Letter on Direct Access to Ob-Gyn Services to House and Senate Managed Care Conferees

March 14, 2000

Dear Senator/Representative:

The conference committee on patients’ rights legislation is now underway. One of the issues that is under discussion is women’s access to obstetrical and gynecological (ob-gyn) services. For the following reasons, we urge the conferees to adopt the approach taken in the bipartisan House-passed Norwood/Dingell bill.

Women have a different set of health care needs than men, and providing direct access to ob-gyn services is an important way to address some of those critical differences. The National Partnership’s nationwide survey, Family Matters, confirmed that women want direct access to these services (78 percent of women responded that this was very or extremely important to them). Other surveys have shown identical, strong support for direct access.

There are three primary differences between the House-passed and Senate-passed bills on this issue:

• whether women will be able to choose among different types of participating providers of ob-gyn services or will be limited in their selection to physicians (ob-gyns);

• the type of services women will be allowed to obtain directly -- all covered services or only "routine," "preventive," or some other subset of covered services -- and that providers can subsequently give referrals for; and

• the scope of the protections, i.e, what groups of women would benefit from the provision.

With respect to each of these issues, the National Partnership believes that the House-passed version is superior.

We believe that federal legislation should recognize that women should be able to choose the type of provider they see among the plan’s participating providers. This means that the final bill, like the House-passed bill, should ensure direct access to the range of providers participating in the plan’s network. Many women will choose an ob-gyn physician, but others will prefer to see a certified nurse midwife or another licensed provider practicing within the scope of state practice laws. The final bill should not accord special status to one type of provider over another, as the Senate-passed bill does. The approach we suggest would not mandate the inclusion of particular providers in the network; it would merely ensure that the choice among participating providers is the woman’s.

Women must be given the right to obtain any covered ob-gyn service directly from the participating provider of their choice. Some plans put limits on the number of visits or types of services that women may obtain directly. For example, direct access to a provider of ob-gyn services may be allowed just once or twice a year for preventive health care. For some women, one visit per year may be enough, but many need to be monitored more closely. If a woman has already had her "preventive" exam and then finds out her Pap smear was irregular or has additional questions about the type of birth control she is using, she should not have to get a referral from a gatekeeper to see the health care professional who should be providing the care that she needs.

Direct access should not be limited to "routine" care, "preventive" care, "primary" care, or "pregnancy-related" care. It is extremely difficult to draw the line between these categories and not all care falls neatly into one category. Use of any of these terms will surely lead to ambiguities in interpretation -- and frustration and delays for women needing care.

For example, care that may be "routine" for one woman may not be routine for another woman, and the plan may have yet a different idea of what care it considers routine. How is the decision made whether the care a particular woman is seeking fits in the right box, and who makes the decision? Is it made before the woman can even schedule the appointment, or is it made after-the-fact when the plan denies payment? Is it made by someone on a 1-800 line who has no information about the woman’s medical history? Limiting access in any of these ways will put unnecessary obstacles in the way of women seeking care.

Under the approach we suggest, plans would continue to have flexibility to impose prior authorization requirements before certain treatments or procedures may be obtained. For example, nothing would prevent plans from requiring that providers obtain prior authorization before performing a hysterectomy. But plans should not be permitted to impose unnecessary barriers to essential women’s health care by impeding direct access to the providers who provide those services.

The Senate bill limits this provision to women in self-insured ERISA plans. We urge the conference committee to ensure broader, and more uniform, application of this provision by adopting the House approach of covering women in all ERISA plans, women covered by governmental plans, and women who obtain coverage in the individual market.

To best protect the health of America’s women, we urge you to adopt the approach taken in the House-passed bill.

If you have any questions, please do not hesitate to call me or Joanne Hustead, Director of Legal and Public Policy.

Sincerely,

Judith L. Lichtman
President