Summer 2000 / Vol 4, No 3
of Women's Health Care: Selected Results
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.
Reasons and Goals for Studying Women's Health
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
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 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.
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.
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.
Freedom of Choice and Their Flexibility in Selecting Type of Practitioner
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.
Supportive Clinicians and Staff
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.
Areas of Importance to Health Plan Members
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.
Information and Services
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.
The Importance of "Word of Mouth"
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.
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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