What lies ahead for women's health? Challenges, and opportunities, as ACOG and US leadership transition

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.