Laws take gatekeeper hats off family practitioners, expand women’s choices

Direct access opens doors to OB/GYN care

A victory for women under managed care plans is making its way across the country. In a move that casts a woman-friendly light on managed care, state lawmakers are telling managed care plans to let women go straight to reproductive health professionals without a referral. After all, isn’t that what most women need until they reach their 40s?

Direct access laws, as they’re called, strengthen the position of women’s health centers that offer reproductive services. Before the direct access trend gathered momentum, family practitioners often exercised the gatekeeper function of primary care providers. Insurers funneled women to them for routine pap smears and mammograms. Instead of referring patients needing well-woman care to women’s health centers or to OB/GYNs, many family practitioners elected to provide the care themselves, thus keeping that portion of the capitation fee. This left women’s health centers that didn’t offer primary care in a weak position, depending on referrals from family practitioners.

At press time, 22 states had direct access laws. (See map, p. 70.) Provisions run the gamut from choice of OB/GYN as primary care provider to one or more self-referred visits to an OB/GYN.

For women ages 18 to 38, the most-needed health service is obstetrical and gynecological care, says Irma Cruz, women’s health associate at the University of Illinois Medical Center in Chicago.

"Before our legislature passed the direct access law, the family practitioners in managed care plans would do paps and be the gatekeepers," Cruz says.

The law frees women to choose their care providers without risking bad feelings with their family practitioners, she says. "Some family practitioners wanted to deliver babies also," Cruz adds, "but some women didn’t feel comfortable with their doctor’s skills. Yet they were afraid to insist on a referral to an obstetrician. It was a case of insurance controlling how many services women received, and women were caught in the middle."

Direct access laws can improve women’s health care, explains Teri G. Fontenot, MBA, CPA, president and chief executive officer at Women’s Health Foundation and Hospital in Baton Rouge, LA. Fontenot observes that when women have to visit a primary provider simply to get a referral to an obstetrician for a pap smear, some will throw up their hands and say, "I’m feeling all right, so it’s not worth the trouble,"

"If a woman is healthy," Fontenot argues, "it isn’t cost effective to have her make two doctor visits to get routine gynecological care. It’s the wrong place to be trying to save money."

She adds that "OB/GYNs have the expertise to detect problems early, whereas a family practitioner might overlook an important warning of a problem [such as a change in menstrual patterns] or might not make a referral in a timely manner."

Speaking to the other side of the issue is Elizabeth Reich, who works in Arizona, a state without direct access laws. Director of Women’s and Children’s Services at Lutheran Healthcare Network in Mesa and board member of the National Association of Women’s Health Professionals in Chicago, Reich says that some laws are so limited they’re useless.

"It’s one thing to OK self-referral to an obstetrician for one visit," Reich says. "But anything after that, and you’re right back to the primary care provider. An obstetrician can write a prescription for a mammogram, but the woman has to go back to the primary provider or get it someplace within the plan."

Reich adds that direct access laws are no good to women’s health centers unless they belong to a managed care plan’s provider group. Her center, for instance, does no diagnostic care, so direct access legislation would not bring new patients. The concept sounds like a good deal, Reich says, "but it’s another example of lawmakers doing something they think is great, and maybe it’s not so great after all."

Cruz sees it differently. Direct access is a boon to women of all ages, she says. "Even during menopause, many women still come here for paps, mammograms, and hormone replacement therapy." They’re more comfortable with the place and the providers they know, she says.

Women like a women’s health center environment better, asserts Ann Boeke, MS, CHE, executive director of Woman’s Health Care Plus at Bellevue Woman’s Hospital in Niskayuna, NY. In New York, "the law is actually working. Women are very pleased with it," says Boeke, who serves on the board of the National Association of Women’s Health Professionals.

In her area, one plan authorizes women to choose OB/GYNs as their primary physicians or to make one self-referred and one repeat OB/GYN visit a year.

Cruz raises another point in the debate over where the power belongs as insurance evolves from fee-for-service to managed care: "Being a woman, I’ve always sought the services of OB/GYNs. And under managed care, I’ve often had to use unfamiliar providers. This is happening to more and more women. As more employers offer managed care, and nonmanaged-care plans become much more expensive, fewer women can afford them."

That’s where direct access laws are a victory for women and for women’s health centers. While laws can’t guarantee good health care, they at least give women an opportunity to choose what they trust is best. And often, they trust their women’s health center.

"This type of law gives women a voice to make that decision themselves," Cruz says.