Who's Worth More? Gender Bias in Reimbursement

 Texas Medicine Logo  

Cover Story - October 2006  

 

By  Erin Prather
Associate Editor  

In 1997, a Gynecologic Oncology article asked, "Is Adam Worth More Than Eve?" The answer, according to Austin obstetrician-gynecologist Margaret Thompson, MD, is unfortunately "yes." She has personal experience to prove it.

In February 2001, the 24-bed Renaissance Women's Center of Austin closed its doors, and Universal Health Services (UHS), the national company that financed the hospital, announced it would also abandon plans to create a chain of specialty women's hospitals.

The closure was a defeat for Austin's Renaissance Women's Group, whose offices were housed on the hospital's second floor. The 10-physician group had sued UHS to keep the facility open, claiming the chain was breeching its 15-year lease agreement with the physicians. Because a jury awarded the group $6.9 million in damages, a judge determined UHS could close the hospital's doors. UHS appealed and in 2003, the Texas Supreme Court ruled the company did not have to pay the damages. The Renaissance Women's Center stayed closed.

Dr. Thompson, then president and founder of the Renaissance Women's Group, blames the hospital's closure primarily on low reimbursements for obstetrics services. She says the patient load was not the problem, as the hospital was often at capacity. Gender discrimination in medical insurance payments proved its undoing.

"Even though Renaissance Women's Center was well received, patients loved it, the community liked it, and we were at capacity at all times, reimbursements for our obstetrics services were very low," she said.

The Renaissance was not alone in experiencing poor reimbursement.

The Gynecologic Oncology study concluded that "significant gender bias" in reimbursement based on Medicare relative value units for female-specific services leads to a lower net reimbursement for gynecologic procedures. The study examined 24 matched procedures, such as biopsy of male and female genitals, hysterectomy versus prostatectomy, and staging for ovarian versus testicular cancer. Procedures on men were reimbursed at a higher amount in 19 of the cases. The procedures on women paid more in three cases, and there was no difference in reimbursement for two of the procedures. Overall, the study showed, procedures on men paid 44 percent higher than those on women.

A few months after the Renaissance Women's Center closed, the Texas Legislature passed the Omnibus Women's Equal Health Care Act. It bans gender discrimination in health insurance reimbursement. Advocates for the bill pointed to Medicare payment formulas. Under the formulas, an average of $2,000 was reimbursed for childbirth, which included 13 to 15 office visits, labor, and postpartum care. But removal of a nonruptured appendix, a one-hour surgery with two follow-up visits, paid $1,400.

Although the bill passed and was cited as a victory for women's health care, Dr. Thompson believes the system has a long way to go.

"Reimbursements have traditionally been and continue to be low for obstetrics. Fifty years ago, obstetrics was not high-tech intensive care. It was basic, very routine, low technology. That's completely changed, but reimbursements for services have not caught up with that development. Although the Omnibus Act addressed equal payment for ailments affecting both men and women, it did not address low reimbursements for services affecting only women," she said.

Robert Watson, MD, medical director of the new Paul and Judy Andrews Women's Hospital being built by Baylor All Saints Medical Center in Fort Worth, agrees with Dr. Thompson that reimbursement for women's health care services is low. "I think that is a disservice to the women of our country," he added. 

Women Only  

The idea of a women's hospital is not new. During the19th century, Elizabeth Blackwell, the first woman to graduate from medical school, and other physicians were instrumental in creating hospitals for women. Existing facilities did not admit or employ women to their staffs. During this time, and for years afterward, women's health was primarily equated with their roles as mothers; there was little recognition that men and women have different health needs.

In the report, A Century of Women's Health: 1900-2000 , the Office on Women's Health in the U.S. Department of Health and Human Services said it took the better part of the 20th century for medical researchers, practitioners, and policymakers to directly address the issue of sex-based differences in the diagnosis and treatment of disease.

"Throughout most of the century, medical research and practice were based on an androcentric view of science. The male model was the norm. Joined to this practice were fears regarding the effects of clinical trials on women of childbearing age," it said.

The report cited tragedies linked to the use of diethylstilbestrol and thalidomide in pregnant women in the 1950s and 1960s, which led to regulations in the 1970s that restricted testing of new treatments in women of reproductive age. This ultimately led to widespread exclusion of women of all ages from clinical trials and resulted in women continuing to use medical treatments and techniques tested solely on men. It was not until 1990, when a General Accounting Office report brought to light the under-representation of women in federally funded clinical trials, that federal agencies changed their policies to include women in population-based studies. 

More recent research has shown gender-based differences in women's health care use and costs, the probability of them receiving major therapeutic procedures in acute settings, and the likelihood a woman will undergo a major diagnostic procedure. Gender-linked differences in patient satisfaction and communication with physicians also was shown.

Ironically, many of these factors are the very reason Stanley Rogers, MD, Warren Jacobs, MD, and Jack Moore, MD, opened The Woman's Hospital of Texas in Houston 30 years ago. They envisioned a facility that catered to women's wants and health care needs. Together with 25 other colleagues, they opened the hospital, now the largest facility of its kind in the state. The Woman's Hospital began allowing fathers in the delivery room and requiring them to take childbirth classes, long before both practices were common.

"The reason we wanted to start the hospital is simple," said Dr. Moore. "We cared about women's health and wanted to create a place that provided the best possible care. Although I'm retired, my heart is still tied to the place. It's where I delivered a lot of young people into the world, and I'm proud to have watched the hospital's services grow these last 30 years."

Reproductive endocrinologist Leah Schenk, MD, joined The Woman's Hospital staff after her husband moved to Houston for medical training.

"Patients receive specialized health care from physicians and staff who are very experienced with women's needs," she said. "A woman can come here as a teenager and receive services through her reproductive years, menopause, and beyond. Most medical needs a woman has during her life can be addressed here."

The hospital eventually was acquired by Hospital Corporation of America. It is affiliated with Baylor College of Medicine and The University of Texas OB-Gyn programs and provides training for residents. A $72.3 million expansion is scheduled to start by the end of the year. 

Not Women Only  

When asked if women's hospitals specifically benefit women physicians, Dr. Schenk replied, "I don't think women physicians, but definitely women patients. Women I've treated like the concept of a women's hospital. I live in the suburbs, about 45 minutes away from the hospital. My neighbors, associates, mothers of children that attend my kids' schools, many come to my partners for health care. There are even some men who opt for services at Woman's. In fact, a lot of the male physicians practicing here choose the hospital for their own surgeries."

Last year, close to 7,000 surgical procedures unrelated to childbirth were performed on women of all ages at The Woman's Hospital. Surgeries included breast reconstruction, gallbladder removal, hernia repair, and scar tissue removal.

Dr. Thompson thinks the hospital's expansion into these services was the key to its success. Without that expansion, she believes, Woman's might have had the same experience as that of Austin's Renaissance.

"We tried to add other procedures - plastic surgery, general breast surgery - but the bulk of our business was obstetrics and gynecology," she said. "I now believe the project was doomed from the start. Any women's hospital that primarily offers obstetrics simply can't make it financially."    

Dr. Watson anticipates the new Baylor All Saints facility will be successful because it is following the same path as The Woman's Hospital in Houston and will not be limited to obstetrics.  

Another hospital catering to women's health care needs is being developed - the Women's Hospital at Renaissance in Edinburg - and more could be on the way. "With the surge in population, aging baby boomers, and medical advances, I predict that more women's hospitals will be built because I am seeing firsthand the demand for these comprehensive services," Dr. Watson said.

Both the Fort Worth and Edinburg hospitals plan to offer traditional maternity services, as well as a wide range of specialty services for diagnostics, screenings, and treatment. 

"Hospital Within a Hospital"  

Sometimes providing specialized women's services takes a little ingenuity. The Renaissance Women's Center is history, but Austin continues to have a women's health facility, even if it's not in the traditional sense. Housed in the city-owned Brackenridge Hospital, the Austin Women's Hospital often has been described as "a hospital within a hospital."

The Catholic-affiliated Seton Healthcare Network began leasing Brackenridge from the city in 1995 after years of financial problems prompted city officials to look for ways to get the expensive hospital operation off their books.

Although the original agreement between the city and Seton allowed all reproductive health services, except for abortion, to continue at Brackenridge, the Catholic Church eventually ordered Seton to end the arrangement. Beginning in 2001, sterilizations and other forms of birth control were no longer provided. Austin physicians, activists, and women's rights organizations immediately voiced their concerns that a lack of access to these services harmed the reproductive rights of the women Brackenridge served.

A solution was crafted in which the city now funds the Austin Women's Hospital, while The University of Texas Medical Branch at Galveston operates it. The hospital is on the fifth floor of Brackenridge Hospital and exists completely independent of Seton. It has its own entrance and provides sterilizations and contraception services, but not abortions. A patient must be transferred to another hospital if a physician determines that an abortion is medically necessary. Seton has agreed to refer women to Austin Women's Hospital if the women request services the Seton network does not provide. 

Peggy Romberg, executive director of the Women's Health and Family Planning Association of Texas, says creation of Austin Women's Hospital is positive, but it's far from a perfect solution.

"The compromise between the city and Seton was unusual, but not the disagreement," she said. "Mergers like this occur all over the United States. Religious networks impose their doctrine on health care facilities, and women lose access to certain services.   Regarding women hospitals, it's troubling to think those existing hospitals might have to stop certain services if they choose to partner with a religious network, especially if that type of merger is their only hope of remaining open."  

Erin Prather   can be reached at (800) 880-1300, ext. 1385, or (512) 370-1385; by fax at (512) 370-1629; or by e-ail at  Erin Prather .  

 

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