Introduction
Not one to sit back as women's health issues--"drive-by" deliveries and mastectomies--hit the front page, Kaiser Permanente Northern California (KPNC) in 1996 formed its Women's Health Task Force, a group of 20 physicians and staff selected for their expertise in women's health.

The Task Force accepted the challenge of developing both a rationale and a direction for changing KPNC's system of delivering health care to its women members: The group recommended to the Board of Directors of TPMG that KP focus on becoming the premier provider of women's health care in Northern California. To ensure that this goal would become reality, KP in 1997 appointed a women's health leader and created Women's Health-KP (Table 1).¹

Women's Health-KP addresses a spectrum of women's health care needs which arise throughout life. Issues targeted by Women's Health-KP include the leading causes of death among women as well as the societal influences and policies affecting women's health. The ultimate goal of Women's Health-KP is to improve the quality of health care services delivered to KP's primary customers: women.

KPNC's Reasons and Goals for Studying Women's Health
KPNC's interest in women's health was based on sound reasoning. National² and KPNC³ consumer research indicated that women constitute the primary customer base for health care. Further research by the Task Force showed that most health care purchasing decisions are made by women, who drive medical utilization: by coordinating care for themselves and for their entire families, women consume two thirds of all medical care.² Even more telling was the fact that KPNC's women members expressed substantially less satisfaction with their care than women in competing HMOs.³ Therefore, to retain and attract members, KPNC's clear mandate was to develop strategies for meeting women's health care needs, preferences, and expectations. KPNC faced the additional challenge of providing health care that would become the industry benchmark for improving the health and total health care experience of women and their families.

To determine what its primary customers want and value in health care, KPNC conducted a Women's Health Study, funded by the Innovations Program, from July to November 1999. Operating from 1990 until 1999, the Innovations Program supported projects which promote innovative thinking and practice in three areas: clinical care, use of support services and automated systems, and the health plan's relationships with its members and their employers. Of the more than 380 projects that have received grants from the Innovations Program, 75% have been adopted by the health plan.

The Women's Health Study had three primary objectives: 1) to determine what would increase women members' satisfaction, cause them to remain health plan members, and create more positive public opinion about the health plan; 2) to determine how redesign of delivery systems for adult primary care, obstetrics/gynecology services, pediatrics services, and other services would be accepted by women; and 3) to develop an action plan for meeting the demands of KP members.¹

Study Methods
The study used multifaceted research methodology, which included a telephone survey of 1500 randomly selected women members and 500 women who were members of competing health plans in Northern California; ten focus groups representing a variety of service areas, ages, sexual orientations, and ethnic groups; experiential interviews that tracked 75 women through medical visits; and two roundtable discussion groups with community advocates and employers. Given the large number of questions we needed to ask in the telephone survey, three versions of this survey were presented to random thirds of this study population. The rigorous research design produced not only quantitative results but also qualitative ones as women provided their thoughts and words in detail, confirming and providing an understanding of the quantitative results. The results allowed findings to be reproduced across multiple measures and methods.

To determine what its primary customers want and value in health care, KPNC conducted a Women's Health Study, funded by the Innovations Program, from July to November 1999.

The study examined characteristics of more-satisfied and less-satisfied subsets of the KPNC population in connection with the roles and responsibilities of women in Northern California and highlights four areas of value that should be targeted by KPNC: 1) when, where, and from whom women want access to care; 2) the importance of coordination of care; 3) how flexible women are in accepting alternatives to appointments with their own primary care physician; and 4) the importance of perceiving Kaiser Permanente, its physicians, and its staff as friendly and supportive. In addition to these major themes, the study collected data on women's preferences for the gender of their physician, women's interest in new services, and health care for midlife women.

Results
General findings of the KP Women's Health Study corroborated what other consumer research has foundie, that women are key purchasers of health carebut also showed that this key role of women is even more important in Northern California than previous national research indicated: Of the 2000 women surveyed, 92% said they had primary or equal input in choosing health care coverage. This result is comparable with the national statistic, 75%.

Results also confirmed that attracting new members is both a challenge and an opportunity for KPNC: A reputation of providing excellent medical services and health improvement programs for women was an important criterion in selection of a health plan for 46% of nonmembers surveyed. When asked who comes to mind as providing superior women's health care, 78 health plans were mentioned; however, no health plan was mentioned twice, and KPNC was not mentioned once! This outcome indicates that Northern California has no recognized leader in women's health care.

To relate all the results of and implications of the KP Women's Health Study would take a book. Instead, we present some findings that are unexpected or that provide information that KPNC may find useful for meeting the needs of its members, attracting new members, and raising the level of member satisfaction. These results are grouped into the four key areas found to be most important to members: access to care; coordination of care; choice and flexibility; and friendly, supportive clinicians.

Access to Care
Problems accessing urgent and routine care have an effect on members' satisfaction with the health plan (Figure 1). More members (23%) have difficulty accessing routine care than acute care (9%), and 6% indicated problems accessing both types of care. Access has a strong bearing on member loyalty: Members who had no problem accessing either urgent or routine care were twice as likely to stay with KPNC than were members who had difficulty accessing care.

Adopting strategies for improving access to routine appointments has the potential to improve members' satisfaction, increase their loyalty, and lead to more positive word of mouth (reputation). Options for scheduling appointments beyond normal work hours were applauded by members as well as nonmembers, especially women aged <55 years: 80% of the members under age 55 years would be "somewhat or very likely" to make Saturday or evening appointments, 63% would be "very likely" to schedule evening appointments, and 55% would be "very likely" to choose Saturday appointments. Half indicated that they would switch from their current primary care practitioner to a doctor who offers evening appointments and weekend appointments.

Coordination of Care
Coordination of care was the second greatest differentiator between satisfied and dissatisfied women: 66% of members would have "somewhat" or "a lot" more satisfaction if they felt KPNC was able to help them coordinate care (Figure 2). Coordination of care has two aspects: 1) ensuring that a woman member's care does not "fall through the cracks," and 2) helping women fulfill their roles as care coordinators for the rest of the family. Although 20% of members surveyed felt that their care "falls through the cracks," the good news is that most of the members believed KPNC is doing a good job of coordinating their care: 78% said their doctors are good at keeping track of medications and treatments.

As many as 84% of the members surveyed praised KPNC's "Preventive Health Prompts"reminders about appointments and preventive measures such as mammography, immunization, and cholesterol screening that are printed on the registration slipsand said they found the information helpful for coordinating care.

The study findings put the importance of coordinating health care into perspective: 69% of married women indicated that they coordinate their spouse's health care, and 59% of the women surveyed said they had accompanied a family member on a health care visit in the past year. In addition, 21% of the women surveyed said they regularly take care of a family member or friend who has an ongoing health problem or who is disabled in some way. The women most likely to be a caregiver are aged >55 years, are married, and have an annual income under $40,000.

Creating services that enhance coordination of care provides "one-stop shopping," saves time, and makes it easier for women members to assume their role as the coordinator of health care for themselves and for their families. Indeed, when asked to evaluate the desirability of new services, women ranked most highly those services that could improve coordination of care: family visits, multiple screenings during regular office visits, and same-day appointments for mammograms. One fourth of women interviewed during a visit indicated that they could have avoided a future visit if they could have obtained another test or received additional care during the index visit.

Members' Freedom of Choice and Their Flexibility in Selecting Type of Practitioner
Most women (as many as 73%) indicated a strong preference for seeing the same doctor during each visit, but women also expressed flexibility in whom they see if their regular clinician is not available (Figure 3). This response was seen especially with regard to low-acuity urgent care: As many as 72% of women were willing to see another doctor for flu or a sore throat, whereas only 35% agreed to see another doctor for routine care. Most women (72%) also would see a registered nurse for low-acuity urgent problems, and 64% would visit a nurse practitioner (NP) for a routine checkup.

The importance of choice was again seen in women's preferences for gynecologic care. For instance, 39% of women preferred to see their obstetrician/gynecologist for a Pap smear, whereas 26% preferred to receive their Pap smear from their general medical doctor. Another 35% expressed no preference.

KPNC asked women their opinions of the newly introduced health care team model, a grouping of physicians, NPs, health educators, behavioral health specialists, and physical therapists that enables members to see another doctor when their own is unavailable or to receive care directly from another team member if their complaints could be better addressed by that health care professional.

Although 81% of the women surveyed perceived the team approach to be more an asset than a barrier to seeing their regular doctor, about a third of the women said they would prefer to see their own physician every time they need care, regardless of the reason for the visit. The study further explored the multidisciplinary approach and found that 37% of the women wanted to see their physician for the same amount of time at every visit, 26% were willing to see other team providers and have only brief interaction with their regular doctor, and 37% said they would not have to see their doctor at all if their needs were met by other providers. Women who objected to multidisciplinary, team-based care generally were less satisfied with their KPNC experience.

Clearly, a "one-size-fits-all" approach to delivering health care will not satisfy women.

Friendly, Supportive Clinicians and Staff
Of the women surveyed, 32% indicated that a provider or staff member had said something rude or insensitive (Figure 4). Women who experienced rudeness were much more likely to say negative things about KPNC; 49% of these related only negative comments about KPNC to friends, family, or coworkers. The good news, however, is that 82% said they believed their KPNC facility is friendly and supportive (Figure 4). The bad news is that compared with members of other health plans, twice as many women KPNC members said they had experienced rudeness, insensitivity, or discomfort.

Experiencing KPNC as "friendly and supportive" was the top differentiator between members who were satisfied and those who were not. Of those who said they found KPNC unfriendly, only 6% felt highly satisfied, whereas 38% expressed low-to-moderate satisfaction. Of those who experienced rudeness, 26% were highly satisfied, whereas 45% said they had low-to-moderate satisfaction with KPNC.

The impact of rudeness and insensitive behavior by clinicians and staff is so strong that it undercuts KPNC's competitive position and negatively influences satisfaction, word of mouth, and member retention.

Other Areas of Importance to Health Plan Members
Physician Gender Preference
An unexpected result was that more than half (57%) of the women expressed no preference for gender of their physician. Even when it came to receiving Pap smears, only 44% said they preferred a female physician. However, overall satisfaction was negatively affected among members who had a strong preference for a woman physician but who were unable to see one.^4,5

The challenge for KPNC is to match women who strongly prefer a female physician with a female physician, allowing women with no preference to be matched with a male physician.

Menopause Information and Services
Menopause education is inadequate at KPNC: 78% of women surveyed said they had not received counseling about menopause. As many as 94% said they had not been given a brochure or seen an educational video on menopause, and 98% said they had not attended a class at KPNC on the subject, yet half of the women aged between 45 years and 60 years said they are informed about menopause. A clear possibility is that women who are informed about menopause are not receiving the information from KPNC.

A new HEDIS 2000 measure⁶one which evaluates health plans' efforts to counsel women about menopauseshould increase motivation to develop other strategies to better inform members about menopause.

New Services
Complementary and alternative medicine services held high interest for 70% of the women surveyed. Interest did not vary by members' geographic service area, age or ethnic group, socioeconomic class, health status, or whether members were satisfied or unsatisfied. Complementary and alternative medicine services held substantially more appeal for members who work full-time. As many as 72% of nonmembers indicated that they would be more likely to join KPNC if complementary health services were offered.

Nonmembers: The Importance of "Word of Mouth"
Word of mouth about KPNC had a strong effect on nonmembers' opinions of the organization: 74% of those who had a positive impression had heard only positive comments about KP. The percentage of nonmembers who have a positive opinion drops to 50% if they have heard both positive and negative comments about the organization. Of nonmembers who had heard nothing about KP, 48% had a positive impression; but among nonmembers who had heard only negative comments about KP, only 15% had a positive opinion.

About one in five nonmembers surveyed were interested in possibly joining KPNC. Increasing positive and decreasing negative comments and anecdotes about KP among women could increase our market penetration.

Because positive word of mouth about KP strongly influences nonmembers' opinion and their interest in joining the health plan, it is imperative for KPNC to improve nonmembers' impressions of the health plan.

Comment
Women are the major point of contact between KPNC and the populations it serves. Women coordinate care for themselves and for their partners, children, disabled friends, dependent family, andincreasinglyfor their aging parents. Women call the health plan, use the parking garages, and interact with the office staff, doctors, and health care professionals more often than any other definable group.⁷ How well KPNC performs will be judged in large part by this subset of the population.

Women are also the major decision-makers: They select a health plan to purchase and determine whether to stay with that plan.^1,2,7 Although multiple national sources state that 75% of women serve as the primary purchaser of health care, the KP Women's Health Study¹ shows an even greater influence of women on how families spend their health care dollars.⁸

Women's decisions about their health care are influenced by many factors. Women rely on word of mouth from friends, coworkers, and family to determine which health plan is right for them and their families.¹ In addition, what women value in health care is affected by the extent of their participation in the work force.^7,9 And because women are not all alike, KP should use its substantial capability in information technology to identify members' individual preferences and to address their specific needsand thus realize an advantage over our competitors.

Women use health care services more than men do: Two thirds of all inpatient, outpatient, and pharmaceutical services are used by women.^6,10 This fact is true today and will remain true for the foreseeable future, in part due to use of obstetric and gynecologic care and because of women's longer life expectancygenerally, a span of seven years.² These additional years are often characterized by chronic illness and high utilization of health care services.

Health care utilization by women is also affected by other issues. Compared with men, women are more susceptible to immunologic, neurologic, psychiatric, and many other disorders and are more often subjects of violence and poverty.⁷ Although cardiovascular disease is as likely to occur in women as in men, rates of morbidity and mortality from cardiovascular disease are higher in women.¹¹

KP conducted the Women's Health Study because of two important commitments incumbent on the health care industry: 1) knowing what women value in health care delivery and 2) meeting those needs. The results of the study are applicable and useful for all KP Regions and are being shared with all charged with focusing on women's health across KP. In Northern California, each Physician-in-Chief has appointed a Women's Health Liaison, who reports the study findings to audiences at each KPNC facility and works to implement changes in care delivery to meet and exceed the expectation of KP's women members.

Several women's health demonstration projectsfunded by the Innovations Program as a follow-up to the Women's Health Studyare underway in Northern California. Such projects include the KP Fremont Project, "Multilingual women's health project," conducted by Maria Servin; the KP South Sacramento Project, "Coordinated Preventive Health Visit," conducted by Jan Langston and Kathleen O'Brien; and the KP Richmond Project, "Care Coordination for Women and Families," conducted by Brigid McCaw. These demonstration projects will evaluate new models of care delivery to meet the demands of women who have multiple roles and needs. Each project will be evaluated andif successfulwill be incorporated into the facilities' operating budgets at the conclusion of the one-year project's funding. The models will be shared for adaptation and implementation across KPNC and in other KP Regions.

In addition to focusing KP's care delivery systems on the needs of women, Women's Health-KP is committed to improving health care outcomes for women. By using KP's robust research capability to better understand some of the differences between genders, we will contribute to improving the health of women nationwide.

KP finds itself at the beginning of an exciting new era in American medicine. In this new era, gender differences in biology, health, and illnessas well as gender differences among racial and cultural subgroupswill be recognized and incorporated into the health care delivery system to improve the health of all.

Acknowledgment: This article would not have been possible without the professional assistance of Mari Edlin, a freelance writer specializing in health care and a regular contributor to a variety of national publications. She took the mountain of data from the study and put it into a form that will allow the reader to get the most out of it. Mari's skill as a writer is matched by her commitment to improving the health of women.

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