The well-woman visit comes of age: What it offers, how we got here

When the Affordable Care Act (ACA) was passed in 2010, it represented an intended shift from reactive medicine, with its focus on acute and urgent needs, to a model focused on disease prevention.

OBG Management readers know about the important women’s health services ensured by the ACA, including well-woman care, as well as the key role played by the American Congress of Obstetricians and Gynecologists (ACOG) in winning this coverage. ACOG worked closely with the Institute of Medicine (IOM) to help define this set of services. And the ACA ensured that women have access to these services, often without copays and deductibles.

ACOG and the National Women’s Law Center (NWLC) work closely on many issues. At first independently and then together, the 2 organizations set out to explore some fundamental issues:

• How does a woman experience the new well-woman benefit when she visits her doctor?
• Does she receive a consistent care set?
• Do some patients have copays while patients in other clinics do not for the same services?
• What does well-woman care mean from one doctor to another, from an ObGyn to an internist to a family physician?

This article explores these issues.

2 initiatives focused on components of women’s health care
During her tenure as president of ACOG, Jeanne Conry, MD, PhD, decided to tackle clinical issues associated with well-woman care. She convened a Well-Woman Task Force, led by Haywood Brown, MD, and included the NWLC among other partner organizations (TABLE).

Table. Partipating organizations of the ACOG Well-Woman Task Force
• American Academy of Family Physicians
• American Academy of Pediatrics
• American Academy of Physician Assistants
• American College of Nurse–Midwives
• American College of Osteopathic Obstetricians and Gynecologists
• Association of Reproductive Health Professionals
• Association of Women’s Health, Obstetric, and Neonatal Nurses
• National Association of Nurse Practitioners in Women’s Health
• National Medical Association
• National Women’s Law Center
• Planned Parenthood Federation of America
• Society for Maternal-Fetal Medicine
• Society of Academic Specialists in General Obstetrics and Gynecology
• Society of Gynecologic Oncology

The NWLC and Brigham and Women’s Hospital also partnered with ACOG and others to help ensure a consistent patient experience. These 2 closely related initiatives were designed to work together to help patients and physicians understand and benefit from new coverage under the ACA.

1. How does a woman experience well-woman care?
Experts associated with these 2 initiatives recognized that well-woman care includes attention to the history, physical examination, counseling, and screening intended to maintain physical, mental, and social wellbeing and general health throughout a woman’s lifespan. Experts also recognized that the ACA guarantees coverage of at least one annual well-woman visit, although not all of the recommended components necessarily would be performed at the same visit or by the same provider.

For many women who have gained insurance coverage under the ACA, the well-woman visit represents their entry into the insured health care system. These women may have limited understanding of the services they should receive during this visit.

To address this issue, the NWLC invited ACOG to participate in its initiative with Brigham and Women’s Hospital to understand the well-woman visit from the patient’s point of view. This effort yielded patient education materials in English and Spanish that help women understand:

• that their health insurance now covers a well-woman visit
• what care is included in that visit
• that there is no deductible or copay for this visit
• how to prepare for this visit
• what questions to ask during the visit.

These materials help women understand that the purpose of the well-woman visit is to provide them with a chance to:

• “receive care and counseling that is appropriate, based on age, cognitive development, and life experience
• review their current health and risks to their health with their health care professional
• ask any questions they may have about their health or risk factors
• talk about what they can do to prevent future health problems
• build a trusting relationship with their health care provider, with an emphasis on confidentiality
• receive appropriate preventive screenings and immunizations and make sure they know which screenings and immunizations they should receive in the future
• review their reproductive plan and contraceptive choices.”¹                 

The materials also advise patients that they may be asked about:

• current health concerns
• current medications, both prescription and over the counter
• family history on both the mother’s and father’s sides
• life management, including family relationships, work, and stress
• substance use habits, including alcohol and tobacco
• sexual activity
• eating habits and physical activity
• past reproductive health experience and any pregnancy complications
• any memory problems (older women)
• screening for depression, anxiety, substance use disorders, and interpersonal violence.

To view some of these materials, visit http://www.nwlc.org/sites/default/files/final_well-womanbrochure.pdf.

2. Does each woman receive consistent well-woman care?
ACOG’s Well-Woman Task Force was shaped by an awareness that many medical societies and government agencies provide recommendations and guidelines about the basic elements of women’s health. While these recommendations and guidelines all may be based on evidence and expert opinion, the recommendations vary. A goal of the task force was to work with providers across the women’s health spectrum to find consensus and provide guidance to women and clinicians with age-appropriate recommendations for a well-woman visit.

In the fall of 2015, the task force’s findings were published in an article entitled “Components of the well-woman visit” in the journal Obstetrics & Gynecology.² Those findings outline a core set of well-woman care practices across a woman’s lifespan, from adolescence through the reproductive years and into maturity, and they are usable by any provider who cares for adolescent girls or women.

ACOG has summarized its well-woman recommendations, by age, on its website,³ at http://www.acog.org/About-ACOG/ACOG-Departments/Annual-Womens-Health-Care/Well-Woman-Recommendations.

3. Do all women have a copay for the well-woman visit?
Because research has revealed that any type of copay or deductible for preventive care significantly lessens the likelihood that patients will seek out such care, the ACA sought to make basic preventive care available without cost sharing.⁴

The US Department of Health and Human Services notes that: “The Affordable Care Act requires most health plans to cover recommended preventive services without cost sharing. In 2011 and 2012, 71 million Americans with private health insurance gained access to preventive services with no cost sharing because of the law.”⁴

Grandfathered plans (those created or sold before March 23, 2010) are exempt from this requirement, as are Medicare, TRICARE, and traditional Medicaid plans.

4. What does well-woman care mean from one doctor to another?
Under the ACA, well-woman care can be provided by a “wide range of providers, including family physicians, internists, nurse–midwives, nurse practitioners, obstetrician-gynecologists, pediatricians, and physician assistants,” depending on the age of the patient, her particular needs and preferences, and access to health services.²

The ACOG Well-Woman Task Force “focused on delineating the well-woman visit throughout the lifespan, across all providers and health plans.”²

In determining the components of well-woman care, ACOG’s task force compiled existing guidelines from many sources, including the Department of Health and Human Services, the IOM, the US Preventive Services Task Force, and each member organization.

Members categorized guidelines as:

• single source (eg, abdominal examination)
• no agreement (breast cancer/mammography screening)
• limited agreement (pelvic examination)
• general agreement (hypertension, osteoporosis)
• sound agreement (screening for sexually transmitted infections)

The task force also agreed that final recommendations would rely on evidence-based guidelines, evidence-informed guidelines, and uniform expert agreement. Recommendations were considered “strong” if they relied primarily on evidence-based or evidence-informed guidelines and “qualified” if they relied primarily on expert consensus.

Guidelines were further separated into age bands:

• adolescents (13–18 years)
• reproductive-aged women (19–45 years)
• mature women (46–64 years)
• women older than 64 years.

The task force recommended that, during the well-woman visit, health care professionals educate patients about:

• healthy eating habits and maintenance of healthy weight
• exercise and physical activity
• seat belt use
• risk factors for certain types of cancer
• heart health
• breast health
• bone health
• safer sex practices and prevention of sexually transmitted infections
• healthy interpersonal relationships
• prevention and management of chronic disease
• resources for the patient (online, written, community, patient groups)
• medication use
• fall prevention.

Health care providers also should counsel patients regarding:

• recommended preventive screenings and immunizations
• any concerns about mood, such as prolonged periods of sadness, a failure to enjoy what they usually find pleasant, or anxiety or irritability that seems out of proportion to events
• what to expect in terms of effects on mood and anxiety at reproductive life transitions, including menarche, pregnancy, the postpartum period, and perimenopause
• body image issues
• what to expect in terms of the menstrual cycle during perimenopause and menopause
• reproductive health or fertility concerns
• reproductive life planning (contraception appropriate for life stage, reproductive plans, and risk factors, including risk factors for breast and ovarian cancer and cardiovascular disease)
• pregnancy planning, including attaining and maintaining a healthy weight and managing any chronic conditions before or during pregnancy
• what to expect during menopause, including signs and symptoms and options for addressing symptoms (midlife and older women)
• symptoms of cardiovascular disease
• urinary incontinence.

The task force acknowledged that not all of these recommendations can be carried out at a single well-woman visit or by a single provider.

See, again, ACOG’s specific well-woman recommendations, by age range, at http://www.acog.org/About-ACOG/ACOG-Departments/Annual-Womens-Health-Care/Well-Woman-Recommendations.³

How to winnow a long list of recommendations to determine the most pressing issues for a specific patient
In an editorial accompanying the ACOG Well-Woman Task Force report, entitled “Re-envisioning the annual well-woman visit: the task forward,” George F. Sawaya, MD, of the University of California, San Francisco, devised a plan to determine the most pressing well-woman needs for a specific patient.¹ He chose as an example a 41-year-old sexually active woman who does not smoke.

While Dr. Sawaya praised the Well-Woman Task Force recommendations for their “comprehensive scope,” he also noted that the sheer number of recommendations might be “overwhelming and difficult to navigate.”¹ One tool for winnowing the recommendations comes from the Agency for Healthcare Research and Quality, which offers an Electronic Preventive Services Selector (http://epss.ahrq.gov/PDA/index.jsp), available both online and as a smartphone app. Once the clinician plugs in the patient’s age and a few risk factors, the tool generates a list of recommended preventive services. This list of services has been evaluated by the US Preventive Services Task Force, with each recommendation graded “A” through “D,” based on benefits versus harms.

Back to that 41-year-old sexually active woman: Using the Electronic Preventive Services Selector, a list of as many as 20 grade A and B recommendations would be generated. However, only 3 of them would be grade A (screening for cervical cancer, HIV, and high blood pressure). An additional 2 grade B recommendations might apply to an average-risk patient such as this: screening for alcohol misuse and depression. All 5 services fall within the Well-Woman Task Force’s recommendations. They also have “good face validity with clinicians as being important, so it seems reasonable that these be prioritized above the others, at least at the first visit,” Dr. Sawaya says.¹

Clinicians can use a similar strategy for patients of various ages and risk factors.

Reference
1. Sawaya GF. Re-envisioning the annual well-woman visit: the task forward [editorial]. Obstet Gynecol. 2015;126(4):695–696.

The bottom line
By defining and implementing the foundational elements of women’s health, we can improve care for all women and ensure, as Dr. Conry emphasized during her tenure as ACOG president, “that every woman gets the care she needs, every time.”

Share your thoughts! Send your Letter to the Editor to rbarbieri@frontlinemedcom.com. Please include your name and the city and state in which you practice.

When the Affordable Care Act (ACA) was passed in 2010, it represented an intended shift from reactive medicine, with its focus on acute and urgent needs, to a model focused on disease prevention.

OBG Management readers know about the important women’s health services ensured by the ACA, including well-woman care, as well as the key role played by the American Congress of Obstetricians and Gynecologists (ACOG) in winning this coverage. ACOG worked closely with the Institute of Medicine (IOM) to help define this set of services. And the ACA ensured that women have access to these services, often without copays and deductibles.

ACOG and the National Women’s Law Center (NWLC) work closely on many issues. At first independently and then together, the 2 organizations set out to explore some fundamental issues:

• How does a woman experience the new well-woman benefit when she visits her doctor?
• Does she receive a consistent care set?
• Do some patients have copays while patients in other clinics do not for the same services?
• What does well-woman care mean from one doctor to another, from an ObGyn to an internist to a family physician?

This article explores these issues.

2 initiatives focused on components of women’s health care
During her tenure as president of ACOG, Jeanne Conry, MD, PhD, decided to tackle clinical issues associated with well-woman care. She convened a Well-Woman Task Force, led by Haywood Brown, MD, and included the NWLC among other partner organizations (TABLE).

Table. Partipating organizations of the ACOG Well-Woman Task Force
• American Academy of Family Physicians
• American Academy of Pediatrics
• American Academy of Physician Assistants
• American College of Nurse–Midwives
• American College of Osteopathic Obstetricians and Gynecologists
• Association of Reproductive Health Professionals
• Association of Women’s Health, Obstetric, and Neonatal Nurses
• National Association of Nurse Practitioners in Women’s Health
• National Medical Association
• National Women’s Law Center
• Planned Parenthood Federation of America
• Society for Maternal-Fetal Medicine
• Society of Academic Specialists in General Obstetrics and Gynecology
• Society of Gynecologic Oncology

The NWLC and Brigham and Women’s Hospital also partnered with ACOG and others to help ensure a consistent patient experience. These 2 closely related initiatives were designed to work together to help patients and physicians understand and benefit from new coverage under the ACA.

1. How does a woman experience well-woman care?
Experts associated with these 2 initiatives recognized that well-woman care includes attention to the history, physical examination, counseling, and screening intended to maintain physical, mental, and social wellbeing and general health throughout a woman’s lifespan. Experts also recognized that the ACA guarantees coverage of at least one annual well-woman visit, although not all of the recommended components necessarily would be performed at the same visit or by the same provider.

For many women who have gained insurance coverage under the ACA, the well-woman visit represents their entry into the insured health care system. These women may have limited understanding of the services they should receive during this visit.

To address this issue, the NWLC invited ACOG to participate in its initiative with Brigham and Women’s Hospital to understand the well-woman visit from the patient’s point of view. This effort yielded patient education materials in English and Spanish that help women understand:

• that their health insurance now covers a well-woman visit
• what care is included in that visit
• that there is no deductible or copay for this visit
• how to prepare for this visit
• what questions to ask during the visit.

These materials help women understand that the purpose of the well-woman visit is to provide them with a chance to:

• “receive care and counseling that is appropriate, based on age, cognitive development, and life experience
• review their current health and risks to their health with their health care professional
• ask any questions they may have about their health or risk factors
• talk about what they can do to prevent future health problems
• build a trusting relationship with their health care provider, with an emphasis on confidentiality
• receive appropriate preventive screenings and immunizations and make sure they know which screenings and immunizations they should receive in the future
• review their reproductive plan and contraceptive choices.”¹                 

The materials also advise patients that they may be asked about:

• current health concerns
• current medications, both prescription and over the counter
• family history on both the mother’s and father’s sides
• life management, including family relationships, work, and stress
• substance use habits, including alcohol and tobacco
• sexual activity
• eating habits and physical activity
• past reproductive health experience and any pregnancy complications
• any memory problems (older women)
• screening for depression, anxiety, substance use disorders, and interpersonal violence.

To view some of these materials, visit http://www.nwlc.org/sites/default/files/final_well-womanbrochure.pdf.

2. Does each woman receive consistent well-woman care?
ACOG’s Well-Woman Task Force was shaped by an awareness that many medical societies and government agencies provide recommendations and guidelines about the basic elements of women’s health. While these recommendations and guidelines all may be based on evidence and expert opinion, the recommendations vary. A goal of the task force was to work with providers across the women’s health spectrum to find consensus and provide guidance to women and clinicians with age-appropriate recommendations for a well-woman visit.

In the fall of 2015, the task force’s findings were published in an article entitled “Components of the well-woman visit” in the journal Obstetrics & Gynecology.² Those findings outline a core set of well-woman care practices across a woman’s lifespan, from adolescence through the reproductive years and into maturity, and they are usable by any provider who cares for adolescent girls or women.

ACOG has summarized its well-woman recommendations, by age, on its website,³ at http://www.acog.org/About-ACOG/ACOG-Departments/Annual-Womens-Health-Care/Well-Woman-Recommendations.

3. Do all women have a copay for the well-woman visit?
Because research has revealed that any type of copay or deductible for preventive care significantly lessens the likelihood that patients will seek out such care, the ACA sought to make basic preventive care available without cost sharing.⁴

The US Department of Health and Human Services notes that: “The Affordable Care Act requires most health plans to cover recommended preventive services without cost sharing. In 2011 and 2012, 71 million Americans with private health insurance gained access to preventive services with no cost sharing because of the law.”⁴

Grandfathered plans (those created or sold before March 23, 2010) are exempt from this requirement, as are Medicare, TRICARE, and traditional Medicaid plans.

4. What does well-woman care mean from one doctor to another?
Under the ACA, well-woman care can be provided by a “wide range of providers, including family physicians, internists, nurse–midwives, nurse practitioners, obstetrician-gynecologists, pediatricians, and physician assistants,” depending on the age of the patient, her particular needs and preferences, and access to health services.²

The ACOG Well-Woman Task Force “focused on delineating the well-woman visit throughout the lifespan, across all providers and health plans.”²

In determining the components of well-woman care, ACOG’s task force compiled existing guidelines from many sources, including the Department of Health and Human Services, the IOM, the US Preventive Services Task Force, and each member organization.

Members categorized guidelines as:

• single source (eg, abdominal examination)
• no agreement (breast cancer/mammography screening)
• limited agreement (pelvic examination)
• general agreement (hypertension, osteoporosis)
• sound agreement (screening for sexually transmitted infections)

The task force also agreed that final recommendations would rely on evidence-based guidelines, evidence-informed guidelines, and uniform expert agreement. Recommendations were considered “strong” if they relied primarily on evidence-based or evidence-informed guidelines and “qualified” if they relied primarily on expert consensus.

Guidelines were further separated into age bands:

• adolescents (13–18 years)
• reproductive-aged women (19–45 years)
• mature women (46–64 years)
• women older than 64 years.

The task force recommended that, during the well-woman visit, health care professionals educate patients about:

• healthy eating habits and maintenance of healthy weight
• exercise and physical activity
• seat belt use
• risk factors for certain types of cancer
• heart health
• breast health
• bone health
• safer sex practices and prevention of sexually transmitted infections
• healthy interpersonal relationships
• prevention and management of chronic disease
• resources for the patient (online, written, community, patient groups)
• medication use
• fall prevention.

Health care providers also should counsel patients regarding:

• recommended preventive screenings and immunizations
• any concerns about mood, such as prolonged periods of sadness, a failure to enjoy what they usually find pleasant, or anxiety or irritability that seems out of proportion to events
• what to expect in terms of effects on mood and anxiety at reproductive life transitions, including menarche, pregnancy, the postpartum period, and perimenopause
• body image issues
• what to expect in terms of the menstrual cycle during perimenopause and menopause
• reproductive health or fertility concerns
• reproductive life planning (contraception appropriate for life stage, reproductive plans, and risk factors, including risk factors for breast and ovarian cancer and cardiovascular disease)
• pregnancy planning, including attaining and maintaining a healthy weight and managing any chronic conditions before or during pregnancy
• what to expect during menopause, including signs and symptoms and options for addressing symptoms (midlife and older women)
• symptoms of cardiovascular disease
• urinary incontinence.

The task force acknowledged that not all of these recommendations can be carried out at a single well-woman visit or by a single provider.

See, again, ACOG’s specific well-woman recommendations, by age range, at http://www.acog.org/About-ACOG/ACOG-Departments/Annual-Womens-Health-Care/Well-Woman-Recommendations.³

How to winnow a long list of recommendations to determine the most pressing issues for a specific patient
In an editorial accompanying the ACOG Well-Woman Task Force report, entitled “Re-envisioning the annual well-woman visit: the task forward,” George F. Sawaya, MD, of the University of California, San Francisco, devised a plan to determine the most pressing well-woman needs for a specific patient.¹ He chose as an example a 41-year-old sexually active woman who does not smoke.

While Dr. Sawaya praised the Well-Woman Task Force recommendations for their “comprehensive scope,” he also noted that the sheer number of recommendations might be “overwhelming and difficult to navigate.”¹ One tool for winnowing the recommendations comes from the Agency for Healthcare Research and Quality, which offers an Electronic Preventive Services Selector (http://epss.ahrq.gov/PDA/index.jsp), available both online and as a smartphone app. Once the clinician plugs in the patient’s age and a few risk factors, the tool generates a list of recommended preventive services. This list of services has been evaluated by the US Preventive Services Task Force, with each recommendation graded “A” through “D,” based on benefits versus harms.

Back to that 41-year-old sexually active woman: Using the Electronic Preventive Services Selector, a list of as many as 20 grade A and B recommendations would be generated. However, only 3 of them would be grade A (screening for cervical cancer, HIV, and high blood pressure). An additional 2 grade B recommendations might apply to an average-risk patient such as this: screening for alcohol misuse and depression. All 5 services fall within the Well-Woman Task Force’s recommendations. They also have “good face validity with clinicians as being important, so it seems reasonable that these be prioritized above the others, at least at the first visit,” Dr. Sawaya says.¹

Clinicians can use a similar strategy for patients of various ages and risk factors.

Reference
1. Sawaya GF. Re-envisioning the annual well-woman visit: the task forward [editorial]. Obstet Gynecol. 2015;126(4):695–696.

The bottom line
By defining and implementing the foundational elements of women’s health, we can improve care for all women and ensure, as Dr. Conry emphasized during her tenure as ACOG president, “that every woman gets the care she needs, every time.”

Share your thoughts! Send your Letter to the Editor to rbarbieri@frontlinemedcom.com. Please include your name and the city and state in which you practice.

When the Affordable Care Act (ACA) was passed in 2010, it represented an intended shift from reactive medicine, with its focus on acute and urgent needs, to a model focused on disease prevention.

OBG Management readers know about the important women’s health services ensured by the ACA, including well-woman care, as well as the key role played by the American Congress of Obstetricians and Gynecologists (ACOG) in winning this coverage. ACOG worked closely with the Institute of Medicine (IOM) to help define this set of services. And the ACA ensured that women have access to these services, often without copays and deductibles.

ACOG and the National Women’s Law Center (NWLC) work closely on many issues. At first independently and then together, the 2 organizations set out to explore some fundamental issues:

• How does a woman experience the new well-woman benefit when she visits her doctor?
• Does she receive a consistent care set?
• Do some patients have copays while patients in other clinics do not for the same services?
• What does well-woman care mean from one doctor to another, from an ObGyn to an internist to a family physician?

This article explores these issues.

2 initiatives focused on components of women’s health care
During her tenure as president of ACOG, Jeanne Conry, MD, PhD, decided to tackle clinical issues associated with well-woman care. She convened a Well-Woman Task Force, led by Haywood Brown, MD, and included the NWLC among other partner organizations (TABLE).

Table. Partipating organizations of the ACOG Well-Woman Task Force
• American Academy of Family Physicians
• American Academy of Pediatrics
• American Academy of Physician Assistants
• American College of Nurse–Midwives
• American College of Osteopathic Obstetricians and Gynecologists
• Association of Reproductive Health Professionals
• Association of Women’s Health, Obstetric, and Neonatal Nurses
• National Association of Nurse Practitioners in Women’s Health
• National Medical Association
• National Women’s Law Center
• Planned Parenthood Federation of America
• Society for Maternal-Fetal Medicine
• Society of Academic Specialists in General Obstetrics and Gynecology
• Society of Gynecologic Oncology

The NWLC and Brigham and Women’s Hospital also partnered with ACOG and others to help ensure a consistent patient experience. These 2 closely related initiatives were designed to work together to help patients and physicians understand and benefit from new coverage under the ACA.

1. How does a woman experience well-woman care?
Experts associated with these 2 initiatives recognized that well-woman care includes attention to the history, physical examination, counseling, and screening intended to maintain physical, mental, and social wellbeing and general health throughout a woman’s lifespan. Experts also recognized that the ACA guarantees coverage of at least one annual well-woman visit, although not all of the recommended components necessarily would be performed at the same visit or by the same provider.

For many women who have gained insurance coverage under the ACA, the well-woman visit represents their entry into the insured health care system. These women may have limited understanding of the services they should receive during this visit.

To address this issue, the NWLC invited ACOG to participate in its initiative with Brigham and Women’s Hospital to understand the well-woman visit from the patient’s point of view. This effort yielded patient education materials in English and Spanish that help women understand:

• that their health insurance now covers a well-woman visit
• what care is included in that visit
• that there is no deductible or copay for this visit
• how to prepare for this visit
• what questions to ask during the visit.

These materials help women understand that the purpose of the well-woman visit is to provide them with a chance to:

• “receive care and counseling that is appropriate, based on age, cognitive development, and life experience
• review their current health and risks to their health with their health care professional
• ask any questions they may have about their health or risk factors
• talk about what they can do to prevent future health problems
• build a trusting relationship with their health care provider, with an emphasis on confidentiality
• receive appropriate preventive screenings and immunizations and make sure they know which screenings and immunizations they should receive in the future
• review their reproductive plan and contraceptive choices.”¹                 

The materials also advise patients that they may be asked about:

• current health concerns
• current medications, both prescription and over the counter
• family history on both the mother’s and father’s sides
• life management, including family relationships, work, and stress
• substance use habits, including alcohol and tobacco
• sexual activity
• eating habits and physical activity
• past reproductive health experience and any pregnancy complications
• any memory problems (older women)
• screening for depression, anxiety, substance use disorders, and interpersonal violence.

To view some of these materials, visit http://www.nwlc.org/sites/default/files/final_well-womanbrochure.pdf.

2. Does each woman receive consistent well-woman care?
ACOG’s Well-Woman Task Force was shaped by an awareness that many medical societies and government agencies provide recommendations and guidelines about the basic elements of women’s health. While these recommendations and guidelines all may be based on evidence and expert opinion, the recommendations vary. A goal of the task force was to work with providers across the women’s health spectrum to find consensus and provide guidance to women and clinicians with age-appropriate recommendations for a well-woman visit.

In the fall of 2015, the task force’s findings were published in an article entitled “Components of the well-woman visit” in the journal Obstetrics & Gynecology.² Those findings outline a core set of well-woman care practices across a woman’s lifespan, from adolescence through the reproductive years and into maturity, and they are usable by any provider who cares for adolescent girls or women.

ACOG has summarized its well-woman recommendations, by age, on its website,³ at http://www.acog.org/About-ACOG/ACOG-Departments/Annual-Womens-Health-Care/Well-Woman-Recommendations.

3. Do all women have a copay for the well-woman visit?
Because research has revealed that any type of copay or deductible for preventive care significantly lessens the likelihood that patients will seek out such care, the ACA sought to make basic preventive care available without cost sharing.⁴

The US Department of Health and Human Services notes that: “The Affordable Care Act requires most health plans to cover recommended preventive services without cost sharing. In 2011 and 2012, 71 million Americans with private health insurance gained access to preventive services with no cost sharing because of the law.”⁴

Grandfathered plans (those created or sold before March 23, 2010) are exempt from this requirement, as are Medicare, TRICARE, and traditional Medicaid plans.

4. What does well-woman care mean from one doctor to another?
Under the ACA, well-woman care can be provided by a “wide range of providers, including family physicians, internists, nurse–midwives, nurse practitioners, obstetrician-gynecologists, pediatricians, and physician assistants,” depending on the age of the patient, her particular needs and preferences, and access to health services.²

The ACOG Well-Woman Task Force “focused on delineating the well-woman visit throughout the lifespan, across all providers and health plans.”²

In determining the components of well-woman care, ACOG’s task force compiled existing guidelines from many sources, including the Department of Health and Human Services, the IOM, the US Preventive Services Task Force, and each member organization.

Members categorized guidelines as:

• single source (eg, abdominal examination)
• no agreement (breast cancer/mammography screening)
• limited agreement (pelvic examination)
• general agreement (hypertension, osteoporosis)
• sound agreement (screening for sexually transmitted infections)

The task force also agreed that final recommendations would rely on evidence-based guidelines, evidence-informed guidelines, and uniform expert agreement. Recommendations were considered “strong” if they relied primarily on evidence-based or evidence-informed guidelines and “qualified” if they relied primarily on expert consensus.

Guidelines were further separated into age bands:

• adolescents (13–18 years)
• reproductive-aged women (19–45 years)
• mature women (46–64 years)
• women older than 64 years.

The task force recommended that, during the well-woman visit, health care professionals educate patients about:

• healthy eating habits and maintenance of healthy weight
• exercise and physical activity
• seat belt use
• risk factors for certain types of cancer
• heart health
• breast health
• bone health
• safer sex practices and prevention of sexually transmitted infections
• healthy interpersonal relationships
• prevention and management of chronic disease
• resources for the patient (online, written, community, patient groups)
• medication use
• fall prevention.

Health care providers also should counsel patients regarding:

• recommended preventive screenings and immunizations
• any concerns about mood, such as prolonged periods of sadness, a failure to enjoy what they usually find pleasant, or anxiety or irritability that seems out of proportion to events
• what to expect in terms of effects on mood and anxiety at reproductive life transitions, including menarche, pregnancy, the postpartum period, and perimenopause
• body image issues
• what to expect in terms of the menstrual cycle during perimenopause and menopause
• reproductive health or fertility concerns
• reproductive life planning (contraception appropriate for life stage, reproductive plans, and risk factors, including risk factors for breast and ovarian cancer and cardiovascular disease)
• pregnancy planning, including attaining and maintaining a healthy weight and managing any chronic conditions before or during pregnancy
• what to expect during menopause, including signs and symptoms and options for addressing symptoms (midlife and older women)
• symptoms of cardiovascular disease
• urinary incontinence.

The task force acknowledged that not all of these recommendations can be carried out at a single well-woman visit or by a single provider.

See, again, ACOG’s specific well-woman recommendations, by age range, at http://www.acog.org/About-ACOG/ACOG-Departments/Annual-Womens-Health-Care/Well-Woman-Recommendations.³

How to winnow a long list of recommendations to determine the most pressing issues for a specific patient
In an editorial accompanying the ACOG Well-Woman Task Force report, entitled “Re-envisioning the annual well-woman visit: the task forward,” George F. Sawaya, MD, of the University of California, San Francisco, devised a plan to determine the most pressing well-woman needs for a specific patient.¹ He chose as an example a 41-year-old sexually active woman who does not smoke.

While Dr. Sawaya praised the Well-Woman Task Force recommendations for their “comprehensive scope,” he also noted that the sheer number of recommendations might be “overwhelming and difficult to navigate.”¹ One tool for winnowing the recommendations comes from the Agency for Healthcare Research and Quality, which offers an Electronic Preventive Services Selector (http://epss.ahrq.gov/PDA/index.jsp), available both online and as a smartphone app. Once the clinician plugs in the patient’s age and a few risk factors, the tool generates a list of recommended preventive services. This list of services has been evaluated by the US Preventive Services Task Force, with each recommendation graded “A” through “D,” based on benefits versus harms.

Back to that 41-year-old sexually active woman: Using the Electronic Preventive Services Selector, a list of as many as 20 grade A and B recommendations would be generated. However, only 3 of them would be grade A (screening for cervical cancer, HIV, and high blood pressure). An additional 2 grade B recommendations might apply to an average-risk patient such as this: screening for alcohol misuse and depression. All 5 services fall within the Well-Woman Task Force’s recommendations. They also have “good face validity with clinicians as being important, so it seems reasonable that these be prioritized above the others, at least at the first visit,” Dr. Sawaya says.¹

Clinicians can use a similar strategy for patients of various ages and risk factors.

Reference
1. Sawaya GF. Re-envisioning the annual well-woman visit: the task forward [editorial]. Obstet Gynecol. 2015;126(4):695–696.

The bottom line
By defining and implementing the foundational elements of women’s health, we can improve care for all women and ensure, as Dr. Conry emphasized during her tenure as ACOG president, “that every woman gets the care she needs, every time.”

Share your thoughts! Send your Letter to the Editor to rbarbieri@frontlinemedcom.com. Please include your name and the city and state in which you practice.