Disparities and Social Determinants Impacting Care for Endometriosis

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Maria Lopes, MD, MS: Health inequalities and social determinants of health are now something that has been touted in the quintuple aim, big things that payers typically pay attention to. Part of the quintuple aim is health equity and health disparities. That’s the fifth element that was recently added. I’m wondering if Tara can comment on this. Is this true of endometriosis? Has it been worsened by COVID-19?

Tara Hilton: Yes, in our endometriosis community, we definitely see a lot of disparities, and not just among insurance. Some of the ladies who have state Medicaid have a very hard time getting in to see a reproductive endocrinologist. They don’t necessarily have the same access to some of the higher-cost medicines that might help them more. That’s definitely one of the disparities we see a lot, and one of the most frequent requests we get for help for referrals for advocacy.

When the COVID-19 pandemic first hit, a lot of the endometriosis sufferers in our community were impacted because their doctors’ offices were closed. They weren’t able to get their GnRH [gonadotropin-releasing hormone] drugs because they have to be administered in a clinician’s office. They weren’t able to get their endometriosis surgeries. Maybe they had been scheduled for months, and then all of a sudden hospitals needed the ORs [operating rooms] for a lot of the pandemic-type surgeries and critical life-threatening surgeries. Patients with endometriosis were back in pain, at home, and not able to even get their next dose of the GnRH. Then they were no longer suppressed and the pain symptoms came back, so it was definitely a challenge.

COVID-19 has hit it hard, and like a lot of other things in the world, some of the GYN [gynecological] offices are short-staffed, so they aren’t taking new patients, or it’s very hard to get that appointment. A lot of people in the community are saying, “Can you help me find a doctor’s office that takes Medicaid and will take a new patient?” It has definitely created a perfect storm in already existing medical disparity.

Maria Lopes, MD, MS: Absolutely. Dr Surrey, what has been your experience? Are you offering alternative services, including telehealth? How can we bridge this gap in terms of access?

Eric Surrey, MD: With all aspects of medicine, the issue of disparity in health care became magnified when COVID-19 came to the fore, which is good news and bad news. COVID-19 wasn’t the good news, but it drove home this total disparity within our social framework. This is more of a national issue that I don’t think is going to be addressed by a single clinician, but it needs to be addressed with making sure that there’s a safety net for folks. Things like pelvic pain tend to be put on the back burner unless you have it. We tend to think this isn’t quite so important.

I feel that the pandemic played a big role in medical practice. Our practice was closed for months, but it increased access to telehealth. My practice is unique in that it had a large out-of-state population to begin with, so it wasn’t that hard for us to segue into doing telehealth, which I had been doing before. It has a certain positive too. Although you can’t lay hands on a patient through the computer screen, as long as that person has internet access, and usually when they don’t personally have it, they have access to it somehow, you can touch base with that patient. They don’t have to get on the bus or arrange for a ride. You can see how they’re doing fairly easily and decide whether we’re going down the right road with treatment. Can I reinstitute therapy?

To Tara’s point about injectable drugs, now that a lot of these drugs are oral, patients don’t have to be in a clinician’s office as much. Telehealth has a silver lining in the cloud in that it’s also compensated for, which had been an issue previously. It was hard for a clinician to do telehealth if they weren’t getting paid at all for it. If there’s compensation and it allows for much more rapid access for the patient, most folks are now comfortable using telehealth. I’ve even had dermatologists say, “Take a picture of your rash and send it to me.” When we’re talking about how you’re doing, you can do that just as well. It takes a while to get comfortable both as a clinician and as a patient, but this is a huge advance.

Maria Lopes, MD, MS: Absolutely. We’re thinking about meeting the patient wherever they may be in that journey, so more touch points and convenient scheduling [are helpful]. If you have downtime in your practice, they can look at the practice, which hopefully is a win for everyone, especially if patients have a difficult time with travel, transportation, cost, etc. The parallel analogy, especially around population health and health care disparities, as a payer, we’re trying to tackle a lot of these issues as well.

I totally agree with Dr Surrey and Tara that it’s an incredible opportunity for the role of technology and bringing the education into the home, especially now with digital therapeutics and apps that can direct a lot of that education but also personalize it, incorporating some of the things that Amber, Tara, and Dr Surrey were discussing earlier about tracking symptoms and individual goals, which can then be shared with a health care professional. It can even be shared with managed care so that the continuation of treatment can occur. Technology is revolutionizing the scalability but also the timeliness of how we can deliver content and information. It’s certainly a big area. We’re just at the beginning of trying to tackle what this means for patients and being able to incorporate the right services and the right messages so that all can benefit from it.

Transcript edited for clarity.