Well-woman care: Reshaping the routine visit

“We want patients to understand that, even though they no longer need the Pap every year, they still should see us for good, comprehensive care ... that we can help them achieve their health care goals,” she said.

How often well-woman visits should occur has been a subject of much discussion. The HRSA-supported preventive services guidelines call for well-woman preventive care annually but note that “several visits may be needed to obtain all the necessary recommended services.”

And, in its first set of draft recommendations for HRSA, WPSI offered clarifications, saying there’s a need for “at least one annual preventive care visit for women beginning in adolescence and continuing across the lifespan to ensure that women obtain recommended preventive services” as determined by age and risk factors.

The draft recommendations, aimed at reviewing and updating the 2011 HRSA-sponsored guidelines, will be finalized by the end of 2016. WPSI will submit additional recommendations over the next 4 years.

Carol S. Weisman, PhD, a sociologist and health services researcher who sat on the Institute of Medicine committee that wrote the Women’s Preventive Services Guidelines, said the IOM’s recommendation for well-women visits – “in plural” form – recognizes “that historically many women have patched together their well-woman care from multiple providers, getting some of their preventive care from their generalist, and some from their ob.gyn.”

What’s more, the current list of preventive services covered under the Affordable Care Act is “enormous” – too long to address in one visit for many patients, said Dr. Weisman of the Penn State Center for Women’s Health Research in Hershey.

In addition to the women’s preventive services, the Affordable Care Act requires plans to cover services recommended with a grade A or B rating by the U.S. Preventive Services Task Force (counseling and screening for cancer, cardiovascular disease, and more) as well as vaccines recommended by the Advisory Committee on Immunization Practices, and HRSA’s Bright Futures services (for adolescents as well as children).

Beyond gynecology

How much further ob.gyns. will reach outside the gynecologic realm to offer additional preventive care services is an open question, but it’s likely to be based mainly on comfort levels, sources said.

“The changing needs of the gynecologic visit enable us to spend more time on other things,” said Hal C. Lawrence III, MD, ACOG’s executive vice president and chief executive officer. “But within the specialty, there’s going to be variation as to what level of expanded services ob.gyns. provide. Some will provide a lot of what women need, others not as much.”

Heather Johnson, MD, practices with a large ob.gyn. group in Chevy Chase, Md. and provides well-woman care largely to women in their 50s and 60s, whose children she delivered. She’s comfortable, she said, with screening for and treating osteoporosis and mild depression, for instance. She regularly performs lipid testing but refers out for management of high cholesterol levels or high blood pressure.

“I encourage all my patients to have a primary care physician of record,” she said, “but I still am happy to discuss the issues with them.”

What’s key, according to Dr. Lawrence and Dr. Conry, is coordination.

“We know there will be different individuals providing different components [of well-woman care],” Dr. Conry said. “I may see a woman for various things. Then she may go to her internist. But we should be able to collaborate to hit all the preventive health goals for her.”

Dr. Conry emphasized that the ob.gyn.’s expertise in reproductive health is critical to well-woman care planning, especially given medicine’s growing knowledge of how obstetric health and pregnancy complications can have long-term impacts on cardiovascular disease and other conditions. “It’s important for all providers to realize this,” she said.

Primary care status?

Intertwined with the future of well-women care is the issue of primary care status for ob.gyns. ACOG continues to advocate for ob.gyns. to be listed as primary care providers and part of primary care payment policies. Leaders are also pushing for projects on ob.gyn.–led medical homes.

At the same time, ACOG has been taking a broad collaborative approach to shaping well-woman care, aiming to develop comprehensive, age-specific recommendations for use by any provider who cares for adolescent girls and women.

Representatives of the American Academy of Family Physicians, the American College of Physicians, and the National Association of Nurse Practitioners in Women’s Health were involved in a Well-Woman Task Force that Dr. Conry appointed while serving as ACOG president in 2013-2014. These organizations now sit on WPSI’s advisory panel with ACOG.