Florida, Iowa, Indiana, Maryland, Massachusetts, Michigan, Missouri, New Hampshire, New York, Ohio, Oklahoma, Rhode Island, South Carolina, Tennessee, Utah, Washington, and Wisconsin.

Legislation is not the only outlet for physician frustration. Some medical specialty societies are considering dropping board certification as a membership requirement; physicians are exploring developing alternative boards; and some physicians are defying the board certification requirement altogether, with thousands signing anti-MOC petitions.

ACOG asserts importance of maintaining self-regulation

While other specialties are actively advocating state legislation, ACOG and ABOG have worked together to oppose state legislation, believing that physician self-regulation is paramount. In fact, in 2017, ACOG and ABOG issued a joint statement urging state lawmakers to “not interfere with our decades of successful self-regulation and to realize that each medical society has its own experience with its MOC program.”⁵

Negotiations lead to new initiative

This brings us to an interesting situation. ACOG’s Executive Vice President and CEO Hal Lawrence III, MD, was tapped (in his position as Chair of the Specialty Society CEO Consortium) to represent physician specialties in negotiations and discussions with the boards, which were represented by Lois Nora, MD, JD, President and CEO of the ABMS, and state medical societies, represented by Donald Palmisano Jr, JD, Executive Director and CEO of the Medical Association of Georgia. Many state medical societies, boards, and physician specialty organizations participated in these meetings.

Throughout months of debate, Dr. Lawrence urged his colleagues to stay at the table and do the hard work of reaching an agreement, rather than ask politicians to solve medicine’s problems. This approach was leveraged by the serious efforts and threats of state legislation, which brought the boards to the table. In August 2017, 41 state medical societies and 33 national medical specialty societies wrote to Dr. Nora expressing their concerns that “professional self-regulation is under attack. Concerns regarding the usefulness of the high-stakes exam, the exorbitant costs of the MOC process, and the lack of transparent communication from the certifying boards have led to damaging the MOC brand, and creating state-based attacks on the MOC process.”⁶

In December 2017, Dr. Lawrence and Mr. Palmisano led a meeting of principals from the national medical specialty societies and state medical societies with leaders of ABMS and 8 specialty boards, including ABOG, an opportunity to secure meaningful change. Dr. Lawrence began by stressing that the interests of physicians and patients would be best served by all parties coming together and collaborating on a meaningful solution, to repair trust and preserve physician self-regulation.

Dr. Ramin presented ABOG’s approach to continuous certification, lifelong learning, and self-assessment. The American Board of Urology and the American Board of Psychiatry and Neurology indicated that they were basing important changes in their MOC process on ABOG’s work, including using 5 modules (1 general and 4 specific to the physician’s practice) and multiple open-book mini-exams based on selected journal articles as an alternative to the 10-year MOC exam.

The Vision Initiative. At that meeting and others, the ABMS and other boards heard physicians’ candid and sometimes blunt concerns. Dr. Nora spoke to the recently announced Continuing Board Certification: Vision for the Future program, also known as the “Vision Initiative,” a process designed to fundamentally rebuild the continuing certification process with input and guidance from practicing physicians. Physician response seemed uniform: Seeing is believing.

Importantly, all participants at the December meeting agreed to work together to rebuild trust and ensure professionalism and professional self-regulation, reflected in this Statement of Shared Purpose:

ABMS certifying boards and national medical specialty societies will collaborate to resolve differences in the process of ongoing certification and to fulfill the principles of professional self-regulation, achieving appropriate standardization, and assuring that ongoing certification is relevant to the practices of physicians without undue burden. Furthermore, the boards and societies, and their organizations (ABMS and CMSS [Council of Medical Specialty Societies]), will undertake necessary changes in a timely manner, and will commit to ongoing communication with state medical associations to solicit their input.⁴

Two ObGyns participating in the Vision Initiative are Haywood Brown, MD, ACOG’s Immediate Past President, and George Wendel, MD, ABOG’s Executive Director. The Vision Initiative is composed of 3 parts. Part 1, Organization, is complete. The committee is currently working on part 2, Envisioning the Future, an information-gathering component that includes physician surveys, hearings, open solicited input, and identifying new and better approaches. After the final report is delivered to the ABMS in February 2019, part 3, Implementation, will begin.

Make your voice heard

---

The Vision Initiative offers physicians an important opportunity to help shape the future of continuing education and certification. ObGyns and other physicians should consider reviewing and commenting on the draft report, due in November, during the public comment period. Visit https://visioninitiative.org for more information and to sign up for email updates.

Share your thoughts! Send your Letter to the Editor to [email protected]. Please include your name and the city and state in which you practice.

Illustration: Paul Zwolak for OBG Management

The American Board of Medical Specialties (ABMS) has decided to trade the phrase “maintenance of certification” (MOC) for “continuing board certification,” a seemingly minor change that has an important backstory. This is the story of how the physician community flexed its collective muscle and how the American College of Obstetricians and Gynecologists (ACOG) helped broker an important détente and pathway in a highly contentious issue.

Founded in 1933 as a nonprofit organization dedicated to maintaining high uniform standards among physicians, the ABMS and many of its specialty boards have found themselves, for more than a decade, under heavy fire from physicians (especially family physicians, internists, and surgeons), their 24 subspecialties, and the state medical societies representing them.

The ObGyn experience with the American Board of Obstetrics and Gynecology (ABOG), however, is better for a number of reasons. Historically, ABOG and ACOG have worked closely together, which is an anomaly among boards as many boards have an arms-length or even an antagonistic relationship with their specialty society.

The discussion below outlines physician concerns with the ABMS and related boards and describes efforts to address and rebuild the continuing board certification process.

Direct and indirect costs

Physicians are very concerned with the costs involved in MOC. Measurable costs include testing fees, while indirect costs include time, stress, travel to test centers, and threats to livelihood for failing a high-stakes examination. Physicians want the high-stakes exam eliminated.

Relevance to practice

Physicians often feel that the MOC has little relevance to their practice, which fuels a sense of resentment toward boards that they believe are dominated by physicians who no longer practice. Subspecialists feel farther away from general practice and the base exams. Generalists feel that the exams miss the points of their daily practice.

Lack of data to show improved quality of care

Physicians want to know that the MOC is worth their time, effort, and money because it improves patient care. To date, however, empirical or clinical data on patient outcomes are absent or ambiguous; most studies lack high-level data or do not investigate the MOC requirements. Physicians want to know what the best MOC practices are, what improves care, and that practices that make no difference will be discarded. In addition, they want timely knowledge alerts when evidence changes.

Relationship to licensing, employment, privileging, credentialing, and reimbursement

Hospitals, insurers, and states increasingly—and inappropriately—use board certification as the primary (sometimes only) default measure of a physician’s fitness for patient care. Physicians without board certification often are denied hospital privileges, inclusion in insurance panels, and even medical licenses. This changes certification from a voluntary physician self-improvement exercise into a can’t-earn-a-living-without-it cudgel.

Variation

Boards vary significantly in their MOC requirements and costs. The importance of an equal standard across all boards is a clear theme among physician concerns.

Role and authority of the ABMS and related boards

Many physicians are frustrated with the perceived autocratic nature of their boards—boards that lack transparency, do not solicit or allow input from practicing physicians, and are unresponsive to physician concerns.

According to Susan Ramin, MD, ABOG Associate Executive Director, ABOG is leading in a number of these areas, including:

• rapidly disseminating clinical information on emerging topics, such as Zika virus infection and opioid misuse
• offering physician choice of testing categories
• exempting high scorers from the secured written exam, which saved physicians a total of $881,000 in exam fees
• crediting physicians for what they already are doing, including serving on maternal mortality review committees, participating in registries, and participating in the Alliance for Innovation on Maternal Health (AIM)
• providing Lifelong Learning and Self-Assessment (LLSA) articles that, according to 90% of diplomates surveyed, are beneficial to their clinical practice (FIGURE).^1,2

Our colleague physicians are not so lucky. In a 2015 New England Journal of Medicine Perspective, one physician called out the American Board of Internal Medicine as “a private, self-appointed certifying organization,” a not-for-profit organization that has “grown into a $55-million-per-year business.”³ He concluded that “many physicians are waking up to the fact that our profession is increasingly controlled by people not directly involved in patient care who have lost contact with the realities of day-to-day clinical practice.”³

State and society responses to MOC requirements

Frustration with an inability to resolve these concerns has grown steadily, bubbling over into state governments. The American Medical Association developed “model state legislation intended to prohibit hospitals, health care insurers, and state boards of medicine and osteopathic medicine from requiring participation in MOC processes as a condition of credentialing, privileging, insurance panel participation, licensure, or licensure renewal.”⁴

Some states are proposing or have enacted legislation that prohibits the use of MOC as a criterion for licensure, privileging, employment, reimbursement, and/or insurance panel participation. Eight states (Arizona, Georgia, Kentucky, Maryland, Maine, Missouri, Oklahoma, Tennessee) have enacted laws to prohibit the use of MOC for initial and renewal licensure decisions. Many states are actively considering MOC-related legislation, including Alaska, Florida, Iowa, Indiana, Maryland, Massachusetts, Michigan, Missouri, New Hampshire, New York, Ohio, Oklahoma, Rhode Island, South Carolina, Tennessee, Utah, Washington, and Wisconsin.

Legislation is not the only outlet for physician frustration. Some medical specialty societies are considering dropping board certification as a membership requirement; physicians are exploring developing alternative boards; and some physicians are defying the board certification requirement altogether, with thousands signing anti-MOC petitions.

ACOG asserts importance of maintaining self-regulation

While other specialties are actively advocating state legislation, ACOG and ABOG have worked together to oppose state legislation, believing that physician self-regulation is paramount. In fact, in 2017, ACOG and ABOG issued a joint statement urging state lawmakers to “not interfere with our decades of successful self-regulation and to realize that each medical society has its own experience with its MOC program.”⁵

Negotiations lead to new initiative

This brings us to an interesting situation. ACOG’s Executive Vice President and CEO Hal Lawrence III, MD, was tapped (in his position as Chair of the Specialty Society CEO Consortium) to represent physician specialties in negotiations and discussions with the boards, which were represented by Lois Nora, MD, JD, President and CEO of the ABMS, and state medical societies, represented by Donald Palmisano Jr, JD, Executive Director and CEO of the Medical Association of Georgia. Many state medical societies, boards, and physician specialty organizations participated in these meetings.

Throughout months of debate, Dr. Lawrence urged his colleagues to stay at the table and do the hard work of reaching an agreement, rather than ask politicians to solve medicine’s problems. This approach was leveraged by the serious efforts and threats of state legislation, which brought the boards to the table. In August 2017, 41 state medical societies and 33 national medical specialty societies wrote to Dr. Nora expressing their concerns that “professional self-regulation is under attack. Concerns regarding the usefulness of the high-stakes exam, the exorbitant costs of the MOC process, and the lack of transparent communication from the certifying boards have led to damaging the MOC brand, and creating state-based attacks on the MOC process.”⁶

In December 2017, Dr. Lawrence and Mr. Palmisano led a meeting of principals from the national medical specialty societies and state medical societies with leaders of ABMS and 8 specialty boards, including ABOG, an opportunity to secure meaningful change. Dr. Lawrence began by stressing that the interests of physicians and patients would be best served by all parties coming together and collaborating on a meaningful solution, to repair trust and preserve physician self-regulation.

Dr. Ramin presented ABOG’s approach to continuous certification, lifelong learning, and self-assessment. The American Board of Urology and the American Board of Psychiatry and Neurology indicated that they were basing important changes in their MOC process on ABOG’s work, including using 5 modules (1 general and 4 specific to the physician’s practice) and multiple open-book mini-exams based on selected journal articles as an alternative to the 10-year MOC exam.

The Vision Initiative. At that meeting and others, the ABMS and other boards heard physicians’ candid and sometimes blunt concerns. Dr. Nora spoke to the recently announced Continuing Board Certification: Vision for the Future program, also known as the “Vision Initiative,” a process designed to fundamentally rebuild the continuing certification process with input and guidance from practicing physicians. Physician response seemed uniform: Seeing is believing.

Importantly, all participants at the December meeting agreed to work together to rebuild trust and ensure professionalism and professional self-regulation, reflected in this Statement of Shared Purpose:

ABMS certifying boards and national medical specialty societies will collaborate to resolve differences in the process of ongoing certification and to fulfill the principles of professional self-regulation, achieving appropriate standardization, and assuring that ongoing certification is relevant to the practices of physicians without undue burden. Furthermore, the boards and societies, and their organizations (ABMS and CMSS [Council of Medical Specialty Societies]), will undertake necessary changes in a timely manner, and will commit to ongoing communication with state medical associations to solicit their input.⁴

Two ObGyns participating in the Vision Initiative are Haywood Brown, MD, ACOG’s Immediate Past President, and George Wendel, MD, ABOG’s Executive Director. The Vision Initiative is composed of 3 parts. Part 1, Organization, is complete. The committee is currently working on part 2, Envisioning the Future, an information-gathering component that includes physician surveys, hearings, open solicited input, and identifying new and better approaches. After the final report is delivered to the ABMS in February 2019, part 3, Implementation, will begin.

Make your voice heard

---

The Vision Initiative offers physicians an important opportunity to help shape the future of continuing education and certification. ObGyns and other physicians should consider reviewing and commenting on the draft report, due in November, during the public comment period. Visit https://visioninitiative.org for more information and to sign up for email updates.

Share your thoughts! Send your Letter to the Editor to [email protected]. Please include your name and the city and state in which you practice.

Illustration: Paul Zwolak for OBG Management

The American Board of Medical Specialties (ABMS) has decided to trade the phrase “maintenance of certification” (MOC) for “continuing board certification,” a seemingly minor change that has an important backstory. This is the story of how the physician community flexed its collective muscle and how the American College of Obstetricians and Gynecologists (ACOG) helped broker an important détente and pathway in a highly contentious issue.

Founded in 1933 as a nonprofit organization dedicated to maintaining high uniform standards among physicians, the ABMS and many of its specialty boards have found themselves, for more than a decade, under heavy fire from physicians (especially family physicians, internists, and surgeons), their 24 subspecialties, and the state medical societies representing them.

The ObGyn experience with the American Board of Obstetrics and Gynecology (ABOG), however, is better for a number of reasons. Historically, ABOG and ACOG have worked closely together, which is an anomaly among boards as many boards have an arms-length or even an antagonistic relationship with their specialty society.

The discussion below outlines physician concerns with the ABMS and related boards and describes efforts to address and rebuild the continuing board certification process.

Direct and indirect costs

Physicians are very concerned with the costs involved in MOC. Measurable costs include testing fees, while indirect costs include time, stress, travel to test centers, and threats to livelihood for failing a high-stakes examination. Physicians want the high-stakes exam eliminated.

Relevance to practice

Physicians often feel that the MOC has little relevance to their practice, which fuels a sense of resentment toward boards that they believe are dominated by physicians who no longer practice. Subspecialists feel farther away from general practice and the base exams. Generalists feel that the exams miss the points of their daily practice.

Lack of data to show improved quality of care

Physicians want to know that the MOC is worth their time, effort, and money because it improves patient care. To date, however, empirical or clinical data on patient outcomes are absent or ambiguous; most studies lack high-level data or do not investigate the MOC requirements. Physicians want to know what the best MOC practices are, what improves care, and that practices that make no difference will be discarded. In addition, they want timely knowledge alerts when evidence changes.

Relationship to licensing, employment, privileging, credentialing, and reimbursement

Hospitals, insurers, and states increasingly—and inappropriately—use board certification as the primary (sometimes only) default measure of a physician’s fitness for patient care. Physicians without board certification often are denied hospital privileges, inclusion in insurance panels, and even medical licenses. This changes certification from a voluntary physician self-improvement exercise into a can’t-earn-a-living-without-it cudgel.

Variation

Boards vary significantly in their MOC requirements and costs. The importance of an equal standard across all boards is a clear theme among physician concerns.

Role and authority of the ABMS and related boards

Many physicians are frustrated with the perceived autocratic nature of their boards—boards that lack transparency, do not solicit or allow input from practicing physicians, and are unresponsive to physician concerns.

According to Susan Ramin, MD, ABOG Associate Executive Director, ABOG is leading in a number of these areas, including:

• rapidly disseminating clinical information on emerging topics, such as Zika virus infection and opioid misuse
• offering physician choice of testing categories
• exempting high scorers from the secured written exam, which saved physicians a total of $881,000 in exam fees
• crediting physicians for what they already are doing, including serving on maternal mortality review committees, participating in registries, and participating in the Alliance for Innovation on Maternal Health (AIM)
• providing Lifelong Learning and Self-Assessment (LLSA) articles that, according to 90% of diplomates surveyed, are beneficial to their clinical practice (FIGURE).^1,2

Our colleague physicians are not so lucky. In a 2015 New England Journal of Medicine Perspective, one physician called out the American Board of Internal Medicine as “a private, self-appointed certifying organization,” a not-for-profit organization that has “grown into a $55-million-per-year business.”³ He concluded that “many physicians are waking up to the fact that our profession is increasingly controlled by people not directly involved in patient care who have lost contact with the realities of day-to-day clinical practice.”³

State and society responses to MOC requirements

Frustration with an inability to resolve these concerns has grown steadily, bubbling over into state governments. The American Medical Association developed “model state legislation intended to prohibit hospitals, health care insurers, and state boards of medicine and osteopathic medicine from requiring participation in MOC processes as a condition of credentialing, privileging, insurance panel participation, licensure, or licensure renewal.”⁴

Some states are proposing or have enacted legislation that prohibits the use of MOC as a criterion for licensure, privileging, employment, reimbursement, and/or insurance panel participation. Eight states (Arizona, Georgia, Kentucky, Maryland, Maine, Missouri, Oklahoma, Tennessee) have enacted laws to prohibit the use of MOC for initial and renewal licensure decisions. Many states are actively considering MOC-related legislation, including Alaska, Florida, Iowa, Indiana, Maryland, Massachusetts, Michigan, Missouri, New Hampshire, New York, Ohio, Oklahoma, Rhode Island, South Carolina, Tennessee, Utah, Washington, and Wisconsin.

Legislation is not the only outlet for physician frustration. Some medical specialty societies are considering dropping board certification as a membership requirement; physicians are exploring developing alternative boards; and some physicians are defying the board certification requirement altogether, with thousands signing anti-MOC petitions.

ACOG asserts importance of maintaining self-regulation

While other specialties are actively advocating state legislation, ACOG and ABOG have worked together to oppose state legislation, believing that physician self-regulation is paramount. In fact, in 2017, ACOG and ABOG issued a joint statement urging state lawmakers to “not interfere with our decades of successful self-regulation and to realize that each medical society has its own experience with its MOC program.”⁵

Negotiations lead to new initiative

This brings us to an interesting situation. ACOG’s Executive Vice President and CEO Hal Lawrence III, MD, was tapped (in his position as Chair of the Specialty Society CEO Consortium) to represent physician specialties in negotiations and discussions with the boards, which were represented by Lois Nora, MD, JD, President and CEO of the ABMS, and state medical societies, represented by Donald Palmisano Jr, JD, Executive Director and CEO of the Medical Association of Georgia. Many state medical societies, boards, and physician specialty organizations participated in these meetings.

Throughout months of debate, Dr. Lawrence urged his colleagues to stay at the table and do the hard work of reaching an agreement, rather than ask politicians to solve medicine’s problems. This approach was leveraged by the serious efforts and threats of state legislation, which brought the boards to the table. In August 2017, 41 state medical societies and 33 national medical specialty societies wrote to Dr. Nora expressing their concerns that “professional self-regulation is under attack. Concerns regarding the usefulness of the high-stakes exam, the exorbitant costs of the MOC process, and the lack of transparent communication from the certifying boards have led to damaging the MOC brand, and creating state-based attacks on the MOC process.”⁶

In December 2017, Dr. Lawrence and Mr. Palmisano led a meeting of principals from the national medical specialty societies and state medical societies with leaders of ABMS and 8 specialty boards, including ABOG, an opportunity to secure meaningful change. Dr. Lawrence began by stressing that the interests of physicians and patients would be best served by all parties coming together and collaborating on a meaningful solution, to repair trust and preserve physician self-regulation.

Dr. Ramin presented ABOG’s approach to continuous certification, lifelong learning, and self-assessment. The American Board of Urology and the American Board of Psychiatry and Neurology indicated that they were basing important changes in their MOC process on ABOG’s work, including using 5 modules (1 general and 4 specific to the physician’s practice) and multiple open-book mini-exams based on selected journal articles as an alternative to the 10-year MOC exam.

The Vision Initiative. At that meeting and others, the ABMS and other boards heard physicians’ candid and sometimes blunt concerns. Dr. Nora spoke to the recently announced Continuing Board Certification: Vision for the Future program, also known as the “Vision Initiative,” a process designed to fundamentally rebuild the continuing certification process with input and guidance from practicing physicians. Physician response seemed uniform: Seeing is believing.

Importantly, all participants at the December meeting agreed to work together to rebuild trust and ensure professionalism and professional self-regulation, reflected in this Statement of Shared Purpose:

ABMS certifying boards and national medical specialty societies will collaborate to resolve differences in the process of ongoing certification and to fulfill the principles of professional self-regulation, achieving appropriate standardization, and assuring that ongoing certification is relevant to the practices of physicians without undue burden. Furthermore, the boards and societies, and their organizations (ABMS and CMSS [Council of Medical Specialty Societies]), will undertake necessary changes in a timely manner, and will commit to ongoing communication with state medical associations to solicit their input.⁴

Two ObGyns participating in the Vision Initiative are Haywood Brown, MD, ACOG’s Immediate Past President, and George Wendel, MD, ABOG’s Executive Director. The Vision Initiative is composed of 3 parts. Part 1, Organization, is complete. The committee is currently working on part 2, Envisioning the Future, an information-gathering component that includes physician surveys, hearings, open solicited input, and identifying new and better approaches. After the final report is delivered to the ABMS in February 2019, part 3, Implementation, will begin.

Make your voice heard

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The Vision Initiative offers physicians an important opportunity to help shape the future of continuing education and certification. ObGyns and other physicians should consider reviewing and commenting on the draft report, due in November, during the public comment period. Visit https://visioninitiative.org for more information and to sign up for email updates.

Share your thoughts! Send your Letter to the Editor to [email protected]. Please include your name and the city and state in which you practice.

More women die from pregnancy complications in the United States than in any other developed country. The United States is the only industrialized nation with a rising maternal mortality rate.

Those 2 sentences should stop us all in our tracks.

In fact, the United States ranks 47th globally with the worst maternal mortality rate. More than half these deaths are likely preventable, with suicide and drug overdose the leading causes of maternal death in many states. All this occurs despite our advanced medical system, premier medical colleges and universities, embrace of high-tech medical advances, and high percentage of gross domestic product spent on health care.

Need more numbers? According to a 2016 report in Obstetrics and Gynecology, the United States saw a 26% increase in the maternalmortality rate (unadjusted) in only 15 years: from 18.8 deaths per 100,000 live births in 2000 to 23.8 in 2014 (FIGURE 1).¹

Considerable variations by race and by state

The racial disparities in maternal mortality are staggering and have not improved in more than 20 years: African American women are 3.4 times more likely to die than non-Hispanic white women of pregnancy-related complications. In 2011–2013, the maternal mortality ratio for non-Hispanic white women was 12.7 deaths per 100,000 live births compared with 43.5 deaths for non-Hispanic black women (FIGURE 2).² American Indian or Alaska Native women, Asian women, and some Latina women also experience higher rates than non-Hispanic white women. The rate for American Indian or Alaska Native women is 16.9 deaths per 100,000 live births.³

Some states are doing better than others, showing that there is nothing inevitable about the maternal mortality crisis. Texas, for example, has seen the highest rate of maternal mortality increase. Its rate doubled from 2010 to 2012, while California reduced its maternal death rate by 30%, from 21.5 to 15.1, during roughly the same period.¹

This is a challenge of epic proportions, and one that the American College of Obstetricians and Gynecologists (ACOG), under the leadership of President Haywood Brown, MD, and Incoming President Lisa Hollier, MD, is determined to meet, ensuring that a high maternal death rate does not become our nation’s new normal.

Dr. Brown put it this way, “ACOG collaborative initiatives such as Levels of Maternal Care (LOMC) and implementation of OB safety bundles for hemorrhage, hypertension, and thromboembolism through the AIM [Alliance for Innovation on Maternal Health] Program target maternal morbidity and mortality at the community level. Bundles have also been developed to address the disparity in maternal mortality and for the opiate crisis.”

ACOG is making strides in putting in place nationwide meaningful, evidence-driven systems and care approaches that are proven to reduce maternal mortality and morbidity, saving mothers’ lives and keeping families whole.

Read about the AIM Program’s initiatives

ACOG’s AIM Program established to make an impact

The AIM Program (www.safehealthcare foreverywoman.org) is bringing together clinicians, public health officials, hospital administrators, patient safety organizations, and advocates to eliminate preventable maternal mortality throughout the United States. With funding and support from the US Health Resources and Services Administration, AIM is striving to:

• reduce maternal mortality by 1,000 deaths by 2018
• reduce severe maternal morbidity
• assist states and hospitals to improve outcomes
• create and encourage use of maternal safety bundles (evidence-based tool kits to guide the best care).

AIM offers participating physicians and hospitals online learning modules, checklists, work plans, and links to tool kits and published resources. Implementation data is shared with hospitals and states to further improve care. Physicians participating in AIM can receive Part IV maintenance of certification; continuing education units will soon be offered for nurses. In the future, AIM-participating hospitals may be able to receive reduced liability protection costs, too.

To date, 17 states are participating in the AIM initiative (FIGURE 3), with more states ready to enroll.⁴ States must demonstrate a commitment to lasting change to participate. Each AIM state must have an active maternal mortality review committee (MMRC); committed leadership from public health, hospital associations, and provider associations; and a commitment to report AIM data.

• reducing disparities in maternity care
• severe hypertension in pregnancy
• safe reduction of primary cesarean birth
• prevention of venous thromboembolism
• obstetric hemorrhage
• maternal mental health
• patient, family, and staff support following a severe maternal event
• postpartum care basics
• obstetric care of women with opioid use disorder (in use by Illinois, Massachusetts, Maryland, New Jersey, Maine, New Hampshire, Vermont, New York, Ohio, Oklahoma, Tennessee, Texas, and Virginia).

Read about how active MMRCS are critical to success

Review committees are critical to success

In use in many states, MMRCs are groups of local ObGyns, nurses, social workers, and other health care professionals who review specific cases of maternal deaths from their local area and recommend local solutions to prevent future deaths. MMRCs can be a critically important source of data to help us understand the underlying causes of maternal mortality.

Remember California’s success in reducing its maternal mortality rate, previously mentioned? That state was an early adopter of an active MMRC and has worked to bring best practices to maternity care throughout the state.

While every state should have an active MMRC, not every state does. ACOG is working with states, local leaders, and state and federal legislatures to help develop MMRCs in every state.

Dr. Brown pointed out that, “For several decades, Indiana had a legislatively authorized multidisciplinary maternal mortality review committee that I actively participated in and led in the late 1990s. The authorization for the program lapsed in the early 2000s, and the Indiana MMRC had to shut down. Bolstering the federal government’s capacity to help states like Indiana rebuild MMRCs, or start them from scratch, will help state public health officials, hospitals, and physicians take better care of moms and babies.”

Dr. Hollier explained, “In Texas, I chair our Maternal Mortality and Morbidity Task Force, which was legislatively authorized in 2013 in response to the rising rate of maternal death. The detailed state-based maternal mortality reviews provide critical information: verification of vital statistics data, assessment of the causes and contributing factors, and determination of pregnancy relatedness. These reviews identify opportunities for prevention and implementation of the most appropriate interventions to reduce maternal mortality on a local level. Support of essential review functions at the federal level would also enable data to be combined across jurisdictions for national learning that was previously not possible.”

Pending legislation will strengthen efforts

ACOG is working to enact into law the Preventing Maternal Deaths Act, HR 1318 and S1112. This is bipartisan legislation under which the Centers for Disease Control and Prevention would help states create or expand MMRCs and will require the Department of Health and Human Services to research ways to reduce disparities in maternal health outcomes.

Acknowledgement
The author thanks Jean Mahoney, ACOG’s Senior Director, AIM, for her generous assistance.

Share your thoughts! Send your Letter to the Editor to [email protected]. Please include your name and the city and state in which you practice.

More women die from pregnancy complications in the United States than in any other developed country. The United States is the only industrialized nation with a rising maternal mortality rate.

Those 2 sentences should stop us all in our tracks.

In fact, the United States ranks 47th globally with the worst maternal mortality rate. More than half these deaths are likely preventable, with suicide and drug overdose the leading causes of maternal death in many states. All this occurs despite our advanced medical system, premier medical colleges and universities, embrace of high-tech medical advances, and high percentage of gross domestic product spent on health care.

Need more numbers? According to a 2016 report in Obstetrics and Gynecology, the United States saw a 26% increase in the maternalmortality rate (unadjusted) in only 15 years: from 18.8 deaths per 100,000 live births in 2000 to 23.8 in 2014 (FIGURE 1).¹

Considerable variations by race and by state

The racial disparities in maternal mortality are staggering and have not improved in more than 20 years: African American women are 3.4 times more likely to die than non-Hispanic white women of pregnancy-related complications. In 2011–2013, the maternal mortality ratio for non-Hispanic white women was 12.7 deaths per 100,000 live births compared with 43.5 deaths for non-Hispanic black women (FIGURE 2).² American Indian or Alaska Native women, Asian women, and some Latina women also experience higher rates than non-Hispanic white women. The rate for American Indian or Alaska Native women is 16.9 deaths per 100,000 live births.³

Some states are doing better than others, showing that there is nothing inevitable about the maternal mortality crisis. Texas, for example, has seen the highest rate of maternal mortality increase. Its rate doubled from 2010 to 2012, while California reduced its maternal death rate by 30%, from 21.5 to 15.1, during roughly the same period.¹

This is a challenge of epic proportions, and one that the American College of Obstetricians and Gynecologists (ACOG), under the leadership of President Haywood Brown, MD, and Incoming President Lisa Hollier, MD, is determined to meet, ensuring that a high maternal death rate does not become our nation’s new normal.

Dr. Brown put it this way, “ACOG collaborative initiatives such as Levels of Maternal Care (LOMC) and implementation of OB safety bundles for hemorrhage, hypertension, and thromboembolism through the AIM [Alliance for Innovation on Maternal Health] Program target maternal morbidity and mortality at the community level. Bundles have also been developed to address the disparity in maternal mortality and for the opiate crisis.”

ACOG is making strides in putting in place nationwide meaningful, evidence-driven systems and care approaches that are proven to reduce maternal mortality and morbidity, saving mothers’ lives and keeping families whole.

Read about the AIM Program’s initiatives

ACOG’s AIM Program established to make an impact

The AIM Program (www.safehealthcare foreverywoman.org) is bringing together clinicians, public health officials, hospital administrators, patient safety organizations, and advocates to eliminate preventable maternal mortality throughout the United States. With funding and support from the US Health Resources and Services Administration, AIM is striving to:

• reduce maternal mortality by 1,000 deaths by 2018
• reduce severe maternal morbidity
• assist states and hospitals to improve outcomes
• create and encourage use of maternal safety bundles (evidence-based tool kits to guide the best care).

AIM offers participating physicians and hospitals online learning modules, checklists, work plans, and links to tool kits and published resources. Implementation data is shared with hospitals and states to further improve care. Physicians participating in AIM can receive Part IV maintenance of certification; continuing education units will soon be offered for nurses. In the future, AIM-participating hospitals may be able to receive reduced liability protection costs, too.

To date, 17 states are participating in the AIM initiative (FIGURE 3), with more states ready to enroll.⁴ States must demonstrate a commitment to lasting change to participate. Each AIM state must have an active maternal mortality review committee (MMRC); committed leadership from public health, hospital associations, and provider associations; and a commitment to report AIM data.

• reducing disparities in maternity care
• severe hypertension in pregnancy
• safe reduction of primary cesarean birth
• prevention of venous thromboembolism
• obstetric hemorrhage
• maternal mental health
• patient, family, and staff support following a severe maternal event
• postpartum care basics
• obstetric care of women with opioid use disorder (in use by Illinois, Massachusetts, Maryland, New Jersey, Maine, New Hampshire, Vermont, New York, Ohio, Oklahoma, Tennessee, Texas, and Virginia).

Read about how active MMRCS are critical to success

Review committees are critical to success

In use in many states, MMRCs are groups of local ObGyns, nurses, social workers, and other health care professionals who review specific cases of maternal deaths from their local area and recommend local solutions to prevent future deaths. MMRCs can be a critically important source of data to help us understand the underlying causes of maternal mortality.

Remember California’s success in reducing its maternal mortality rate, previously mentioned? That state was an early adopter of an active MMRC and has worked to bring best practices to maternity care throughout the state.

While every state should have an active MMRC, not every state does. ACOG is working with states, local leaders, and state and federal legislatures to help develop MMRCs in every state.

Dr. Brown pointed out that, “For several decades, Indiana had a legislatively authorized multidisciplinary maternal mortality review committee that I actively participated in and led in the late 1990s. The authorization for the program lapsed in the early 2000s, and the Indiana MMRC had to shut down. Bolstering the federal government’s capacity to help states like Indiana rebuild MMRCs, or start them from scratch, will help state public health officials, hospitals, and physicians take better care of moms and babies.”

Dr. Hollier explained, “In Texas, I chair our Maternal Mortality and Morbidity Task Force, which was legislatively authorized in 2013 in response to the rising rate of maternal death. The detailed state-based maternal mortality reviews provide critical information: verification of vital statistics data, assessment of the causes and contributing factors, and determination of pregnancy relatedness. These reviews identify opportunities for prevention and implementation of the most appropriate interventions to reduce maternal mortality on a local level. Support of essential review functions at the federal level would also enable data to be combined across jurisdictions for national learning that was previously not possible.”

Pending legislation will strengthen efforts

ACOG is working to enact into law the Preventing Maternal Deaths Act, HR 1318 and S1112. This is bipartisan legislation under which the Centers for Disease Control and Prevention would help states create or expand MMRCs and will require the Department of Health and Human Services to research ways to reduce disparities in maternal health outcomes.

Acknowledgement
The author thanks Jean Mahoney, ACOG’s Senior Director, AIM, for her generous assistance.

Share your thoughts! Send your Letter to the Editor to [email protected]. Please include your name and the city and state in which you practice.

More women die from pregnancy complications in the United States than in any other developed country. The United States is the only industrialized nation with a rising maternal mortality rate.

Those 2 sentences should stop us all in our tracks.

In fact, the United States ranks 47th globally with the worst maternal mortality rate. More than half these deaths are likely preventable, with suicide and drug overdose the leading causes of maternal death in many states. All this occurs despite our advanced medical system, premier medical colleges and universities, embrace of high-tech medical advances, and high percentage of gross domestic product spent on health care.

Need more numbers? According to a 2016 report in Obstetrics and Gynecology, the United States saw a 26% increase in the maternalmortality rate (unadjusted) in only 15 years: from 18.8 deaths per 100,000 live births in 2000 to 23.8 in 2014 (FIGURE 1).¹

Considerable variations by race and by state

The racial disparities in maternal mortality are staggering and have not improved in more than 20 years: African American women are 3.4 times more likely to die than non-Hispanic white women of pregnancy-related complications. In 2011–2013, the maternal mortality ratio for non-Hispanic white women was 12.7 deaths per 100,000 live births compared with 43.5 deaths for non-Hispanic black women (FIGURE 2).² American Indian or Alaska Native women, Asian women, and some Latina women also experience higher rates than non-Hispanic white women. The rate for American Indian or Alaska Native women is 16.9 deaths per 100,000 live births.³

Some states are doing better than others, showing that there is nothing inevitable about the maternal mortality crisis. Texas, for example, has seen the highest rate of maternal mortality increase. Its rate doubled from 2010 to 2012, while California reduced its maternal death rate by 30%, from 21.5 to 15.1, during roughly the same period.¹

This is a challenge of epic proportions, and one that the American College of Obstetricians and Gynecologists (ACOG), under the leadership of President Haywood Brown, MD, and Incoming President Lisa Hollier, MD, is determined to meet, ensuring that a high maternal death rate does not become our nation’s new normal.

Dr. Brown put it this way, “ACOG collaborative initiatives such as Levels of Maternal Care (LOMC) and implementation of OB safety bundles for hemorrhage, hypertension, and thromboembolism through the AIM [Alliance for Innovation on Maternal Health] Program target maternal morbidity and mortality at the community level. Bundles have also been developed to address the disparity in maternal mortality and for the opiate crisis.”

ACOG is making strides in putting in place nationwide meaningful, evidence-driven systems and care approaches that are proven to reduce maternal mortality and morbidity, saving mothers’ lives and keeping families whole.

Read about the AIM Program’s initiatives

ACOG’s AIM Program established to make an impact

The AIM Program (www.safehealthcare foreverywoman.org) is bringing together clinicians, public health officials, hospital administrators, patient safety organizations, and advocates to eliminate preventable maternal mortality throughout the United States. With funding and support from the US Health Resources and Services Administration, AIM is striving to:

• reduce maternal mortality by 1,000 deaths by 2018
• reduce severe maternal morbidity
• assist states and hospitals to improve outcomes
• create and encourage use of maternal safety bundles (evidence-based tool kits to guide the best care).

AIM offers participating physicians and hospitals online learning modules, checklists, work plans, and links to tool kits and published resources. Implementation data is shared with hospitals and states to further improve care. Physicians participating in AIM can receive Part IV maintenance of certification; continuing education units will soon be offered for nurses. In the future, AIM-participating hospitals may be able to receive reduced liability protection costs, too.

To date, 17 states are participating in the AIM initiative (FIGURE 3), with more states ready to enroll.⁴ States must demonstrate a commitment to lasting change to participate. Each AIM state must have an active maternal mortality review committee (MMRC); committed leadership from public health, hospital associations, and provider associations; and a commitment to report AIM data.

• reducing disparities in maternity care
• severe hypertension in pregnancy
• safe reduction of primary cesarean birth
• prevention of venous thromboembolism
• obstetric hemorrhage
• maternal mental health
• patient, family, and staff support following a severe maternal event
• postpartum care basics
• obstetric care of women with opioid use disorder (in use by Illinois, Massachusetts, Maryland, New Jersey, Maine, New Hampshire, Vermont, New York, Ohio, Oklahoma, Tennessee, Texas, and Virginia).

Read about how active MMRCS are critical to success

Review committees are critical to success

In use in many states, MMRCs are groups of local ObGyns, nurses, social workers, and other health care professionals who review specific cases of maternal deaths from their local area and recommend local solutions to prevent future deaths. MMRCs can be a critically important source of data to help us understand the underlying causes of maternal mortality.

Remember California’s success in reducing its maternal mortality rate, previously mentioned? That state was an early adopter of an active MMRC and has worked to bring best practices to maternity care throughout the state.

While every state should have an active MMRC, not every state does. ACOG is working with states, local leaders, and state and federal legislatures to help develop MMRCs in every state.

Dr. Brown pointed out that, “For several decades, Indiana had a legislatively authorized multidisciplinary maternal mortality review committee that I actively participated in and led in the late 1990s. The authorization for the program lapsed in the early 2000s, and the Indiana MMRC had to shut down. Bolstering the federal government’s capacity to help states like Indiana rebuild MMRCs, or start them from scratch, will help state public health officials, hospitals, and physicians take better care of moms and babies.”

Dr. Hollier explained, “In Texas, I chair our Maternal Mortality and Morbidity Task Force, which was legislatively authorized in 2013 in response to the rising rate of maternal death. The detailed state-based maternal mortality reviews provide critical information: verification of vital statistics data, assessment of the causes and contributing factors, and determination of pregnancy relatedness. These reviews identify opportunities for prevention and implementation of the most appropriate interventions to reduce maternal mortality on a local level. Support of essential review functions at the federal level would also enable data to be combined across jurisdictions for national learning that was previously not possible.”

Pending legislation will strengthen efforts

ACOG is working to enact into law the Preventing Maternal Deaths Act, HR 1318 and S1112. This is bipartisan legislation under which the Centers for Disease Control and Prevention would help states create or expand MMRCs and will require the Department of Health and Human Services to research ways to reduce disparities in maternal health outcomes.

Acknowledgement
The author thanks Jean Mahoney, ACOG’s Senior Director, AIM, for her generous assistance.

Share your thoughts! Send your Letter to the Editor to [email protected]. Please include your name and the city and state in which you practice.

I recently spoke with 2 outstanding leaders in our field, members of the American College of Obstetricians and Gynecologists (ACOG) task force on telehealth and telemedicine, about the future of providing health care to women in remote locations.

Haywood Brown, MD, is President of ACOG for 2017–2018 and is F. Bayard Carter Professor of Obstetrics and Gynecology at Duke University Medical Center in Durham, North Carolina, and Peter Nielsen, MD, is Professor and Vice Chair of the Department of Obstetrics and Gynecology at Baylor College of Medicine in Houston, Texas, and Obstetrician-in-Chief at Children’s Hospital of San Antonio. Dr. Nielsen is a retired US Army colonel.

Why an ACOG telehealth task force?

Haywood Brown, MD: Our overall goals in telehealth and telemedicine are to coordinate and better facilitate the health care of women in remote locations and to improve maternal morbidity and mortality. Telehealth can be used on both an outpatient and an inpatient basis.

Outpatient telehealth is used for consultations. In maternal-fetal medicine, for instance, we use it for ultrasonography consultations. I also have used telehealth technology to “see” a pregnant patient with type 1diabetes. During our sessions, I managed her blood sugar levels and did all the other things I would have done if we had been together at my clinic. Without telehealth technology, however, this patient would have needed to drive 4 hours round-trip for each appointment.

Our colleagues in rural communities and at lower-level hospitals can use telehealth and telemedicine as aids in treating their high-risk patients, such as those with preeclampsia, prematurity risk, or other conditions. Physicians can consult with specialists through a face-to-face conversation that takes place through telecommunications. The result is that the quality of care for women in our communities is improved.

Genetic counseling, infertility consultation, and fetal anomaly management are some of the other applications. Our task force is discussing different ways to improve patient care and ways to collaborate with our colleagues around the country. Ultimately, we are developing best practices—a model for the best uses of technology to improve women’s health care in the United States.

Task force focus: Telehealth technology, billing, services

Dr. Brown: Our task force, a diverse group of members from all over the country, represents the spectrum of ObGyns. Although task force members have various levels of telehealth experience, all are very interested in these new channels of communication. The task force also includes billers, who understand billing ramifications, and payers, who know firsthand what will and will not be paid.

Technology and its availability is the most important topic for the task force. While some communities have Internet service, not all do. We need to determine which areas need service, how much it would cost, and who pays for it. Can a hospital afford it? A practice? Their partners? Identifying partners in tertiary care settings is a task force goal.

We are engaging a broad range of experts to study all the components and associated costs of technology, licensing, and cross-state credentialing. Gathering this information will help in developing a best practices model that general ObGyns can use.

Telehealth is redefining aspects of care: prenatal care (how many visits are required?), postpartum care, and other types of services that can be done remotely. Genetic counseling—who can provide it, what education is required—is another topic of discussion. Once we surmount the billing obstacles, we can do much with teleconferencing, such as provide genetic consultation with ObGyns in various settings.

Learn about ways clinicians can use telemedicine.

Making progress in rural and underserved communities

Peter Nielsen, MD: When we saw that some high-risk obstetrics patients were having a difficult time getting to our downtown San Antonio office—the trip from surrounding communities was taking too long, or city driving and parking were stressful or too costly—we looked to improve access to care. Collaborating with a health care network that has a hospital in a town north of San Antonio, we set up a pilot program to provide telemedicine perinatal consultation services.

In this kind of service, which occurs entirely in real time, ultrasound images taken at the hospital are streamed by high-speed fiberoptic cable to our office, where a maternal-fetal medicine physician views them. If a repeat image or a different image is needed, the physician requests another scan. Linked to the physician and listening through an earpiece, the ultrasonographer performs the new scan with little delay and without disturbing the patient. The conversation between physician and ultrasonographer is private.

After ultrasound scanning is complete, the patient goes to a private room at the hospital for a video conference with our physician in San Antonio, who has reviewed the images in the PACS (picture archiving and communication system) or ultrasound recording system. They discuss the images, the findings, and the follow-up.

We tested the technology during a 6-month pilot program to make sure it worked at the highest quality and safety levels. Then the program went live and we started seeing patients remotely. Now we have a robust telemedicine training capability at that hospital outside San Antonio, and we are looking to expand to other south and west Texas areas, some even farther from our office.

I have done some of these remote consultations. In response to my informal queries about the experience, patients said that no one else was offering it, and they were participating for the first time. Naturally they had questions and concerns. Nevertheless, patients, family members, and the ultrasonographer and physicians in the communities seem to think this is a high-quality, safe program that makes it easier for patients to access health care.

Patients uniformly describe these consultations in positive terms. They do not have to drive far, into the city, and deal with traffic; parking is easy and free; and less travel means much less time off from work. Given these very practical advantages, patients are interested in having more appointments done remotely. In addition, they say the appointment itself is easy, being there is effortless, and they feel their physician is sitting in the same room. It is like video chatting with family members—they are comfortable with the technology.

Related article:
Landmark women’s health care remains law of the land

The patients’ perspective

Dr. Brown: Patient satisfaction is an important issue. In psychiatry, dermatology, and other disciplines, patients have indicated that they are very satisfied with telehealth sessions. Telehealth in obstetrics and gynecology, I think, will receive similar positive feedback.

The issue of driving distance led us to reconsider the number of face-to-face prenatal visits a normal, healthy patient needs. These days, a patient can use a prenatal care app to track her weight and blood pressure and send the data to her physician. Besides being convenient, these monitoring apps can give a patient an important sense of control. Our pilot programs found that a patient who self-monitors understands her weight gain better and is more in tune with it. Apps and other technologies can thus improve quality of care and, in reducing the number of trips to an office, increase patient satisfaction.

Many people use or are familiar with the programs Skype and FaceTime (audiovideo chat software), and I envision that our postpartum task force will recommend using such programs for follow-up appointments. For each visit, the question to ask is whether the patient really needs to meet with her physician in person, or can she stay with her new baby and receive postpartum counseling at home. I am excited about the potential of telehealth in obstetrics and gynecology. Our task force is exploring that potential.

Telehealth for both routine and specialized care

Dr. Brown: Specialized care applications are here. In a pilot program in Wisconsin, a colleague has been providing remote psychiatric care. Perhaps such a program can be used to follow up on patients with postpartum depression. In addition, other psychiatry colleagues have long been using telehealth for adolescent behavior follow-ups, and we can do this too.

Another colleague has been performing remote perinatal follow-up for children with congenital anomalies. The physician interacts with the parent or parents as well as the patient. This seems to represent only the tip of the iceberg of what can be done in terms of follow-up.

We can also use telehealth in infertility settings. High-risk patients can benefit, too. Our guidelines say patients with preeclampsia should be seen within 3 days to 1 week. Many are transferred from low-access hospitals to our office. This follow-up, however, also can be done remotely, with patients at health department clinics or even at home. Reporting blood pressure readings and health-related feelings to a physician during a teleconsultation removes driving as a potential inconvenience or obstacle.

Telemedicine can be advantageous in gynecology. Physicians are doing important work with telecolposcopy as a follow-up to abnormal Pap test findings in patients in sub-Saharan Africa.

Routine wound care, which is commonly needed, can be performed in the home by a home health nurse telecommunicating with a physician. I can see broad telehealth use, and indeed our dermatology colleagues have been practicing telemedicine for quite some time.

Read about solving financial barriers and physician shortages.

An affordable solution to financial barriers and physician shortages

Dr. Nielsen: Telehealth can reduce barriers to care. For example, knowing that our teleconsultation services are covered by insurance, referring physicians and patients are more likely to try them and continue to use them. Payers are on board as well. Other barriers can be harder to overcome, particularly for patients at risk for complex diagnoses and medical decisions. Our pilot program, however, has demonstrated success in this area. It has provided safe, high-quality imaging, accurate diagnoses, productive discussions, and helpful management recommendations.

Telehealth also helps address relative and absolute physician shortages. In some areas, a relative shortage may indicate misdistribution. In other areas, specialists simply are too few in number. This absolute shortage of specialists likely will increase, as many communities are too small to sustain and support having them in person.

Outpatients can obtain care 5 days a week with telemedicine, as opposed to only 1 to 3 times a month in person. Physicians travel to remote clinics that are staffed only 1 or 2 days a month. Where the window for care is so small, patients and physicians are likely to turn to telemedicine. In addition, that utility results in better use of resources. For example, studies that were performed earlier would not need to be repeated, since you could access centrally located archives.

Related article:
ICD-10-CM code changes: What's new for 2018

Dr. Brown: For teleconsultations and televisits, all that payers need do is modify the billing codes they use for our usual services. Once that is done, payers can develop a payment model that works for both themselves and the teleconsultants.

The US health care system is fragmented. Health care is provided in various facilities, including federally qualified health centers and health department clinics. As Dr. Nielsen said, physicians travel to remote facilities once or twice a week or even a month, whereas telehealth can be offered 5 days a week. Many residents go to remote clinics, where an attending physician is required. Instead of an attending driving there, he or she could be teleconsulting—interacting with residents and patients from afar. So, telehealth is a win-win situation. It increases access to physicians and facilitates appropriate interactions with them, wherever they are. Telehealth can be an important contribution to developing a more effective health care delivery system than the fragmented one we have now.

Effective health care delivery is so important for obstetrics and gynecology, and the reported workforce challenges are real. A maternal-fetal medicine physician is unlikely to travel to remote communities once a week or even every 2 weeks, but that same physician can teleconsult multiple days each week.

How telehealth can close service gaps

Dr. Brown: Having established relationships with physicians in other clinics and communities paves the way for teleconsultation and remote supervision. Technology can help Planned Parenthood and other clinics continue to provide contraceptive counseling and other health care services. Even medical abortions can be supervised through teleconsultation.

With funds to Medicaid being cut, with the potential for Planned Parenthood to be defunded, physicians must think of ways they can continue to provide care to all patients and communities. By addressing these issues now, we will be ready to take charge of patient care, wherever it is needed.

But, we need partners, no question. We need hospital partners in all communities, and especially in rural communities. Rural hospitals and maternity care are at risk. Health care in rural communities faces many challenges. Telehealth, teleconferencing, and teleconsultation not only can improve access to services, but also can curb travel costs as well as costs to the communities and hospitals.

Who pays the operating costs, and who benefits

Dr. Brown: Payers are already discovering that teleconsultations are as billable as in-person visits. In addition, physicians are realizing that remote consultation can work as well as in-person consultation, with its own merits and advantages. Education is key—education about billing and about what is doable in telehealth. We can learn from colleagues in other specialties.

Dr. Nielsen: Several entities and groups must start covering the technology costs. Federal and state entities need to determine how the country’s information infrastructure can be improved to give rural areas access to high-quality, high-speed, wide-bandwidth communications, which will help expand telehealth and increase other industries’ opportunities to grow and sustain these communities. Improving the infrastructure also can help keep rural areas sustainable.

Health care systems themselves can join federal, state, and local governments in building this infrastructure. They can also start identifying opportunities to support and sustain physicians and hospitals in smaller towns and start combating the perception that the infrastructure is being developed only to migrate patients over to accessing their care through telehealth provided by physicians in the larger cities.

Many payers see telehealth as improving access and outcomes and already support it, but more payers need to become involved. All need to understand how routine and complex consultations, even inpatient consultations, can be performed remotely and can be properly reimbursed, and incentivized with payments for improved outcomes and value.

As barriers fall and telehealth improves, acceptance by patients and physicians will increase. In addition, telehealth will enter medical education in a significant way. The instruction that students, residents, and Fellows receive will be enhanced by new telehealth approaches in various specialties, and residents will come out of these programs with telehealth experience and a sense of both financial benefits and payment structures. This early exposure will pique their interest in using telehealth and advocating its use where it may never before have been considered, owing to real and perceived barriers.

Read about telehealth solutions for ObGyns.

Learning from other specialties and agencies

Dr. Brown: The physician shortage negatively affects access to health care in rural areas. Many city and suburban physicians, including ObGyns, want to stay where they are. Education is needed to show them that a rural practice can be successful. They would have a good patient base and be able to use telehealth to improve care and maintain contact with tertiary care centers.

Several task force members have described their experience within their health systems, and we hope to borrow from that. A health system in South Dakota received a Health Resources and Services Administration grant to use telehealth and teleconsultation in the Indian Health Service (IHS). To women who access their health care through the IHS, being able to remain in the community is culturally important. Telehealth and teleconsultation bring care to these women where they live.

To develop the best telehealth and teleconsultation model, we are borrowing from these health systems and from the experience of our colleagues in dermatology, behavioral health, psychiatry, and other disciplines. These physicians already have overcome many hurdles and discovered the importance of patient satisfaction in providing remote health care.

Patients will benefit in various ways, and here is another example: A clinic refers a patient to an ObGyn to discuss whether it is possible to have a vaginal birth after a cesarean delivery. The drive to the ObGyn’s office takes an hour, but the patient just as easily could have had all her questions answered during a teleconsultation.

Related articles:
Telehealth and you (4-part audiocast)

Telehealth recommendations for ObGyns

Dr. Brown: Our task force will develop recommended best practices for telehealth. We will outline how a practice can engage with telehealth and will address licensing requirements, as a practice must be licensed in each state where it uses telehealth. Our goal is to help our specialty get started in telehealth and telemedicine.

In practices with telehealth, it will be incumbent on ObGyns to identify any barriers to care. For example, we are concerned about early discontinuation of breastfeeding, particularly among African American communities. Fortunately, we have learned that video chat follow-ups can help improve breastfeeding continuation rates.

It also will be incumbent on ObGyns to think differently about how best to follow up. For a patient who calls to say she thinks she has mastitis, much of the consultation can be handled by telephone or video conference with the physician and a nurse practi‑tioner, and then medication can be prescribed without the need for in-person follow-up. We must then determine how to ensure these follow-up methods are compensated.

Final thoughts

Dr. Nielsen: It is time for all US health care players to more seriously and aggressively consider how telehealth can improve health care access, quality, and safety. Even more important, patients and physicians in small communities need to feel that they can access specialists and care that is as good as those available in larger communities without having to pull up stakes and move.

Telehealth can help small communities become sustainable over the long term. As the majority of the people in this country are born in and receive health care in community hospitals, not large tertiary care centers, the state of US health care should be measured by the ability to provide as much care as is technically possible in the small communities where patients live and work and raise their kids.

Dr. Brown: More than 50% of all babies are born in hospitals where fewer than 1,000 deliveries are performed, and almost 40% are born in hospitals where fewer than 500 are performed. To provide high-level care and have patients feel comfortable, to improve morbidity and mortality, we need telehealth and telemedicine.

If I can help a physician in East Africa place a Bakri balloon for postpartum hemorrhaging, surely I can help a physician in rural areas of Wyoming, South Dakota, or North Carolina deal with this obstetric emergency. In obstetrics and gynecology, telehealth and telemedicine have great potential in terms of morbidity and mortality, but we are also doing genetic counseling and a great deal of patient follow-up, and so much more can be done.

That is the key, and the reason for the training, the task force, the deliberations, and the best practices model that we will be sharing with our colleagues.

Share your thoughts! Send your Letter to the Editor to [email protected]. Please include your name and the city and state in which you practice.

I recently spoke with 2 outstanding leaders in our field, members of the American College of Obstetricians and Gynecologists (ACOG) task force on telehealth and telemedicine, about the future of providing health care to women in remote locations.

Haywood Brown, MD, is President of ACOG for 2017–2018 and is F. Bayard Carter Professor of Obstetrics and Gynecology at Duke University Medical Center in Durham, North Carolina, and Peter Nielsen, MD, is Professor and Vice Chair of the Department of Obstetrics and Gynecology at Baylor College of Medicine in Houston, Texas, and Obstetrician-in-Chief at Children’s Hospital of San Antonio. Dr. Nielsen is a retired US Army colonel.

Why an ACOG telehealth task force?

Haywood Brown, MD: Our overall goals in telehealth and telemedicine are to coordinate and better facilitate the health care of women in remote locations and to improve maternal morbidity and mortality. Telehealth can be used on both an outpatient and an inpatient basis.

Outpatient telehealth is used for consultations. In maternal-fetal medicine, for instance, we use it for ultrasonography consultations. I also have used telehealth technology to “see” a pregnant patient with type 1diabetes. During our sessions, I managed her blood sugar levels and did all the other things I would have done if we had been together at my clinic. Without telehealth technology, however, this patient would have needed to drive 4 hours round-trip for each appointment.

Our colleagues in rural communities and at lower-level hospitals can use telehealth and telemedicine as aids in treating their high-risk patients, such as those with preeclampsia, prematurity risk, or other conditions. Physicians can consult with specialists through a face-to-face conversation that takes place through telecommunications. The result is that the quality of care for women in our communities is improved.

Genetic counseling, infertility consultation, and fetal anomaly management are some of the other applications. Our task force is discussing different ways to improve patient care and ways to collaborate with our colleagues around the country. Ultimately, we are developing best practices—a model for the best uses of technology to improve women’s health care in the United States.

Task force focus: Telehealth technology, billing, services

Dr. Brown: Our task force, a diverse group of members from all over the country, represents the spectrum of ObGyns. Although task force members have various levels of telehealth experience, all are very interested in these new channels of communication. The task force also includes billers, who understand billing ramifications, and payers, who know firsthand what will and will not be paid.

Technology and its availability is the most important topic for the task force. While some communities have Internet service, not all do. We need to determine which areas need service, how much it would cost, and who pays for it. Can a hospital afford it? A practice? Their partners? Identifying partners in tertiary care settings is a task force goal.

We are engaging a broad range of experts to study all the components and associated costs of technology, licensing, and cross-state credentialing. Gathering this information will help in developing a best practices model that general ObGyns can use.

Telehealth is redefining aspects of care: prenatal care (how many visits are required?), postpartum care, and other types of services that can be done remotely. Genetic counseling—who can provide it, what education is required—is another topic of discussion. Once we surmount the billing obstacles, we can do much with teleconferencing, such as provide genetic consultation with ObGyns in various settings.

Learn about ways clinicians can use telemedicine.

Making progress in rural and underserved communities

Peter Nielsen, MD: When we saw that some high-risk obstetrics patients were having a difficult time getting to our downtown San Antonio office—the trip from surrounding communities was taking too long, or city driving and parking were stressful or too costly—we looked to improve access to care. Collaborating with a health care network that has a hospital in a town north of San Antonio, we set up a pilot program to provide telemedicine perinatal consultation services.

In this kind of service, which occurs entirely in real time, ultrasound images taken at the hospital are streamed by high-speed fiberoptic cable to our office, where a maternal-fetal medicine physician views them. If a repeat image or a different image is needed, the physician requests another scan. Linked to the physician and listening through an earpiece, the ultrasonographer performs the new scan with little delay and without disturbing the patient. The conversation between physician and ultrasonographer is private.

After ultrasound scanning is complete, the patient goes to a private room at the hospital for a video conference with our physician in San Antonio, who has reviewed the images in the PACS (picture archiving and communication system) or ultrasound recording system. They discuss the images, the findings, and the follow-up.

We tested the technology during a 6-month pilot program to make sure it worked at the highest quality and safety levels. Then the program went live and we started seeing patients remotely. Now we have a robust telemedicine training capability at that hospital outside San Antonio, and we are looking to expand to other south and west Texas areas, some even farther from our office.

I have done some of these remote consultations. In response to my informal queries about the experience, patients said that no one else was offering it, and they were participating for the first time. Naturally they had questions and concerns. Nevertheless, patients, family members, and the ultrasonographer and physicians in the communities seem to think this is a high-quality, safe program that makes it easier for patients to access health care.

Patients uniformly describe these consultations in positive terms. They do not have to drive far, into the city, and deal with traffic; parking is easy and free; and less travel means much less time off from work. Given these very practical advantages, patients are interested in having more appointments done remotely. In addition, they say the appointment itself is easy, being there is effortless, and they feel their physician is sitting in the same room. It is like video chatting with family members—they are comfortable with the technology.

Related article:
Landmark women’s health care remains law of the land

The patients’ perspective

Dr. Brown: Patient satisfaction is an important issue. In psychiatry, dermatology, and other disciplines, patients have indicated that they are very satisfied with telehealth sessions. Telehealth in obstetrics and gynecology, I think, will receive similar positive feedback.

The issue of driving distance led us to reconsider the number of face-to-face prenatal visits a normal, healthy patient needs. These days, a patient can use a prenatal care app to track her weight and blood pressure and send the data to her physician. Besides being convenient, these monitoring apps can give a patient an important sense of control. Our pilot programs found that a patient who self-monitors understands her weight gain better and is more in tune with it. Apps and other technologies can thus improve quality of care and, in reducing the number of trips to an office, increase patient satisfaction.

Many people use or are familiar with the programs Skype and FaceTime (audiovideo chat software), and I envision that our postpartum task force will recommend using such programs for follow-up appointments. For each visit, the question to ask is whether the patient really needs to meet with her physician in person, or can she stay with her new baby and receive postpartum counseling at home. I am excited about the potential of telehealth in obstetrics and gynecology. Our task force is exploring that potential.

Telehealth for both routine and specialized care

Dr. Brown: Specialized care applications are here. In a pilot program in Wisconsin, a colleague has been providing remote psychiatric care. Perhaps such a program can be used to follow up on patients with postpartum depression. In addition, other psychiatry colleagues have long been using telehealth for adolescent behavior follow-ups, and we can do this too.

Another colleague has been performing remote perinatal follow-up for children with congenital anomalies. The physician interacts with the parent or parents as well as the patient. This seems to represent only the tip of the iceberg of what can be done in terms of follow-up.

We can also use telehealth in infertility settings. High-risk patients can benefit, too. Our guidelines say patients with preeclampsia should be seen within 3 days to 1 week. Many are transferred from low-access hospitals to our office. This follow-up, however, also can be done remotely, with patients at health department clinics or even at home. Reporting blood pressure readings and health-related feelings to a physician during a teleconsultation removes driving as a potential inconvenience or obstacle.

Telemedicine can be advantageous in gynecology. Physicians are doing important work with telecolposcopy as a follow-up to abnormal Pap test findings in patients in sub-Saharan Africa.

Routine wound care, which is commonly needed, can be performed in the home by a home health nurse telecommunicating with a physician. I can see broad telehealth use, and indeed our dermatology colleagues have been practicing telemedicine for quite some time.

Read about solving financial barriers and physician shortages.

An affordable solution to financial barriers and physician shortages

Dr. Nielsen: Telehealth can reduce barriers to care. For example, knowing that our teleconsultation services are covered by insurance, referring physicians and patients are more likely to try them and continue to use them. Payers are on board as well. Other barriers can be harder to overcome, particularly for patients at risk for complex diagnoses and medical decisions. Our pilot program, however, has demonstrated success in this area. It has provided safe, high-quality imaging, accurate diagnoses, productive discussions, and helpful management recommendations.

Telehealth also helps address relative and absolute physician shortages. In some areas, a relative shortage may indicate misdistribution. In other areas, specialists simply are too few in number. This absolute shortage of specialists likely will increase, as many communities are too small to sustain and support having them in person.

Outpatients can obtain care 5 days a week with telemedicine, as opposed to only 1 to 3 times a month in person. Physicians travel to remote clinics that are staffed only 1 or 2 days a month. Where the window for care is so small, patients and physicians are likely to turn to telemedicine. In addition, that utility results in better use of resources. For example, studies that were performed earlier would not need to be repeated, since you could access centrally located archives.

Related article:
ICD-10-CM code changes: What's new for 2018

Dr. Brown: For teleconsultations and televisits, all that payers need do is modify the billing codes they use for our usual services. Once that is done, payers can develop a payment model that works for both themselves and the teleconsultants.

The US health care system is fragmented. Health care is provided in various facilities, including federally qualified health centers and health department clinics. As Dr. Nielsen said, physicians travel to remote facilities once or twice a week or even a month, whereas telehealth can be offered 5 days a week. Many residents go to remote clinics, where an attending physician is required. Instead of an attending driving there, he or she could be teleconsulting—interacting with residents and patients from afar. So, telehealth is a win-win situation. It increases access to physicians and facilitates appropriate interactions with them, wherever they are. Telehealth can be an important contribution to developing a more effective health care delivery system than the fragmented one we have now.

Effective health care delivery is so important for obstetrics and gynecology, and the reported workforce challenges are real. A maternal-fetal medicine physician is unlikely to travel to remote communities once a week or even every 2 weeks, but that same physician can teleconsult multiple days each week.

How telehealth can close service gaps

Dr. Brown: Having established relationships with physicians in other clinics and communities paves the way for teleconsultation and remote supervision. Technology can help Planned Parenthood and other clinics continue to provide contraceptive counseling and other health care services. Even medical abortions can be supervised through teleconsultation.

With funds to Medicaid being cut, with the potential for Planned Parenthood to be defunded, physicians must think of ways they can continue to provide care to all patients and communities. By addressing these issues now, we will be ready to take charge of patient care, wherever it is needed.

But, we need partners, no question. We need hospital partners in all communities, and especially in rural communities. Rural hospitals and maternity care are at risk. Health care in rural communities faces many challenges. Telehealth, teleconferencing, and teleconsultation not only can improve access to services, but also can curb travel costs as well as costs to the communities and hospitals.

Who pays the operating costs, and who benefits

Dr. Brown: Payers are already discovering that teleconsultations are as billable as in-person visits. In addition, physicians are realizing that remote consultation can work as well as in-person consultation, with its own merits and advantages. Education is key—education about billing and about what is doable in telehealth. We can learn from colleagues in other specialties.

Dr. Nielsen: Several entities and groups must start covering the technology costs. Federal and state entities need to determine how the country’s information infrastructure can be improved to give rural areas access to high-quality, high-speed, wide-bandwidth communications, which will help expand telehealth and increase other industries’ opportunities to grow and sustain these communities. Improving the infrastructure also can help keep rural areas sustainable.

Health care systems themselves can join federal, state, and local governments in building this infrastructure. They can also start identifying opportunities to support and sustain physicians and hospitals in smaller towns and start combating the perception that the infrastructure is being developed only to migrate patients over to accessing their care through telehealth provided by physicians in the larger cities.

Many payers see telehealth as improving access and outcomes and already support it, but more payers need to become involved. All need to understand how routine and complex consultations, even inpatient consultations, can be performed remotely and can be properly reimbursed, and incentivized with payments for improved outcomes and value.

As barriers fall and telehealth improves, acceptance by patients and physicians will increase. In addition, telehealth will enter medical education in a significant way. The instruction that students, residents, and Fellows receive will be enhanced by new telehealth approaches in various specialties, and residents will come out of these programs with telehealth experience and a sense of both financial benefits and payment structures. This early exposure will pique their interest in using telehealth and advocating its use where it may never before have been considered, owing to real and perceived barriers.

Read about telehealth solutions for ObGyns.

Learning from other specialties and agencies

Dr. Brown: The physician shortage negatively affects access to health care in rural areas. Many city and suburban physicians, including ObGyns, want to stay where they are. Education is needed to show them that a rural practice can be successful. They would have a good patient base and be able to use telehealth to improve care and maintain contact with tertiary care centers.

Several task force members have described their experience within their health systems, and we hope to borrow from that. A health system in South Dakota received a Health Resources and Services Administration grant to use telehealth and teleconsultation in the Indian Health Service (IHS). To women who access their health care through the IHS, being able to remain in the community is culturally important. Telehealth and teleconsultation bring care to these women where they live.

To develop the best telehealth and teleconsultation model, we are borrowing from these health systems and from the experience of our colleagues in dermatology, behavioral health, psychiatry, and other disciplines. These physicians already have overcome many hurdles and discovered the importance of patient satisfaction in providing remote health care.

Patients will benefit in various ways, and here is another example: A clinic refers a patient to an ObGyn to discuss whether it is possible to have a vaginal birth after a cesarean delivery. The drive to the ObGyn’s office takes an hour, but the patient just as easily could have had all her questions answered during a teleconsultation.

Related articles:
Telehealth and you (4-part audiocast)

Telehealth recommendations for ObGyns

Dr. Brown: Our task force will develop recommended best practices for telehealth. We will outline how a practice can engage with telehealth and will address licensing requirements, as a practice must be licensed in each state where it uses telehealth. Our goal is to help our specialty get started in telehealth and telemedicine.

In practices with telehealth, it will be incumbent on ObGyns to identify any barriers to care. For example, we are concerned about early discontinuation of breastfeeding, particularly among African American communities. Fortunately, we have learned that video chat follow-ups can help improve breastfeeding continuation rates.

It also will be incumbent on ObGyns to think differently about how best to follow up. For a patient who calls to say she thinks she has mastitis, much of the consultation can be handled by telephone or video conference with the physician and a nurse practi‑tioner, and then medication can be prescribed without the need for in-person follow-up. We must then determine how to ensure these follow-up methods are compensated.

Final thoughts

Dr. Nielsen: It is time for all US health care players to more seriously and aggressively consider how telehealth can improve health care access, quality, and safety. Even more important, patients and physicians in small communities need to feel that they can access specialists and care that is as good as those available in larger communities without having to pull up stakes and move.

Telehealth can help small communities become sustainable over the long term. As the majority of the people in this country are born in and receive health care in community hospitals, not large tertiary care centers, the state of US health care should be measured by the ability to provide as much care as is technically possible in the small communities where patients live and work and raise their kids.

Dr. Brown: More than 50% of all babies are born in hospitals where fewer than 1,000 deliveries are performed, and almost 40% are born in hospitals where fewer than 500 are performed. To provide high-level care and have patients feel comfortable, to improve morbidity and mortality, we need telehealth and telemedicine.

If I can help a physician in East Africa place a Bakri balloon for postpartum hemorrhaging, surely I can help a physician in rural areas of Wyoming, South Dakota, or North Carolina deal with this obstetric emergency. In obstetrics and gynecology, telehealth and telemedicine have great potential in terms of morbidity and mortality, but we are also doing genetic counseling and a great deal of patient follow-up, and so much more can be done.

That is the key, and the reason for the training, the task force, the deliberations, and the best practices model that we will be sharing with our colleagues.

Share your thoughts! Send your Letter to the Editor to [email protected]. Please include your name and the city and state in which you practice.

I recently spoke with 2 outstanding leaders in our field, members of the American College of Obstetricians and Gynecologists (ACOG) task force on telehealth and telemedicine, about the future of providing health care to women in remote locations.

Haywood Brown, MD, is President of ACOG for 2017–2018 and is F. Bayard Carter Professor of Obstetrics and Gynecology at Duke University Medical Center in Durham, North Carolina, and Peter Nielsen, MD, is Professor and Vice Chair of the Department of Obstetrics and Gynecology at Baylor College of Medicine in Houston, Texas, and Obstetrician-in-Chief at Children’s Hospital of San Antonio. Dr. Nielsen is a retired US Army colonel.

Why an ACOG telehealth task force?

Haywood Brown, MD: Our overall goals in telehealth and telemedicine are to coordinate and better facilitate the health care of women in remote locations and to improve maternal morbidity and mortality. Telehealth can be used on both an outpatient and an inpatient basis.

Outpatient telehealth is used for consultations. In maternal-fetal medicine, for instance, we use it for ultrasonography consultations. I also have used telehealth technology to “see” a pregnant patient with type 1diabetes. During our sessions, I managed her blood sugar levels and did all the other things I would have done if we had been together at my clinic. Without telehealth technology, however, this patient would have needed to drive 4 hours round-trip for each appointment.

Our colleagues in rural communities and at lower-level hospitals can use telehealth and telemedicine as aids in treating their high-risk patients, such as those with preeclampsia, prematurity risk, or other conditions. Physicians can consult with specialists through a face-to-face conversation that takes place through telecommunications. The result is that the quality of care for women in our communities is improved.

Genetic counseling, infertility consultation, and fetal anomaly management are some of the other applications. Our task force is discussing different ways to improve patient care and ways to collaborate with our colleagues around the country. Ultimately, we are developing best practices—a model for the best uses of technology to improve women’s health care in the United States.

Task force focus: Telehealth technology, billing, services

Dr. Brown: Our task force, a diverse group of members from all over the country, represents the spectrum of ObGyns. Although task force members have various levels of telehealth experience, all are very interested in these new channels of communication. The task force also includes billers, who understand billing ramifications, and payers, who know firsthand what will and will not be paid.

Technology and its availability is the most important topic for the task force. While some communities have Internet service, not all do. We need to determine which areas need service, how much it would cost, and who pays for it. Can a hospital afford it? A practice? Their partners? Identifying partners in tertiary care settings is a task force goal.

We are engaging a broad range of experts to study all the components and associated costs of technology, licensing, and cross-state credentialing. Gathering this information will help in developing a best practices model that general ObGyns can use.

Telehealth is redefining aspects of care: prenatal care (how many visits are required?), postpartum care, and other types of services that can be done remotely. Genetic counseling—who can provide it, what education is required—is another topic of discussion. Once we surmount the billing obstacles, we can do much with teleconferencing, such as provide genetic consultation with ObGyns in various settings.

Learn about ways clinicians can use telemedicine.

Making progress in rural and underserved communities

Peter Nielsen, MD: When we saw that some high-risk obstetrics patients were having a difficult time getting to our downtown San Antonio office—the trip from surrounding communities was taking too long, or city driving and parking were stressful or too costly—we looked to improve access to care. Collaborating with a health care network that has a hospital in a town north of San Antonio, we set up a pilot program to provide telemedicine perinatal consultation services.

In this kind of service, which occurs entirely in real time, ultrasound images taken at the hospital are streamed by high-speed fiberoptic cable to our office, where a maternal-fetal medicine physician views them. If a repeat image or a different image is needed, the physician requests another scan. Linked to the physician and listening through an earpiece, the ultrasonographer performs the new scan with little delay and without disturbing the patient. The conversation between physician and ultrasonographer is private.

After ultrasound scanning is complete, the patient goes to a private room at the hospital for a video conference with our physician in San Antonio, who has reviewed the images in the PACS (picture archiving and communication system) or ultrasound recording system. They discuss the images, the findings, and the follow-up.

We tested the technology during a 6-month pilot program to make sure it worked at the highest quality and safety levels. Then the program went live and we started seeing patients remotely. Now we have a robust telemedicine training capability at that hospital outside San Antonio, and we are looking to expand to other south and west Texas areas, some even farther from our office.

I have done some of these remote consultations. In response to my informal queries about the experience, patients said that no one else was offering it, and they were participating for the first time. Naturally they had questions and concerns. Nevertheless, patients, family members, and the ultrasonographer and physicians in the communities seem to think this is a high-quality, safe program that makes it easier for patients to access health care.

Patients uniformly describe these consultations in positive terms. They do not have to drive far, into the city, and deal with traffic; parking is easy and free; and less travel means much less time off from work. Given these very practical advantages, patients are interested in having more appointments done remotely. In addition, they say the appointment itself is easy, being there is effortless, and they feel their physician is sitting in the same room. It is like video chatting with family members—they are comfortable with the technology.

Related article:
Landmark women’s health care remains law of the land

The patients’ perspective

Dr. Brown: Patient satisfaction is an important issue. In psychiatry, dermatology, and other disciplines, patients have indicated that they are very satisfied with telehealth sessions. Telehealth in obstetrics and gynecology, I think, will receive similar positive feedback.

The issue of driving distance led us to reconsider the number of face-to-face prenatal visits a normal, healthy patient needs. These days, a patient can use a prenatal care app to track her weight and blood pressure and send the data to her physician. Besides being convenient, these monitoring apps can give a patient an important sense of control. Our pilot programs found that a patient who self-monitors understands her weight gain better and is more in tune with it. Apps and other technologies can thus improve quality of care and, in reducing the number of trips to an office, increase patient satisfaction.

Many people use or are familiar with the programs Skype and FaceTime (audiovideo chat software), and I envision that our postpartum task force will recommend using such programs for follow-up appointments. For each visit, the question to ask is whether the patient really needs to meet with her physician in person, or can she stay with her new baby and receive postpartum counseling at home. I am excited about the potential of telehealth in obstetrics and gynecology. Our task force is exploring that potential.

Telehealth for both routine and specialized care

Dr. Brown: Specialized care applications are here. In a pilot program in Wisconsin, a colleague has been providing remote psychiatric care. Perhaps such a program can be used to follow up on patients with postpartum depression. In addition, other psychiatry colleagues have long been using telehealth for adolescent behavior follow-ups, and we can do this too.

Another colleague has been performing remote perinatal follow-up for children with congenital anomalies. The physician interacts with the parent or parents as well as the patient. This seems to represent only the tip of the iceberg of what can be done in terms of follow-up.

We can also use telehealth in infertility settings. High-risk patients can benefit, too. Our guidelines say patients with preeclampsia should be seen within 3 days to 1 week. Many are transferred from low-access hospitals to our office. This follow-up, however, also can be done remotely, with patients at health department clinics or even at home. Reporting blood pressure readings and health-related feelings to a physician during a teleconsultation removes driving as a potential inconvenience or obstacle.

Telemedicine can be advantageous in gynecology. Physicians are doing important work with telecolposcopy as a follow-up to abnormal Pap test findings in patients in sub-Saharan Africa.

Routine wound care, which is commonly needed, can be performed in the home by a home health nurse telecommunicating with a physician. I can see broad telehealth use, and indeed our dermatology colleagues have been practicing telemedicine for quite some time.

Read about solving financial barriers and physician shortages.

An affordable solution to financial barriers and physician shortages

Dr. Nielsen: Telehealth can reduce barriers to care. For example, knowing that our teleconsultation services are covered by insurance, referring physicians and patients are more likely to try them and continue to use them. Payers are on board as well. Other barriers can be harder to overcome, particularly for patients at risk for complex diagnoses and medical decisions. Our pilot program, however, has demonstrated success in this area. It has provided safe, high-quality imaging, accurate diagnoses, productive discussions, and helpful management recommendations.

Telehealth also helps address relative and absolute physician shortages. In some areas, a relative shortage may indicate misdistribution. In other areas, specialists simply are too few in number. This absolute shortage of specialists likely will increase, as many communities are too small to sustain and support having them in person.

Outpatients can obtain care 5 days a week with telemedicine, as opposed to only 1 to 3 times a month in person. Physicians travel to remote clinics that are staffed only 1 or 2 days a month. Where the window for care is so small, patients and physicians are likely to turn to telemedicine. In addition, that utility results in better use of resources. For example, studies that were performed earlier would not need to be repeated, since you could access centrally located archives.

Related article:
ICD-10-CM code changes: What's new for 2018

Dr. Brown: For teleconsultations and televisits, all that payers need do is modify the billing codes they use for our usual services. Once that is done, payers can develop a payment model that works for both themselves and the teleconsultants.

The US health care system is fragmented. Health care is provided in various facilities, including federally qualified health centers and health department clinics. As Dr. Nielsen said, physicians travel to remote facilities once or twice a week or even a month, whereas telehealth can be offered 5 days a week. Many residents go to remote clinics, where an attending physician is required. Instead of an attending driving there, he or she could be teleconsulting—interacting with residents and patients from afar. So, telehealth is a win-win situation. It increases access to physicians and facilitates appropriate interactions with them, wherever they are. Telehealth can be an important contribution to developing a more effective health care delivery system than the fragmented one we have now.

Effective health care delivery is so important for obstetrics and gynecology, and the reported workforce challenges are real. A maternal-fetal medicine physician is unlikely to travel to remote communities once a week or even every 2 weeks, but that same physician can teleconsult multiple days each week.

How telehealth can close service gaps

Dr. Brown: Having established relationships with physicians in other clinics and communities paves the way for teleconsultation and remote supervision. Technology can help Planned Parenthood and other clinics continue to provide contraceptive counseling and other health care services. Even medical abortions can be supervised through teleconsultation.

With funds to Medicaid being cut, with the potential for Planned Parenthood to be defunded, physicians must think of ways they can continue to provide care to all patients and communities. By addressing these issues now, we will be ready to take charge of patient care, wherever it is needed.

But, we need partners, no question. We need hospital partners in all communities, and especially in rural communities. Rural hospitals and maternity care are at risk. Health care in rural communities faces many challenges. Telehealth, teleconferencing, and teleconsultation not only can improve access to services, but also can curb travel costs as well as costs to the communities and hospitals.

Who pays the operating costs, and who benefits

Dr. Brown: Payers are already discovering that teleconsultations are as billable as in-person visits. In addition, physicians are realizing that remote consultation can work as well as in-person consultation, with its own merits and advantages. Education is key—education about billing and about what is doable in telehealth. We can learn from colleagues in other specialties.

Dr. Nielsen: Several entities and groups must start covering the technology costs. Federal and state entities need to determine how the country’s information infrastructure can be improved to give rural areas access to high-quality, high-speed, wide-bandwidth communications, which will help expand telehealth and increase other industries’ opportunities to grow and sustain these communities. Improving the infrastructure also can help keep rural areas sustainable.

Health care systems themselves can join federal, state, and local governments in building this infrastructure. They can also start identifying opportunities to support and sustain physicians and hospitals in smaller towns and start combating the perception that the infrastructure is being developed only to migrate patients over to accessing their care through telehealth provided by physicians in the larger cities.

Many payers see telehealth as improving access and outcomes and already support it, but more payers need to become involved. All need to understand how routine and complex consultations, even inpatient consultations, can be performed remotely and can be properly reimbursed, and incentivized with payments for improved outcomes and value.

As barriers fall and telehealth improves, acceptance by patients and physicians will increase. In addition, telehealth will enter medical education in a significant way. The instruction that students, residents, and Fellows receive will be enhanced by new telehealth approaches in various specialties, and residents will come out of these programs with telehealth experience and a sense of both financial benefits and payment structures. This early exposure will pique their interest in using telehealth and advocating its use where it may never before have been considered, owing to real and perceived barriers.

Read about telehealth solutions for ObGyns.

Learning from other specialties and agencies

Dr. Brown: The physician shortage negatively affects access to health care in rural areas. Many city and suburban physicians, including ObGyns, want to stay where they are. Education is needed to show them that a rural practice can be successful. They would have a good patient base and be able to use telehealth to improve care and maintain contact with tertiary care centers.

Several task force members have described their experience within their health systems, and we hope to borrow from that. A health system in South Dakota received a Health Resources and Services Administration grant to use telehealth and teleconsultation in the Indian Health Service (IHS). To women who access their health care through the IHS, being able to remain in the community is culturally important. Telehealth and teleconsultation bring care to these women where they live.

To develop the best telehealth and teleconsultation model, we are borrowing from these health systems and from the experience of our colleagues in dermatology, behavioral health, psychiatry, and other disciplines. These physicians already have overcome many hurdles and discovered the importance of patient satisfaction in providing remote health care.

Patients will benefit in various ways, and here is another example: A clinic refers a patient to an ObGyn to discuss whether it is possible to have a vaginal birth after a cesarean delivery. The drive to the ObGyn’s office takes an hour, but the patient just as easily could have had all her questions answered during a teleconsultation.

Related articles:
Telehealth and you (4-part audiocast)

Telehealth recommendations for ObGyns

Dr. Brown: Our task force will develop recommended best practices for telehealth. We will outline how a practice can engage with telehealth and will address licensing requirements, as a practice must be licensed in each state where it uses telehealth. Our goal is to help our specialty get started in telehealth and telemedicine.

In practices with telehealth, it will be incumbent on ObGyns to identify any barriers to care. For example, we are concerned about early discontinuation of breastfeeding, particularly among African American communities. Fortunately, we have learned that video chat follow-ups can help improve breastfeeding continuation rates.

It also will be incumbent on ObGyns to think differently about how best to follow up. For a patient who calls to say she thinks she has mastitis, much of the consultation can be handled by telephone or video conference with the physician and a nurse practi‑tioner, and then medication can be prescribed without the need for in-person follow-up. We must then determine how to ensure these follow-up methods are compensated.

Final thoughts

Dr. Nielsen: It is time for all US health care players to more seriously and aggressively consider how telehealth can improve health care access, quality, and safety. Even more important, patients and physicians in small communities need to feel that they can access specialists and care that is as good as those available in larger communities without having to pull up stakes and move.

Telehealth can help small communities become sustainable over the long term. As the majority of the people in this country are born in and receive health care in community hospitals, not large tertiary care centers, the state of US health care should be measured by the ability to provide as much care as is technically possible in the small communities where patients live and work and raise their kids.

Dr. Brown: More than 50% of all babies are born in hospitals where fewer than 1,000 deliveries are performed, and almost 40% are born in hospitals where fewer than 500 are performed. To provide high-level care and have patients feel comfortable, to improve morbidity and mortality, we need telehealth and telemedicine.

If I can help a physician in East Africa place a Bakri balloon for postpartum hemorrhaging, surely I can help a physician in rural areas of Wyoming, South Dakota, or North Carolina deal with this obstetric emergency. In obstetrics and gynecology, telehealth and telemedicine have great potential in terms of morbidity and mortality, but we are also doing genetic counseling and a great deal of patient follow-up, and so much more can be done.

That is the key, and the reason for the training, the task force, the deliberations, and the best practices model that we will be sharing with our colleagues.

Share your thoughts! Send your Letter to the Editor to [email protected]. Please include your name and the city and state in which you practice.

Starting in 2010 with the Patient Protection and Affordable Care Act (ACA), our patients have had insurance that provides maternity care coverage, no-deductible or copay contraceptives, and access to breast cancer screening. They also have been protected from predatory insurance practices—such as preexisting condition exclusions, arbitrary rescission, and annual or lifetime coverage limits—which had previously and regularly been used to deny coverage. These landmark protections apply to all our patients, regardless of where they live, how much they earn, who their employers are, and which insurance plan they use. They have become part of the fabric of our society.

Between 2008 and 2010, members of the American College of Obstetricians and Gynecologists (ACOG) worked hard to define and help enact these provisions, which we considered the women’s piece of the health care reform puzzle. We also worked with a broad community of clinicians to try to make sure reform would benefit them too. That effort did not go as well, and ACOG ultimately did not endorse the ACA.

Early ACA troubles, misguided solutions

Since the ACA was signed into law 7 years ago, insurers have raised premiums and deductibles and narrowed their provider networks—putting needed care out of the reach of many patients. In addition, skyrocketing prescription drug prices have driven health care costs even higher. Against this backdrop, Congress in 2017 started trying to pass bills that would undo the ACA.

ACOG and our medical colleague organizations stepped up. We brought many ideas to House and Senate Republicans and Democrats and sought opportunities to work with them to improve the ACA for our physicians and patients. Unfortunately, the statute was so polarizing that few in Congress wanted to amend or revise it; most wanted it repealed or left as is.

Throughout these proceedings, ACOG remained committed to ensuring that no one with health insurance coverage would lose it and that Congress would not turn back the clock on women’s health. As long as these 2 principles were assured, we would work with anyone on improving health insurance.

Path to a better way

We delivered our message repeatedly. ACOG President Haywood Brown, MD, often accompanied by his American College of Physicians, American Academy of Pediatrics, American Academy of Family Physicians, American Psychiatric Association, and American Osteopathic Association counterparts, attended high-level meetings with Congressional Republicans and Democrats. Dr. Brown also led fly-ins of our members. In addition, ACOG Past President Tom Gellhaus, MD, together with all 600 ObGyns at the 2017 ACOG Congressional Leadership Conference, spoke out.

Somehow, though, the proposed bills kept getting worse—more patients would be losing coverage, and women’s health protections would be stripped away—and Congress was not seeking or including physician input. None at all.

The ACOG teleconference

In response, ACOG set up a member teleconference headed by Dr. Brown, Dr. Gellhaus, Incoming President Lisa Hollier, MD, Past President and ObGyn PAC Chair Mark DeFrancesco, MD, and Executive Vice President and CEO Hal Lawrence, MD. Discussing our concerns, we focused on the Senate’s Better Care Reconciliation Act (BCRA) and its potential impact on maternity care coverage, preexisting condition coverage, Medicaid, Planned Parenthood (PP), and the opioid epidemic.

BCRA

Dr. Brown led off the teleconference with this assessment: “Without a doubt, the BCRA would not result in better care for our patients. This legislation would pull the rug out from under women and families. The nonpartisan Congressional Budget Office estimated that 22 million Americans, more than half of them women, would lose coverage. More than $770 billion would be cut from Medicaid, the program that covers nearly half of all births nationwide as well as primary and preventive care for low-income patients.”

Coverage for maternity care and preexisting conditions

Dr. Gellhaus discussed how the BCRA would gut maternity care coverage and hurt patients with preexisting conditions. Under this bill, states would be able to drop the requirement for such coverage, thereby creating an enormous hole in patient care. He asked an important question: “If your state opted out and allowed private insurers not to offer maternity care or preventive care, what would this mean for your patients?”

His answer: “It would take us back to a time when only 9 states required insurers cover maternity care, and when only 12% of plans included such coverage; a time when patients had to buy expensive riders, sometimes with 12-month waiting periods, if they wanted maternity coverage; a time when expecting families faced thousands of dollars in out-of-pocket costs. Do we want to go back to that time? It is also important to note that roughly half of all pregnancies are unplanned. Pregnancy should not leave patients fearing bankruptcy and unable to afford the full range of prenatal and postnatal care.

“States that opt out of covering preventive care would discontinue no-copay coverage for women’s preventive services, including contraception. Fifty-five million American women currently have this coverage, and as a result the country’s unintended pregnancy rate is at a 30-year low, and its teen pregnancy rate the lowest in recorded history. We cannot go back.”

Medicaid

Dr. Hollier pointed out that the BCRA would cut $772 billion from Medicaid, ending the program as we know it and shifting costs to states. “This section alone would devastate our patients in every state,” she said.

ACOG is a strong supporter of Medicaid expansion, which increased access to primary and preventive care, including contraception, for low-income women who otherwise would not see a physician until they became pregnant. Thirty-two states and the District of Columbia expanded their Medicaid programs, and other states have expressed interest in doing the same.

Medicaid expansion was a major factor in the almost 50% decrease in the rate of uninsured women since 2010. The BCRA would roll back coverage for essential health benefits beginning in 2020 and end federal expansion funding by 2023.

Dr. Hollier continued, “Regular Medicaid would be threatened, too. The Senate bill would limit, for the first time ever, federal funding for Medicaid services per beneficiary. This would jeopardize the ability of the United States to respond to disasters and public health crises and pose a threat to health care coverage and benefits for tens of millions of Americans.”

“Given that nearly half of US births are covered by Medicaid, cutting this program would have a huge impact on our practices and on our patients with high-risk and expensive pregnancies. What happens when a low-income pregnant patient with hypertension, gestational diabetes, or preeclampsia reaches her Medicaid cap? What happens to a patient with an opioid use disorder or a patient who may have been exposed to the Zika virus? In all likelihood, physicians would have to continue providing care, regardless of coverage, or states would have to reduce physician payments to fill the gap in federal funding. I am sure you are as horrified as I am by these scenarios,” said Dr. Hollier.

Planned Parenthood

Dr. DeFrancesco discussed the threat to PP. First, he explained what defunding the organization would mean. “Planned Parenthood does not just receive a check from the government each year. Like other qualified providers, like us, PP health centers receive federal reimbursement for primary and preventive services provided to patients with Medicaid coverage. Fifty-four percent of these centers are located in rural and medically underserved communities.”

The BCRA would exclude PP health centers from the Medicaid program, which means Medicaid patients would be denied primary and preventive care at these centers. Within the first year, up to 1 million women would find their access to care restricted. In addition, about half of all PP centers would have to close, and most would not reopen. Dr. DeFrancesco asked, “How would this move help our patients? It wouldn’t.”

Two examples shed light on the situation. First, when PP was excluded from a Texas program serving low-income patients, the number of women using the most effective birth control methods decreased by 35%, and the number of Medicaid-covered births increased by 27%. Second, when public health funding cuts forced many Indiana clinics to close, rural areas of the state experienced one of the fastest and largest HIV outbreaks ever to occur in the United States.

Dr. DeFrancesco said, “Excluding Planned Parenthood from the Medicaid program interferes with the patient–physician relationship and sets a dangerous precedent of targeting qualified providers for political purposes.”

Opioid epidemic

Dr. Brown indicated that the BCRA would cripple attempts to address our very serious national opioid epidemic. The $2 billion the bill would allocate for opioid use disorder treatment for 1 year would replace funding lost by Medicaid and would pay for only a fraction of what is needed. Dr. Brown called this measure a “token, not a commitment, and a big step back in the progress we have made to address this public health crisis.”

The Hippocratic oath

While preparing for the teleconference, I kept thinking about the Hippocratic oath and our deep obligation to our patients. Every physician I know goes beyond the exam room to care for patients. We lose sleep not only when we get up to deliver babies, but when we worry about the ailing mother of four we saw yesterday, or the scared teenager who missed last week’s appointment. We care for our patients because it is the right thing to do, and it is our calling. Well, this year, our patients needed us more than ever. We had to step up, speak out, do everything we could to stop BCRA from passing. The stakes could not have been higher.

The vote, and the road ahead

The morning after Senators Collins, Murkowski, and McCain joined Senate Democrats to end the bill, Dr. Brown wrote the following to ACOG members and the US Congress:

“This was a battle we simply had to win to protect our patients. Thanks to your tireless advocacy, landmark women’s health care protections remain law, and millions of our patients will continue to get the care they need. And our work continues. The ACA is not perfect and needs major reform. ACOG is ready, willing, and able to work with Republicans and Democrats in the US House and Senate to reform the law, through an open and collaborative process. We hope it is clear to everyone in Congress that physicians must be part of the conversation and the solution.”

Starting in 2010 with the Patient Protection and Affordable Care Act (ACA), our patients have had insurance that provides maternity care coverage, no-deductible or copay contraceptives, and access to breast cancer screening. They also have been protected from predatory insurance practices—such as preexisting condition exclusions, arbitrary rescission, and annual or lifetime coverage limits—which had previously and regularly been used to deny coverage. These landmark protections apply to all our patients, regardless of where they live, how much they earn, who their employers are, and which insurance plan they use. They have become part of the fabric of our society.

Between 2008 and 2010, members of the American College of Obstetricians and Gynecologists (ACOG) worked hard to define and help enact these provisions, which we considered the women’s piece of the health care reform puzzle. We also worked with a broad community of clinicians to try to make sure reform would benefit them too. That effort did not go as well, and ACOG ultimately did not endorse the ACA.

Early ACA troubles, misguided solutions

Since the ACA was signed into law 7 years ago, insurers have raised premiums and deductibles and narrowed their provider networks—putting needed care out of the reach of many patients. In addition, skyrocketing prescription drug prices have driven health care costs even higher. Against this backdrop, Congress in 2017 started trying to pass bills that would undo the ACA.

ACOG and our medical colleague organizations stepped up. We brought many ideas to House and Senate Republicans and Democrats and sought opportunities to work with them to improve the ACA for our physicians and patients. Unfortunately, the statute was so polarizing that few in Congress wanted to amend or revise it; most wanted it repealed or left as is.

Throughout these proceedings, ACOG remained committed to ensuring that no one with health insurance coverage would lose it and that Congress would not turn back the clock on women’s health. As long as these 2 principles were assured, we would work with anyone on improving health insurance.

Path to a better way

We delivered our message repeatedly. ACOG President Haywood Brown, MD, often accompanied by his American College of Physicians, American Academy of Pediatrics, American Academy of Family Physicians, American Psychiatric Association, and American Osteopathic Association counterparts, attended high-level meetings with Congressional Republicans and Democrats. Dr. Brown also led fly-ins of our members. In addition, ACOG Past President Tom Gellhaus, MD, together with all 600 ObGyns at the 2017 ACOG Congressional Leadership Conference, spoke out.

Somehow, though, the proposed bills kept getting worse—more patients would be losing coverage, and women’s health protections would be stripped away—and Congress was not seeking or including physician input. None at all.

The ACOG teleconference

In response, ACOG set up a member teleconference headed by Dr. Brown, Dr. Gellhaus, Incoming President Lisa Hollier, MD, Past President and ObGyn PAC Chair Mark DeFrancesco, MD, and Executive Vice President and CEO Hal Lawrence, MD. Discussing our concerns, we focused on the Senate’s Better Care Reconciliation Act (BCRA) and its potential impact on maternity care coverage, preexisting condition coverage, Medicaid, Planned Parenthood (PP), and the opioid epidemic.

BCRA

Dr. Brown led off the teleconference with this assessment: “Without a doubt, the BCRA would not result in better care for our patients. This legislation would pull the rug out from under women and families. The nonpartisan Congressional Budget Office estimated that 22 million Americans, more than half of them women, would lose coverage. More than $770 billion would be cut from Medicaid, the program that covers nearly half of all births nationwide as well as primary and preventive care for low-income patients.”

Coverage for maternity care and preexisting conditions

Dr. Gellhaus discussed how the BCRA would gut maternity care coverage and hurt patients with preexisting conditions. Under this bill, states would be able to drop the requirement for such coverage, thereby creating an enormous hole in patient care. He asked an important question: “If your state opted out and allowed private insurers not to offer maternity care or preventive care, what would this mean for your patients?”

His answer: “It would take us back to a time when only 9 states required insurers cover maternity care, and when only 12% of plans included such coverage; a time when patients had to buy expensive riders, sometimes with 12-month waiting periods, if they wanted maternity coverage; a time when expecting families faced thousands of dollars in out-of-pocket costs. Do we want to go back to that time? It is also important to note that roughly half of all pregnancies are unplanned. Pregnancy should not leave patients fearing bankruptcy and unable to afford the full range of prenatal and postnatal care.

“States that opt out of covering preventive care would discontinue no-copay coverage for women’s preventive services, including contraception. Fifty-five million American women currently have this coverage, and as a result the country’s unintended pregnancy rate is at a 30-year low, and its teen pregnancy rate the lowest in recorded history. We cannot go back.”

Medicaid

Dr. Hollier pointed out that the BCRA would cut $772 billion from Medicaid, ending the program as we know it and shifting costs to states. “This section alone would devastate our patients in every state,” she said.

ACOG is a strong supporter of Medicaid expansion, which increased access to primary and preventive care, including contraception, for low-income women who otherwise would not see a physician until they became pregnant. Thirty-two states and the District of Columbia expanded their Medicaid programs, and other states have expressed interest in doing the same.

Medicaid expansion was a major factor in the almost 50% decrease in the rate of uninsured women since 2010. The BCRA would roll back coverage for essential health benefits beginning in 2020 and end federal expansion funding by 2023.

Dr. Hollier continued, “Regular Medicaid would be threatened, too. The Senate bill would limit, for the first time ever, federal funding for Medicaid services per beneficiary. This would jeopardize the ability of the United States to respond to disasters and public health crises and pose a threat to health care coverage and benefits for tens of millions of Americans.”

“Given that nearly half of US births are covered by Medicaid, cutting this program would have a huge impact on our practices and on our patients with high-risk and expensive pregnancies. What happens when a low-income pregnant patient with hypertension, gestational diabetes, or preeclampsia reaches her Medicaid cap? What happens to a patient with an opioid use disorder or a patient who may have been exposed to the Zika virus? In all likelihood, physicians would have to continue providing care, regardless of coverage, or states would have to reduce physician payments to fill the gap in federal funding. I am sure you are as horrified as I am by these scenarios,” said Dr. Hollier.

Planned Parenthood

Dr. DeFrancesco discussed the threat to PP. First, he explained what defunding the organization would mean. “Planned Parenthood does not just receive a check from the government each year. Like other qualified providers, like us, PP health centers receive federal reimbursement for primary and preventive services provided to patients with Medicaid coverage. Fifty-four percent of these centers are located in rural and medically underserved communities.”

The BCRA would exclude PP health centers from the Medicaid program, which means Medicaid patients would be denied primary and preventive care at these centers. Within the first year, up to 1 million women would find their access to care restricted. In addition, about half of all PP centers would have to close, and most would not reopen. Dr. DeFrancesco asked, “How would this move help our patients? It wouldn’t.”

Two examples shed light on the situation. First, when PP was excluded from a Texas program serving low-income patients, the number of women using the most effective birth control methods decreased by 35%, and the number of Medicaid-covered births increased by 27%. Second, when public health funding cuts forced many Indiana clinics to close, rural areas of the state experienced one of the fastest and largest HIV outbreaks ever to occur in the United States.

Dr. DeFrancesco said, “Excluding Planned Parenthood from the Medicaid program interferes with the patient–physician relationship and sets a dangerous precedent of targeting qualified providers for political purposes.”

Opioid epidemic

Dr. Brown indicated that the BCRA would cripple attempts to address our very serious national opioid epidemic. The $2 billion the bill would allocate for opioid use disorder treatment for 1 year would replace funding lost by Medicaid and would pay for only a fraction of what is needed. Dr. Brown called this measure a “token, not a commitment, and a big step back in the progress we have made to address this public health crisis.”

The Hippocratic oath

While preparing for the teleconference, I kept thinking about the Hippocratic oath and our deep obligation to our patients. Every physician I know goes beyond the exam room to care for patients. We lose sleep not only when we get up to deliver babies, but when we worry about the ailing mother of four we saw yesterday, or the scared teenager who missed last week’s appointment. We care for our patients because it is the right thing to do, and it is our calling. Well, this year, our patients needed us more than ever. We had to step up, speak out, do everything we could to stop BCRA from passing. The stakes could not have been higher.

The vote, and the road ahead

The morning after Senators Collins, Murkowski, and McCain joined Senate Democrats to end the bill, Dr. Brown wrote the following to ACOG members and the US Congress:

“This was a battle we simply had to win to protect our patients. Thanks to your tireless advocacy, landmark women’s health care protections remain law, and millions of our patients will continue to get the care they need. And our work continues. The ACA is not perfect and needs major reform. ACOG is ready, willing, and able to work with Republicans and Democrats in the US House and Senate to reform the law, through an open and collaborative process. We hope it is clear to everyone in Congress that physicians must be part of the conversation and the solution.”

Starting in 2010 with the Patient Protection and Affordable Care Act (ACA), our patients have had insurance that provides maternity care coverage, no-deductible or copay contraceptives, and access to breast cancer screening. They also have been protected from predatory insurance practices—such as preexisting condition exclusions, arbitrary rescission, and annual or lifetime coverage limits—which had previously and regularly been used to deny coverage. These landmark protections apply to all our patients, regardless of where they live, how much they earn, who their employers are, and which insurance plan they use. They have become part of the fabric of our society.

Between 2008 and 2010, members of the American College of Obstetricians and Gynecologists (ACOG) worked hard to define and help enact these provisions, which we considered the women’s piece of the health care reform puzzle. We also worked with a broad community of clinicians to try to make sure reform would benefit them too. That effort did not go as well, and ACOG ultimately did not endorse the ACA.

Early ACA troubles, misguided solutions

Since the ACA was signed into law 7 years ago, insurers have raised premiums and deductibles and narrowed their provider networks—putting needed care out of the reach of many patients. In addition, skyrocketing prescription drug prices have driven health care costs even higher. Against this backdrop, Congress in 2017 started trying to pass bills that would undo the ACA.

ACOG and our medical colleague organizations stepped up. We brought many ideas to House and Senate Republicans and Democrats and sought opportunities to work with them to improve the ACA for our physicians and patients. Unfortunately, the statute was so polarizing that few in Congress wanted to amend or revise it; most wanted it repealed or left as is.

Throughout these proceedings, ACOG remained committed to ensuring that no one with health insurance coverage would lose it and that Congress would not turn back the clock on women’s health. As long as these 2 principles were assured, we would work with anyone on improving health insurance.

Path to a better way

We delivered our message repeatedly. ACOG President Haywood Brown, MD, often accompanied by his American College of Physicians, American Academy of Pediatrics, American Academy of Family Physicians, American Psychiatric Association, and American Osteopathic Association counterparts, attended high-level meetings with Congressional Republicans and Democrats. Dr. Brown also led fly-ins of our members. In addition, ACOG Past President Tom Gellhaus, MD, together with all 600 ObGyns at the 2017 ACOG Congressional Leadership Conference, spoke out.

Somehow, though, the proposed bills kept getting worse—more patients would be losing coverage, and women’s health protections would be stripped away—and Congress was not seeking or including physician input. None at all.

The ACOG teleconference

In response, ACOG set up a member teleconference headed by Dr. Brown, Dr. Gellhaus, Incoming President Lisa Hollier, MD, Past President and ObGyn PAC Chair Mark DeFrancesco, MD, and Executive Vice President and CEO Hal Lawrence, MD. Discussing our concerns, we focused on the Senate’s Better Care Reconciliation Act (BCRA) and its potential impact on maternity care coverage, preexisting condition coverage, Medicaid, Planned Parenthood (PP), and the opioid epidemic.

BCRA

Dr. Brown led off the teleconference with this assessment: “Without a doubt, the BCRA would not result in better care for our patients. This legislation would pull the rug out from under women and families. The nonpartisan Congressional Budget Office estimated that 22 million Americans, more than half of them women, would lose coverage. More than $770 billion would be cut from Medicaid, the program that covers nearly half of all births nationwide as well as primary and preventive care for low-income patients.”

Coverage for maternity care and preexisting conditions

Dr. Gellhaus discussed how the BCRA would gut maternity care coverage and hurt patients with preexisting conditions. Under this bill, states would be able to drop the requirement for such coverage, thereby creating an enormous hole in patient care. He asked an important question: “If your state opted out and allowed private insurers not to offer maternity care or preventive care, what would this mean for your patients?”

His answer: “It would take us back to a time when only 9 states required insurers cover maternity care, and when only 12% of plans included such coverage; a time when patients had to buy expensive riders, sometimes with 12-month waiting periods, if they wanted maternity coverage; a time when expecting families faced thousands of dollars in out-of-pocket costs. Do we want to go back to that time? It is also important to note that roughly half of all pregnancies are unplanned. Pregnancy should not leave patients fearing bankruptcy and unable to afford the full range of prenatal and postnatal care.

“States that opt out of covering preventive care would discontinue no-copay coverage for women’s preventive services, including contraception. Fifty-five million American women currently have this coverage, and as a result the country’s unintended pregnancy rate is at a 30-year low, and its teen pregnancy rate the lowest in recorded history. We cannot go back.”

Medicaid

Dr. Hollier pointed out that the BCRA would cut $772 billion from Medicaid, ending the program as we know it and shifting costs to states. “This section alone would devastate our patients in every state,” she said.

ACOG is a strong supporter of Medicaid expansion, which increased access to primary and preventive care, including contraception, for low-income women who otherwise would not see a physician until they became pregnant. Thirty-two states and the District of Columbia expanded their Medicaid programs, and other states have expressed interest in doing the same.

Medicaid expansion was a major factor in the almost 50% decrease in the rate of uninsured women since 2010. The BCRA would roll back coverage for essential health benefits beginning in 2020 and end federal expansion funding by 2023.

Dr. Hollier continued, “Regular Medicaid would be threatened, too. The Senate bill would limit, for the first time ever, federal funding for Medicaid services per beneficiary. This would jeopardize the ability of the United States to respond to disasters and public health crises and pose a threat to health care coverage and benefits for tens of millions of Americans.”

“Given that nearly half of US births are covered by Medicaid, cutting this program would have a huge impact on our practices and on our patients with high-risk and expensive pregnancies. What happens when a low-income pregnant patient with hypertension, gestational diabetes, or preeclampsia reaches her Medicaid cap? What happens to a patient with an opioid use disorder or a patient who may have been exposed to the Zika virus? In all likelihood, physicians would have to continue providing care, regardless of coverage, or states would have to reduce physician payments to fill the gap in federal funding. I am sure you are as horrified as I am by these scenarios,” said Dr. Hollier.

Planned Parenthood

Dr. DeFrancesco discussed the threat to PP. First, he explained what defunding the organization would mean. “Planned Parenthood does not just receive a check from the government each year. Like other qualified providers, like us, PP health centers receive federal reimbursement for primary and preventive services provided to patients with Medicaid coverage. Fifty-four percent of these centers are located in rural and medically underserved communities.”

The BCRA would exclude PP health centers from the Medicaid program, which means Medicaid patients would be denied primary and preventive care at these centers. Within the first year, up to 1 million women would find their access to care restricted. In addition, about half of all PP centers would have to close, and most would not reopen. Dr. DeFrancesco asked, “How would this move help our patients? It wouldn’t.”

Two examples shed light on the situation. First, when PP was excluded from a Texas program serving low-income patients, the number of women using the most effective birth control methods decreased by 35%, and the number of Medicaid-covered births increased by 27%. Second, when public health funding cuts forced many Indiana clinics to close, rural areas of the state experienced one of the fastest and largest HIV outbreaks ever to occur in the United States.

Dr. DeFrancesco said, “Excluding Planned Parenthood from the Medicaid program interferes with the patient–physician relationship and sets a dangerous precedent of targeting qualified providers for political purposes.”

Opioid epidemic

Dr. Brown indicated that the BCRA would cripple attempts to address our very serious national opioid epidemic. The $2 billion the bill would allocate for opioid use disorder treatment for 1 year would replace funding lost by Medicaid and would pay for only a fraction of what is needed. Dr. Brown called this measure a “token, not a commitment, and a big step back in the progress we have made to address this public health crisis.”

The Hippocratic oath

While preparing for the teleconference, I kept thinking about the Hippocratic oath and our deep obligation to our patients. Every physician I know goes beyond the exam room to care for patients. We lose sleep not only when we get up to deliver babies, but when we worry about the ailing mother of four we saw yesterday, or the scared teenager who missed last week’s appointment. We care for our patients because it is the right thing to do, and it is our calling. Well, this year, our patients needed us more than ever. We had to step up, speak out, do everything we could to stop BCRA from passing. The stakes could not have been higher.

The vote, and the road ahead

The morning after Senators Collins, Murkowski, and McCain joined Senate Democrats to end the bill, Dr. Brown wrote the following to ACOG members and the US Congress:

“This was a battle we simply had to win to protect our patients. Thanks to your tireless advocacy, landmark women’s health care protections remain law, and millions of our patients will continue to get the care they need. And our work continues. The ACA is not perfect and needs major reform. ACOG is ready, willing, and able to work with Republicans and Democrats in the US House and Senate to reform the law, through an open and collaborative process. We hope it is clear to everyone in Congress that physicians must be part of the conversation and the solution.”

The United States undoubtedly will undergo tremendous change under its new President and Congress. These branches of government are already indicating their determination to rewrite a vast array of health care laws. If carried out, proposals regarding the Affordable Care Act, Medicare, and Medicaid will dramatically alter the landscape of women’s health care and significantly affect ObGyns and their patients.

These shifts are coming as ACOG’s top leadership undergoes its annual transition. In May 2017, we will thank American College of Obstetricians and Gynecologists (ACOG) President Thomas Gellhaus, MD, for his tremendous service and welcome Haywood Brown, MD, as our new President.

With so much uncertainty ahead, I recently asked these 2 leaders for their reflections, predictions, hardest challenges, and plans to help our specialty surmount any new obstacles to move forward with positive initiatives.

What have we faced down in the past year; what faces us now?

Thomas Gellhaus, MD: When I took this position almost 1 year ago, our specialty and our ability to care for patients were challenged on 3 fronts: MACRA, workforce, and politics.

Through the efforts of a united American Medical Association, we saw MACRA, the Medicare Access and CHIP (Children’s Health Insurance Program) Reauthorization Act of 2015, replace the sustainable growth rate formula, which would have drastically reduced provider payments under Medicare’s Physician Fee Schedule. With this change, a major challenge was crossed off our list and a major new one added. Now, we must ensure proper enactment of MACRA’s new payment system and be continually vigilant with respect to its implementation.

Second, we must ensure there are enough ObGyns to care for patients nationally, across all areas of the country. We must find new ways to recruit ObGyns and maintain and expand our workforce.

Third, we must stand firm against political interference. The future of our patients, our practices, and our specialty depend on it. Only 2 people are allowed in the exam room—the patient and her ObGyn—and we must close its door to politicians who want to make decisions about the kind of care our patients need and how we should provide it. We must defeat the many state efforts to decree or limit care. Patient’s access to care, including reproductive care, must not be subject to politics.

These challenges can be opportunities. For example, the more we make MACRA work for practicing ObGyns now, the brighter our future will be, as private payers likely will be following suit.

Ilustration: Paul Zwolak for OBG Management

We stand with patients on reproductive rights and access to care

Haywood Brown, MD: We face several challenges. First, when we become ObGyns, we join our patients in taking on the everyday challenges of women’s health care, reproduction, and reproductive rights. These will continue to be major issues for our specialty. In addition, in our continued efforts to address health care disparities, we must take the lead at ACOG as well as enlist other women’s health care providers as partners. Too often, access to high-quality perinatal, cancer, and other women’s health care is determined or influenced by a patient’s race, residence, or income. This must change.

A future for team-based care

Another challenge is to define clinical practice expectations for the newer generations of Fellows. We must impart to Junior Fellows that team-based care will:

• help them see obstetrics and gynecology as an immensely satisfying calling and career rather than as just a job
• contribute to the expansion of care to women in all communities
• allow for the maintenance of a good work–life balance for many years. (See “Steps to address ObGyn work–life balance” on page 30.)

It’s a new Washington. We are poised for new challenges.

Dr. Gellhaus: With the new US President, Congress, governors, and state legislators in office, a new challenge is to maintain the women’s health protections in the Affordable Care Act—particularly insurance coverage for maternity care and preventive and contraceptive services. We must guard against a resurgence in the number of the uninsured and underinsured, including patients whose health insurance is cut off once they become seriously ill or reach their annual or lifetime coverage limit.

We also must be ready to fight the anticipated onslaught of state and federal attempts to limit our patients’ access to reproductive health care. Many of us remember the days of illegal, unsafe abortions and their devastating effects on women’s health. No lawmaker should doubt that having access to contraceptives helps reduce the rates of unwanted pregnancies and abortions, improves maternal and infant outcomes, and decreases health care costs. It’s a win-win!

Groundwork has been laid, and opportunities will surface

Dr. Gellhaus: The best opportunities will emerge from our long-standing history of bipartisan political cooperation in this area, as we work with lawmakers from both parties on issues that benefit ObGyns and their patients. Over the years, ACOG has well positioned itself and developed important long-term relationships with Republican and Democratic lawmakers to focus on women’s health as a central issue. This position will give ACOG a voice in the new federal Administration, in Congress, and in state houses.

We also will have opportunities to educate elected officials, debunk many of the false or mistaken ideas surrounding contraceptive methods, and reinforce the need for politicians to stop interfering with the sacred physician–patient relationship and stay out of our exam rooms.

Our commitment to our patients is strong

Dr. Brown: It is more important than ever for ACOG to affirm its commitment to women’s reproductive choices and their access to contraceptives—especially with respect to programs funded by Medicaid and Title X. In the United States, Medicaid covers 48% of all births, as well as preventive and screening services provided by Planned Parenthood clinics. Over the next years, these programs will be challenged and could fall into jeopardy. We must remind our Fellows that both Title X contraception coverage and abortion choice have been the law of the land for almost 50 years. We cannot allow politicians to return us to an era that was far worse for our patients.

Steps to address ObGyn work-life balance

In my article, "ObGyn burnout: ACOG takes aim," published in the August 2016 issue of OBG Management, Thomas Gellhaus, MD, current President of the American Congress of Obstetricians and Gynecologists (ACOG), while recognizing that physician satisfaction is affected by increasing bureaucratic tasks that can be seen as obstacles to patient care, offered several strategies to maintain career satisfaction. Those strategies included mentorship, global volunteering, and advocacy.

I asked Haywood Brown, MD, the incoming ACOG President as of May 2017, how he views ACOG's role in addressing a main reason for ObGyn burnout--the increasing burden of compliance with required electronic documentation.

Haywood Brown, MD: We must develop new models of care that foster the ability of ObGyns to embrace practicing the depth and breadth of ObGyn long term, and maintain their enthusiasm about providing care to women throughout the life span. Compliance and electronic documentation requirements can enhance patient care by allowing us to better communicate with our practice partners and our patients, improve quality, safety, and patient satisfaction. It can also quickly wear us down.

Burnout can be reduced through shared practice models, development of niches within shared practices, and being creative with better incorporating advanced practice providers into team-based care. I sincerely believe that if we embrace new models of clinical practice, the satisfaction for what we are trained to do will improve and burnout will be less a threat to our specialty over time.

All-In for Advocacy tops presidential initiatives list

Dr. Gellhaus: With political legislative interference increasing across all of medicine, we need a unified, powerful, cohesive voice. Advocacy is at the top of my presidential initiatives list. The voice of our national organization can have a huge impact on maintaining and improving women’s health care in the United States. That is why All-In for Advocacy is vital. This initiative has significantly increased members’ involvement in ACOG. We will harness this power to pass vital legislation to help the women we serve and our specialty.

Addressing health disparities drives career and presidential focus

Dr. Brown: My presidential initiatives are rooted in my career decision to focus on health disparities, particularly race-based health disparities.

Maternal morbidity and mortality and infant mortality are complex issues shrouded in the social determinants of health. Access to care, fragmentation of care, and quality of care are other factors relevant in disparity. There is evidence of an implicit bias in health care delivery.

My telehealth initiative will focus on implementing Levels of Maternal Care (of which there are 4), the National Partnership for Maternal Safety (NPMS), and the Alliance for Innovation on Maternal Health (AIM) as well as redefining healthy pregnancies and postpartum periods as the gateway to women’s long-term health. The February 2015 Levels of Maternal Care Obstetric Care Consensus Statement, jointly issued by ACOG and the Society for Maternal–Fetal Medicine (SMFM),¹ proposes a classification system for birth centers, from basic to specialized regional perinatal health care centers. ACOG is working with hospitals throughout the country to designate the Levels of Maternal Care and thereby ensure each patient receives the appropriate level of care.

The AIM program, led by ACOG and funded by the Health Resources and Services Administration (HRSA), reduces obstetric complications by encouraging hospitals to adopt defined evidence-based patient safety measures. The goal is to prevent 100,000 severe labor and delivery complications and 1,000 maternal deaths over 4 years.

ACOG is committed to a “big tent” approach

Dr. Gellhaus: Like US citizens, ACOG represents members with many points of view. ACOG can best represent our members’ diversity in the future by remaining the moderate voice, and by opposing federal and state proposals that are inconsistent with facts and science. We need to bring to our membership’s attention the federal and state successes we have had, show how they have helped our patients and our specialty, and make it clear that our successes are due to our bipartisan work over the years, which we have achieved regardless of which political party has been in office.

For ACOG to continue to be a leader in women’s health care and our specialty, we must remain vigilant against political interference in the patient–physician relationship and be ready to counter with science, facts, and evidence.

Compassion and passion lie at the heart of member similarities

Dr. Brown: First and foremost, we ObGyns care about our patients and, regardless of personal politics, most of us understand the reproductive health challenges facing the women of this country as well as our history with respect to those challenges. All of us must be willing to provide counsel to patients when needed, and that counseling must be nonjudgmental. We also must be willing to protect confidentially and to refer patients whose decisions are at odds with our personal views.

ACOG recognizes that we are a melting pot of specialists and subspecialists and that we are all guided by our personal beliefs and values. Choosing to become an exclusive women’s health care physician requires our passion and compassion.

Let us use our collective voice!

Dr. Gellhaus: Our members must realize the power of our collective voice and that we must use it to deliver a unified, cohesive message. We cannot sit on the sidelines and expect others to speak for us. If we are not part of the solution, then we cede our future to others and have no right to complain about the result. Our members need to commit to advocating outside their exam rooms. A good first step is to see how ACOG makes advocacy easy. When thousands of ACOG members contact elected officials about important issues, officials listen.

Dr. Brown: Yes! We all need to get involved in ACOG and in our communities. Together, we will accomplish many important things.

[polldaddy:9703185]

The United States undoubtedly will undergo tremendous change under its new President and Congress. These branches of government are already indicating their determination to rewrite a vast array of health care laws. If carried out, proposals regarding the Affordable Care Act, Medicare, and Medicaid will dramatically alter the landscape of women’s health care and significantly affect ObGyns and their patients.

These shifts are coming as ACOG’s top leadership undergoes its annual transition. In May 2017, we will thank American College of Obstetricians and Gynecologists (ACOG) President Thomas Gellhaus, MD, for his tremendous service and welcome Haywood Brown, MD, as our new President.

With so much uncertainty ahead, I recently asked these 2 leaders for their reflections, predictions, hardest challenges, and plans to help our specialty surmount any new obstacles to move forward with positive initiatives.

What have we faced down in the past year; what faces us now?

Thomas Gellhaus, MD: When I took this position almost 1 year ago, our specialty and our ability to care for patients were challenged on 3 fronts: MACRA, workforce, and politics.

Through the efforts of a united American Medical Association, we saw MACRA, the Medicare Access and CHIP (Children’s Health Insurance Program) Reauthorization Act of 2015, replace the sustainable growth rate formula, which would have drastically reduced provider payments under Medicare’s Physician Fee Schedule. With this change, a major challenge was crossed off our list and a major new one added. Now, we must ensure proper enactment of MACRA’s new payment system and be continually vigilant with respect to its implementation.

Second, we must ensure there are enough ObGyns to care for patients nationally, across all areas of the country. We must find new ways to recruit ObGyns and maintain and expand our workforce.

Third, we must stand firm against political interference. The future of our patients, our practices, and our specialty depend on it. Only 2 people are allowed in the exam room—the patient and her ObGyn—and we must close its door to politicians who want to make decisions about the kind of care our patients need and how we should provide it. We must defeat the many state efforts to decree or limit care. Patient’s access to care, including reproductive care, must not be subject to politics.

These challenges can be opportunities. For example, the more we make MACRA work for practicing ObGyns now, the brighter our future will be, as private payers likely will be following suit.

Ilustration: Paul Zwolak for OBG Management

We stand with patients on reproductive rights and access to care

Haywood Brown, MD: We face several challenges. First, when we become ObGyns, we join our patients in taking on the everyday challenges of women’s health care, reproduction, and reproductive rights. These will continue to be major issues for our specialty. In addition, in our continued efforts to address health care disparities, we must take the lead at ACOG as well as enlist other women’s health care providers as partners. Too often, access to high-quality perinatal, cancer, and other women’s health care is determined or influenced by a patient’s race, residence, or income. This must change.

A future for team-based care

Another challenge is to define clinical practice expectations for the newer generations of Fellows. We must impart to Junior Fellows that team-based care will:

• help them see obstetrics and gynecology as an immensely satisfying calling and career rather than as just a job
• contribute to the expansion of care to women in all communities
• allow for the maintenance of a good work–life balance for many years. (See “Steps to address ObGyn work–life balance” on page 30.)

It’s a new Washington. We are poised for new challenges.

Dr. Gellhaus: With the new US President, Congress, governors, and state legislators in office, a new challenge is to maintain the women’s health protections in the Affordable Care Act—particularly insurance coverage for maternity care and preventive and contraceptive services. We must guard against a resurgence in the number of the uninsured and underinsured, including patients whose health insurance is cut off once they become seriously ill or reach their annual or lifetime coverage limit.

We also must be ready to fight the anticipated onslaught of state and federal attempts to limit our patients’ access to reproductive health care. Many of us remember the days of illegal, unsafe abortions and their devastating effects on women’s health. No lawmaker should doubt that having access to contraceptives helps reduce the rates of unwanted pregnancies and abortions, improves maternal and infant outcomes, and decreases health care costs. It’s a win-win!

Groundwork has been laid, and opportunities will surface

Dr. Gellhaus: The best opportunities will emerge from our long-standing history of bipartisan political cooperation in this area, as we work with lawmakers from both parties on issues that benefit ObGyns and their patients. Over the years, ACOG has well positioned itself and developed important long-term relationships with Republican and Democratic lawmakers to focus on women’s health as a central issue. This position will give ACOG a voice in the new federal Administration, in Congress, and in state houses.

We also will have opportunities to educate elected officials, debunk many of the false or mistaken ideas surrounding contraceptive methods, and reinforce the need for politicians to stop interfering with the sacred physician–patient relationship and stay out of our exam rooms.

Our commitment to our patients is strong

Dr. Brown: It is more important than ever for ACOG to affirm its commitment to women’s reproductive choices and their access to contraceptives—especially with respect to programs funded by Medicaid and Title X. In the United States, Medicaid covers 48% of all births, as well as preventive and screening services provided by Planned Parenthood clinics. Over the next years, these programs will be challenged and could fall into jeopardy. We must remind our Fellows that both Title X contraception coverage and abortion choice have been the law of the land for almost 50 years. We cannot allow politicians to return us to an era that was far worse for our patients.

Steps to address ObGyn work-life balance

In my article, "ObGyn burnout: ACOG takes aim," published in the August 2016 issue of OBG Management, Thomas Gellhaus, MD, current President of the American Congress of Obstetricians and Gynecologists (ACOG), while recognizing that physician satisfaction is affected by increasing bureaucratic tasks that can be seen as obstacles to patient care, offered several strategies to maintain career satisfaction. Those strategies included mentorship, global volunteering, and advocacy.

I asked Haywood Brown, MD, the incoming ACOG President as of May 2017, how he views ACOG's role in addressing a main reason for ObGyn burnout--the increasing burden of compliance with required electronic documentation.

Haywood Brown, MD: We must develop new models of care that foster the ability of ObGyns to embrace practicing the depth and breadth of ObGyn long term, and maintain their enthusiasm about providing care to women throughout the life span. Compliance and electronic documentation requirements can enhance patient care by allowing us to better communicate with our practice partners and our patients, improve quality, safety, and patient satisfaction. It can also quickly wear us down.

Burnout can be reduced through shared practice models, development of niches within shared practices, and being creative with better incorporating advanced practice providers into team-based care. I sincerely believe that if we embrace new models of clinical practice, the satisfaction for what we are trained to do will improve and burnout will be less a threat to our specialty over time.

All-In for Advocacy tops presidential initiatives list

Dr. Gellhaus: With political legislative interference increasing across all of medicine, we need a unified, powerful, cohesive voice. Advocacy is at the top of my presidential initiatives list. The voice of our national organization can have a huge impact on maintaining and improving women’s health care in the United States. That is why All-In for Advocacy is vital. This initiative has significantly increased members’ involvement in ACOG. We will harness this power to pass vital legislation to help the women we serve and our specialty.

Addressing health disparities drives career and presidential focus

Dr. Brown: My presidential initiatives are rooted in my career decision to focus on health disparities, particularly race-based health disparities.

Maternal morbidity and mortality and infant mortality are complex issues shrouded in the social determinants of health. Access to care, fragmentation of care, and quality of care are other factors relevant in disparity. There is evidence of an implicit bias in health care delivery.

My telehealth initiative will focus on implementing Levels of Maternal Care (of which there are 4), the National Partnership for Maternal Safety (NPMS), and the Alliance for Innovation on Maternal Health (AIM) as well as redefining healthy pregnancies and postpartum periods as the gateway to women’s long-term health. The February 2015 Levels of Maternal Care Obstetric Care Consensus Statement, jointly issued by ACOG and the Society for Maternal–Fetal Medicine (SMFM),¹ proposes a classification system for birth centers, from basic to specialized regional perinatal health care centers. ACOG is working with hospitals throughout the country to designate the Levels of Maternal Care and thereby ensure each patient receives the appropriate level of care.

The AIM program, led by ACOG and funded by the Health Resources and Services Administration (HRSA), reduces obstetric complications by encouraging hospitals to adopt defined evidence-based patient safety measures. The goal is to prevent 100,000 severe labor and delivery complications and 1,000 maternal deaths over 4 years.

ACOG is committed to a “big tent” approach

Dr. Gellhaus: Like US citizens, ACOG represents members with many points of view. ACOG can best represent our members’ diversity in the future by remaining the moderate voice, and by opposing federal and state proposals that are inconsistent with facts and science. We need to bring to our membership’s attention the federal and state successes we have had, show how they have helped our patients and our specialty, and make it clear that our successes are due to our bipartisan work over the years, which we have achieved regardless of which political party has been in office.

For ACOG to continue to be a leader in women’s health care and our specialty, we must remain vigilant against political interference in the patient–physician relationship and be ready to counter with science, facts, and evidence.

Compassion and passion lie at the heart of member similarities

Dr. Brown: First and foremost, we ObGyns care about our patients and, regardless of personal politics, most of us understand the reproductive health challenges facing the women of this country as well as our history with respect to those challenges. All of us must be willing to provide counsel to patients when needed, and that counseling must be nonjudgmental. We also must be willing to protect confidentially and to refer patients whose decisions are at odds with our personal views.

ACOG recognizes that we are a melting pot of specialists and subspecialists and that we are all guided by our personal beliefs and values. Choosing to become an exclusive women’s health care physician requires our passion and compassion.

Let us use our collective voice!

Dr. Gellhaus: Our members must realize the power of our collective voice and that we must use it to deliver a unified, cohesive message. We cannot sit on the sidelines and expect others to speak for us. If we are not part of the solution, then we cede our future to others and have no right to complain about the result. Our members need to commit to advocating outside their exam rooms. A good first step is to see how ACOG makes advocacy easy. When thousands of ACOG members contact elected officials about important issues, officials listen.

Dr. Brown: Yes! We all need to get involved in ACOG and in our communities. Together, we will accomplish many important things.

[polldaddy:9703185]

The United States undoubtedly will undergo tremendous change under its new President and Congress. These branches of government are already indicating their determination to rewrite a vast array of health care laws. If carried out, proposals regarding the Affordable Care Act, Medicare, and Medicaid will dramatically alter the landscape of women’s health care and significantly affect ObGyns and their patients.

These shifts are coming as ACOG’s top leadership undergoes its annual transition. In May 2017, we will thank American College of Obstetricians and Gynecologists (ACOG) President Thomas Gellhaus, MD, for his tremendous service and welcome Haywood Brown, MD, as our new President.

With so much uncertainty ahead, I recently asked these 2 leaders for their reflections, predictions, hardest challenges, and plans to help our specialty surmount any new obstacles to move forward with positive initiatives.

What have we faced down in the past year; what faces us now?

Thomas Gellhaus, MD: When I took this position almost 1 year ago, our specialty and our ability to care for patients were challenged on 3 fronts: MACRA, workforce, and politics.

Through the efforts of a united American Medical Association, we saw MACRA, the Medicare Access and CHIP (Children’s Health Insurance Program) Reauthorization Act of 2015, replace the sustainable growth rate formula, which would have drastically reduced provider payments under Medicare’s Physician Fee Schedule. With this change, a major challenge was crossed off our list and a major new one added. Now, we must ensure proper enactment of MACRA’s new payment system and be continually vigilant with respect to its implementation.

Second, we must ensure there are enough ObGyns to care for patients nationally, across all areas of the country. We must find new ways to recruit ObGyns and maintain and expand our workforce.

Third, we must stand firm against political interference. The future of our patients, our practices, and our specialty depend on it. Only 2 people are allowed in the exam room—the patient and her ObGyn—and we must close its door to politicians who want to make decisions about the kind of care our patients need and how we should provide it. We must defeat the many state efforts to decree or limit care. Patient’s access to care, including reproductive care, must not be subject to politics.

These challenges can be opportunities. For example, the more we make MACRA work for practicing ObGyns now, the brighter our future will be, as private payers likely will be following suit.

Ilustration: Paul Zwolak for OBG Management

We stand with patients on reproductive rights and access to care

Haywood Brown, MD: We face several challenges. First, when we become ObGyns, we join our patients in taking on the everyday challenges of women’s health care, reproduction, and reproductive rights. These will continue to be major issues for our specialty. In addition, in our continued efforts to address health care disparities, we must take the lead at ACOG as well as enlist other women’s health care providers as partners. Too often, access to high-quality perinatal, cancer, and other women’s health care is determined or influenced by a patient’s race, residence, or income. This must change.

A future for team-based care

Another challenge is to define clinical practice expectations for the newer generations of Fellows. We must impart to Junior Fellows that team-based care will:

• help them see obstetrics and gynecology as an immensely satisfying calling and career rather than as just a job
• contribute to the expansion of care to women in all communities
• allow for the maintenance of a good work–life balance for many years. (See “Steps to address ObGyn work–life balance” on page 30.)

It’s a new Washington. We are poised for new challenges.

Dr. Gellhaus: With the new US President, Congress, governors, and state legislators in office, a new challenge is to maintain the women’s health protections in the Affordable Care Act—particularly insurance coverage for maternity care and preventive and contraceptive services. We must guard against a resurgence in the number of the uninsured and underinsured, including patients whose health insurance is cut off once they become seriously ill or reach their annual or lifetime coverage limit.

We also must be ready to fight the anticipated onslaught of state and federal attempts to limit our patients’ access to reproductive health care. Many of us remember the days of illegal, unsafe abortions and their devastating effects on women’s health. No lawmaker should doubt that having access to contraceptives helps reduce the rates of unwanted pregnancies and abortions, improves maternal and infant outcomes, and decreases health care costs. It’s a win-win!

Groundwork has been laid, and opportunities will surface

Dr. Gellhaus: The best opportunities will emerge from our long-standing history of bipartisan political cooperation in this area, as we work with lawmakers from both parties on issues that benefit ObGyns and their patients. Over the years, ACOG has well positioned itself and developed important long-term relationships with Republican and Democratic lawmakers to focus on women’s health as a central issue. This position will give ACOG a voice in the new federal Administration, in Congress, and in state houses.

We also will have opportunities to educate elected officials, debunk many of the false or mistaken ideas surrounding contraceptive methods, and reinforce the need for politicians to stop interfering with the sacred physician–patient relationship and stay out of our exam rooms.

Our commitment to our patients is strong

Dr. Brown: It is more important than ever for ACOG to affirm its commitment to women’s reproductive choices and their access to contraceptives—especially with respect to programs funded by Medicaid and Title X. In the United States, Medicaid covers 48% of all births, as well as preventive and screening services provided by Planned Parenthood clinics. Over the next years, these programs will be challenged and could fall into jeopardy. We must remind our Fellows that both Title X contraception coverage and abortion choice have been the law of the land for almost 50 years. We cannot allow politicians to return us to an era that was far worse for our patients.

Steps to address ObGyn work-life balance

In my article, "ObGyn burnout: ACOG takes aim," published in the August 2016 issue of OBG Management, Thomas Gellhaus, MD, current President of the American Congress of Obstetricians and Gynecologists (ACOG), while recognizing that physician satisfaction is affected by increasing bureaucratic tasks that can be seen as obstacles to patient care, offered several strategies to maintain career satisfaction. Those strategies included mentorship, global volunteering, and advocacy.

I asked Haywood Brown, MD, the incoming ACOG President as of May 2017, how he views ACOG's role in addressing a main reason for ObGyn burnout--the increasing burden of compliance with required electronic documentation.

Haywood Brown, MD: We must develop new models of care that foster the ability of ObGyns to embrace practicing the depth and breadth of ObGyn long term, and maintain their enthusiasm about providing care to women throughout the life span. Compliance and electronic documentation requirements can enhance patient care by allowing us to better communicate with our practice partners and our patients, improve quality, safety, and patient satisfaction. It can also quickly wear us down.

Burnout can be reduced through shared practice models, development of niches within shared practices, and being creative with better incorporating advanced practice providers into team-based care. I sincerely believe that if we embrace new models of clinical practice, the satisfaction for what we are trained to do will improve and burnout will be less a threat to our specialty over time.

All-In for Advocacy tops presidential initiatives list

Dr. Gellhaus: With political legislative interference increasing across all of medicine, we need a unified, powerful, cohesive voice. Advocacy is at the top of my presidential initiatives list. The voice of our national organization can have a huge impact on maintaining and improving women’s health care in the United States. That is why All-In for Advocacy is vital. This initiative has significantly increased members’ involvement in ACOG. We will harness this power to pass vital legislation to help the women we serve and our specialty.

Addressing health disparities drives career and presidential focus

Dr. Brown: My presidential initiatives are rooted in my career decision to focus on health disparities, particularly race-based health disparities.

Maternal morbidity and mortality and infant mortality are complex issues shrouded in the social determinants of health. Access to care, fragmentation of care, and quality of care are other factors relevant in disparity. There is evidence of an implicit bias in health care delivery.

My telehealth initiative will focus on implementing Levels of Maternal Care (of which there are 4), the National Partnership for Maternal Safety (NPMS), and the Alliance for Innovation on Maternal Health (AIM) as well as redefining healthy pregnancies and postpartum periods as the gateway to women’s long-term health. The February 2015 Levels of Maternal Care Obstetric Care Consensus Statement, jointly issued by ACOG and the Society for Maternal–Fetal Medicine (SMFM),¹ proposes a classification system for birth centers, from basic to specialized regional perinatal health care centers. ACOG is working with hospitals throughout the country to designate the Levels of Maternal Care and thereby ensure each patient receives the appropriate level of care.

The AIM program, led by ACOG and funded by the Health Resources and Services Administration (HRSA), reduces obstetric complications by encouraging hospitals to adopt defined evidence-based patient safety measures. The goal is to prevent 100,000 severe labor and delivery complications and 1,000 maternal deaths over 4 years.

ACOG is committed to a “big tent” approach

Dr. Gellhaus: Like US citizens, ACOG represents members with many points of view. ACOG can best represent our members’ diversity in the future by remaining the moderate voice, and by opposing federal and state proposals that are inconsistent with facts and science. We need to bring to our membership’s attention the federal and state successes we have had, show how they have helped our patients and our specialty, and make it clear that our successes are due to our bipartisan work over the years, which we have achieved regardless of which political party has been in office.

For ACOG to continue to be a leader in women’s health care and our specialty, we must remain vigilant against political interference in the patient–physician relationship and be ready to counter with science, facts, and evidence.

Compassion and passion lie at the heart of member similarities

Dr. Brown: First and foremost, we ObGyns care about our patients and, regardless of personal politics, most of us understand the reproductive health challenges facing the women of this country as well as our history with respect to those challenges. All of us must be willing to provide counsel to patients when needed, and that counseling must be nonjudgmental. We also must be willing to protect confidentially and to refer patients whose decisions are at odds with our personal views.

ACOG recognizes that we are a melting pot of specialists and subspecialists and that we are all guided by our personal beliefs and values. Choosing to become an exclusive women’s health care physician requires our passion and compassion.

Let us use our collective voice!

Dr. Gellhaus: Our members must realize the power of our collective voice and that we must use it to deliver a unified, cohesive message. We cannot sit on the sidelines and expect others to speak for us. If we are not part of the solution, then we cede our future to others and have no right to complain about the result. Our members need to commit to advocating outside their exam rooms. A good first step is to see how ACOG makes advocacy easy. When thousands of ACOG members contact elected officials about important issues, officials listen.

Dr. Brown: Yes! We all need to get involved in ACOG and in our communities. Together, we will accomplish many important things.

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Related content on burnout:

• Is burnout on the rise and what are the signs ObGyns should be on the lookout for?
• ObGyn burnout: ACOG takes aim
• Strategies for maintaining resilience to the burnout threat

Related content on burnout:

• Is burnout on the rise and what are the signs ObGyns should be on the lookout for?
• ObGyn burnout: ACOG takes aim
• Strategies for maintaining resilience to the burnout threat

Related content on burnout:

• Is burnout on the rise and what are the signs ObGyns should be on the lookout for?
• ObGyn burnout: ACOG takes aim
• Strategies for maintaining resilience to the burnout threat

In a peer-to-peer audiocast, Ms. DiVenere probed Dr. Smith for the problem areas that appear in the early to late stages of burnout. He spoke to the stressors that residents experience in the learning situation and that ObGyns must deal with in practice, as well as described strategies to deal with that stress.   

Have you read "ObGyn burnout: ACOG takes aim," by Lucia DiVenere, MA (September 2016)?

In a peer-to-peer audiocast, Ms. DiVenere probed Dr. Smith for the problem areas that appear in the early to late stages of burnout. He spoke to the stressors that residents experience in the learning situation and that ObGyns must deal with in practice, as well as described strategies to deal with that stress.   

Have you read "ObGyn burnout: ACOG takes aim," by Lucia DiVenere, MA (September 2016)?

In a peer-to-peer audiocast, Ms. DiVenere probed Dr. Smith for the problem areas that appear in the early to late stages of burnout. He spoke to the stressors that residents experience in the learning situation and that ObGyns must deal with in practice, as well as described strategies to deal with that stress.   

Have you read "ObGyn burnout: ACOG takes aim," by Lucia DiVenere, MA (September 2016)?