Managed Care Perspectives: Optimizing Women’s Reproductive Health - Episode 2

Payer Considerations in Women’s Reproductive Health

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Dr Lopes, OB-GYN and payer, discusses a focus on screening and prevention and availability of contraception among health plans in women’s health.

Neil Minkoff, MD: Dr Lopes, let me switch to you. We’re lucky to have somebody like you on our panel who looks at things as a trained OB-GYN and has practiced for a number of years, but also who looks at things through the lens of a payer through population health. They aren’t a completely overlapping Venn diagram, but there’s enough overlap that it will be nice to get your perspective. When you think of this from your payer point of view as opposed to your OB-GYN point of view, what are the key priorities that payers have when they’re thinking about women of childbearing years?

Maria Lopes, MD, MS: In terms of priorities, fibroids aren’t typically a priority for most health plans. Typically, payers at a population level will focus on quality metrics, which include HEDIS [Healthcare Effectiveness Data and Information Set] Medicare Star Ratings, and that primarily focuses on screening and prevention. For women, it’s mammography, colorectal screening, cervical cancer screening, and screening for osteoporosis and osteopenia. It’s also infertility, especially in states that have mandates for infertility benefits, and the cost associated with infertility and what that may represent, especially as you go into assisted reproductive technologies.

In childbearing, there may be a lot of focus on C-section prevention and preterm birth prevention. But at a high level outside childbirth, it’s screening prevention that’s tied to the US Preventive Services Task Force. Along with that, payers have freed up any restrictions around contraception. We’ll get to this later.

But essentially, it’s having options. We’re talking about options here in terms of alternative surgical options that meet the patient’s needs and are as individualized as the patients need them to be. It’s not just whether you want conservative options or not. Many times, it’s about what else has been tried. What’s safe? What’s effective? How long has somebody needed to be on these treatments to potentially bridge to a menopausal state where they’re going to be hypoestrogenic? All these are part of the considerations as a payer thinks about not just priorities but how big a priority some of these categories are in terms of alternative treatment options.

Transcripts edited for clarity.