We’ve spoken in the past about the rise of “femtech” in recent years, as investors rush to fund start-ups specifically catering to women’s health needs. At the same time, employers have homed in on women’s health as they explore opportunities to enhance their benefits. But amid all this activity, it can be easy to forget—or perhaps never learn—the fundamental challenges and inequities at the heart of women’s health. In this post we’re going to explore what every healthcare generalist needs to know about disparities in women’s healthcare and some approaches to improving them.
This is an excerpt from a larger presentation about the state of health disparities, which members can access here.
What do we mean when we talk about disparities in women’s healthcare?
Women’s healthcare disparities encompass two main issues:
Disparities in treatment, experience, and outcomes between women and men
Disparities in treatment, experience, and outcomes between women from different demographic groups
However, this distinction is not always acknowledged or specified in high-level conversations about women’s healthcare needs. Understanding the nuances of both issues, and the different possible approaches to ameliorate each, are vital pre-requisites for minimizing disparities in women’s healthcare.
Gender inequity covers both interpersonal and systemic disparities
We’ll start things off with the first issue: disparities between men and women. As with other forms of inequity, women face both individual bias—unconscious or otherwise—and systemic adversity.
Individual bias
Women are more likely than their male counterparts to say that they’ve had negative experiences with their healthcare providers, including being ignored, blamed, or having assumptions made about them and their health. These presumptions and dismissals translate to a variety of negative outcomes. For example, women are more frequently refused pain medication, have to wait longer to be treated for certain conditions in the ED, and are more likely to be diagnosed with a mental health condition than men presenting with the same symptoms.
Systemic inequity
On average, women spend more on healthcare than men. Women of working age (18-64) have a smaller share of their health spending covered by their health plan than men, despite having the same premiums and cost-sharing. On average women spend almost 20% more on out-of-pocket costs than men, even when excluding maternity costs. Including maternity care, the number is much higher.
This discrepancy is in large part because health benefits are historically not designed with women’s nuanced needs in mind. For example, women are recommended to get health screenings at an earlier age and more frequently than men. And many of the screenings they do get, like mammograms and Pap smears, require higher cost ancillary services like labs and imaging. While most initial wellness checks are covered by insurance, follow-up care after abnormal results may not be. This is a prime illustration of the distinction between equality vs. equity—a concept integral to understanding health disparities. Men and women may get equal health benefits (i.e. pay the same amount for the same coverage), but they experience unequal outcomes (i.e. women spending more on care) because women’s needs are different. An equitable solution would accommodate those differences to mitigate the gap between men and women.
Race and ethnicity further exacerbate disparities in women’s health
Alongside differences in how men and women experience the healthcare system, we also know that not all women experience the healthcare system in the same way. Across most conditions and service lines—including heart disease, diabetes, and cancer—non-Hispanic White women have better experiences and outcomes than women of other racial and ethnic groups. Reproductive health is often pointed to as the archetypical example of racial disparities in women’s healthcare both because the severity of the gap and what it suggests about the care that women of color receive across the board. For example, Black mothers are twice as likely as White mothers to report late or absent prenatal care and—most disturbing of all—more than three times as likely to die of pregnancy-related causes.
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What can be done to mitigate disparities in women’s healthcare?
The solutions to address disparities in women’s healthcare are as multitudinous as their causes, many of which are rooted in decades of unequal treatment across a range of societal factors like housing, employment, and education to name a few. While there’s a role for healthcare organizations to improve the social determinants of health—including partnering with community organizations and advocating for constructive social policy—we’re going to describe a few initiatives that providers, plans, and/or payers can implement directly.
Gender/racial concordance and enhanced medical training
A growing body of evidence is showing that racial concordance (i.e. patient and provider sharing the same race) improves health outcomes across conditions, for example Black infant mortality, emergency department use, and treatment adherence. Unfortunately Black and Hispanic Americans (who make up about 13% and 20% of the US population respectively) are severely underrepresented in the ranks for doctors (accounting for only 7% and 6% respectively). Creating pathways for more Black and Hispanic students to pursue medicine and offering provider networks that represent their communities are two ways to support access to high quality care.
Similarly, researchers are finding that in some cases women who are treated by female doctors get better care. One study found that female patients being treated by male providers after a heart attack have worse outcomes than male patients; female providers had equal outcomes whether they were treating men or women. Another observed that female diabetes patients were less likely to receive treatment intensification after suboptimal health metrics were observed, a disparity that intensified when they were treated by male doctors. Some good news is that, while only about a third of current doctors are female, men and women now make up almost equal shares of entering medical students (women actually have a slight edge). But of course, perfect gender concordance will never be possible, or even desirable. But studies suggest that male physicians with more exposure to female patients and female physicians achieve greater success treating women, suggesting that more can be done to promote sex- and gender-specific education in both medical school and continuing medical education curricula.
Coverage modification
As we discussed, women on average pay more for healthcare than men, in part because health insurance is not designed with women’s specific needs in mind. Offering health benefits that can help offset the higher cost burden borne by women would not only benefit their financial and physical health in the short-term but encourage the use of life saving preventive care that would likely save payers more in the long term. Services like imaging, lab, and mental health are all used more frequently by women than men and would be great starting points for reassessing benefits with women’s health equity in mind.
Access to reproductive care
About 40% of pregnancies in the United States are unintended, the vast majority of which could be prevented with highly effective birth control methods currently available on the market. Unintended pregnancy is associated with higher risks of many negative health outcomes for both mother and baby, in addition to a significant financial and mental burden. Health plans are currently required to cover birth control at no cost. But healthcare organizations can still play a crucial role by supporting access for uninsured women and providing culturally appropriate education for insured women not yet using any/the most effective contraceptive methods.
When patients do decide they’re ready to have a baby, proper pre-and peri-natal care is vital. Like contraception, pre-natal services must be covered by health plans, but there is more than can be done to increase quality, cultural sensitivity, and awareness. One extremely promising option is doula services, which more and more studies are showing can reduce disparities in maternal health. Women with doulas had fewer C-sections, were less likely to give birth prematurely, and were significantly less likely to experience post-partum depression. Health plans, payers, and providers should look for opportunities to connect expecting mothers with affordable doula services, among other avenues shown to lessen disparities in women’s healthcare.
Care standardization
One of the most important steps to promote women’s health equity, and maternal mortality in particular, may also be the most challenging—quality improvement and care standardization during and after pregnancy. Black and Hispanic women are more likely to give birth in hospitals with lower quality ratings and higher maternal death rates. By implementing protocols that reduce care variation—including safety bundles, triggers, simulations training, and credentialling—hospitals can begin to equalize the care women receive regardless of race and ethnicity. Payers and plans can also push for these measures in their contracting, connecting completion to payment for example.
More than half of maternal deaths happen in the year after birth, meaning the health plans and providers also have an important role to play in the on-going health and safety of new mothers. Ensuring that care quality and frequency protocols are being met during that all important time could significantly diminish the 80% of maternal deaths considered preventable.
We’ve outlined just a few examples of how disparities in women’s healthcare can manifest, and a small number of promising interventions that healthcare organizations can pursue to promote women’s health equity. While we only scratched the surface, women’s health is a huge area of discussion and investment, and thus a must-know topic for any healthcare generalists. If you want to learn more about our health equity research or how we can support your organization’s DEI journey, reach out to us at info@unionhealthcareinsight.com or schedule time to meet with our CEO directly here.
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